Physician Compliance With Advanced Cardiac Life Support Guidelines

doi:10.1016/S0196-0644(95)70355-1

Annals of Emergency Medicine

Volume 25, Issue 1, January 1995, Pages 52-57

Presented at the Society for Academic Emergency Medicine Annual Meeting in Toronto, Canada, May 1992.

https://doi.org/10.1016/S0196-0644(95)70355-1 Get rights and content

Abstract

Study objective: To determine compliance with advanced cardiac life support (ACLS) guidelines among ACLS-certified and non-ACLS-certified physicians.

Design: Retrospective review of consecutive cardiac arrests between July 1989 and June 1990, including assessment of the resuscitation leaders' ACLS certification. Setting and participants: All nontraumatic prehospital and hospital cardiac arrests in a rural university hospital. Results: Two hundred seven arrests were studied for a total of 436 rhythms with a maximum of 4 rhythms per arrest. There were 78 resuscitations (36.3%) with return of spontaneous circulation. A total of 2,038 interventions were recorded for all rhythms, with 1,320 (64.8%) compliant with ACLS guidelines compared with 718 (35.2%) deviations. Synchronized cardioversion, calcium chloride and sodium bicarbonate were used with significantly higher noncompliance. Ventricular fibrillation had significantly higher mean rhythm deviation scores, whereas scores were significantly lower for sinus rhythm and stable bradycardia (P<.003). Resuscitations led by ACLS-certified and nonACLS-certified physicians were compared for mean number of deviations per resuscitation attempt, and no differences were found. Resuscitations with return of spontaneous circulation were compared with unsuccessful resuscitations, and there was no difference between groups in controlled deviation scores. No differences could be found between ACLS-certified and nonACLS-certified physicians for return of spontaneous circulation and survival-to-discharge rates. Conclusion: Despite biannual ACLS training of all medical residents and ICU nurses, noncompliance with ACLS guidelines was noted in 35.2% of treatments. We found no correlation between ACLS certification and ACLS guideline compliance. [Cline DM, Welch KJ, Cline LS, Brown CK: Physician compliance with advanced cardiac life support guidelines.Ann Emerg Med January 1995;25:52-57.]

Section snippets

INTRODUCTION

Cardiovascular disease is the leading cause of death in the United States, with sudden cardiac death accounting for the majority of fatalities.1, 2, 3, 4 Survival is dependent on prompt initiation of CPR and emergency cardiac care (ECC).5, 6, 7, 8, 9, 10, 11, 12 Since the introduction of a standardized course in advanced cardiac life support (ACLS) by the American Heart Association (AHA) in 1974,13, 14 the treatment guidelines have become widely accepted as the standard of ECC.15, 16 ACLS

MATERIALS AND METHODS

Prehospital and hospital records of adult patients who had nontraumatic cardiopulmonary arrest between July 1989 and June 1990 were reviewed retrospectively to determine compliance with current ACLS guidelines. The study group consisted of patients presenting to the ED with prehospital cardiopulmonary arrest as well as ED patients and inpatients who suffered a cardiopulmonary arrest at Pitt County Memorial Hospital (PCMH), Greenville, North Carolina. All cases were included when a "code blue"

RESULTS

Two hundred seven arrests were studied for a total of 436 rhythms (mean, 2.11 rhythms per arrest); 207 initial rhythms, 122 second rhythms, 73 third rhythms, and 34 fourth rhythms were analyzed. Asystole, VF, VT, and bradycardia were the most commonly encountered rhythms, as illustrated in the Table. The rhythms are separated by order of occurrence. There were 78 (36.3%) successful resuscitations based on ROSC.

Table. Rhythm frequency and order of occurrence.

Order of Occurrence
Rhythm	First (n=207)

DISCUSSION

In this rural, tertiary-care center setting, we did not see a difference in physician ACLS compliance based on ACLS certification. It should be noted that in our hospital, one ACLS-certified nurse, and often two, attend every cardiac arrest resuscitation attempt. In addition, our cardiopulmonary technicians, who are authorized to intubate under standing orders, are certified in ACLS. These individuals may therefore influence non-ACLS-certified physicians attending resuscitations and the

CONCLUSION

Despite biannual ACLS training of all residents and ICU nurses, noncompliance with ACLS guidelines totaled 35.2% of all cardiac arrest treatments at our hospital. We found that non-ACLS-certified physicians do not deviate from ACLS protocols more than ACLS-certified physicians in this tertiary care center environment. Successful resuscitations include fewer treatments than unsuccessful resuscitations and have fewer total ACLS deviations; however, successful arrests do not have fewer deviations

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Cited by (39)

The association between ACLS guideline deviations and outcomes from in-hospital cardiac arrest
2020, Resuscitation
Citation Excerpt :
ACLS guidelines summarize the best available evidence for resuscitation efforts yet only few studies have assessed whether compliance to the guidelines improves outcomes. Cline et al. initially identified that compliance to the ACLS algorithm was low and deviations did not vary between trained ACLS providers and non-ACLS trained providers.9 McEvoy and colleagues performed a retrospective analysis investigating the effect of protocol deviations on ROSC but failed to include to survival to discharge as an outcome.11
In hospital cardiac arrests occur at a rate of 1–5 per 1000 admissions and are associated with significant morbidity and mortality. We aimed to investigate the association between deviations from ACLS protocol and patient outcomes.
This retrospective review was conducted at a single academic medical center. Data was collected on patients who suffered cardiac arrest from December 2015-November 2019. Our primary endpoint was return of spontaneous circulation. Secondary endpoints included survival to discharge and discharge with favorable neurological outcomes.
108 patients were included, 74 obtained return of spontaneous circulation, and 23 survived to discharge. The median number of deviations from the ACLS protocol per event in ROSC group was 1 (IQR 0–3) compared to 6.5 (IQR 4–12) in non-ROSC group (p < .0001). The probability of obtaining ROSC was 96% with 0−2 deviations per event, 59% with 2–5 deviations per event, and 11% with greater than 6 deviations per event (p < .0001). The median deviation per event in patients who survived to discharge was 0 (IQR 0–1) vs. 3 (IQR 1–6, p < .0001) in those who did not. Lastly, survival to discharge with a favorable neurological outcome may be associated we less deviations per event (p < .006).
Our findings highlight the importance of adherence to the ACLS protocol. We found that deviations from the algorithm are associated with decreased rates of ROSC and survival to discharge. Additionally, higher rates of protocol deviations may be associated with higher rates of neurological impairments after cardiac arrest.
Adherence to advanced cardiovascular life support (ACLS) guidelines during in-hospital cardiac arrest is associated with improved outcomes
2018, Resuscitation
Citation Excerpt :
Three studies have previously explored this association. Cline et al. [10] reviewed 207 in-hospital cardiac arrests and found no significant difference between ACLS-certified and non-certified physicians in adherence to ACLS guidelines. Ornato et al. [11] explored the effect of resuscitation system errors as reported to the National Registry of Cardiopulmonary Resuscitation in pulseless in-hospital cardiac arrests from 549 hospitals.
Identifying modifiable factors associated with survival following in-hospital cardiac arrest is crucial. The purpose of this study was to determine the extent to which adherence to the 2010 American Heart Association (AHA) Advanced Cardiac Life Support (ACLS) guidelines in their entirety affects patient outcomes. In addition, we explored the role of code leader training level on patient outcomes.
We conducted a retrospective review of records for cardiac arrests that occurred on hospital wards and were run by the hospital code team, at three tertiary care centres over 2 to 4 years. Deviations from the ACLS guidelines were quantified using a standardized checklist. Primary outcomes included return of spontaneous circulation (ROSC) and survival to hospital discharge.
Of 160 resuscitation events, ROSC was achieved in 75 events (46.9%) and survival to hospital discharge in 20 patients (13.1%). On average, there were 2.3 deviations from ACLS guidelines during events that led to ROSC and 3.9 deviations during events that did not lead to ROSC (p < 0.0001). There were fewer deviations during events that led to survival to hospital discharge (2.1) compared to those where the patient did not survive to hospital discharge (3.1; p = 0.016). Code leader training level was not associated with patient outcomes. Multivariable logistic regression analysis confirmed an association between deviations from ACLS guidelines and ROSC, but not for survival to hospital discharge. The latter finding may reflect a very low survival rate.
We found that higher numbers of deviations from ACLS guidelines were associated with a lower likelihood of ROSC and survival to hospital discharge. These findings emphasize the importance of adherence to ACLS guidelines and the need for training healthcare personnel in resuscitation guidelines in order to improve outcomes for victims of in-hospital cardiac arrest.
Resuscitation Education: Narrowing the Gap Between Evidence-Based Resuscitation Guidelines and Performance Using Best Educational Practices
2008, Pediatric Clinics of North America
Citation Excerpt :
In addition to data regarding the poor quality of CPR or BLS during actual cardiopulmonary arrests, data suggest that the quality of ALS can also be improved. Studies reported poor compliance with American Heart Association (AHA) Advanced Cardiac Life Support (ACLS) guidelines in both in- and out-of-hospital cardiopulmonary arrests [7–9]. For example, Chan and colleagues [9] recently published data from the National Registry of Cardiopulmonary Resuscitation revealing that 30% of in-hospital cardiac arrest patients who had a reported initial rhythm of pulseless ventricular tachycardia or ventricular fibrillation were not defibrillated within 2 minutes per AHA recommendations, with worsening outcomes for each passing minute without defibrillation.
Recent data from in- and out-of-hospital cardiopulmonary arrests reveal that health care teams frequently deviate from American Heart Association guidelines during resuscitation efforts. These discrepancies between the current state of evidence-based resuscitation guidelines and the quality of basic and advanced life support actually delivered represent a missed opportunity and provide a significant target for optimizing patient outcomes through improved educational effectiveness. This article presents discussion of the quality of resuscitation delivered to patients, a brief history of the development of cardiopulmonary resuscitation and attempts to translate the science of resuscitation to the bedside through effective educational strategies, a review of educational best practices that relate to resuscitation education, and discussion of the role of medical simulation in resuscitation training.
Emergency medicine residents effectively direct inhospital cardiac arrest teams
2005, American Journal of Emergency Medicine
We compared 2 models of physician leadership for inhospital cardiac arrest teams (CATs): emergency medicine (EM) residents and staff hospitalist physicians.
A before-after study was conducted on all adult inhospital CAT activations over a 2-year period. The primary outcome was return of spontaneous circulation (ROSC).
There were 749 total code blues during the 2-year study period. Ninety-one were excluded by protocol. EM residents directed 288 codes, hospitalists directed 248 codes, and other specialties directed the remaining 62. There was no statistically significant difference in percent ROSC or survival to hospital discharge. EM residents responded first for 59.2% of the codes compared with a first response rate of 28% for hospitalists (P < .05). Time to achieve ROSC was quicker in the EM resident cohort.
Our findings validate the use of a 24-hour EM resident staffing model for CAT response to inhospital cardiac arrests.
Advanced life support courses for board-certified emergency physicians: Lowering the standard of care?
2003, Journal of Emergency Medicine
Clinical use of sodium bicarbonate during cardiopulmonary resuscitation - Is it used sensibly?
2002, Resuscitation
This study retrospectively analyzed the pattern of sodium bicarbonate (SB) use during cardiopulmonary resuscitation (CPR) in the Brain Resuscitation Clinical Trial III (BRCT III). BRCT III was a prospective clinical trial, which compared high-dose to standard-dose epinephrine during CPR. SB use was left optional in the study protocol. Records of 2915 patients were reviewed. Percentage, timing and dosage of SB administration were correlated with demographic and cardiac arrest variables and with times from collapse to Basic Life Support, to Advanced Cardiac Life Support (ACLS) and to the major interventions performed during CPR. SB was administered in 54.5% of the resuscitations. The rate of SB use decreased with increasing patient age—primarily reflecting shorter CPR attempts. Mean time intervals from arrest, from start of ACLS and from first epinephrine to administration of the first SB were 29±16, 19±13, and 10.8±11.1 min, respectively. No correlation was found between the rate of SB use and the pre-ACLS hypoxia times. On the other hand, a direct linear correlation was found between the rate of SB use and the duration of ACLS. We conclude that when SB was used, the time from initiation of ACLS to administration of its first dose was long and severe metabolic acidosis probably already existed at this point. Therefore, if SB is used, earlier administration may be considered. Contrary to physiological rationale, clinical decisions regarding SB use did not seem to take into consideration the duration of pre-ACLS hypoxia times. We suggest that guidelines for SB use during CPR should emphasize the importance of pre-ACLS hypoxia time in contributing to metabolic acidosis and should be more specific in defining the duration of ‘protracted CPR or long resuscitative efforts’, the most frequent indication for SB administration.

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^☆: From the Department of Emergency Medicine, Wake Medical Center, Raleigh;^* Emergency Department Cabarrus Hospital, Concord;^† Department of Emergency Medicine, EAst Carolina University, Greenville,^‡ North Carolina.

^☆☆: This study was supported in part by the East Carolina University Medical Student Summer Research Award.

^★: Address for reprints: David M Cline, MD, Wake Medical Center, PO Box 14465, Raleigh, North Carolina 27620-4465

^★★: Reprint no. 47/1/61075

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Physician Compliance With Advanced Cardiac Life Support Guidelines☆,☆☆,★,★★

Abstract

Section snippets

INTRODUCTION

MATERIALS AND METHODS

RESULTS

DISCUSSION

CONCLUSION

Am J Emer Med

Lancet

Ann Emerg Med

Ann Emerg Med

Recurrent ventricular fibrillation and modes of death in survivors of out-of-hospital ventricular fibrillation

N Engl J Med

Survival after resuscitation from out-of-hospital ventricular fibrillation

Circulation

Bystander-initiated cardiopulmonary resuscitation in the management of ventricular fibrillation

Ann Intern Med

Prehospital cardiopulmonary resuscitation: Is it effective?

JAMA

Cardiac arrest: Comparison of paramedic and conventional ambulance services

Can Med Assoc J

The survival benefit of bystander cardiopulmonary resuscitation in a paramedic-served metropolitan area

Am J Public Health

Improved outcome from prehospital cardiopulmonary collapse with resuscitation by bystander

Circulation