The Case

Case #1: An 80-year-old man with history of Parkinson’s disease and left iliac artery aneurysm underwent elective endovascular repair and endograft placement. Several days later, he developed sudden confusion, slurred speech, and tongue deviation with new bradycardia to the 30s. The primary bedside nurse attempted to contact the Rapid Response team; however, they were occupied in another emergent event. The primary vascular surgery team was paged, but that listed pager was not functional. A code stroke was called, neurology arrived at the bedside and transported the patient to the computed tomography (CT) scanner. Unfortunately, the patient lost pulses in the CT scanner and cardiopulmonary resuscitation (CPR) was initiated with return of spontaneous circulation (ROSC). The post-code rhythm on electrocardiography (ECG) was notable for new heart block. Atropine was administered, a transvenous pacemaker was inserted, and the patient was intubated for transport to the critical care unit. Despite intensive care, the patient’s condition remained unstable, and he expired several days later.

Case #2: A 74-year-old man with a history of hypertensive end-stage renal disease and significant cardiac disease, including current antibiotic treatment for bacterial endocarditis, was seen in the outpatient renal transplant clinic for evaluation of medical stability. The patient’s cardiac history included paroxysmal atrial fibrillation with ablation, balloon dilation of the right coronary artery, and a diffusely calcified left anterior descending artery. Recent radionuclide myocardial perfusion imaging showed a small inferolateral infarct with ischemia, a recent echocardiogram showed mild to moderate aortic regurgitation with a normal ejection fraction and no vegetations, and a recent ECG showed prolonged QT interval.

In the transplant clinic, the patient was undergoing pre-transplant evaluation. He was able to walk twenty minutes with no distress; however, he reported significant dyspnea after climbing three flights of stairs. He sat on a chair in the hallway and then became suddenly unresponsive. Physicians initiated CPR. Intubation was attempted but the vocal cords were not visualized, multiple intravenous (IV) access attempts were unsuccessful, and there was no nearby outlet for suction equipment. Emergency medical services (EMS) promptly arrived and assisted with CPR. ROSC was achieved after approximately four minutes. The patient was transported to the emergency department and admitted to the cardiology service, where he was found to have severe aortic insufficiency due to bacterial endocarditis. He underwent coronary artery bypass surgery (CABG), surgical aortic valve replacement, and left atrial appendage ligation with successful results.

The Commentary

By Garima Agrawal, MD, MPH, and Mithu Molla, MD, MBA

Both of the cases described above illustrate the need to provide CPR in unconventional settings, one in the radiology suite, and the other in a clinic hallway. Several factors led to these challenging circumstances, but at the most basic level, adherence to Advanced Cardiac Life Support (ACLS) guidelines would likely have led to better outcomes. ACLS is an algorithm-based approach to cardiovascular resuscitation, and successful resuscitation attempts often require healthcare providers to perform a variety of interventions while functioning together as a team. Successful teams not only have medical expertise and mastery of resuscitation skills, but also demonstrate effective communication and team dynamics¹. Our commentary will focus on why the ACLS algorithms were not followed, and interventions to ensure more successful execution moving forward.

Threats to Patient Safety

Failure to Follow ACLS Algorithms

In the first case, a series of assessment errors led to the patient being sent down to radiology without addressing his life-threatening bradycardia. The vascular surgery team that was most familiar with the patient’s recent surgical procedure and likely perioperative complications could not be reached due to a faulty paging system. The rapid response team, which would have been most adept handling an acute cardiovascular emergency, was busy and unable to assist. Addressing the patient’s urgent condition relied on ACLS execution by providers available at the scene. According to the ACLS Adult Bradycardia algorithm, if there is persistent bradyarrhythmia associated with acutely altered mental status, therapies such as atropine or transcutaneous pacing should be initiated.¹ Rather than following the algorithm, focus was instead diverted to the patient’s neurologic symptoms and ACLS execution was delayed until the patient was in the radiology suite.

Failure of the hospital staff to follow ACLS algorithms may reflect gaps in their ACLS training requirements and maintenance of proficiency. The ACLS provider course is designed to train providers in the management of cardiopulmonary arrest or other cardiovascular emergencies through didactic instruction and active participation in simulated cases. Certification is renewed every two years, or annually online for physicians. However, retention of knowledge and resuscitation skills have been shown to decline over time. In one study, overall competency in ACLS skills performance was poor for both stable and unstable tacharrythmia scenarios.² In another study, providers were unable to perform ACLS and Basic Life Support (BLS) skills to the expected standard for the entire certification period, with an ACLS pass rate of 30% at three months and 14% at 12 months from last certification.³ Recent research suggests that resuscitation training should be carried out at least at 3- to 6-month intervals to prevent deterioration of the skills and knowledge competencies.⁴ Logistically, it may be impossible for many health care organizations to provide this frequency of training and assessment, given staffing limitations and financial constraints.

Lack of Skills Required for Successful ACLS Execution

The second case reflects the challenges of ACLS execution in an unconventional setting. Locations such as the ambulatory clinic, cafeteria, or bathroom may present challenges to implementing the algorithms that are crucial to resuscitation. In the transplant clinic, an IV line could not be obtained. According to ACLS protocols, when a peripheral IV can not be established, the intraosseous route is pursued. Current guidelines recommend administration of certain drugs (epinephrine and amiodarone/lidocaine) as part of advanced life support during cardiac arrest.⁵ Given the relative ease of intraosseous (IO) access, despite occasional complications, it has emerged as an excellent option for drug administration during cardiac arrest in all age groups. Guidelines recommend that drugs be administered through an IO route if IV access is difficult or impossible to obtain.⁶ The providers at the transplant clinic may not have been familiar with IO access or skilled in its placement.

When cardiac arrest occurs, clinicians must determine the best way to support ventilation and oxygenation. Options include standard bag-mask ventilation versus the placement of an advanced airway such as an endotracheal tube (ETT) or supraglottic airway device (SGA). In the transplant clinic, intubation was attempted, but the vocal cords were not visualized. Bag mask ventilation is a commonly used method for providing oxygenation and ventilation in patients with respiratory insufficiency or arrest. This approach has several advantages, including more straightforward implementation and potentially fewer complications.⁷ However, bag-mask ventilation without an advanced airway device may not allow adequate ventilation in all patients and does not protect against pulmonary aspiration of orogastric secretions. As a result, advanced airway devices are frequently placed by providers during CPR.⁶

In 2015, and again in 2019, the International Liaison Committee on Resuscitation (ILCOR) evaluated the evidence comparing the effect of bag-mask ventilation versus advanced airway placement on overall survival and neurologic outcome from cardiac arrest. Based on their review and updated recommendations, either a bag-mask device or an advanced airway may be used for oxygenation and ventilation during CPR in both in-hospital and out-of-hospital settings.⁸ Thus, the choice of bag-mask ventilation versus advanced airway insertion should be determined by the skill and experience of the provider.⁶ Given their unsuccessful attempts at ETT placement, the clinicians at the transplant clinic should have used bag-mask ventilation until the arrival of emergency medical personnel.

Adherence to ACLS algorithms was also limited by lack of a power outlet for suctioning to clear the airway. Suctioning is an essential component of maintaining a patient’s airway and it is part of BLS and ACLS airway management. Suction devices consist of both portable and wall-mounted units, and most crash carts are stocked with a portable device. Portable suction machines are equipped with disposable or rechargeable batteries that can provide suction capabilities when a reliable power source is not available, along with a power cord that can be used to charge the machine when resuscitators are close to a power outlet. In this case, the providers may have been confused by the power cord and not realized that the suction device ran on batteries. We informally surveyed several nurses and physicians on several units about the portable suction device contained in their crash carts. None of the surveyed staff knew that the portable suction machine was powered by rechargeable batteries. Simply turning the suction machine on, without plugging it in, was all that was needed to effectively suction the airway.

Lack of Effective Communication Required for ACLS Execution

The challenges of ACLS execution in a hospital ward as well as in more unconventional settings, such as the clinic hallway, demonstrate the value of enhanced communication skills training. The skills required to run an effective code include effective multidisciplinary communication, familiarity with the type of equipment contained in the crash cart, and skill in effectively using the equipment. The American Heart Association (AHA) suggested the “pit crew” model to improve code team communication and key ACLS metrics.⁹ Teams are comprised of members from diverse disciplines with delineated roles and responsibilities that ideally work together to determine diagnoses, develop care plans, conduct procedures, provide appropriate follow-up, and generally provide quality care for patients.¹⁰ Teamwork and communication failures likely had a role in what appears to have been a chaotic, disorganized, and poorly coordinated approach to resuscitation in both cases.

Approaches to Improve Patient Safety

The errors that occurred in both cases reflect errors of omission that commonly occur in healthcare settings. Root causes may include not formulating a plan that anticipates potential consequences, communication gaps, and deficiencies in clinician education, training, orientation, and experience¹¹. Especially pronounced in case 2 were technical failures associated with medical equipment and lack of consistency in procedures¹¹.

Anticipation and careful planning may prevent some of these errors from occurring. For example, clinics that need to evaluate patients’ functional status or exercise tolerance before surgery should consider a more structured, monitored approach. This assessment should be performed in a designated area where critical ACLS equipment (i.e., crash cart) is available, including an electrical outlet and adequate illumination. Use of a treadmill may be safer than having the patient walk up three flights of steps, as stairwells are usually located in areas that are hard to access and suboptimal for implementing ACLS.

Interventions to improve proficiency in ACLS can also help to prevent such errors of omission. These interventions include classes on emergency resuscitation, demonstrations of resuscitative equipment, use of computer or video-based practice scenarios, or simulation centers where members can practice what they have learned¹². However, it is important to acknowledge the limited live experience that clinicians have in using and maintaining ACLS skills. Mock codes can help team members to gain hands-on experience with resuscitative equipment and medications to rehearse their responsibilities, and to identify educational or competency needs. They can also decrease team member anxiety, build confidence, improve response times, enhance critical thinking skills, and improve teamwork.¹² Mock interventions should be based on the American Heart Association’s BLS and ACLS principles and algorithms. During a mock code, team members should become familiar with their facility’s emergency cart, the standard defibrillator and the automatic external defibrillator, and where these items are located. The educator should review equipment functions and discuss issues such as transcutaneous pacing and synchronized electrical cardioversion.¹² High-quality CPR and the timely use of the defibrillator have been associated with improved survival; these treatments should be prioritized over other interventions to increase survival rates.^13,14

Finally, there have been a number of quality improvement interventions to improve outcomes during cardiac arrest. Before 2000, a lack of uniformity in reporting cardiac arrest outcomes, patient population, and variables existed. To address this deficiency, the 1997 ILCOR developed and published guidelines for reviewing, reporting, and conducting research on in-hospital resuscitation.^15,16 On January 1, 2000, the American Heart Association (AHA) launched the National Registry of Cardiopulmonary Resuscitation (NRCPR), and in 2010, the NRCPR was incorporated into the AHA Get-With-The-Guidelines-Resuscitation program. This quality improvement program was enhanced with additional tools and resources designed to facilitate the efficient capture, analysis, and reporting of data from inpatient cardiac arrests. The data from these registries have been the driving force behind changes to responses and processes in cardiac arrest events.¹⁷

In summary, successful execution of ACLS algorithms and guidelines are critical to optimizing outcomes during cardiopulmonary arrest. These guidelines are applicable to a variety of both conventional settings, such as the medical intensive care unit or hospital ward, and unconventional settings, such as the clinic hallway or bathroom. All clinical providers in these settings should be familiar with ACLS guidelines and competent in the skills needed for effective multi-disciplinary communication and use of the available crash-cart equipment. This proficiency can be maintained by Code Blue drills or mock codes.

Take-Home Points

• Adherence to ACLS algorithms provides the best chance of optimal outcomes from cardiac arrest in the intensive care unit or the hospital ward, or more unconventional locations, such as the radiology suite or clinic.
• Successful teams not only have medical expertise and mastery of resuscitation skills, including use of the available equipment, but they also demonstrate effective communication and team dynamics.
• The use of mock codes can help providers in clinical settings gain hands-on experience with resuscitative equipment and medications. Mock codes can reinforce knowledge and skills competencies while also identifying gaps that require additional training.

Garima Agrawal, MD, MPH
Associate Physician Diplomate
Division of Hospital Medicine
Department of Internal Medicine
University of California, Davis
gagrawal@ucdavis.edu

Mithu Molla, MD, MBA
Health Sciences Clinical Professor
Chief, Division of Hospital Medicine
Department of Internal Medicine
University of California, Davis
mmolla@ucdavis.edu

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