VANCOUVER, B.C. — The traditional “code blue” strategy of handling in-hospital cardiac arrests has remained essentially unchanged for 30 years, a period during which—in sharp contrast—massive resources have been devoted to improving public access defibrillation for out-of-hospital cardiac arrest, Antoni Martinez-Rubio, M.D., said at a meeting of the International Academy of Cardiology.
“We [cardiologists] have spent lots of money and done lots of reports looking at what happens outside our hospitals, but we have not looked hard enough at what happens inside our hospitals,” according to Dr. Martinez-Rubio, a cardiologist at Sabadell Hospital, Barcelona.
Thirty percent of all sudden cardiac deaths occur in-hospital. The literature indicates that the acute survival rate following attempted resuscitation of in-hospital cardiac arrest is 40%–45%. Only 15%–20% of patients are discharged alive, many with permanent neurologic impairment.
Given the inefficiencies and generally poor outcomes of the code blue approach, it is time for a major change in how in-hospital cardiac arrests are managed. And the necessary tool is already at hand in the form of the Food and Drug Administration-approved Powerheart Cardiac Rhythm Module (CRM), Dr. Martinez-Rubio added.
The CRM continuously monitors a patient's heart at the bedside, detects onset of a life-threatening arrhythmia, and automatically delivers a shock for external cardioversion. In the multicenter European trial headed by Dr. Martinez-Rubio and sponsored by Cardiac Science Inc., the mean lapsed time between arrhythmia onset and delivery of a defibrillatory shock was 15 seconds.
Contrast that to the traditional code blue scenario, in which a patient is monitored by telemetry in a high-cost ICU or coronary care unit. In that setting, a detected arrhythmia triggers an alarm, which has to be recognized by the nursing staff, which then calls for the crash cart and physicians to come to the bedside. All of this takes time. And, as a recent American Heart Association report emphasized, the earlier cardiac resuscitation can be performed, the better. Indeed, survival rates decrease by 7%–10% for every minute defibrillation is delayed, the cardiologist continued.
In addition to the 117-patient European multicenter study led by Dr. Martinez-Rubio (J. Am. Coll. Cardiol. 2003;41:627–32), there has also been a favorable single-center Brazilian study of the CRM (Resuscitation 2004;63:11–6). In another example, physicians at Maimonides Medical Center in Brooklyn, N.Y., reported that the response time to simulated cardiac arrest in their ICU and CCU averaged nearly 3 minutes, compared with just 38 seconds for the CRM to charge up and deliver a shock (Resuscitation 2004;63:183–8).
“In my opinion, this should be the new standard of care,” Dr. Martinez-Rubio declared.
He provided an update on an ongoing study he is directing in which patients at risk for arrhythmic death are being randomized to traditional monitoring and code blue response in the CCU or to a stay in a regular hospital ward while connected to the Powerheart.
With 95 patients randomized to date, during 5,340 hours of monitoring outside the CCU there have been 122 arrhythmic events, including 36 cases of ventricular arrhythmia. There are as yet no significant differences in clinical outcome; however, the cost savings achieved by using the CRM on a regular ward instead of traditional monitoring in the CCU amounts thus far to $89,000. And that's assuming a $400 per day difference in the cost of staying in a regular ward, compared with the CCU, which is probably a considerable underestimate.
In addition, an ongoing prospective study at the University of Michigan, Ann Arbor, is comparing the effectiveness of the traditional code blue emergency response protocol with the CRM in patients in the university hospital's cardiac ICU. The study is being led by Kim A. Eagle, M.D., clinical director of the university's cardiovascular center.