Perception of inappropriate cardiopulmonary resuscitation by clinicians working in emergency departments and ambulance services: The REAPPROPRIATE international, multi-centre, cross sectional survey

Abstract

Introduction: Cardiopulmonary resuscitation (CPR) is often started irrespective of comorbidity or cause of arrest. We aimed to determine the prevalence of perception of inappropriate CPR of the last cardiac arrest encountered by clinicians working in emergency departments and out-of-hospital, factors associated with perception, and its relation to patient outcome. Methods: A cross-sectional survey was conducted in 288 centres in 24 countries. Factors associated with perception of CPR and outcome were analyzed by Cochran-Mantel-Haenszel tests and conditional logistic models. Results: Of the 4018 participating clinicians, 3150 (78.4%) perceived their last CPR attempt as appropriate, 548 (13.6%) were uncertain about its appropriateness and 320 (8.0%) perceived inappropriateness; survival to hospital discharge was 370/2412 (15.3%), 8/481 (1.7%) and 8/294 (2.7%) respectively. After adjusting for country, team and clinician's characteristics, the prevalence of perception of inappropriate CPR was higher for a non-shockable initial rhythm (OR 3.76 [2.13-6.64]; P < .0001), a non-witnessed arrest (2.68 [1.89-3.79]; P < .0001), in older patients (2.94 [2.18-3.96]; P < .0001, for patients > 79 years) and in case of a "poor" first physical impression of the patient (3.45 [2.36-5.05]; P < .0001). In accordance, non-shockable and nonwitnessed arrests were both associated with lower survival to hospital discharge (0.33 [0.26−0.41]; P < 0.0001 and 0.25 [0.15−0.41]; P < 0.0001, respectively), as were older patient age (0.25 [0.14−0.44]; P < 0.0001 for patients > 79 years) and a "poor" first physical impression (0.26 [0.19-0.35]; P < 0.0001). Conclusions: The perception of inappropriate CPR increased when objective indicators of poor prognosis were present and was associated with a low survival to hospital discharge. Factoring clinical judgment into the decision to (not) attempt CPR may reduce harm inflicted by excessive resuscitation attempts.

Cardiopulmonary Resuscitation in Adults Over 80: Outcome and the Perception of Appropriateness by Clinicians

“…To attain a greater synergy between the clinician's perception of appropriateness of CPR and the expected patient outcome, we propose several interventions. Resuscitation team leaders should invite and take into account the opinion of their team members regarding the appropriateness of a CPR attempt, apart from their clinical role, especially when they are experienced . Closed‐loop systems assuring that all clinicians involved in a CPR attempt receive feedback on the patient's outcome will improve their clinical insight for future encounters.…”

“…The observed low prevalence of perception of inappropriate CPR in patients with a poor outcome emphasizes the “CPR by default” mindset of clinicians. In the main survey, statistical adjustment for ROSC did not affect the findings . Second, no linkage was made to medical records; therefore, data on survival to hospital discharge were provided solely by the clinician and were incomplete in some cases.…”

“…Resuscitation team leaders should invite and take into account the opinion of their team members regarding the appropriateness of a CPR attempt, apart from their clinical role, especially when they are experienced. 13 Closed-loop systems assuring that all clinicians involved in a CPR attempt receive feedback on the patient's outcome will improve their clinical insight for future encounters. Within teams, time should be made for debriefing and interdisciplinary ethical reflection to improve decision making for the benefit of their patients.…”

“…In the main survey, statistical adjustment for ROSC did not affect the findings. 13 Second, no linkage was made to medical records; therefore, data on survival to hospital discharge were provided solely by the clinician and were incomplete in some cases. Third, we cannot exclude that some clinicians reported on the same patient, which might influence the outcome results.…”

“…After creating a network of national coordinators with a lead position in national or international scientific organizations or conducting research related to emergency medicine, 288 centers were recruited in 24 countries. More in‐depth information on the study protocol can be found in an earlier publication …”