Kevin Stewart

Predicting unsuccessful cardiopulmonary resuscitation (CPR): a comparison of three morbidity scores.

The aim of the study was to assess the usefulness of three different morbidity scores in predicting unsuccessful resuscitation. We reviewed the records of adult patients who underwent CPR between September 1994 and June 1996 in The Royal Hampshire County Hospital, Winchester. Demographic data and enough clinical data to calculate the Pre-Arrest Morbidity score (PAM), the Prognosis After Resuscitation score (PAR) and the Modified PAM Index (MPI) were collected. During the study period 264 consecutive adult patients underwent inpatient CPR. Twenty-eight (11%) of the patients survived to discharge from hospital. Patients who died had significantly higher morbidity scores than those who survived. No patient with a PAM score greater than 6/25, PAR greater than 7/28 or MPI greater than 6/24 survived. There were 47/264 patients who scored above this threshold for the PAM score giving a sensitivity for predicting unsuccessful CPR of 20%. The sensitivity of the PAR was 29% and MPI was 22%. Each score identified a different group of patients for whom CPR was unsuccessful. Using all three scores in combination identified 42% of the unsuccessful CPR attempts. Morbidity scores are likely to need further refinement in order to be a useful bedside tool for predicting success for individual patient resuscitation attempts.

Weekly variation in health-care quality by day and time of admission: a nationwide, registry-based, prospective cohort study of acute stroke care.

BACKGROUND Studies in many health systems have shown evidence of poorer quality health care for patients admitted on weekends or overnight than for those admitted during the week (the so-called weekend effect). We postulated that variation in quality was dependent on not only day, but also time, of admission, and aimed to describe the pattern and magnitude of variation in the quality of acute stroke care across the entire week. METHODS We did this nationwide, registry-based, prospective cohort study using data from the Sentinel Stroke National Audit Programme. We included all adult patients (aged >16 years) admitted to hospital with acute stroke (ischaemic or primary intracerebral haemorrhage) in England and Wales between April 1, 2013, and March 31, 2014. Our outcome measure was 30 day post-admission survival. We estimated adjusted odds ratios for 13 indicators of acute stroke-care quality by fitting multilevel multivariable regression models across 42 4-h time periods per week. FINDINGS The study cohort comprised 74,307 patients with acute stroke admitted to 199 hospitals. Care quality varied across the entire week, not only between weekends and weekdays, with different quality measures showing different patterns and magnitudes of temporal variation. We identified four patterns of variation: a diurnal pattern (thrombolysis, brain scan within 12 h, brain scan within 1 h, dysphagia screening), a day of the week pattern (stroke physician assessment, nurse assessment, physiotherapy, occupational therapy, and assessment of communication and swallowing by a speech and language therapist), an off-hours pattern (door-to-needle time for thrombolysis), and a flow pattern whereby quality changed sequentially across days (stroke-unit admission within 4 h). The largest magnitude of variation was for door-to-needle time within 60 min (range in quality 35-66% [16/46-232/350]; coefficient of variation 18·2). There was no difference in 30 day survival between weekends and weekdays (adjusted odds ratio 1·03, 95% CI 0·95-1·13), but patients admitted overnight on weekdays had lower odds of survival (0·90, 0·82-0·99). INTERPRETATION The weekend effect is a simplification, and just one of several patterns of weekly variation occurring in the quality of stroke care. Weekly variation should be further investigated in other health-care settings, and quality improvement should focus on reducing temporal variation in quality and not only the weekend effect. FUNDING None.

Effect of witnessed resuscitation on bereaved relatives

Sir—Sue Robinson and colleagues’ (Aug 22, p 614) results cannot be said to be meaningful enough to support Robinson’s view, available on the internet from the day that the paper was published (http://news.bbc.co.uk/ hi /engl ish/health/newsid—154000 /154852.stm), that it should become common practice for relatives to be allowed to witness resuscitation. The main reason that relatives are excluded from watching resuscitation is to protect patient confidentiality, rather than to spare the next of kin psychological distress. Doctors have a duty of confidentiality to patients and are obliged to treat them with due regard to privacy and dignity. This duty extends to the critically ill and those who subsequently die. To allow relatives to be present during resuscitation breaches this confidentiality, and if patients survive they could theoretically take legal action. That Robinson and colleagues did not encounter problems with their three survivors is hardly reassuring. The methodology of Robinson’s study seems to have been weakened because, over 15 months, only 25 patients were recruited. There is no indication what proportion of total resuscitation attempts this number represents, and without this information it is difficult to be convinced that the study group was representative. The investigators administered a battery of psychological tests to eight relatives who had witnessed resuscitation. We doubt the validity of this approach given the small numbers of patients in the study and the uncertain nature of their selection. They state that the tests found lower psychological morbidity in the group who witnessed resuscitation, but do not mention that this did not reach significance for any test. This finding is hardly surprising since their own calculation had predicted that they would need 64 patients in each group to detect a moderate effect. 14 references are cited, the most recent published in 1995, but we are surprised that no reference is made to the Resuscitation Council’s 1996 report on this subject. Surely its content is highly relevant to this study. The trial was terminated because the “clinical team became convinced of the benefits to relatives of allowing them to witness resuscitation”. This is a value judgment that calls into question the objectivity of the study. Robinson and colleagues have undertaken a difficult task, but, in this era of evidence-based medicine, it is surely not acceptable to advocate widespread changes to medical practice based on interviews with eight people, no matter how well the study may be publicised in the lay media.

Elderly patients and resuscitation. Some patients can benefit.

EDITOR, - Marguerite E Hill and colleagues and R Morgan and colleagues have highlighted the difference between doctors and patients regarding resuscitation decision making.1,2 We sought the opinions of doctors and nurses regarding 100 elderly patients admitted through casualty in a district general hospital. All patients were over 70 (mean age 80 years); 59 were admitted under the care of a general physician and 41 a geriatrician. There was no formal resuscitation policy. A questionnaire was completed by the junior doctor (senior house officer or registrar) and senior ward nurse in all cases and by the consultant in 88 cases. Each was asked whether the patient that had taken place, and the importance of various factors (graded on a scale of 1-5) in making a decision. There was no significant difference, by matched analysis, between junior and senior doctors in the likelihood of making a decision for resuscitation; consultants felt that 55/88 (63%) should be resuscitated and juniors 63/100 (63%). In 23/88 (26%) cases there was disagreement between junior and senior doctors. Nurses felt that 51/100 (51%) should be resuscitated. In only 53/88 (60%) cases was there agreement among all three groups. There was no difference between general physicians and geriatricians. In only 7/33 (21%) cases, when the consultant felt that resuscitation was not appropriate, had there been any discussion of resuscitation with either the …