European Resuscitation Council Guidelines for Resuscitation 2010 ...

1230 J.P. Nolan et al. / Resuscitation 81 (2010) 1219–1276
with traditional cardiac arrest teams, which typically respond to
patients already in cardiac arrest. MET/RRT usually comprise medical
and nursing staff from intensive care and general medicine and
respond to specific calling criteria. CCOT are based predominantly
on individual or teams of nurses. 201 A recent meta-analysis showed
RRT/MET systems were associated with a reduction in rates of cardiopulmonary
arrest outside the intensive care unit but are not
associated with lower hospital mortality rates. 202 Medical emergency
teams have an important role in improving end-of-life and
do-not-attempt resuscitation (DNAR) decision-making, which at
least partly accounts for the reduction in cardiac arrest rates. 203–206
Guidelines for prevention of in-hospital cardiac arrest
Hospitals should provide a system of care that includes: (a) staff
education about the signs of patient deterioration, and the rationale
for rapid response to illness, (b) appropriate and regular vital
signs monitoring of patients, (c) clear guidance (e.g., via calling criteria
or early warning scores) to assist staff in the early detection of
patient deterioration, (d) a clear, uniform system of calling for assistance,
and (e) an appropriate and timely clinical response to calls
for assistance. 183 The following strategies may prevent avoidable
in-hospital cardiac arrests:
1. Provide care for patients who are critically ill or at risk of clinical
deterioration in appropriate areas, with the level of care
provided matched to the level of patient sickness.
2. Critically ill patients need regular observations: each patient
should have a documented plan for vital signs monitoring that
identifies which variables need to be measured and the frequency
of measurement according to the severity of illness or
the likelihood of clinical deterioration and cardiopulmonary
arrest. Recent guidance suggests monitoring of simple physiological
variables including pulse, blood pressure, respiratory
rate, conscious level, temperature and SpO 2 . 192,207
3. Use a track and trigger system (either ‘calling criteria’ or early
warning system) to identify patients who are critically ill and,
or at risk of clinical deterioration and cardiopulmonary arrest.
4. Use a patient charting system that enables the regular measurement
and recording of vital signs and, where used, early
warning scores.
5. Have a clear and specific policy that requires a clinical response
to abnormal physiology, based on the track and trigger system
used. This should include advice on the further clinical management
of the patient and the specific responsibilities of medical
and nursing staff.
6. The hospital should have a clearly identified response to critical
illness. This may include a designated outreach service or
resuscitation team (e.g., MET, RRT system) capable of responding
in a timely fashion to acute clinical crises identified by the
track and trigger system or other indicators. This service must
be available 24 h per day. The team must include staff with the
appropriate acute or critical care skills.
7. Train all clinical staff in the recognition, monitoring and management
of the critically ill patient. Include advice on clinical
management while awaiting the arrival of more experienced
staff. Ensure that staff know their role(s) in the rapid response
system.
8. Hospitals must empower staff of all disciplines to call for help
when they identify a patient at risk of deterioration or cardiac
arrest. Staff should be trained in the use of structured
communication tools (e.g., SBAR – Situation-Background-
Assessment-Recommendation) 208 to ensure effective handover
of information between doctors, nurses and other
healthcare professions.
9. Identify patients for whom cardiopulmonary arrest is an anticipated
terminal event and in whom CPR is inappropriate, and
patients who do not wish to be treated with CPR. Hospitals
should have a DNAR policy, based on national guidance, which
is understood by all clinical staff.
10. Ensure accurate audit of cardiac arrest, ‘false arrest’, unexpected
deaths and unanticipated ICU admissions using
common datasets. Audit also the antecedents and clinical
response to these events.
Prevention of sudden cardiac death (SCD) out-of-hospital
Coronary artery disease is the commonest cause of SCD. Nonischaemic
cardiomyopathy and valvular disease account for most
other SCD events. A small percentage of SCDs are caused by
inherited abnormalities (e.g., Brugada syndrome, hypertrophic cardiomyopathy)
or congenital heart disease. Most SCD victims have
a history of cardiac disease and warning signs, most commonly
chest pain, in the hour before cardiac arrest. 209 Apparently healthy
children and young adults who suffer SCD can also have signs and
symptoms (e.g., syncope/pre-syncope, chest pain and palpitations)
that should alert healthcare professionals to seek expert help to
prevent cardiac arrest. 210–218
Prehospital resuscitation
EMS personnel
There is considerable variation across Europe in the structure
and process of EMS systems. Some countries have adopted almost
exclusively paramedic/emergency medical technician (EMT)-based
systems while other incorporate prehospital physicians to a greater
or lesser extent. Studies indirectly comparing resuscitation outcomes
between physician-staffed and other systems are difficult
to interpret because of the extremely high variability between systems,
independent of physician-staffing. 23 Given the inconsistent
evidence, the inclusion or exclusion of physicians among prehospital
personnel responding to cardiac arrests will depend largely on
existing local policy.
Termination of resuscitation rules
One high-quality, prospective study has demonstrated that
application of a ‘basic life support termination of resuscitation rule’
is predictive of death when applied by defibrillation-only emergency
medical technicians. 219 The rule recommends termination
when there is no ROSC, no shocks are administered, and the arrest is
not witnessed by EMS personnel. Prospectively validated termination
of resuscitation rules such as the ‘basic life support termination
of resuscitation rule’ can be used to guide termination of prehospital
CPR in adults; however, these must be validated in an
emergency medical services system similar to the one in which
implementation is proposed. Other rules for various provider levels,
including in-hospital providers, may be helpful to reduce variability
in decision-making; however, rules should be prospectively validated
before implementation.
In-hospital resuscitation
After in-hospital cardiac arrest, the division between basic life
support and advanced life support is arbitrary; in practice, the
resuscitation process is a continuum and is based on common sense.
The public expect that clinical staff can undertake CPR. For all inhospital
cardiac arrests, ensure that:
• cardiorespiratory arrest is recognised immediately;
• help is summoned using a standard telephone number;