Review of: Shah M, Fairbanks R, Lerner E: "Cardiac arrests in skilled nursing facilities: Continuing room for improvement?" Journal of the American Medical Directors Association. 7(6):350-354, 2006
This paper, which was published in a relatively obscure journal, examined cardiac arrests of patients at the Rochester, New York, skilled nursing facilities (SNF) and compared them to those in the community.
Over a three-year period, a total of 8% of all cardiac arrests in this study occurred at the SNF. From the SNF group, 38% of the patients that had a cardiac arrest were witnessed, and 67% of those that had a cardiac arrest at the SNF received CPR. No patient in either group received defibrillation prior to EMS arrival. After one year from the initial arrest, 2% of the SNF patients were still alive, compared to 5% of the community dwelling population.
The authors' conclusion states, "SNF patients suffering cardiac arrest often did not receive CPR or defibrillation while awaiting EMS arrival. SNF patients have a very low survival rate, similar to the community dwelling population."
OK, many of you will say, "So what else is new?" But this paper raises some interesting questions. Though the paper had relatively low numbers to examine, there were some significant differences between the two groups that may have bearing on the results.
The average age of nursing home patients at the SNF was 74 years old, compared to 66 years old in the community. This was significant. Another significant fact is that the ethnicity of the SNF patients did not mirror that of the community. At the SNF, 79% of the patients were white and 19% of the patients were black, while those in the community were 48% white and 37% black. There have been reports that black community dwelling cardiac arrests have worse outcomes comparable white communities.
Another interesting thing to point out is that the SNF patients were three times more likely to have CPR performed on them prior to EMS arrival than those in the community. The conclusion statement that they "often did not receive CPR" is misleading, as the SNF patients actually received CPR more frequently than did the general population. Neither group had the benefit of AED use.
One last difference to take note of is that the SNF patients were more likely to be in asystole or PEA than those in the community.
So what does this study tell us? You can't simply take the conclusion of the study as the final take home message. These two populations were clearly different. Drawing any conclusions regarding the efficacy of CPR and defibrillation of skilled nursing home patients.
The real question we face is, what is the value of cardiac arrest resuscitation of nursing home residents? The fact that they are older and may have more co-morbid medical conditions and poorly defined advanced directives makes answering this question impossible by comparing them to the general population. Should there be AEDs in nursing homes? Would it make a difference? Just because you are in a nursing home should not mean we won't attempt to resuscitate you. More and more elderly patients are staying in these facilities for short-term rehabilitation following strokes, surgery and prolonged hospitalizations.
The only way to answer those questions is to compare similar populations with standard methodologies. This will require a multi-center approach with a large number of nursing homes.