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Surviving Cardiac Arrest

Hospitalized patients' survival odds have improved 12 percent since 2001, study says.

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The news is good for patients hospitalized after cardiac arrest. Survival odds are statistically much better than even 10 years ago.

According to a Mayo Clinic study, the death rate among U.S. residents hospitalized after a cardiac arrest stood at just under 58 percent in 2008. That number is down from nearly 70 percent in 2001. Findings are based on a national discharge database of 1.2 million people hospitalized for post-cardiac arrest care.

"Anecdotally, our survival rates are improving at least that much," attested Noelle Riehl, BSN, RN, EMTIC, STEMI coordinator at Sanford Health in Bismarck, ND. "I think there's increased knowledge and education on both the part of practitioners and patients. Early recognition and rapid interventions are increasing our standard of care for the better."

AED Access

There's little question the Public Access to Automated External Defibrillator Act of 2000 has factored significantly into longer life spans for patients who have undergone cardiac arrest.

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The issue is very personal to Sandy Mikulich, MSN, FNP, BC, CHFN, Advocate South Suburban Hospital in Hazel Crest, IL. After her husband had open-heart surgery last year, she participated in a massive fund-raising effort to acquire an AED for her church. Through her work as lead nurse in her facility's heart failure clinic, Mikulih is also strongly lobbying for AEDs in the local schools.

"What's most important is that bystanders know how to use it," she said, echoing the guidelines from the American Heart Association.

Whether or not laypeople actually undergo training on operating the AED, its presence seems to be making a difference.

"In our area, bystanders are very willing to use the AEDs," confirmed Riehl. "The step-by-step instructions are very simplistic and people are comfortable in the knowledge that a machine interprets and understands heart rhythms."

Therapeutic Hypothermia

AEDs help stabilize patients until they reach a hospital. Traditionally, practitioners have lamented a missing link in the care of patients after resuscitation.

Induction of therapeutic hypothermia for patients who have undergone cardiac arrest became the standard of care in recent years for appropriate patients, thus minimizing these concerns. The selection of patients is still being debated, according to Kristine Peterson, MS, RN, CCRN, CCNS, Aspirus Wausau Hospital, Wausau, WI, and past president of the American Association of Critical-Care Nurses.

Though the treatment has been around, in some form, since the days of Hippocrates, it's only recently become universally acknowledged as having a major impact on long-term neurologically intact survival after a full cardiac arrest.

With therapeutic hypothermia, clinicians use ice or a cooling device to drop a person's body temperature several degrees, from a normal 98.6 degrees to between 89.6 and 93.2. A day later, clinicians begin re-warming the body.

"We've had good patient outcomes using therapeutic hypothermia after cardiac arrest from ventricular tachycardia and/or fibrillation," said Peterson. "It's not clear whether we can have similar outcomes when other rhythms, such as asystole or pulseless electrical activity (also called PEA), are involved."

Further challenging patient selection is the reality that the information upon arrival in the emergency department doesn't always help nurses identify the causal rhythm, she said.

Interestingly, the rising survival rate in the Mayo Clinic study and the adoption of therapeutic hypothermia in this country occurred right around the same time, strengthening the link between the two.

CPR Changes

The timing is notable in another factor as well. In 2008, the American Heart Association changed its recommendations and endorsed hand-only CPR. The association recommended bystanders simply press on the chest to the beat of the Bee Gee's song "Stayin' Alive" to keep a patient alive.

The rationale behind the recommendation was that people are more likely to attempt resuscitation if they don't have to perform rescue breaths. At the time, various studies concluded that hands-only CPR was equally effective.

Many in the healthcare community still aren't sold on the hands-only CPR endorsement.

"More patients benefit from bystander CPR today," acknowledged Peterson. "It's unclear whether this is because of the hands-only modification or more consumers with training."

Earlier Angioplasty Initiation

Every facility touts its door-to-vessel open time or initial presentation-to-vessel open time. Early angioplasty (also called percutaneous coronary intervention or PCI) is generally the treatment of choice when it's available. In centers where PCI can't be performed, protocols guide the healthcare team to arrange for immediate transfer. Some protocols include facilitated PCI in which a thrombolytic agent is administered while a patient is being prepared for transfer. Most PCI centers record two time intervals: door-to-vessel-open time and initial-presentation-to-vessel open time. Both of those times have steadily decreased over the past 5 years.

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Initial-presentation-to-vessel-open time is the elapsed time from a patient's arrival in ED to the time the PCI center (whether that is in the same hospital or a different location) has the affected coronary vessel open. The time includes initial evaluation, ECG and transport to where the PCI will be done. Door-to-vessel-open time measures from when a patient arrived at the door of the PCI center to when the affected coronary vessel has been opened.

Increased emphasis on attaining the American Heart Association's and American College of Cardiology's gold standard of 90-minute door-to-vessel-open time has paid off, with many facilities meeting the standard and a growing number reporting 60-minute time frames.

Among those facilities is Sanford Health. According to Riehl, patients with a STEMI type heart attack are diagnosed, transferred to the cath lab and treated at rates higher than ever. The facility recently qualified for the American Heart Association's Mission: Lifeline Bronze Performance Award for attaining the desired timeframes.

"We've cut our time in half," Riehl boasted. "I see so many great success stories."

Robin Hocevar is senior regional editor at ADVANCE.

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