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Cardiopulmonary resuscitation on television: Miracles and misinformation
96
Abstracts
one-tier system. The data available for this analysis were suboptimal. Policymakers need more methodologically rigorous research to have more reliable and valid estimates of the effectivenessof different EMS systems. Cost-effectiveness analysis of potential improvements to emergency medical services for victims of out-of-hospital cardiac arrest Nichol G, Laupacis A, Stiell IG, O’Rourke K, Anis A, Bolley H, Detsky AS Clinical Epidemiology Unit, Ottawa Civic Hospital, 1053 Carling Avenue, Ottawa, Ont. Kl Y 4E9, CAN Ann Emerg Med 1996; 2716: 711-720 Study objective: To measure the increment cost-effectiveness of various improvements to emergency medical services (EMS) system aimed at increasing survival after out-of-hospital cardiac arrest. Methods: We performed cost-effectiveness analysis based on (1) metaanalysis of effectiveness of the variou EM systems, (2) costing of each component of EMS systems, (3) modeling of relationship between the proportion of cardiac arrest victims who receive CPR and the proportion of individuals trained, (4) modeling of the relationship between response time interval and the characteritics of the EMS system, (5) measurement of quality of life, and (6) decision analysis to combine the results of the first five components. Results: The incremental cost-effectiveness ratio for a 48-second improvement in mean response in a one-tier EMS system yielded by the addition of more EMS providers was $368000 per quality-adjusted life year (QALUY). For improved response time in a two-tier EMS system by the addition of more basic life support (BLS)/BLS-defibrillator (BLS-D) providers to the first tier, the ratio was $53000 per QALY with pump vehicles or $159000 per QALY with ambulances. Changee from a one-tier EMS to a two-tier EMS system by the addition of initial BLS/BLS-D providers in pump vehicles as the first tier was associated with a cost per QALY of $40000. Change from none-tier EMS to two-tier EMS by the addition of initial BLS/BLS-D providers in ambulances as the first tier was associated with a cost per QALY of $94000. Conclusion: The most attractive options in terms of incremental cost-effectivenes were improved response time in a two-tier EMS system or change from a one-tier to a two-tier EMS system. Future research should be directed toward identification of the costs of instituting the first tier of a two-tier EMS system and identification of cost-effective methods of improving response time. Cardiopulmonary resuscitation on television: Miracles and misinformation Diem SJ, Lantos JD, Tulsky JA Health Services Research (152), Veterans Affairs Medical Center, 508 F&on St., Durham, NC 27705, USA New Engl J Med 1996; 334124: 1578-1582 Background: Responsible, shared decision making on the part of physicians and patients about the potential use of cardiopulmonary resuscitation (CPR) requires patients who are educated about the procedure’s risks and benefits. Television is an important source of information about CPR for patients. We analyzed how three popular television programs depict CPR. Methods: We watched all the episodes of the television programs ER and Chicago Hope during the 19941995viewing season and 50 consecutive episodes of Rescue 911 broadcast over a three-month period in 1995. We identified all occurrences of CPR in each episode and recorded the causes of cardiac arrest, the identifiable demographic characteristics of the patients, the underlying illnesses, and the outcomes. Results: There were 60 occurrences of CPR in the 97 television episodes - 31 on ER, 11 on Chicago Hope, and 18 on Rescue 911. In the majority of cases,cardiac arrest was caused by trauma; only 28 percent were due to primary cardiac causes. Sixty-five percent of the cardiac arrests occurred in children, teenagers, or young adults. Seventy-five percent
of the patients survived the immediate arrest, and 67 percent appeared to have survived to hospital discharge. Conclusions: The survival rates in our study are significantly higher than the most optimistic survival rates in the medical literature, and the portrayal of CPR on television may lead the viewing public to have an unrealistic impression of CPR and its chances for success.Physicians discussing the use of CPR with patients and families should be aware of the images of CPR depicted on television and the misperceptions these images may foster. Patterns of cognitive recovery in sudden cardiac arrest survivors: The pilot study Sauve MJ, Walker JA, Massa SM, Winkle RA, Scheinman MM Department of Physiological Nursing, School of Nursing, University of Southern California, San Francisco, CA 94143-0610, USA Heart Lung J Acute Crit Care 1996; 25/3: 172- 181 Objective: To determine the prevalence, type, severity, and natural evolution of cognitive impairments in survivors of sudden cardiac arrest over time and to assessthe relation of selected clinical and psychologic variables to those outcomes. Design: Longitudinal with repeated measures. Twenty-five consecutive patients underwent extensive neuropsychologic testing during hospitalization within 3 weeks of the initial cardiac arrest. Of these, 17 completed additional testing at 6 to 9 weeks, 12 to 15 weeks, and 22 to 25 weeks after the event. Setting: Cardiac electrophysiologic services at a university teaching hospital, a community hospital, and home. Outcome Variables: Orientation, attention, concentration, immediate recall, early retention, delayed recall, reasoning, motor speed, and motor regularity were measured. Results: During hospitalization, 72% of the patients had mild to severe impairments in one or more cognitive areas. Memory, particularly delayed recall, was the most common deficit. At 6 months after the arrest event, 29% (5 of 17) of the patients continued to be impaired, and all had deficits in delayed recall. Depression was significantly related to deficits in attention and delayed recall at 6 months only. Time to pasteurized awakening was the most reliable predictor of long-term cognitive functioning in this patient sample. Conclusion: A significant minority of sudden death survivors incur long-term cognitive impairments, particularly in delayed recall or short-term memory. The occurrence of long-term cognitive deficits in these patients can be estimated from the duration of unconsciousness after resuscitation (time-to-awakening). Resuscitating the elderly: What do the patients want? Bruce-Jones P, Roberts H, Bowker L, Cooney V Department Medicine for the Elderly, Poole Hospital and Elderly Care Unit, Southampton General Hospital, Southampton, GBR J Med Ethics 1996; 22/3: 154-159 Objective: To study the resuscitation preferences, choice of decision-maker, views on the seeking of patients’ wishes and determinants of these of elderly hospital in-patients. Design: Questionnaire administered an admission and prior to discharge. Setting: Two acute geriatric medicine units (Southampton and Poole). Participants: Two hundred and fourteen consecutive consenting mentally competent patients admitted to hospital as emergencies. Results: Resuscitation was wanted by 60%, particularly married and functionally independent patients and those who had not already considered it. Not wanting resuscitation was associated with lack of social contacts. Sixty-seven per cent welcomed enquiry about their preferences and 78% wanted participation in decisions, 43% as sole decision-maker. Wishing to choose oneself was associated with not wanting resuscitation, prior knowledge of it, and lack of a spouse. Patients’ opinions remained stable during their admission. Conclusions: Discussion of resuscitation is practical on hospital admission without causing distress and the views expressed endure through the period of hospitalisation. Elderly patients’ attitudes depend partly on personal health
Abstracts
one-tier system. The data available for this analysis were suboptimal. Policymakers need more methodologically rigorous research to have more reliable and valid estimates of the effectivenessof different EMS systems. Cost-effectiveness analysis of potential improvements to emergency medical services for victims of out-of-hospital cardiac arrest Nichol G, Laupacis A, Stiell IG, O’Rourke K, Anis A, Bolley H, Detsky AS Clinical Epidemiology Unit, Ottawa Civic Hospital, 1053 Carling Avenue, Ottawa, Ont. Kl Y 4E9, CAN Ann Emerg Med 1996; 2716: 711-720 Study objective: To measure the increment cost-effectiveness of various improvements to emergency medical services (EMS) system aimed at increasing survival after out-of-hospital cardiac arrest. Methods: We performed cost-effectiveness analysis based on (1) metaanalysis of effectiveness of the variou EM systems, (2) costing of each component of EMS systems, (3) modeling of relationship between the proportion of cardiac arrest victims who receive CPR and the proportion of individuals trained, (4) modeling of the relationship between response time interval and the characteritics of the EMS system, (5) measurement of quality of life, and (6) decision analysis to combine the results of the first five components. Results: The incremental cost-effectiveness ratio for a 48-second improvement in mean response in a one-tier EMS system yielded by the addition of more EMS providers was $368000 per quality-adjusted life year (QALUY). For improved response time in a two-tier EMS system by the addition of more basic life support (BLS)/BLS-defibrillator (BLS-D) providers to the first tier, the ratio was $53000 per QALY with pump vehicles or $159000 per QALY with ambulances. Changee from a one-tier EMS to a two-tier EMS system by the addition of initial BLS/BLS-D providers in pump vehicles as the first tier was associated with a cost per QALY of $40000. Change from none-tier EMS to two-tier EMS by the addition of initial BLS/BLS-D providers in ambulances as the first tier was associated with a cost per QALY of $94000. Conclusion: The most attractive options in terms of incremental cost-effectivenes were improved response time in a two-tier EMS system or change from a one-tier to a two-tier EMS system. Future research should be directed toward identification of the costs of instituting the first tier of a two-tier EMS system and identification of cost-effective methods of improving response time. Cardiopulmonary resuscitation on television: Miracles and misinformation Diem SJ, Lantos JD, Tulsky JA Health Services Research (152), Veterans Affairs Medical Center, 508 F&on St., Durham, NC 27705, USA New Engl J Med 1996; 334124: 1578-1582 Background: Responsible, shared decision making on the part of physicians and patients about the potential use of cardiopulmonary resuscitation (CPR) requires patients who are educated about the procedure’s risks and benefits. Television is an important source of information about CPR for patients. We analyzed how three popular television programs depict CPR. Methods: We watched all the episodes of the television programs ER and Chicago Hope during the 19941995viewing season and 50 consecutive episodes of Rescue 911 broadcast over a three-month period in 1995. We identified all occurrences of CPR in each episode and recorded the causes of cardiac arrest, the identifiable demographic characteristics of the patients, the underlying illnesses, and the outcomes. Results: There were 60 occurrences of CPR in the 97 television episodes - 31 on ER, 11 on Chicago Hope, and 18 on Rescue 911. In the majority of cases,cardiac arrest was caused by trauma; only 28 percent were due to primary cardiac causes. Sixty-five percent of the cardiac arrests occurred in children, teenagers, or young adults. Seventy-five percent
of the patients survived the immediate arrest, and 67 percent appeared to have survived to hospital discharge. Conclusions: The survival rates in our study are significantly higher than the most optimistic survival rates in the medical literature, and the portrayal of CPR on television may lead the viewing public to have an unrealistic impression of CPR and its chances for success.Physicians discussing the use of CPR with patients and families should be aware of the images of CPR depicted on television and the misperceptions these images may foster. Patterns of cognitive recovery in sudden cardiac arrest survivors: The pilot study Sauve MJ, Walker JA, Massa SM, Winkle RA, Scheinman MM Department of Physiological Nursing, School of Nursing, University of Southern California, San Francisco, CA 94143-0610, USA Heart Lung J Acute Crit Care 1996; 25/3: 172- 181 Objective: To determine the prevalence, type, severity, and natural evolution of cognitive impairments in survivors of sudden cardiac arrest over time and to assessthe relation of selected clinical and psychologic variables to those outcomes. Design: Longitudinal with repeated measures. Twenty-five consecutive patients underwent extensive neuropsychologic testing during hospitalization within 3 weeks of the initial cardiac arrest. Of these, 17 completed additional testing at 6 to 9 weeks, 12 to 15 weeks, and 22 to 25 weeks after the event. Setting: Cardiac electrophysiologic services at a university teaching hospital, a community hospital, and home. Outcome Variables: Orientation, attention, concentration, immediate recall, early retention, delayed recall, reasoning, motor speed, and motor regularity were measured. Results: During hospitalization, 72% of the patients had mild to severe impairments in one or more cognitive areas. Memory, particularly delayed recall, was the most common deficit. At 6 months after the arrest event, 29% (5 of 17) of the patients continued to be impaired, and all had deficits in delayed recall. Depression was significantly related to deficits in attention and delayed recall at 6 months only. Time to pasteurized awakening was the most reliable predictor of long-term cognitive functioning in this patient sample. Conclusion: A significant minority of sudden death survivors incur long-term cognitive impairments, particularly in delayed recall or short-term memory. The occurrence of long-term cognitive deficits in these patients can be estimated from the duration of unconsciousness after resuscitation (time-to-awakening). Resuscitating the elderly: What do the patients want? Bruce-Jones P, Roberts H, Bowker L, Cooney V Department Medicine for the Elderly, Poole Hospital and Elderly Care Unit, Southampton General Hospital, Southampton, GBR J Med Ethics 1996; 22/3: 154-159 Objective: To study the resuscitation preferences, choice of decision-maker, views on the seeking of patients’ wishes and determinants of these of elderly hospital in-patients. Design: Questionnaire administered an admission and prior to discharge. Setting: Two acute geriatric medicine units (Southampton and Poole). Participants: Two hundred and fourteen consecutive consenting mentally competent patients admitted to hospital as emergencies. Results: Resuscitation was wanted by 60%, particularly married and functionally independent patients and those who had not already considered it. Not wanting resuscitation was associated with lack of social contacts. Sixty-seven per cent welcomed enquiry about their preferences and 78% wanted participation in decisions, 43% as sole decision-maker. Wishing to choose oneself was associated with not wanting resuscitation, prior knowledge of it, and lack of a spouse. Patients’ opinions remained stable during their admission. Conclusions: Discussion of resuscitation is practical on hospital admission without causing distress and the views expressed endure through the period of hospitalisation. Elderly patients’ attitudes depend partly on personal health