Home Blog Shock first, ask later

Shock first, ask later

January 2008

I am always intrigued by the potential impact of any study that concerns hospital medicine, is the lead study for NEJM and lands on the front page of the New York Times. No doubt, this particular study, Delayed Time to Defibrillation after In-Hospital Cardiac Arrest, has the potential to affect hospitalists in many ways.

At first glance, it seems to be just one more article that confirms what the IHI has been telling us and the public for years: that hospitals are very dangerous places. The IHI estimates that there are 40,000 “instances of medical harm” that occur in the hospital every day.

Moreover, if any of these “instances” results in a ventricular tachycardia arrest–well, you may wish you were at an airport or casino instead, because you’d have a better chance of surviving. Of course, this survival-rate comparison involves two different patient populations; those crowding the casinos are generally healthier than our hospitalized patients. (Anyone who has been to a casino on a Tuesday morning may contest this assumption).

Whenever an article demonstrates that things need to be improved in the hospital, we hospitalists generally take this to be a validation of our existence and justification of our mission. Although improving time to defibrillation may become one of our new value-added rallying cries, the article had some interesting points that we might want to consider before we go off to battle.

The first point is that no matter how good we think we may be at running codes for ventricular arrhythmia, a computer probably can do it better. I am not sure if this means that automation is the answer to the hospitalist shortage. But it is important to realize that, much like protocol driven care algorithms, sometimes less is more when it comes to cognitive practices.

Second, short staffing on nights and weekends, as this study and others have suggested, results in poorer patient outcomes. I think this may further strengthen the trend to in-house hospitalist coverage and make it more evident that programs need to be prepared to staff the same on weekends as during the week. Of course, neither 24-hour coverage nor 100% weekend coverage is easily accomplished in this tight hospitalist job market.

Finally, I pride myself on resource allocation. When case management reminds me that we are short on telemetry beds, our team works very hard to triage patients to non-telemetry units. This study suggested, however, that those off telemetry had longer times to resuscitation.

No surprise there, but does that mean I need to think twice before releasing patients from telemetry for fear of medico-legal consequences, no matter how stable my patient may be?

And I imagine that hospital CEOs everywhere are cringing. Will it become the standard of care to place a defibrillator in every room? (Maybe private rooms aren’t such a good idea after all. Perhaps we need to teach roommates how to use automated defibrillators.)

Defibrillators in every room might be affordable, but what about expanding telemetry to link all patients to a central, automated system that recognizes and sounds an alert for an arrhythmia? That solution is alluded to in the NEJM commentary. But in the last few hospitals where I’ve worked, I saw them struggle mightily to expand their telemetry capacity, and I know that the funding for such expansion does not come easily.

Despite some of the issues that bear consideration, I am sure that we hospitalists will be at the forefront of improving time to defibrillation in the hospital. In time, cardiac-arrest-to-shock time may even become a standard measurement akin to door-to-catheterization time in acute MIs. In the end, the key point that I take away from this study is that I need to arrive at codes quickly–and be prepared to shock first and ask questions later.