Investigación Científica y Tecnológica

Wilson Valencia*, José Ricardo Navarro**, Katherine Ramírez***, Julián Mauricio Rubio***, Mario Bautista***, Carolina Truque***

* Profesor de anestesia, Universidad Santiago de Cali, Cali, Colombia. Correspondencia: Carrera 84 No. 14-97, Cali, Colombia. Correo electrónico: wilsonvalenciaa@hotmail.com

** Profesor Asociado de anestesia, Universidad Nacional de Colombia, Bogotá, Colombia

*** Estudiantes de Medicina-Internado, Universidad Santiago de Cali, Cali, Colombia

Recibido: enero 10 de 2011. Enviado para modificaciones: enero 12 de 2011. Aceptado: julio 25 de 2011.

Background. There are no publications in Colombia regarding the implementation of a hospital cardiopulmonary arrest registry despite the fact that the International Liaison Committee on Resuscitation (ILCOR) already in 1991 developed, in a meeting at Utsein Abbey in Norway, a form designed to compare and improve cardiopulmonary resuscitation maneuvers. The purpose of this work was to apply a cardiopulmonary arrest registry in the Utstein style at San Juan de Dios Hospital in Cali, in order to gather data concerning the reality of cardiopulmonary arrest, during the period between July and October, 2010.

Methodology. Prospective observational study. A cardiopulmonary arrest form was developed and communicated, and all physicians who had participated in cardiopulmonary resuscitation maneuvers during the study period were asked to complete the form.

Results. There were 22 cases of cardiopulmonary arrest. Of these, 80 % happened in the emergency service, and 95 % were attended to by a general

practitioner. Only 14 % of the records were filled correctly and, in 23 % of cases, the description had been written by the nursing staff instead of the physician. Conclusion. This study found that the vast majority of physicians do not fill a cardiopulmonary arrest form, even when they are aware of it. Commitment is lacking on the part of the government as well as the medical community regarding the correct implementation of this recommendation of critical importance for resuscitation research.

In 1991, ILCOR created the forms for recording out-of-hospital cardiopulmonary arrest (CA) events, and then went on to develop the forms for in-hospital cardiopulmonary arrest in 1997. The difference between them relates to the way in which data are collected and recorded, considering that the in-hospital form requires including additional information taken from the patient’s chart. However, the premise was to develop an open document, easy to understand, where the information could be recorded readily in any community. An Utstein-style form for recording cerebrocardiopulmonary resuscitation (CCPR) (1) events has not been implemented in our country to this date. This is unfortunate because it has not been possible to undertake a true analysis of the reality of cardiopulmonary arrest (CPA), its management, the outcomes of CCPR, or any related statistics. Every time a medical professional makes a reference to CPA and its management in this country, there is a need to extrapolate data from other countries.

The purpose of this work was to implement an Utstein-style cardiac arrest registry, similar to the ones suggested by ILCOR, at San Juan de Dios Hospital (SJDH) in Cali, in order to gather data on the reality of cardiorespiratory arrest during the period between July and October, 2010. (Annex 1.)

This is a “case series” prospective observational study. The target population consisted of patients presenting with CPA at SJDH in Cali between July 1 and October 30, 2010.

Inclusion criteria: Patients presenting with CPA at SJDH, during the study period.

Exclusion criteria: Patients in whom it was decided no to perform CCPR.

A form was designed for recording in-hospital cardiopulmonary arrest following the Utstein guidelines (Annex 1). The form was submitted to the Clinical Records Committee and, once approved, was included as a mandatory element of all clinical records. The requirement to fill the form became part of the Code Blue process already in place at the Hospital.

The procedure was communicated and a promotional poster (Annex 2) was posted at strategic locations inside the Hospital. An agenda of activities was developed in order to make the project known and to educate the people on the way to complete it. Questions were answered and people were made aware of how relevant the information gathered was for improving quality care processes.

The involvement of the nursing staff was assured and they were given reinforcement on the process. The Medical Director and Deputy Director were made aware of the clinical trial and they endorsed the process all along.

The main goal was to determine whether the physicians participating in CCPR maneuvers during the study period filled the form correctly, and whether they were aware of the feedback provided in the form of suggestions and solutions to the problems encountered.

For data collection, the nursing log of responses to Code Blue (all cases are reported by the nurses and it is highly improbable to find omissions) was reviewed and patient chart numbers were collected in order to retrieve them and find the arrest record (AR).

The research group visited the Men and Women Internal Medicine Rooms, the Intermediate Care Unit, the wards, the Emergency Observation rooms and the Operating rooms three times a week during the study period in order to identify the cases. Overall, 22 patients who underwent CCPR procedures were identified.

Table 1 shows age distribution. There were 9 women (40.9 %) and 13 men (59.1 %). Eighty per cent of the cases occurred at the emergency service, and 20 % in the medical ICU.

The most frequent initial diagnosis was respiratory arrest (6 cases), followed by acute myocardial infarction (3 cases). (Table 2).

Only in three cases was the record suggested by the research group correctly completed (13.6 %). In 17 of the 22 cases, the description of the maneuvers was done by the general practitioner and, in the remaining 5 cases, the description was done by the nursing staff.

Determining the reasons why the physicians did not complete the arrest form was not within the scope of this study. They were asked about it outside the study and they argued that they lacked the time to fill the record, although there are no accurate data regarding the percentage of physicians that gave this response.

The arrest registry, called National Registry of CardioPulmonary Resuscitation (NRCPR®) by the American Heart Association (AHA), is not only a tool to develop a database of events occurring during cerebrocardiopulmonary resuscitation. The registry is also used to assess the performance of the staff in charge of resuscitation, and to provide the feedback required to implement the necessary changes required for improving quality of care (2). These data can also be used for comparison with other populations and for determining survival rates at discharge. For example, the rate of survival among 14,720 patients who developed in-hospital cardiorespiratory arrest in the United States was 17 %. (3,4)

As far as the authors are aware, this would be the first study conducted in Colombia with the goal of implementing the use of a hospital arrest registry.

It was found that most cases of cardiorespiratory arrest occurred in the emergency room and, of those, 95.5 % were managed by general practitioners. Diagnosis is not always specific in many of the cases managed in the emergency room, contrary to what happens in the medical ICU, where patients have already undergone several work-up studies.

Gathering of data regarding resuscitation maneuvers performed in cardiorespiratory arrest victims, as well as recording of the time between processes, helps assess treatment efficacy, compare results with those of other centers, create databases, and conduct self-evaluations. This kind of information has been used to improve CPR guidelines published by authorities in the field such as the AHA and the European Resuscitation Council (ERC) (5-7).

In Latin America, progress has been slow and, particularly in Colombia, no national information is available regarding cerebrocardiopulmonary resuscitation either in in-hospital or out-of-hospital arrest (1). This hinders the development of strategies for improving overall patient prognosis. Despite the work of government agencies such as the Capital District Health Secretariat, and despite the publications on the subject (1,9-11), it has not been possible to implement this tool for recording CCPR maneuvers.

A search was conducted of the files of the SJDH and of the Municipal Health Secretariat in Cali, and no statistical data were found in relation to cardiorespiratory arrest or CCPR; the only figures found were related to mortality rates associated with various diagnoses, taken from death certificates.

The high percentage of practitioners who did not complete the CPA record sheet may be explained by the absence of a culture of reporting, as well as by the desire not to devote time to something that is not mandatory. Certainly, this is a hurdle to resuscitation research in our setting.

On the other hand, reporting based on written notes may lead to unwanted omissions. In an analysis carried out in Colombia, it was found that the quality of arrest reporting was classified as intermediate in 59 % of cases, low in 38.5 %, and high only in 2.4 % of the registries (11).

The authors recommend, as a standard, that a single record form be implemented in order to solve this problem. To this end, an Utstein model was adapted to the country’s reality, in order to enable simple and fast reporting. However, it was completed only in very few cases and, worse still, in 22.7 % of cases, only nursing notes and no doctors’ notes were found in the patient’s chart.

The solution is not in the hands of scientific societies or hospitals; it is a matter of public health policy. The Ministry of Health must organize and assess all that pertains to the way in which CPR is provided, including not only the obligation to complete de arrest form, but the need to provide training to lay people, the availability of automatic external defibrillators (AED) in public places, and the standardization of knowledge in all healthcare institutions, aside from a regular evaluation and recertification of all these mechanisms. None of these steps has yet been taken officially in Colombia, which means that the country is lagging behind the ILCOR consensus of Utstein by 19 years.

1. Navarro JR. Registro de paro cardiaco en el adulto. Rev Fac Med Univ Nac Col 2005;53:196-201.

2. Abella BS, Alvarado JP, Myklebust H, Edelson DP, Barry A, O’Hearn N, et al. Quality of Cardiopulmonary Resuscitation During In-Hospital Cardiac Arrest. JAMA. 2005;293:305-10.

3. National Registry of Cardiopulmonary Resuscitation (NRCPR®) is pleased to announce the release of NRCPR® ESSENTIALS - a Resuscitation Performance Improvement toolkit. American Heart Association. Disponible en: http://www.nrcpr.org/. Consultado el 7 de enero de 2011.

4. Hillman K, Chen J, Cretikos M, Bellomo R, Brown D, Doig G, et al. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. Lancet. 2005;365:2091-97.

5. Hazinsky MF, Chameides L, Elling B, Hemphill R. Highlights of the 2005 American Heart Association Guidelines for Cardiopulmonary Resucitation and Emergency Cardiovascular Care. Currents in Emergency Cardiovascular Care. Winter 2005-2006;16(4).

6. 2010 American Heart Association Guidelines for cardiopulmonary resuscitation and Emergency cardiovascular care. Circulation 2010;122:S640-S946.

7. Resumen de los principales cambios de las Guías para la Resucitación. Guías 2010 para la Resucitación del European Resuscitation Council (ERC). Disponible en: http://www.cprguidelines.eu/. Consultado 7 de enero de 2010.

8. Mayanz S, Barreto J, Grove X, Iglesias V, Breinbauer H. Paro cardiorrespiratorio extra-hospitalario de causa cardiaca en Santiago de Chile: experiencia del equipo medicalizado del SAMU Metropolitano. Revista Chilena de Medicina Intensiva. 2009;24:9-16.

9. Álvarez L, Navarro JR, Barragán G. La importancia del registro en el paro cardiaco perioperatorio. Rev. Médico-Legal. 2008; Año XIV (2):36-39.

10. Matiz H, Gómez H, Gómez A. Soporte vital básico y avanzado (Análisis crítico de las nuevas guías 2005). (Bogotá): Distribuna Editorial; 2007:185-90.

11. Barragán G, Navarro JR, Marulanda N. Análisis de la calidad del Registro de Paro Cardíaco en casos de responsabilidad medicolegal en médicos generales, SCARE-FEPASDE 1999-2007. Rev. Fac. Med. Univ Nac Colomb. 2009;57: 5-17.