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Wednesday, September 18, 2013

New score predicts likelihood of good outcome after in-hospital CPR

Researchers have developed a simple score, useful in discussing do-not-resuscitate orders, which can identify patients who aren't likely to benefit from a resuscitation attempt if they experience in-hospital cardiac arrest.

Study participants were 51,240 inpatients with an index episode of in-hospital cardiac arrest (IHCA) between 2007and 2009 in 366 hospitals participating in the Get With the Guidelines-Resuscitation registry. Researchers created several candidate decision models, and used a test data set to choose the model that best classified patients with very low (<1%), low (1% to 3%), average (>3% to 15%) or higher-than-average (>15%) likelihood of surviving with good neurologic status after resuscitation for IHCA. The main outcome was a Cerebral Performance Category score of 1, meaning the patient could lead a normal life and have only minimal neurologic or psychologic deficits, like mild dysphagia. They checked the final model with a validation data set.

The best model used a simple point score based on 13 pre-arrest variables available at the time of admission: neurologically intact or with minimal deficits at admission, major trauma, acute stroke, metastatic or hematologic cancer, septicemia, medical noncardiac diagnosis, hepatic insufficiency, admitted from skilled nursing facility, hypotension or hypoperfusion, renal insufficiency or dialysis, respiratory insufficiency, pneumonia and older age. Results were published online September 9 by JAMA Internal Medicine.

The resulting clinical prediction rule, the Good Outcome Following Attempted Resuscitation (GO-FAR) score, had a C statistic of 0.78 when applied to the validation set. Overall, the score identified more than a quarter of patients as having low or very low likelihood of surviving to discharge neurologically intact or with minimal deficits after IHCA. Specifically, the score identified 9.4% and 18.9% of patients, respectively, as having very low or low likelihood of a good outcome. Fifty-four percent were identified as having average likelihood of a good outcome and 17.7% as having an above-average likelihood of a good outcome.

The score could be helpful when counseling patients about their "do not resuscitate" (DNR) orders, the authors wrote, adding that past research has found most patients significantly overestimate their post-CPR survival chances. The score could be built into the admission process, they added, and integrated with patient values and expectations to optimize decision making about DNR orders. To this end, the researchers said they are creating a web-based tool to give patients general information about CPR, provide individual estimates of outcomes, and to help them specify their treatment preferences.

An editorial note praised the score but cautioned it should be used "in conjunction with, not as a replacement for, clinical judgement" since such scores "often do not identify subtle patient characteristics … that may render the patient's chance of a good outcome either better or worse than that predicted by the index." The note added that doctors should get a clear sense of patients' wishes as "many patients would accept CPR if it allowed survival with more moderate or even severe forms of disability."

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