The effect of adherence to ACLS protocols on survival of event in the setting of in-hospital cardiac arrest

Abstract

Aim: Advanced Cardiac Life Support (ACLS) algorithms are the default standard of care for in-hospital cardiac arrest (IHCA) management. However, adherence to published guidelines is relatively poor. The records of 149 patients who experienced IHCA were examined to begin to understand the association between overall adherence to ACLS protocols and successful return of spontaneous circulation (ROSC).

Methods: A retrospective chart review of medical records and code team worksheets was conducted for 75 patients who had ROSC after an IHCA event (SE group) and 74 who did not survive an IHCA event (DNS group). Protocol adherence was assessed using a detailed checklist based on the 2005 ACLS Update protocols. Several additional patient characteristics and circumstances were also examined as potential predictors of ROSC.

Results: In unadjusted analyses, the percentage of correct steps performed was positively correlated with ROSC from an IHCA (p<0.01), and the number of errors of commission and omission were both negatively correlated with ROSC from an IHCA (p<0.01). In multivariable models, the percentage of correct steps performed and the number of errors of commission and omission remained significantly predictive of ROSC (p<0.01 and p<0.0001, respectively) even after accounting for confounders such as the difference in age and location of the IHCAs.

Conclusions: Our results show that adherence to ACLS protocols throughout an event is correlated with increased ROSC in the setting of cardiac arrest. Furthermore, the results suggest that, in addition to correct actions, both wrong actions and omissions of indicated actions lead to decreased ROSC after IHCA.

Keywords: Advanced Cardiac Life Support; In-hospital cardiac arrest; Protocol adherence; Quality outcomes; Return of spontaneous circulation.

Figure 1

CONSORT diagram for patient inclusion. Only adult in-hospital cardiac arrest patients with legible and complete charts were eligible for randomization. After meeting inclusion criteria, a random sample of 75 patients surviving to ROSC and a random sample of 75 patients that did not survive to ROSC formed the two groups of patients that underwent detailed abstraction and analysis.

Figure 2

Association of adherence to published ACLS guidelines and the outcome of an IHCA event, as measured by the percentage of correct steps performed during an event. The percentage of correct steps was calculated by determining the number of actions (two-minute CPR intervals, drugs given, shocks administered, etc) performed correctly divided by the total number of indicated actions according to ACLS protocols per pulseless rhythm event.

Figure 3

All different types of errors, defined as divergence from AHA ACLS protocol, were significantly associated with not surviving the event. This included both errors of commission and omission, as well as performing an otherwise correct action at an inappropriate time.

Figure 4

When the 149 total patients are divided into three groups based upon ACLS adherence rather than by ROSC (0-33%, 34-67%, and 68-100% correct actions), there is a significant trend for increasing survival to ROSC with increasing ACLS adherence. Adhering to >70% of the correct ACLS actions, independent of other factors, appears to be associated with nearly doubling the ROSC rate. Error bars reflect 95% confidence intervals.

Figure 5

When the 149 total patients are divided into three groups based upon the number of divergences from ACLS guidelines, as measured by the total number of incorrect actions performed during IHCA management, there appears to be a significant inflection point for decreased survival to ROSC. Accumulating >1 error during IHCA management appears to be associated with roughly halving the ROSC rate.