رهنمود هایی برای مدیریت زمان مناسب تیم اضطراری در بیمارستان : رویکرد مرکز پزشکی ارتش بروک

Successful outcome following cardiac arrest have been reported in the range of 13–59%. It is well established that the time from the onset of a ventricular arrhythmia to successful defibrillation predicts outcome. Recent out of hospital arrest protocols minimizing time to defibrillation have reported significant improvement in outcomes. The Bethesda conference and American Heart Association (AHA) both set standards for defibrillation time for in hospital codes but do not set standards for other interventions. In February 2000, the Brooke Army Medical Center (BAMC) cardiopulmonary resuscitation committee published time guidelines for the initiation of CPR, emergency team arrival, first defibrillation and first medication. We sought to evaluate resuscitation outcomes before and after this intervention. Methods: Data on each response time was prospectively collected as was etiology for the event, emergency location, patient age, gender, and emergency outcome for the 7 months prior to the guideline introduction and 15 months afterwards. Results: The mean response times (in minutes) for initiation of CPR (1.3 vs. 0.4), emergency team arrival (1.6 vs. 1.2), first defibrillation (7.8 vs. 6.6) and first medication (4.1 vs. 3.8) demonstrated trends toward improvement. Compliance with the time standards also increased (67–91, 85–95, 67–71 and 93–86%, respectively). Emergency survival trended toward improvement (47 vs. 57%) while discharge survival significantly increased from 3 to 24% (P=0.017). Conclusions: Setting time guidelines for Advanced Cardiac Life Support (ACLS) improved initiation of CPR, emergency team arrival, first defibrillation, and first medication administration. These time reductions were accompanied by improved event survival and a statistically improved survival to discharge.

An estimated 370 000–750 000 patients have in-hospital cardiac arrest and undergo attempted resuscitation annually [1]. The causes of cardiac arrest are numerous; by far the most common in adults is ischemic cardiovascular disease [2]. The arrest is usually associated with PEA or asystole with only 16–48% having ventricular tachycardia (VT) or ventricular fibrillation (VF) as the presenting rhythm [3], [5], [15] and [18]. Cardiac resuscitation in adults follows the same “chain of survival” concept whether it occurs in the community or in the hospital. Like emergency medical services (EMS), the hospital emergency team reacts and follows the “chain of survival” [4]. Most hospitals have designated emergency teams that are structured as small EMS units. Several studies have shown that medical centers with trained and designated emergency personal have improved event and discharge survival [5]. Most of the improvement in survival was seen with response times of less than 3 min and return of circulation in less than 3 min. In 1998, the Joint Accreditation Commission on Healthcare Organizations (JCAHO) stated that hospitals should track resuscitation events for quality assurance, but made no recommendations on absolute times to initiation of cardiopulmonary resuscitation (CPR), emergency team response, first defibrillation or first medication administration. The American Heart Association (AHA) and Bethesda Conference on Emergency Cardiac Care recommend that hospitals should aim for a goal of delivering the first shock within 2 min of arrest determination in non-critical care areas [4] and [6]. However, no other reference by the AHA or other governing body states any expected times for these other measures. The Brooke Army Medical Center (BAMC) CPR Committee in February 2000, published time guidelines for initiation of CPR, emergency team arrival, first defibrillation and first medication. The objective of this study was to determine compliance with these published standards and effects on emergency survival as well as survival to discharge.

The AHA, through its ACLS subcommittee and the Emergency Cardiac Care committee, published guidelines for CPR and Emergency Cardiac Care with the most recent update in 2000 [19]. The concept of a “chain of survival” initially put forth as applying to the pre-hospital cardiac arrest victim, applies to the in-hospital arrest as well [12]. Successful resuscitation requires early recognition of cardiopulmonary arrest, early activation of trained responders, early CPR, early defibrillation when indicated, and early advanced life support [13], [14] and [15]. The guidelines, however, do not establish measurable time goals that emergency teams should strive to achieve. Our study evaluated specific response time guidelines to assess adherence to the guidelines and any associated improvement in event and discharge survival. After the publication of the specific time guidelines for each of the major steps in the ACLS protocol, an improvement was documented in compliance with the response times. No changes were made to the emergency team composition, the emergency notification system, or to code cart location or number. In general, all measured events improved after the intervention. The compliance with the new standards was high with overall compliance increasing from 78% pre intervention to 85% post intervention. Explanations for the improvement include enhanced awareness of the importance of early ACLS initiation as well as education of the emergency teams and nursing staff as to the new time guidelines. In addition, awareness of the active “monitoring” of emergency guidelines may have motivated the nurses and the emergency team to ensure a satisfactory report. Similar to the Hawthorne effect, monitoring and reporting of the times helps keep training and performance at a higher level. Unfortunately, this monitoring influences the performance of the emergency team to work better and more efficient, regardless of the time guidelines expected, such that removing the guidelines and looking at times after this we may still see improved times and efficiency since the team now has uniformity and cohesion (similar to the original Hawthorne experiments). This increased awareness of the importance of ROSC may have been responsible for faster response times and, therefore, more rapid ROSC which has been shown to improve survival to discharge [5].