While it may come as a surprise to the general public, medical practitioners are well aware that there is no established, formal time to continue attempting to resuscitate a patient who has suffered cardiac arrest. “This is one of the most difficult issues in cardiology. It is still largely an unknown,” explains Zachary Goldberger, MD, a Robert Wood Johnson Foundation (RWJF) Clinical Scholar (2010-2012) and cardiologist at Harborview Medical Center and the University of Washington School of Medicine in Seattle.
In addition, conventional medical wisdom has held that shorter is better when it comes to resuscitation. “Many practitioners feel that long resuscitation efforts provide no additional benefit, because if patients do not survive early on during cardiac arrest, their overall prognosis is poor. But our findings suggest that some patients may benefit from longer attempts,” Goldberger says.
Finding an answer to this extraordinarily difficult question, or at least adding clarity to existing data, could have a considerable impact on public health by improving the poor clinical outcomes of patients suffering cardiac arrest. “Approximately 200,000 hospitalized patients suffer a cardiac arrest each year, and only half of them survive. Fewer than 20 percent survive to discharge,” Goldberger notes.
Minutes Can Save a Life
Using the American Heart Association Get with the Guidelines Resuscitation Registry (the largest in-hospital cardiac arrest registry), Goldberger and his colleagues examined whether the length of resuscitation efforts varied between hospitals. In addition, they considered whether patients treated at hospitals that attempted resuscitation for longer periods of time had higher survival rates than those where resuscitation efforts were shorter.
The study included more than 64 000 patients from 435 hospitals who underwent resuscitation for a cardiac arrest between 2000 and 2008. The research shows that physicians use a variety of times for resuscitation, but the median is 17 minutes.
“In our work, we confirmed that for most patients who were successfully resuscitated, it did happen after a short period of time. Yet, unexpectedly, we also found that approximately 15 percent of patients who survived needed at least 30 minutes to regain a pulse. Overall, this suggests that some patients only responded after longer attempts,” Goldberger says. “In addition, we discovered that efforts were stopped prior to 15 minutes in 33 percent of patients [who] did not survive and [after] 30 minutes in 75 percent of patients.”
The other major findings from Goldberger and his team, reported in the article, “Duration of Resuscitation Efforts and Survival After In-Hospital Cardiac Arrest,” (The Lancet, Sept 5, online), included that patients at hospitals where resuscitation attempts were longer, on average, had a higher likelihood of immediate survival and survival to discharge, even after accounting for differences in overall patient characteristics, such as gender, age, and race. “The findings were most pronounced in patients with pulseless electrical activity and asystole, a heart rhythm problem that generally has the worst prognosis,” Goldberger adds.
Surprisingly Positive Outcomes
One very important finding Goldberger and his team revealed was that longer resuscitation times did not necessarily have a severely negative effect on brain health. “The higher survival rates do not come at the expense of worse neurological outcomes. Patients who survived with longer resuscitation times did not appear to have substantially worse neurological functioning at discharge.” It seems that while there was some neurologic injury, it was more often in the moderate disability range.
While the broad range of resuscitation times and outcomes may seem surprising to a layperson, Goldberger explains that different people simply respond very differently in instances of cardiac arrest.
And while he points out that even this research “cannot definitively tell us that it is the time spent in resuscitation that is leading to higher survival or establish an optimal length of time for resuscitation, this information will provide physicians with additional guidance in deciding when to terminate resuscitation efforts,” Goldberger says.
Goldberger conducted his research during his time as an RWJF Clinical Scholar. “Being a Scholar enabled me to learn the statistical methods needed to conduct the analyses and work with the other analysts. In addition, I was able to receive invaluable feedback from the other scholars and mentors,” Goldberger says.
In his upcoming work, Goldberger will be investigating other factors that contribute to positive patient outcomes in cardiology, including family presence during resuscitation. The Robert Wood Johnson Foundation Clinical Scholars program advances the development of physicians who are leaders in transforming health care through positions in academic medicine, public health, and other roles. The program trains clinicians in the program development and research methods that will enable them to find solutions to the many challenges posed by the health care system, community health, and health services research.