Hospital and Health System

Reducing ER Visits with New Life Support Rules

A new study in the Journal of the American Medical Association shows that a single standard guideline could help EMS and ER teams determine which cardiac arrest victims might benefit from a trip to the hospital, while at the same time reducing futile efforts on patients who have no chance of surviving a cardiac arrest.

The study shows that EMS teams can use either a simple five- or three-part rule to determine when they should discontinue efforts to revive cardiac arrest patients on the scene where their heart stopped beating. The same rule will also tell them when they should keep trying to resuscitate the patient while transporting him or her to the nearest ER. The three-part rule may be sufficient to identify 99.8 percent of those who need to be transported to the hospital for further care, the researchers say.

The three-part rule, called a ‘basic life support’ or BLS rule, calls for EMS teams to end their resuscitation efforts if a cardiac arrest occurred before EMS arrived, if no defibrillator was used (for instance, because there was none for a bystander to use, the EMS crew didn’t have one, or an automated external defibrillator (AED) did not detect a shockable rhythm), and if the team can’t get the patient’s blood to begin circulating again. All three must apply for resuscitation efforts to be stopped. The five-part rule, called the ‘advanced life support’ or ALS rule, adds two more criteria to the list: the cardiac arrest had no witnesses at all, and no bystander attempted to perform CPR. If this more conservative rule had been applied to the 5,505 cardiac arrest victims in the study, 1,192 patients would have been declared dead at the scene, saving 245 trips to the ER.

The study also found that:

• EMS crews pronounced 947 (17 percent) of the 5,505 patients dead at the scene between late 2005 and early 2008. The other 4,558 were transported to one of 111 hospitals by one of 19 EMS agencies. But only 7.1 percent of those transported patients survived long enough to be discharged from the hospital alive.
• If ambulance and fire crews had applied the three-part rule, about 47 percent of all the cardiac arrest patients in the study would not have met the criteria to be transported by ambulance to the hospital. This means that 2,592 patients would have been pronounced dead at the scene — potentially saving 1,645 trips to the ER, compared with what actually happened.
• Only 70 patients who would have been declared dead under the BLS rule survived the ER treatment and were admitted to the hospital. But only five were discharged from the hospital alive, and four of them were able to live a relatively normal life afterward. Meanwhile, only 24 patients who would have been declared dead under the more conservative ALS rule were able to be resuscitated in the ER. None of them survived long enough to be sent home from the hospital.