A Statement for Healthcare Professionals From the American Heart Association Emergency Cardiac Care Committee and the Advanced Cardiac Life Support, Basic Life Support, Pediatric Resuscitation, and Program Administration Subcommittees
Richard O. Cummins, MD; Arthur Sanders, MD; Elizabeth Mancini, RN; Mary Fran Hazinski, MSN, RN
The Emergency Cardiac Care (ECC) Committee of the American Heart Association first published guidelines for cardiopulmonary resuscitation (CPR) and ECC in 1974.1 Updated in 1980, 1986, and 1992, the AHA guidelines are now recognized as the world's most authoritative resuscitation guidelines.2-4 To implement these guidelines, however, hospitals need to establish a systems approach to in-hospital resuscitation rather than depend on the skills of individual professionals. The success and acceptance of the out-of-hospital Utstein-style recommendations5 led the AHA to help develop specific recommendations for documenting in-hospital resuscitation. The Utstein-style recommendations for uniform reporting of in-hospital resuscitations present important recommendations for all hospital facilities.6 With publication of these recommendations, members of the ECC Committee recognized the need to summarize the major actions that enable a hospital to fulfill the resuscitation recommendations.
CPR is one of the few interventions that requires an order to not be administered. Resuscitation efforts, however, are not appropriate for all hospital patients. When indicated, healthcare providers discuss with patients, families, and surrogate decision-makers their options and preferences for resuscitation. Hospitals have in place clear policies that address medical futility, patient self-determination, and do-not-attempt-resuscitation orders.
In-Hospital 'Chain of Survival'
The chain of survival, first conceptualized for out-of-hospital sudden cardiac arrest,7 applies to in-hospital arrest as well.8 Successful resuscitation requires early recognition of cardiopulmonary arrest, early activation of trained responders, early CPR, early defibrillation when indicated, and early advanced life support (ALS). The hospital creates a coordinated, multidisciplinary approach to treating patients with a cardiopulmonary emergency. To establish this approach, the hospital provides written policies and procedures that address and facilitate the following recommendations.
Basic Life Support
All hospital staff who may need to respond to a sudden cardiopulmonary emergency are trained in basic life support (BLS) and, when appropriate, in the use of automated external defibrillators (AEDs). Such AED training is considered a basic skill for healthcare providers, particularly when professionals trained in ALS are not immediately available. Staff members maintain their CPR and AED skills with regular refresher training. Instruction in CPR and use of an AED follow the AHA guidelines. Barrier and noninvasive airway devices are available for immediate use in all patients.
Hospitals are able to identify and shock patients in ventricular fibrillation or pulseless ventricular tachycardia within the shortest possible interval. Cardiac arrest response teams, because they bring defibrillators from only a few locations in a hospital, may not always achieve the goal of early defibrillation. To reduce the time from collapse to defibrillation, defibrillators, including AEDs and conventional defibrillators with shock advisory capabilities, are readily available in strategic areas throughout the facility. Hospitals extend training and authorization to use conventional, automated, and shock advisory defibrillators to all appropriate nonphysician staff, including nurses, respiratory therapists, and physician assistants.9
Advanced Cardiac Life Support
Hospitals have a multidisciplinary response team that includes personnel trained and authorized to provide endotracheal intubation, intravenous medications, transcutaneous pacing, and rhythm and 12-lead electrocardiogram interpretation. In some settings this advanced cardiac life support (ACLS) response appropriately may be delivered by rapidly responding emergency medical system providers. Hospitals have available personnel with these advanced skills, in a timely manner, not only to patients who occupy a hospital bed but for all patients, including patients in outpatient clinics, diagnostic services areas, satellite facilities, and public response areas such as cafeterias and waiting rooms. Some patient care areas, such as the emergency department and critical care units, may not require special response teams if the regular staff members provide these skills.
To ensure common treatment protocols and well-organized resuscitation efforts, healthcare professionals with a reasonable expectation of involvement in resuscitation efforts complete provider, review, or advanced provider courses in the areas of ACLS or pediatric ALS every 2 to 3 years. Treatment protocols adhere to AHA training and guidelines for pediatric resuscitation and adult ACLS. Depending on a facility's goals and types of patients, not all ALS interventions, such as endotracheal intubation and intravenous medications, are required. As a minimum, however, hospitals provide all appropriate immediate-response healthcare personnel with training in BLS and use of AEDs.
All resuscitation efforts are documented accurately by recording specific treatment interventions, event variables, and outcome variables. Resuscitation teams designate a specific recorder to provide event documentation. The in-hospital Utstein guidelines provide a standard reporting form for in-hospital CPR.
Quality Assurance and Quality Improvement
Hospitals establish an interdisciplinary committee whose members have expertise in CPR to assess the quality and efficacy of the facility's resuscitation efforts. To help with this assessment, the in-hospital Utstein guidelines recommend a set of uniform data that includes patient variables, event variables, outcome variables, and hospital variables to collect and review. In addition, the Utstein guidelines recommend gold standard process indicators (eg, time to defibrillation) and several outcome indicators (eg, percent of patients discharged from the hospital alive) to be assessed at regular intervals. Hospitals incorporate these indicators into a program for quality monitoring and continuous quality improvement. Critical care units are not excluded from this recommendation. This quality-improvement program provides feedback, education, and training to resuscitation personnel and staff.
Hospital administrators ensure the availability of appropriate equipment and provide the resources to support the training, education, quality monitoring, and quality-assurance activities required to create a strong chain of survival.
Interhospital and Intrahospital Comparisons
The in-hospital Utstein guidelines provide a detailed checklist of information to include in reports on in-hospital resuscitation and provide a reporting template to summarize a facility's resuscitation experience. Such a uniform reporting style will support both intrahospital and interhospital comparisons of resuscitation activities. The goals of these comparisons are quality improvement for individual hospitals and better understanding of what works and does not work in hospital resuscitation.
- Standards for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). JAMA. 1974;227(suppl):831-868.
- Standards and guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). JAMA. 1980;244:453-509.
- Standards and guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). JAMA. 1986;255:2905-2989.
- Emergency Cardiac Care Committee and Subcommittees, American Heart Association. Guidelines for cardiopulmonary resuscitation and emergency cardiac care. JAMA. 1992;268:2171-2295.
- Cummins RO, Chamberlain DA, Abramson NS, Allen M, Baskett PJ, Becker L, Bossaert L, Delooz HH, Dick WF, Eisenberg MS, Evans TR, Holmberg S, Kerber R, Mullie A, Ornato JP, Sandoe E, Skulberg A, Tunstall-Pedoe H, Swanson R, Thies WH. Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the Utstein style. A statement for health professionals from a task force of the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, and the Australian Resuscitation Council. Circulation. 1991;84:960-975.
- Cummins RO, Chamberlain D, Hazinski MF, Nadkarni V, Kloeck W, Kramer E, Becker L, Robertson C, Koster R, Zaritsky A, Bossaert L, Ornato JP, Callanan V, Allen M, Steen P, Connolly B, Sanders A, Idris A, Cobbe S. Recommended guidelines for reviewing, reporting, and conducting research on in-hospital resuscitation: the in-hospital 'Utstein style.' A statement for healthcare professionals from the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, the Australian Resuscitation Council, and the Resuscitation Councils of Southern Africa. Circulation. 1997;95:2213-2239.
- Cummins RO, Ornato JP, Thies W, Pepe PE. Improving survival from sudden cardiac arrest: the 'chain of survival' concept. A statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Association. Circulation. 1991;83:1832-1847.
- Kaye W, Mancini ME, Giuliano KK, Richards N, Nagid DM, Marler CA, Sawyer-Silva S. Strengthening the in-hospital chain of survival with rapid defibrillation by first responders using automated external defibrillators: training and retention issues. Ann Emerg Med. 1995;25:163-168.
- Kaye W, Mancini ME, Richards N. Organizing and implementing a hospital-wide first-responder automated external defibrillation program: strengthening the in-hospital chain of survival. Resuscitation. 1995;30:151-156.
"In-Hospital Resuscitation" was approved by the American Heart Association Science Advisory and Coordinating Committee in December 1996. It is being copublished in Circulation, Annals of Emergency Medicine, Heart, European Journal of Anaesthesiology, JEUR (European Journal of Emergencies), Resuscitation, Intensivmedizin und Notfallmedizin, Academic Emergency Medicine, Notfallmedizin, and European Journal of Emergency Medicine.
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