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Third of inpatient cardiac arrests preventable, says report

A third of inpatient cardiac arrests and subsequent resuscitation attempts can be prevented by improved practice such as better recognition of deteriorating patients, an investigation has found.

Improved assessment on admission, and recognition and response when acutely ill patients deteriorate could prevent cardiac arrest in many cases, according to the National Confidential Enquiry into Patient Outcome and Death.

NCEPOD’s latest report Time to Intervene?, which was published today, called for improvements in recognising and responding to patient deterioration. It also called for better decision-making around what care was likely to benefit acutely unwell patients, especially do not attempt cardiopulmonary resuscitation decisions.

Nearly 600 hospitals returned data to NCEPOD as part of the review. Its advisors looked at case notes from 526 patients who had suffered a cardiac arrest in hospital and underwent a resuscitation attempt.

The report found patient assessment on admission was deficient in 47% of cases, and there were warning signs that the patient was deteriorating and might arrest in 75% of cases.

However, the warning signs were not recognised in 35% of those patients, not acted on in 56% and not communicated to senior doctors in 55% of cases.

Report author and NCEPOD lead clinical co-ordinator George Findlay said: “The recognition of acute illness, response to it and escalation of concerns to consultants when patients are deteriorating is not happening consistently across hospitals.”

In addition, the report found that when a DNACPR decision had been made, it was not always followed and 52 patients underwent CPR despite their explicit DNACPR decision.

Dr Findlay said CPR was the current “default” decision clinicians took when no alternative care pathway existed, but added: “This does not excuse lack of clarity around the role of CPR for individual patients”.

“CPR status must be considered and recorded for all acute admissions, if not on initial admission, then at the first consultant review,” he said.

For example, in one case, the report said nursing staff had expressed concern about a very elderly, acutely ill patient with severe dementia. The patient had no CPR plan and was dying.

When the patient went into cardiac arrest, CPR was performed for 10 minutes until a senior doctor halted the procedure. All the patient’s reviews had been carried out by junior doctors. NCEPOD advisors concluded this “was an undignified end of life that need not have happened”.

Readers' comments (2)

  • Radio 4's Today program was running this report as its main story earlier today, and the bit it picked up on was that for 52 patients resuscitation had been attempted against their expressed refusals.

    '52 patients underwent CPR despite their explicit DNACPR decision' with, presumably, 'their' meaning 'the patient's'. I have not yet read the report, but the interviewer on Today asked two doctors, including the reports author, 'Can you (the patient) refuse resuscitation in ALL circumstances ?' and he did not very clear answers to his question, from either doctor.

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  • michael stone

    Re the above NT piece:

    'In addition, the report found that when a DNACPR decision had been made, it was not always followed and 52 patients underwent CPR despite their explicit DNACPR decision'

    and the comment by the previous poster, I listened to R4 and read the reports in The Times and The Guardian: all three said, one way or another, that '52 patients had undergone CPR against their explicit wishes'.

    Actually, that is not what the report states. It only says that 52 patients had resuscitation attempted despite a recorded DNACPR Instruction already being extant.

    The Foreword (not the Introduction) to the full version of the report, is a very interesting and thought-provoking read, and I recommend the foreword to anyone who is interested in the legal aspects of CPR decision-making.

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