In-hospital cardiac arrest: Is it time for an in-hospital ‘chain of prevention’?

doi:10.1016/j.resuscitation.2010.04.017

Resuscitation

Volume 81, Issue 9, September 2010, Pages 1209-1211

https://doi.org/10.1016/j.resuscitation.2010.04.017 Get rights and content

Abstract

The ‘chain of survival’ has been a useful tool for improving the understanding of, and the quality of the response to, cardiac arrest for many years. In the 2005 European Resuscitation Council Guidelines the importance of recognising critical illness and preventing cardiac arrest was highlighted by their inclusion as the first link in a new four-ring ‘chain of survival’. However, recognising critical illness and preventing cardiac arrest are complex tasks, each requiring the presence of several essential steps to ensure clinical success. This article proposes the adoption of an additional chain for in-hospital settings – a ‘chain of prevention’ – to assist hospitals in structuring their care processes to prevent and detect patient deterioration and cardiac arrest. The five rings of the chain represent ‘staff education’, ‘monitoring’, ‘recognition’, the ‘call for help’ and the ‘response’. It is believed that a ‘chain of prevention’ has the potential to be understood well by hospital clinical staff of all grades, disciplines and specialties, patients, and their families and friends. The chain provides a structure for research to identify the importance of each of the various components of rapid response systems.

Introduction

The ‘chain of survival’ has proven to be useful in improving the understanding of, and the quality of the response to, cardiac arrest, both outside and in hospital.¹ In the 2005 European Resuscitation Council Guidelines the importance of recognising critical illness and preventing cardiac arrest was highlighted by their inclusion as the first link in a new four-ring ‘chain of survival’.² In the in-hospital setting, patient deterioration is often insidious and potentially preventable, with failure of recognition being a frequent problem.3, 4 However, recognising critical illness and preventing cardiac arrest are complex tasks, each requiring the presence of several essential steps to ensure clinical success. Failures have been reported in each of these steps, many resulting in adverse outcomes for patients.3, 4 This article proposes the use of an additional chain for in-hospital settings – a ‘chain of prevention’ – to assist hospitals in structuring their care processes to prevent and detect patient deterioration and cardiac arrest.

Section snippets

The ‘chain of prevention’

The proposed ‘chain of prevention’ (Fig. 1) consists of five rings linked in series. As no chain is stronger than its weakest link, weakness of one or more of the components (rings) of the chain will inevitably result in failure of the whole system. This would be manifest by patient deterioration and cardiac arrest. If the components of the chain are present and strong, the chain will work perfectly, and this should be measurable as a reduction in the number of preventable cardiac arrests. The

A better alternative?

There has been a prior attempt to develop a structure for the components necessary to prevent and respond to deterioration.²³ In June 2005, a publication resulting from the first International Conference on Medical Emergency Teams described the essential characteristics of rapid response systems, using the concept similar to that of the neurological reflex arc.²³ As a minimum, it was suggested that the system should have an afferent limb (for event detection and response triggering) and an

Summary

This short paper proposes the introduction of a five-ringed ‘chain of prevention’ to assist hospitals in structuring their care processes to best prevent and detect patient deterioration and cardiac arrest. The rings represent ‘staff education’, ‘monitoring’, ‘recognition’, the ‘call for help’ and the ‘response’. It is believed that a ‘chain of prevention’ has the potential to be understood well by hospital clinical staff of all grades, disciplines and specialties, patients, and their families

Conflicts of interest statememt

Professor Smith is a member of the Executive Committee of the Resuscitation Council (UK) and contributed to the 2005 European Resuscitation Council Guidelines for Resuscitation. He is the Director of the Acute Life-threatening Events: Recognition and Treatment (ALERT) course, which is run by his employers, Portsmouth Hospitals NHS Trust. His wife hold shares in The Learning Clinic Ltd., which markets an electronic vital signs capturing and charting system (VitalPAC). VitalPAC is a collaborative

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Cited by (119)

Rapid response team activation prior to in-hospital cardiac arrest: Areas for improvements based on a national cohort study
2023, Resuscitation
Rapid response teams (RRTs) are designed to improve the “chain of prevention” of in-hospital cardiac arrest (IHCA). We studied the 30-day survival of patients reviewed by RRTs within 24 hours prior to IHCA, as compared to patients not reviewed by RRTs.
A nationwide cohort study based on the Swedish Registry of Cardiopulmonary Resuscitation, between January 1st, 2014, and December 31st, 2021. An explorative, hypothesis-generating additional in-depth data collection from medical records was performed in a small subgroup of general ward patients reviewed by RRTs.
In all, 12,915 IHCA patients were included. RRT-reviewed patients (n = 2,058) had a lower unadjusted 30-day survival (25% vs 33%, p < 0.001), a propensity score based Odds ratio for 30-day survival of 0.92 (95% Confidence interval 0.90–0.94, p < 0.001) and were more likely to have a respiratory cause of IHCA (22% vs 15%, p < 0.001). In the subgroup (n = 82), respiratory distress was the most common RRT trigger, and 24% of the RRT reviews were delayed. Patient transfer to a higher level of care was associated with a higher 30-day survival rate (20% vs 2%, p < 0.001).
IHCA preceded by RRT review is associated with a lower 30-day survival rate and a greater likelihood of a respiratory cause of cardiac arrest. In the small explorative subgroup, respiratory distress was the most common RRT trigger and delayed RRT activation was frequent. Early detection of respiratory abnormalities and timely interventions may have a potential to improve outcomes in RRT-reviewed patients and prevent further progress into IHCA.
The association between signs of medical distress preceding in-hospital cardiac arrest and 30-day survival – A register-based cohort study
2022, Resuscitation Plus
Identifying signs of medical distress prior to in-hospital cardiac arrest (IHCA) is important to prevent IHCA and improve survival. The primary objective of this study was to investigate the association between signs of medical distress present within 60 minutes prior to cardiac arrest and survival after cardiac arrest.
The register-based cohort study included adult patients (≥18 years) with IHCA in the Swedish Registry of Cardiopulmonary Resuscitation (SRCR) from 2017-01-01 to 2020–07-15. Signs of distress prior to IHCA were defined as the medical signs arrhythmia, pulmonary oedema, hypotension, hypoxia or seizures present within 60 minutes prior to cardiac arrest (pre-arrest signs). Using multivariable logistic regression, the association between these pre-arrest signs and 30-day survival was analysed in both unadjusted and adjusted models. The covariates used were demographics, comorbidities, characteristics and treatment of cardiac arrest.
In total, 8525 patients were included. After adjusting for covariates, patients with arrhythmia had a 58% higher probability of 30-day survival. The adjusted probability of 30-day survival was 41% and 52% lower for patients with hypotension and hypoxia prior to IHCA, respectively. Pulmonary oedema and seizures were not associated with any change in 30-day survival.
Among signs of medical distress prior to in-hospital cardiac arrest, arrhythmia was associated with a higher 30-day survival. Hypotension and hypoxia were associated with lower survival after IHCA. These findings indicate that future research on survival after cardiac arrest should take pre-arrest signs into account as it impacts the prerequisites for survival.
Attempting cardiac arrest prediction using artificial intelligence on vital signs from Electronic Health Records
2022, Smart Health
This work attempts to determine whether it is possible to predict the occurrence of in-hospital Cardiac Arrest (CA) using vital signs routinely recorded in a hospital's Electronic Health Record (EHR) system. The goal is to give caregivers advance notice of the possibility so they can intervene before its occurrence or prepare for immediate response in case it occurs. The work concentrates on three different aspects: which prediction model, which vital signs, and what time window produce the most accurate prediction. A number of experiments were conducted using six artificial intelligence algorithms and vital sign recordings ranging from 1 to 12 h. The work demonstrates that Random Forest produces the best prediction accuracy, reaching higher than 80%. Accuracy improves by more than 10% when prediction is done using vital sign data from the immediately preceding 60 min. Additionally, performance improves by only 3% when the observation range is increased from 1 h to 12 h.
European Resuscitation Council Guidelines 2021: Adult advanced life support
2021, Resuscitation
Update on Cardiopulmonary Resuscitation in Small Animals
2020, Veterinary Clinics of North America - Small Animal Practice
Nurses' cognitive and perceptual bias in the identification of clinical deterioration cues
2020, Australian Critical Care
Citation Excerpt :
Participants who have had previous training were more likely to exhibit no cognitive bias (Table 6). Appropriate response to a situation of clinical deterioration depends on noticing and accurately interpreting clinical cues.5 In the present study, some participants frequently failed to select the appropriate action despite training and experience that should have resulted in a more efficient and effective management of the (simulated) patient's clinical care.
Perception and processing of clinical cues have rarely been investigated in the nursing literature despite their relevance to the early identification and management of clinical deterioration.
This study used a hypovolemic shock scenario from the Feedback Incorporating Review and Simulation Techniques to Act on Clinical Trends (FIRST2ACT) virtual simulation program, equipped with an eye tracker, to investigate cue processing during the management of patient deterioration.
The study revealed that attention deviation distorted interpretation of subsequent cues, causing 63% of participants to exhibit a cognitive bias (heightened sensitivity to specific but noncritical cues) and 65% to exhibit at least one episode of nonfixation on clinically relevant cues. Attention deviation and distorted interpretations of clinical cues will have an impact on patient safety.
The findings are likely to have important implications for understanding error and associated training implications.

View all citing articles on Scopus

^☆: A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2010.04.017.

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Short communicationIn-hospital cardiac arrest: Is it time for an in-hospital ‘chain of prevention’?☆

Abstract

Introduction

Section snippets

The ‘chain of prevention’

A better alternative?

Summary

Conflicts of interest statememt

Resuscitation

Intensive Crit Care Nurs

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

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

Recognising and responding appropriately to early signs of deterioration in hospitalised patients

National confidential enquiry into patient outcomes and death. “an acute problem?”

A prospective before-and-after trial of a medical emergency team

MJA

Short communication
In-hospital cardiac arrest: Is it time for an in-hospital ‘chain of prevention’?☆