Where to Have a Cardiac Arrest?
Answer: not in the hospital
3 Jan 2008 in Regulatory Science, Information Quality, People & Institutions
New York Times reporter Denise Grady previews a research report due to be published in today's New England Journal of Medicine that says many hospitals do not respond quickly enough to cardiac arrest. Leslie Saxon, who wrote an accompanying editorial, delivered the money quote: “You’re better off having your arrest at Nordstrom, where I’m standing right now, because there are 15 people around me.”
We haven't yet reviewed the article and editorial (neither of which is available to nonsubscribers), but two especially important insights immediately arise.
The first is that hospitals lack the automatic electronic defibrilators that lay people can safely use to administer lifesaving electrical shocks. AEDs increasingly can be found in public places, they can be purchased by anyone over the internet, and they may be required by the Occupational Safety and Health Administration under the "General Duty Clause." But hospital patients are not hospital employees, so even if hospitals are covered their customers are not. (This contrasts sharply with the customers of other public service providers, such as federal facilities.
For patients, hospitals use more complex equipment that requires more specialized training that few hospital employees have. Grady writes:
The second insight is that these response-time data may be seriously biased to understate the actual amount of delay. For all cases in which a patient suffering cardiac arrest was not connected to a heart monitor, the precise moment of the event is likely to be unknown, and as a rule, some time prior to when it was noticed and the "clock" started. (If onset of cardiac arrest is estimated rather than measured, it is subject to a host of statistical complexities associated with estimation.)In the real world, doctors and nurses do not always run fast enough. Expert guidelines say the shock should be given within two minutes after the heart stops, but the study found that it took longer in 30 percent of the cases.
The consequences were striking. When the defibrillation was delayed, only 22.2 percent of patients survived long enough to be discharged from the hospital, as opposed to 39.3 percent when the shock was given on time.
...
Delays were more likely in patients whose hearts stopped at night or on the weekend, who were admitted for noncardiac illnesses, in hospitals with fewer than 250 beds and in units without heart monitors.
Study authors Paul Chan and colleagues say more research is needed to identify best practices in hospitals with high success rates so that this knowledge can be transferred. The likelihood that this effort will succeed seems remote. Hospital anonymity was essential to support their study, and malpractice liability awaits both hospitals and doctors that admit to subpar performance.
In hospitals as a whole, delays may be even more frequent than is suggested by the 30 percent figure in the hospitals studied, said the lead author, Dr. Paul S. Chan of St. Luke’s Mid America Heart Institute in Kansas City, Mo., and the University of Michigan. Dr. Chan said that because all the hospitals in the study had joined a national registry on cardiac arrest, meaning that they were already putting special efforts into trying to meet resuscitation guidelines, they probably performed better than average.Hospitals are challenging environments in which to collect high quality data under the best of circumstances, cardiac arrest not being one of them. Hospitals and doctors whose performance is below average have strong incentives to misreport the onset of cardiac arrest to prevent researchers like Chan from discovering the true amount of delay.
The registry, created by the American Heart Association, keeps the data on which the study was based anonymous, Dr. Chan said, so it not possible to identify hospitals that performed especially well or poorly.
Occupational Safety and Health Act "General Duty Clause" and AEDs
Section 5(a)(1) of the OSH Act, often referred to as the General Duty Clause, requires employers to "furnish to each of his employees employment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees". Section 5(a)(2) requires employers to "comply with occupational safety and health standards promulgated under this Act".
