Article, Rheumatology

Resident physician predictions of survival from cardiopulmonary resuscitation

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Resident physician predictions of survival from cardiopulmonary resuscitationB

To the Editor,

Cardiopulmonary resuscitation (CPR) is highlighted frequently on television, portraying unrealistically high success rates. Multiple surveys have also revealed unreal- istically high expectations of success. Jones et al [1] found expectations to be as high as 75% among the American public and attributed this to the use of television as a source of information. Roberts et al [2], in a study of attending physicians and nurses, found predictions of 24% and 30% survival for adult CPRs, respectively. Overall survival rates to hospital discharge, however, average less than 16% both for out-of-hospital and inhospital arrests [3-9].

Our goal was to examine expectations of success of CPR among residents because we found no studies of prediction rates for residents. We also sought to determine differences between emergency medicine (EM) and non-EM residents’ expectations, hypothesizing that EM physicians were more familiar with CPR and therefore have more realistic expectations. Overly optimistic expectations for success rates of CPR have important adverse implications because lofty optimism may be conveyed to family members while also leading to prolonged futile resuscitations.

We administered a structured survey to residents at scheduled educational conferences at several suburban and urban teaching hospitals. The survey distribution was prefaced by an expectation of prompt return, and the surveys were briefly reviewed for completeness before acceptance by the monitor.

The survey included demographics of the residents, percentage of estimates of patient survival to hospital discharge after CPR, and estimates of surviving patients’ likelihood to return to previous level of neurologic function after a CPR event for 2 groups: older and younger than 55 years.

B This study was funded in part by Emergency Medical Associates Research Foundation, Morristown, NJ.

1 Previously post-graduate year-3; currently Emergency Medical Services Fellowship Director and assistant professor of Emergency Medicine, University of Maryland School of Medicine, Baltimore.

We used SPSS (version 7.5 for Windows, SPSS, Chicago, IL) using 2-tailed Student t tests, with a set at

.05. A priori Power calculations revealed that we needed 120 surveys in each group to have an 80% power to detect a difference of 10%. The institutional review board approved the study.

Of the 266 surveys, there were 146 EM and 120 non-EM residents. The number of non-EM responding residents included 51 family practice, 24 internal medicine, 22 pedi- atrics, and 23 from other residencies. We estimated a completed survey return of greater than 95%.

There were differences in resident level of training between EM and non-EM groups: 2.5 F 0.1 years for EM and 1.9 F 0.1 years for non-EM. The mean age was 31 years for both groups. Emergency medicine residents were more likely to have completed courses in advanced cardiac life support (99% vs 82%), pediatric advanced life support (64% vs 36%), and APLS (19% vs 7%). More EM residents took part in a CPR save in the past 2 years: 88% for EM vs 66% for non-EM residents.

The EM residents’ predictions were consistent with reported success rates, whereas non-EM residents responses for all CPR success categories were statistically significantly higher (see Table 1).

There has been widespread use of CPR since its formal introduction to the medical community in the early 1960s. With nearly 600 000 sudden cardiac deaths occurring annually in the United States, successful resuscitation does take place but is not the norm. Previous studies have shown expectations of success to be unrealistically high.

Our study shows that EM residents have statistically lower perceptions of CPR and more realistic perceptions of CPR success rates than non-EM residents. The differ- ences in expectations between the EM and non-EM groups were greater than 10% in all categories. Emergency medicine residents’ more accurate perception of CPR and its outcome may be due to their greater familiarity with CPR. These differences, however, may be attributed in part to the greater number of resuscitation courses taken by EM residents and the greater number of years spent in residency in our sample: 2.5 years for EM vs 1.9 years for non-EM residents.

We surveyed residents mainly in the metropolitan New York City area. We did not have enough residents in each of the other residencies to allow further subset analyses, and by chance, our samples were not equivalent for average years in training. One may attempt to ascribe these differences in expectations between EM and non-EM residents to differ- ences in survival rates in the areas in which they practice. It has been shown, however, that CPR survival rates among hospitalized patients and patients in the prehospital setting are similar [10-17].

Ultimately, unrealistically high expectations place bur- dens on CPR providers to prolong their attempts despite futil- ity. This may have a cost for providers of prehospital care who rush to the hospital, risking accidents en route. Furthermore,

Table 1

Predictions of residents

b55 y

N55 y

EM

Non-EM

P

95% CI

EM

Non-EM

P

95% CI

Survival to hospital discharge (%)

16 F 1

35 F 2

b.01

3-13

7 F 1

19 F 2

b.01

8-16

Survivors functionally intact (%)

14 F 2

34 F 3

b.01

14-26

6 F 1

18 F 2

b.01

9-16

CI indicates confidence interval.

futile prolonged attempts to resuscitate take resources away from other patients. We recommend that a portion of all resuscitation courses deal with actual resuscitation rates and the downside of prolonged futile resuscitations.

Donald Alves MD1 Department of Emergency Medicine University of Maryland School of Medicine

Baltimore, MD 21201, USA Department of Emergency Medicine Morristown Memorial Hospital Morristown, NJ 07960-6136, USA

E-mail address: [email protected]

John Allegra MD, PhD Paul Allegra BA Michele Wallace BSc

Department of Emergency Medicine Morristown Memorial Hospital Morristown, NJ 07960-6136, USA

doi:10.1016/j.ajem.2005.03.011

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