Trends in Cardiopulmonary Resuscitation Response Times in a Community Hospital in the COVID-19 Era

Abstract

Cardiopulmonary resuscitation (CPR) involves numerous aerosol-generating procedures that increase the risk of coronavirus disease 2019 (COVID-19) exposure to providers. Modified guidelines recommend that all rescuers don personal protective equipment before performing CPR.1Edelson DP Sasson C Chan PS et al.Interim guidance for basic and advanced life support in adults, children, and neonates with suspected or confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With The Guidelines-Resuscitation Adult and Pediatric Task Forces of the American Heart Association.Circulation. 2020; 14: 933-943Google Scholar We aimed to clarify the effect of such a protocol on the administration of CPR during in-hospital cardiopulmonary arrest (CPA). A retrospective chart review was performed of the CPA events that occurred in non-COVID patients from March to November 2019, and in COVID patients during a similar time frame in 2020. A total of 121 non-COVID and 28 COVID CPA events were reviewed. The response time to perform key resuscitation steps was abstracted for each group, including time of the code, time to arrival of respiratory therapy and anesthesia teams, time to initiation of CPR, first epinephrine bolus administration, as well as time to intubation. At our hospital, intubation is performed solely by the anesthesia team. Patients who were already intubated at the time of a CPA were excluded. There was no delay seen in starting chest compressions or arrival of the code team including respiratory therapy once a CPA was identified in COVID patients. Intubation of COVID-19 patients, however, was affected (11 minutes v seven minutes, 95% confidence interval [CI] 1.94-6.06, p < 0.001). This may be attributed to a comparatively prolonged anesthesia arrival time (four minutes v three minutes, CI 0.17-1.83, p = 0.01) despite similar CPA locations. Total code time was shorter in the COVID cohort at 12 minutes versus 20 minutes (CI 3.93-12.07, p < 0.001). Likewise, survival of the code and survival to hospital discharge was lower in the COVID group (43% v 69%, p = 0.02 and 4% v 75%, p < 0.001). We report poor survival of in-hospital CPA in COVID-19 patients. This is consistent with recent reports that have shown no survival to discharge in this population despite return of spontaneous circulation in 13%-to-54% of reported CPAs.2Thapa SB Kakar TS Mayer C et al.Clinical outcomes of in-hospital cardiac arrest in COVID-19.JAMA Intern Med. 2020; 181: 279-281Crossref Scopus (49) Google Scholar,3Shao F Xu S Ma X et al.In-hospital cardiac arrest outcomes among patients with COVID-19 pneumonia in Wuhan.China. Resuscitation. 2020; 151: 18-23Abstract Full Text Full Text PDF PubMed Scopus (187) Google Scholar Thus, safety of first responders and infection control should be prioritized. Previous transmission of severe acute respiratory syndrome coronavirus 1 to providers during CPR has occurred and is highly probable to occur with COVID-19.4Christian MD Loutfy M McDonald LC et al.SARS Investigation Team. Possible SARS coronavirus transmission during cardiopulmonary resuscitation.Emerg Infect Dis. 2004; 10: 287-293Crossref PubMed Scopus (205) Google Scholar Initiation of CPR was similar in both groups, because providers already were wearing personal protective equipment and often in the room at the beginning of the event. Primary resuscitation delays were seen with intubation. Despite almost similar arrival time of anesthesia to the CPA between the two groups, anesthesia providers arrived on-site without donned equipment and often needed assistance to locate available equipment throughout the unit before intubation. Watson et al. previously reported delays to CPR when donning gowns in mannequin simulation situations.5Watson L Sault W Gwyn R et al.The “delay effect” of donning a gown during cardio-pulmonary resuscitation in a simulation model.CJEM. 2008; 10: 333-338Crossref PubMed Scopus (14) Google Scholar Simple gown modifications, including pretied neck straps and longer waist ties that tie in front, shortened delays and may need to be considered in COVID-19 situations.5Watson L Sault W Gwyn R et al.The “delay effect” of donning a gown during cardio-pulmonary resuscitation in a simulation model.CJEM. 2008; 10: 333-338Crossref PubMed Scopus (14) Google Scholar Our institution now has stocked gowns and N95 masks in unit code carts. The clinical implications of this delay and its possible contribution to overall poor survival in COVID-19 patients’ needs to be explored further. No conflicts exist for all authors.