CPR Practices Need Resuscitation, Survey Finds

Kathleen Louden

November 13, 2008

November 13, 2008 — Most emergency medicine physicians believe that cardiopulmonary resuscitation (CPR) practices in the United States are not very effective, a new survey from the American College of Emergency Physicians (ACEP) has found.

The results of the survey may not be new to emergency medicine physicians, but they make an important point, ACEP President Nick Jouriles, MD, told Medscape Emergency Medicine in a phone interview.

"There are potentially people not being saved after sudden cardiac arrest who could be saved," Dr. Jouriles said. Despite scientific advances in resuscitation efforts, more needs to be done to improve survival rates in people who have an out-of-hospital cardiac arrest, he said.

More than 95% of patients who have a cardiac arrest die before reaching the hospital, the American Heart Association (AHA) estimates.

The main goal of the survey, which was an online questionnaire and solicited the opinions of ACEP-member emergency medicine physicians, was to find ways to improve emergency care and survival after sudden cardiac arrest.

Survey Findings

Of 1056 survey respondents, 76% reported that the aging population and prevalence of obesity were the greatest patient contributors to the high mortality rate of sudden cardiac arrest.

Respondents also identified strategies that will have "a great deal" or "moderate amount" of impact on improving survival rates in the future. Deemed most important were increased use of CPR among citizen bystanders (88% of respondents), faster patient-to-physician time (77%), and more widespread local collection and sharing of outcomes data (73%). Most physicians also highly rated technologies, such as real-time feedback on chest compressions during CPR (65%).

Only 55% of surveyed emergency physicians thought that reduction in emergency department crowding would help improve survival rates.

Respondents noted barriers to immediate CPR by bystanders, especially reluctance to give breaths. However, 93% commented that the AHA's new guidelines recommending chest compressions only ("hands-only CPR"), will likely encourage bystanders to administer CPR. More community CPR training could overcome some barriers to bystander intervention, but 28% of surveyed emergency physicians said no one in their community was responsible for promoting CPR training.

Furthermore, 20% of respondents replied that no one in their community collects data on resuscitation outcomes, and 13% answered that their community has no process in place for sharing outcomes data.

The survey response rate was 18% (1,056 of 5,931), and 81% of the respondents work in urban settings. The study has a margin of error no greater than ±3.1 percentage points at the 95% level of confidence, according to Saperstein Associates Inc, an independent opinion research company that conducted the survey for ACEP.

Cardiac Arrest a Community Problem

An ACEP member who was not involved in developing the survey, Arthur B. Sanders, MD, told Medscape Emergency Medicine that the results reinforce the need for emergency physicians to partner with government and community organizations.

"Out-of-hospital sudden cardiac arrest is a community systems problem," said Dr. Sanders, a professor of emergency medicine at the University of Arizona Health Sciences Center in Tucson. "It involves a whole spectrum of care, from bystander CPR, to calling 911 and having paramedics get there as soon as possible, to postresuscitation hospital care."

Physicians should encourage their patients and community members to learn and use hands-only CPR, he recommended. Also, he said emergency physicians should work with emergency medical systems to learn their community's barriers to CPR and cardiac arrest survival rates.

Reported survival rates after cardiac arrest vary widely across the United States — from 3% to 16.3% — according to a report in the September 24 issue of The Journal of the American Medical Association.

"Traditionally, people have been pessimistic about the chances of survival after cardiac arrest, but the science of resuscitation shows we can make a difference [in lowering mortality rates]," Dr. Sanders said. "If we make changes and have clinical practice catch up with the science, we can have an impact."

Bystander CPR is important but just one component of improving survival rates, Dr. Sanders added. Other important strategies and technologies include automatic external defibrillators (AEDs) and therapeutic hypothermia after cardiac arrest. The survey did not directly address the latter, but 73% of respondents said they consider AEDs to be the most important technological advance in treating sudden cardiac arrest.

"A Treatable Disease"

Another emergency physician who was not involved with the ACEP survey, Lance Becker, MD, agreed with the survey conclusions.

"Evidence is that cardiac arrest is a treatable disease, and we have yet to optimize treatment for every patient," Dr. Becker, director of the University of Pennsylvania's Center for Resuscitation Science in Philadelphia, told Medscape Emergency Medicine.

A member of the AHA Emergency Cardiovascular Care Committee, Dr. Becker said the AHA is working to improve resuscitation practices. Efforts include encouraging reporting of out-of-hospital cardiac arrest, beginning to update its CPR guidelines for release in 2010, and developing a personal learning program (CPR Anytime) to simplify CPR education.

ZOLL Medical Corp in Chelmsford, Massachusetts, funded the survey. Dr. Jouriles and Dr. Sanders reported no relevant financial relationships. Dr. Becker disclosed that he is a paid consultant to Philips Healthcare and has intellectual property in patents on cooling and resuscitation science. He also receives grant support from Philips, Laerdal Medical, BeneChill Inc, and Cardiac Science Corp.

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