SLIDE 1
General caveats
- Highly selected population (~ 3 per 1000)
- Retrospective analysis
- Generally in the setting of good medical and
Care of cardiac and non cardiac patients Niall Herity MD Consultant - - PowerPoint PPT Presentation
Care of cardiac and non cardiac patients Niall Herity MD Consultant - - PowerPoint PPT Presentation
Care of cardiac and non cardiac patients Niall Herity MD Consultant Cardiologist Clinical Director (Cardiology) General caveats Highly selected population (~ 3 per 1000) Retrospective analysis Generally in the setting of good
SLIDE 2
SLIDE 3
Survival trends after in hospital cardiac arrest
SLIDE 4
Cardiac versus non‐cardiac patients who have in‐hospital cardiac arrest
SLIDE 5
In‐hospital cardiorespiratory arrest
Myocardial ischaemia Hypoxia Acidosis Usually PEA or asystole Rare Usually VF/VT Commoner Defibrillation Pathology Arrhythmia Treatment Survival CPR and adrenaline CCU Medical and surgical wards Location
SLIDE 6
What did we learn?
- No systematic decision about CPR status on
admission nor on subsequent consultant review
- Evidence of physiological deterioration and
lack of escalation mechanisms
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CPR status
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Death
SLIDE 9
Death and culture
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Recommendation
“CPR status must be considered and recorded for all acute admissions, ideally during the initial admission process and definitely at the first consultant review...”
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CPR decisions at first review
An 88 year old lady is admitted from home with dyspnoea. She has a history of metastatic colonic carcinoma with lung secondaries. Treatment is started with oxygen and antibiotics
- Would you make a CPR decision?
- What would it be?
- Who would you discuss it with?
SLIDE 12
CPR decisions at first review
A 45 year old man is admitted from home with chest pain. He was previously fit and well. A diagnosis of acute coronary syndrome is made and appropriate treatment is commenced
- Would you make a CPR decision?
- What would it be?
- Who would you discuss it with?
SLIDE 13
CPR decisions at first review
A 38 year old lady is admitted from home with chest pain. She has a history of breast carcinoma with bony
- secondaries. She has 2 young children aged 8 and 10
- Would you make a CPR decision?
- What would it be?
- Who would you discuss it with?
SLIDE 14
CPR decisions at first review
- 88
- Dyspnoea
- Metastatic colonic
carcinoma with lung secondaries
- 38
- Chest pain
- Metastatic breast
carcinoma with bony secondaries
SLIDE 15
Why are doctors reluctant to make DNACPR decisions?
SLIDE 16
“Playing God”
“The elderly, disabled, confused ‐ those who are least able to form a rapport with doctors ‐ become an intolerable burden on an over‐ stretched health system Before long, a consultant will make the decision to withdraw treatment in their 'best interests‘ The decision is actually based on an assessment of the patient's quality of life versus the potential resource consumption. Unfortunately, the assessment is rarely either detailed or objective. Doctors are so busy and tired that they make subjective decisions influenced by their own culture, upbringing and opinions. These decisions are often unknown to relatives”
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Sense of failure
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Complaint or litigation
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Personal publicity
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Peer criticism or the GMC
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Early warning systems and escalation
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Barriers to escalation of care
Medical or surgical patients with physiological warning signs HDU/ICU Escalation attempt Professional barriers
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Removing the barriers
Medical or surgical patients with physiological warning signs New management plan in same place Protocol‐led escalation Transfer of responsibility Palliative HDU/ICU/CCU
- r
- r
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Can anything be learned from cardiology?
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How do we manage our sickest patients?
Low risk Ill † ED Lo w risk Ill † Medical or surgical ward
- Nurses and junior doctors
- Limited interventions
- Under‐appreciation of physiological deterioration
- Avoidable cardiorespiratory arrest
High risk conditions: Myocardial infarction Pulmonary embolism Pneumonia COPD Sepsis GI bleeding Acute surgical Stroke Metabolic conditions 999
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ST elevation MI
Low risk Ill † ED Cardiac catheterisation laboratory
- Senior doctors and nurses (with trainees)
- Extensive, immediate, expert and definitive intervention
- Recognition of physiological deterioration
- (Unavoidable cardiorespiratory arrest)
999 24/7/365
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Why not all the others?
Low risk Ill ED
- Senior doctors and nurses (with trainees)
- Extensive, immediate, expert and definitive interventions
- Recognition of physiological deterioration
- (Unavoidable cardiorespiratory arrest)
999 CT scanner +/‐ lysis Stroke Respiratory +/‐ HDU COPD Surgical +/‐ theatre Acute surgical GI +/‐ endoscopy GI bleeding 24/7/365
SLIDE 28
Summary
- CPR decisions on admission and first
consultant review: change in culture required
- Automatic inpatient escalation services
- Pre‐hospital identification of the highest risk
groups and bypass some traditional structures
SLIDE 29