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In-Hospital Cardiac ArrestIn-Hospital Cardiac ArrestEEvidencevidence B Basedased M Medicineedicine
realtà dell’incidenza ed efficacia dei soccorsi realtà dell’incidenza ed efficacia dei soccorsi
Stefano Nardi
AZIENDA OSPEDALIERA SANTA MARIA TERNIAZIENDA OSPEDALIERA SANTA MARIA TERNI DIVISION OF CARDIOLOGY DIVISION OF CARDIOLOGY
ARRHYTHMIA, ELECTROPHYSIOLOGIC CENTER ARRHYTHMIA, ELECTROPHYSIOLOGIC CENTER AND CARDIAC PACING UNIT AND CARDIAC PACING UNIT
SSudden udden CCardiac ardiac DDeatheath
Definition• Natural Death
(due to CARDIAC CAUSES)
• Preceeding by a sudden loose of coscience until 1 h of start of the ACUTE ACUTE SYMPTOMSSYMPTOMS, in a pts W or w/o note pre-existent CARDIAC DISEASECARDIAC DISEASE, in which the die was not considered imminent.
• AGE and modality of DEATH are not prevedible
Myerburg RJ, Castellanos A ’80 Myerburg RJ, Castellanos A ’80
Task- Task-force on SD of ESC. EHJ ’01 force on SD of ESC. EHJ ’01
SSudden udden CCardiac ardiac DDeatheath
Suddenly Suddenly FILIPPIDE FILIPPIDE die immediately after his die immediately after his announcement at Atheniesis the victory ofannouncement at Atheniesis the victory of MARATONAMARATONA
ANCIENT PROBLEM ......
SSudden udden CCardiac ardiac DDeatheath
Vittorio Gassman
Massimo Troisi
Beniamino Andreatta
Umberto Bossi
Sergio Leone
Clark Gable
Dwight Eisenhower
..... CURRENT PROBLEM !!!!
SSudden udden CCardiac ardiac DDeatheath
Total DeathTotal Death 557.584 (100%) 557.584 (100%)
Death for CV diseaseDeath for CV disease 242.248 (43%) 242.248 (43%)
Sudden DeathSudden Death 65.000 (10.2%)65.000 (10.2%)
ISTAT source ‘00ISTAT source ‘00
0
50000
100000
150000
200000
250000 Cancro dellaMammellaCancro ColonRettoCancroBronchi/PolmoniIctus
Morte Improvvisa
MalattieCardiovascolari
Mort
i p
er
an
no
Mortality Distribution
SSudden udden CCardiac ardiac DDeatheath
• Incidence variable 0.36-1.28/1000 Incidence variable 0.36-1.28/1000 pts in general population pts in general population
• In industrialized pts, the total In industrialized pts, the total annual incidence is 1/ 1000 annual incidence is 1/ 1000 inhabitants inhabitants
• In ITALYIn ITALY: studio FACS (Friuli) : studio FACS (Friuli) incidence of 0.95 cases each incidence of 0.95 cases each 1000/people for yr; LIFE PROJECT 1000/people for yr; LIFE PROJECT of Piacenza (Emilia) 1.10 CA each of Piacenza (Emilia) 1.10 CA each 1000 inhabitants for yr 1000 inhabitants for yr
Epidemiology
• Until 8/1000 inhabitants between 60 and 69 yrs
EBM
SSudden udden CCardiac ardiac DDeatheath
• Incidence Incidence 1 1 eacheach 1000/inhabitants/yr1000/inhabitants/yr
• Nr. of cases each yrNr. of cases each yr 65.00065.000
• Nr. of cases each day Nr. of cases each day 172172
• 1 case each 1 case each 9 9 hours hours (UMBRIA)(UMBRIA)
• 10 %10 % of all total mortality of all total mortality
• 40 %40 % of all deaths for CARDIAC DISEASE of all deaths for CARDIAC DISEASE
Epidemiology (Italy)
SSudden udden CCardiac ardiac DDeatheath
Trentino 1/ 9 ore
Lombardia 1/ 57 minuti
Friuli 1/ 7 ore
Veneto 1/ 2 ore
Piemonte 1/ 2 ore
Liguria 1/ 5 ore
Emilia 1/ 2 ore
Marche 1/ 6 ore
Toscana 1/ 2 ore
Umbria 1 caso ogni 9 oreLazio 1 caso ogni ora e 1/2
Abruzzo 1 caso ogni 9 ore
Campania 1 caso ogni ora e 20
Puglia 1 caso ogni 2 ore
Molise 1 caso ogni 26 ore
Basilicata 1 caso ogni 14 ore
Calabria 1 caso ogni 4 ore
Sicilia 1 caso ogni ora e 1/2
Sardegna 1 caso ogni 5 ore
Regional Distribution
SSudden udden CCardiac ardiac DDeatheath
• 2 peak age-related in which SCD is more prevalent • Between born and 6 mo (sudden infant death syndrome)
• Between 45 and 75 years old
• In Adult population, the ratio between SCD and Global mortality decrease with the age.
• 76% of total mortality are SUDDEN between 20 and 39 years
• 58% of total mortality between 55 and 64 years
• 42% are between 65 and 74 years
Relationship with Age
SSudden udden CCardiac ardiac DDeatheath
• Until 20% survival
• Between 30 - 80% of survivals suffer of Anoxic Encephalopaty
Magnitude (annual mortality)
•U. S. U. S. 450.000 450.000
•Europe Europe 600.000 600.000
•Germany Germany 80.000 80.000
•ItalyItaly 65.00065.000
Incidence in Italy Incidence in Italy
1 case each 9 minutes 1 case each 9 minutes
SSudden udden CCardiac ardiac DDeatheath
PATHOGENESIS Bradiarrhythmias Bradiarrhythmias 15-20%15-20%
VT/VF VT/VF 75-80% 75-80%
EMD EMD 5%5%
Cardiac Rhythm Cardiac Rhythm recorded in pts recorded in pts resuscitate to CA resuscitate to CA
Cummins RO, Annals Emerg Med. ‘89
Albert CM. Circulation ‘03
Bayés de Luna A. Am Heart J. ‘89
Which rhythm during CA ?Which rhythm during CA ?
IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest
66% potentially avoidable
IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest
IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest STUDIO BRESUS STUDIO BRESUS
(3765 pts rianimati) in 12 Ospedali Inglesi
IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest Sopravvivenza nell’Arresto Cardiaco Intraospedaliero (ACC)
REGISTRO NAZIONALE AMERICANO REGISTRO NAZIONALE AMERICANO (Virginia University, USA)
BRESUSBRESUS GwinnutGwinnuttt
PeberdyPeberdy
YearYear 1992 2000 2003
Number of Number of arrestsarrests
3765 1368 14720
% Survival % Survival to to
dischargedischarge
17 17.6 17
SURVIVAL
IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest
IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest Sopravvivenza nell’Arresto Cardiaco Intraospedaliero
(ACC)
EFFICACIA del TEAM di SOCCORSO EFFICACIA del TEAM di SOCCORSO (Anestesiologia e Terapia
Intensiva Pol. “Gemelli” di Roma)
• Few seconds after CAFew seconds after CA, , the subject loose the subject loose consciousness and stop to consciousness and stop to breath.breath.
• 4-6 minutes after CA4-6 minutes after CA, , it’s clearly evident a it’s clearly evident a significative Brain Damage significative Brain Damage
• More fastly is recovery More fastly is recovery cerebral circulation cerebral circulation more probability a complete more probability a complete recovery of Cerebral Function recovery of Cerebral Function
• 90 % of CA90 % of CA are completely are completely worked out if defibrillation is worked out if defibrillation is applied until 2 minutes applied until 2 minutes
SURVIVAL is Time-dependent SURVIVAL is Time-dependent
IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest
IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest Sopravvivenza nell’Arresto Cardiaco Intraospedaliero
(ACC)
AECD in pts MONITORIZZATI AECD in pts MONITORIZZATI (Istituto di Coracao – Università di
Sao Paulo, Brazil)
IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest Sopravvivenza nell’Arresto Cardiaco Intraospedaliero
(ACC)
Programma Defibrillazione Intra-Programma Defibrillazione Intra-Ospedaliera Ospedaliera PERSONALE NON PERSONALE NON
RICOVERATO RICOVERATO (Tufts – New England Medical Center Boston, USA)
IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest SINTESI DI CONCETTISINTESI DI CONCETTI
IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest Sopravvivenza nell’Arresto Cardiaco Intraospedaliero
(ACC)
Utilizzo DAEs Intra-Osp. 1Utilizzo DAEs Intra-Osp. 1stst responders responders (Cardiologia –
Università di Bochum, Germania)
IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest Sopravvivenza nell’Arresto Cardiaco Intraospedaliero
(ACC)
Staff infermieristico con AEDs in UWA Staff infermieristico con AEDs in UWA (Ospedale di Lienz,
Austria; 3 yrs sperimentazione)
Schein RMH. Chest ’90; Franklin C. Crit Care Med ‘94Smith AF. Resuscitation 1998; Hodgetts TJ. Resuscitation ’02
• 50-80% have “warning” signs
• 66% potentially avoidable
• 85% pts recovery in Medical or Surgical Division (Unmonitored Ward
Areas – UWA), die for Sudden Death
• Less then 10% pts recovery in Intensive Care Unit (ICU) die for Sudden Death
IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest
• Cardiac Arrest usually is a predictable event NOT caused by primary Cardiac Disease.
• CA follows a period of slow and progressive deterioration (unrecognized or inadequately treated Hypoxemia and Hypotension).
• Rhythm is usually Asystole or PEA
• Chance of survival is extremely poor.
Unmonitored Ward Areas Unmonitored Ward Areas (UWA) (UWA)
IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest
OBJECTIVES
• Identified CA. • Calling Help. • Start CPR (e.g. Mayo)• If appropriate start
with Defibrillation whithin 3’ from loose of consciousness
IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest
END POINT mortality is correct ?END POINT mortality is correct ?
Cardiac Arrest
Complete recovery
Intervention
Brain Damage, kidney Brain Damage, kidney failurefailure
DEATH
Basic
Life
Support
T
I
M
E
IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest
Defibrillazione Elettrica Precoce (DP)Defibrillazione Elettrica Precoce (DP)IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest
The Clinical Staff IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest
IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest
IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest
IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest
IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest
The ‘Swiss cheese’ model of organizational accidents
Some holes dueTo active failures
Other holes due tolatent conditions
Successive layers of defences
Hazards
Losses
It takes an average of 4.5 errors in the system for a medical accident to result Modified from James
Reason, 1991.
N= 78Hodgetts TJ. Resuscitation ‘02
Delay in the Diagnosis 77%Error in the Diagnosis 58%Nurse delay informing MD 35%Delayed response of MD Staff 29%Bad evaluation of altered analisys 58%Deficiencies in Acute Care 100%Failure to interpret X-rays 24%
Reasons for avoidable Reasons for avoidable CACA
IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest
• Pts deterioration is displayed with Common signs (LUNGS, HEART or BRAIN systems)
Recognition of ‘at-risk’ or critically ill pts
• Physiological parameters are monitoring and measured less frequently than desirable.
• Monitoring HR, BP, RR may predict CP arrest.
IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest Unmonitored Ward Areas Unmonitored Ward Areas
(UWA) (UWA) Delay in DiagnosisDelay in Diagnosis
• Significant effects on pt outcome.
• Pts discharged from ICU to GENERAL WARDS during the night have an increased risk of in-hospital death compared to those discharged during the day and those discharged to HIGH-DEPENDENCY UNITS. • Higher NURSE-Pt Staffing RATIOS are also associated with a reduction in CA rates, as well as rates
of PNEUMONIA, SHOCK and DEATH.
Hospital Process
Deficiencies in Acute Deficiencies in Acute CareCare
IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest
• Abnormalities of the A.B.C.
Deficiencies in Acute Deficiencies in Acute CareCare
• MD and Nursing staff with poor acute-care knowledge and skills, with lack of confidence when dealing with problems.
• Incorrect use of O2 therapy and failure to monitor pts
Schein RMH. Chest ’90; Franklin C. Crit Care Med ‘94Smith AF. Resuscitation ’98; Hodgetts TJ. Resuscitation ‘02
IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest
CPR Quality during CA
• Chest compressions were not delivered adequately and compressions were too shallow
• Quality of multiple CPR parameters was inconsistent and often did not meet published guidelines.
Abella BS, Quality of CPR, During In-Hospital Cardiac Arrest. JAMA, ’05
IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest Deficiencies in Acute Deficiencies in Acute CareCare
Hodgetts TJ. Resuscitation ‘02
• Inadequate means (ie defibrillator)• Presence of architectural barriers• Presence of institutional barriers• AED often available in specific divisions• AED often useless for technical reason
(lack of experiences)• Missing of dedicated ‘Emergency Team’• Lengthy delay in CPR
Defibrillation in Italian Hospital Defibrillation in Italian Hospital occurs ‘OFTEN’ very late occurs ‘OFTEN’ very late
Reasons for avoidable CA
Which is the RIGHT way ???Which is the RIGHT way ???
UTIC
Cardiochirurgi
a
Medicina Generale
Rianimazione Generale
Chirurgia Generale
PS
Sale
Operatorie Medicina d’ Urgenza
SERVICE
Educational Organizational
aspects
RESCUE Services • ~ 575 beds• ~ 350 MD• ~ 800 staff Nurses• Complex ‘case mix’
of patients
IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest
Piano Sanitario Emergenza/UrgenzaPiano Sanitario Emergenza/Urgenza OBIETTIVIOBIETTIVI
Hospital staff should provide a resuscitation service that
exceeds what is available in their local airport, railway
station etc
System of Training
Evidence Based Medicine (EBM)
IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest
System of TrainingSystem of Training• Who should we teach?
• What do we teach?
• How do we teach it?
• What resources do we use?
• How meaningful is the session?
• How could this teaching be improved?
IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest
Formazione del PersonaleFormazione del PersonaleIInn-H-Hospitalospital C Cardiacardiac A Arrestrrest
What do we teach?
• Introduction to Critical Care course
•Mandatory Skills Update course
• Immediate or Basic Life Support (BLS)
•Advanced (Cardiac) Life Support (ACLS)
•Newborn Life Support Course (NLS)
•Ad hoc sessions
C
O
U
R
S
E
S
IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest
Time from CA to first
defibrillation (n=2748)
ssuurrvviivvaall
From: Swedish Cardiac Arrest Registry
• Survival decrease each m of 10%
IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest
Audit compliance 2000 - 2004
0
20
40
60
80
100
2000 2001 2002 2003 2004
Year
%
• Systematic analysis of ‘Assistential Quality System’• Comparison between ‘Guided lines’ and ‘Real Word’ proposed new Standard Organizative Models • Implementation of ‘Guided Lines’• Verification of ‘outcomes’ over the time
AED’s and survival (AUDIT)
0
10
20
30
40
50
60
70
80
1999 2000 2001 2003
Number of AED's in situ
0
10
20
30
40
50
60
70
80
% S
urv
iva
l
AED's in situ ROSC Discharge Home
Do outcomes correlate with training?
Survival from ward-based VF/VT CA
IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest Modelli di Critical CareModelli di Critical Care
IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest Modelli di Critical CareModelli di Critical Care
IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest Modelli di Critical CareModelli di Critical Care
IIntrahospital ntrahospital AAccessccess D Defibrillation efibrillation CChainhain
Fornire un trattamento immediato all’individuo in
ACC o in pericolo di ACC mediante precoce BLS-D
SCOPOSCOPO
IIntrahospital ntrahospital AAccessccess D Defibrillation efibrillation CChainhain
Applicazione delle Linee Guida del Applicazione delle Linee Guida del soccorso intra-ospedaliero alla realtà soccorso intra-ospedaliero alla realtà
della Struttura Ospedalieradella Struttura Ospedaliera
Conoscere preliminarmenteConoscere preliminarmente
GRAZIE per la cortese Attenzione