What is your code recovery rate?

[valianteffort]

Recently had been reflecting on the recents codes I have had. I previously worked in a rural town in America for the span of a few years, it felt I had approximately half of the people code achieve ROSC. Yes, a lot of them were likely brain dead but it felt great to be able to let the family say goodbye one last time with the patient 'alive' with some folks having some meaningful recovery.
Over the span of my last few months working in a busy city ER in the South, I can not recall the last code I was able to achieve ROSC on. Atleast the last 10 I was unable to get back and had to pronounce dead.
Its a pretty standard algorithm as everyone knows. Curious if there is some regional variance (due to transport times/hospital staffing/ems competence/etc) as in my experience I have had it. Could just be a fluke though.
How often are you guys able to achieve ROSC?

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[bravotwozero]

If I said 2%, it would be generous.

 

[turkeyjerky]

Most of my time has been in the 'stay and play' era of pre-hospital SCA management, so I would say the recovery rate for patient whom arrive in arrest is quite low. It's a little higher for patients who arrest en route but no where near 50%.

I wouldn't be surprised at all about a streak of 10 straight expirations.

 

[EctopicFetus]

Most of my time has been in the 'stay and play' era of pre-hospital SCA management, so I would say the recovery rate for patient whom arrive in arrest is quite low. It's a little higher for patients who arrest en route but no where near 50%.

I wouldn't be surprised at all about a streak of 10 straight expirations.

AHA says 9%.

CPR Facts and Stats

Read the latest stats and CPR facts, survival rates, success of CPR, and why training more Americans in high-quality CPR is so important to the AHA.

cpr.heart.org

 

[BoardingDoc]

Recently had been reflecting on the recents codes I have had. I previously worked in a rural town in America for the span of a few years, it felt I had approximately half of the people code achieve ROSC. Yes, a lot of them were likely brain dead but it felt great to be able to let the family say goodbye one last time with the patient 'alive' with some folks having some meaningful recovery.
Over the span of my last few months working in a busy city ER in the South, I can not recall the last code I was able to achieve ROSC on. Atleast the last 10 I was unable to get back and had to pronounce dead.
Its a pretty standard algorithm as everyone knows. Curious if there is some regional variance (due to transport times/hospital staffing/ems competence/etc) as in my experience I have had it. Could just be a fluke though.
How often are you guys able to achieve ROSC?

Rosc? Maybe 10%
Neurologically intact rosc? Maybe 1%.

I find your comment about braindead rosc interesting. I very much see those cases as a massive loss and not as a win. Invariably those families don't "say goodbye one last time." They have a vegetable family member on a ventilator who either lingers for days/weeks in the ICU before they die, actively taking up a bed that could be used by a patient I could actually help, or they survive to DC to an LTAC where they exist solely to collect bedsores and bankrupt the family who feels that making the patient CMO would be killing them.

 

[CoolDoc1729]

Rosc? Maybe 10%
Neurologically intact rosc? Maybe 1%.

I find your comment about braindead rosc interesting. I very much see those cases as a massive loss and not as a win. Invariably those famies don't "say goodbye one last time." They have a vegetable family member on a ventilator who either lingers for days/weeks in the ICU before they die, actively taking up a bed that could be used by a patient I could actually help, or they survive to DC to an LTAC where they exist solely to collect bedsores and bankrupt the family who feels that making the patient CMO would be killing them.

Recently had a family member pass away … It was very much time to make her comfort care .. even my mom and brother, who are highly educated but non medical, are like aren’t we starving her to death? No, we’re not forcing her to eat or putting in a feeding tube, we’re letting her decide she’s done eating and she’s ready to be done. I think the general public has no clue what they should do in these circumstances. I’m glad I was there to guide the discussion.

10% sounds right for ROSC. Where I work now, they only transport if they get pulses back though, so that’s a big factor vs other places I’ve worked where they transport with cpr in progress.

 

[GonnaBeADoc2222]

Non-neurologically intact ROSC is a massive L

 

[Tipsy McStagger]

I'd say that ROSC is not a marker of success. Follow up on how many of your ROSC patients actually leave the hospital alive, neurologically intact. That's something.

I wish the culture of American medicine allowed for more flexibility with respects to who gets coded, who gets admitted to an ICU and so on. But I suppose we have to practice within the realms we have.

If I had money, I'd take out a superbowl add that just shows a code in progress. No words, just the code, and at the end the patient dies, with frothy bloody sputum coming from their ETT, mottled and horrible looking. Then at the end it'd say something like "go fill out a realistic POLST you rascal"

 

[CoolDoc1729]

I'd say that ROSC is not a marker of success. Follow up on how many of your ROSC patients actually leave the hospital alive, neurologically intact. That's something.

I wish the culture of American medicine allowed for more flexibility with respects to who gets coded, who gets admitted to an ICU and so on. But I suppose we have to practice within the realms we have.

If I had money, I'd take out a superbowl add that just shows a code in progress. No words, just the code, and at the end the patient dies, with frothy bloody sputum coming from their ETT, mottled and horrible looking. Then at the end it'd say something like "go fill out a realistic POLST you rascal"

Yeah I mean every time the family is like do everything! ::take to bedside CPR in progress:: please stop
I blame in part the medical tv shows - everything is immediate, every doctor can fill into every specialty and unless tragedy is necessary to the plot everyone is always dramatically saved even when it seemed hopeless .. so no one believes us when we say it is hopeless or that nothing is immediate

 

[Tipsy McStagger]

Yeah I mean every time the family is like do everything! ::take to bedside CPR in progress:: please stop
I blame in part the medical tv shows - everything is immediate, every doctor can fill into every specialty and unless tragedy is necessary to the plot everyone is always dramatically saved even when it seemed hopeless .. so no one believes us when we say it is hopeless or that nothing is immediate

Oh dude, everytime the family is there and I bring them back to watch the code, I'd say 90%+ of the time they immediately ask us to stop. I've actually seen a few push people out of the way and scream "stop hurting them!" It's nuts.

I try to explain everything in my code status discussions, but everyone's a fighter and everyone's gonna be 20 years old again. It's a societal failure.

 

[turkeyjerky]

Non-neurologically intact ROSC is a massive L

Right. In terms of talking to people about code status, I see most people focus on the code itself we'll break your ribs and you probably won't survive anyway'. But to me, the biggest potential negative is ROSC + poor outcome. I don't care if someone flogs my corpse for 45 min, but I would care if I survive but end up profoundly diabled or in a persistent vegetative state.

 

[Apollyon]

I don't care if someone flogs my corpse for 45 min, but I would care if I survive but end up... in a persistent vegetative state.

In this case, you wouldn't know, so, you wouldn't care!

 

[AlmostAnMD]

Glad people are hovering around the 10% number because that's generally reflective of my experience

 

[RuralEDDoc]

In this case, you wouldn't know, so, you wouldn't care!

Maybe a joke, but we don’t really know. It could be hell.
Don’t code me if I’m sick. Code me if I’m well and drop dead. Otherwise, no thanks.

 

[Apollyon]

Maybe a joke, but we don’t really know. It could be hell.
Don’t code me if I’m sick. Code me if I’m well and drop dead. Otherwise, no thanks.

Fair enough. Yeah, maybe I was a bit flippant. I didn't consider the living hell.

 

[Arcan57]

A lot of survival to hospitalization/discharge is going to be dependent on your EMS pattern. When I was in Houston, I'd have maybe 1-2 codes a year brought in that survived to hospitalization. But HFD would code someone for 15-17 rounds before transporting so the people they brought in still coding were all the way dead. People that coded in the ED seem to get ROSC somewhere in the 30-40% range.

 

[emergentmd]

I find what I do in the ER has very little outcome for the pt. A monkey can intubate, do ACLS, push drugs.

I would say I get ROSC then admit for cooling probably 30% of the time but I doubt many leave and those who gets to live like a veggie.

I can't remember many in my 20 yrs doing this where the came in Coding/CPR and I felt they would have a good quality of life after leaving the ER. I would say 99%+, I just left feeling bad that I put them through this and gave the family hope.

 

[gro2001]

Lots of misunderstanding and outdated information about cardiac arrest survivorship in this thread.

For context, I am an EM trained neurointensivist, and my area of interest is cardiac arrest.

While outcomes vary somewhat across locales and hospital systems, the rate of survival to ICU admission for out of hospital arrest for non traumatic arrests in the typical hospital system should be in the 10-30% range. Pretty wide, but obviously varies with cohort, typical transport times, etc. If you are getting numbers outside of that range, your experience is atypical and/or your system is doing something unusual.

For those that do survive to ICU admission (again, this varies by hospital system somewhat, but not as much as you'd think):
-about 30-40% survive with a good neurologic outcome (CPC 1 (back to work) or CPC 2 (independent in daily life, can work in a modified environment))
-another 30-40% die during their admission (80% of those from withdrawal of life sustaining therapy)
~10% survive with a poor neurologic outcome
~10% progress to brain death (and should end up getting counted among the dead, as they are in fact legally dead)

This shocks a lot of ER docs and (non-neuro) intensivists, because cardiac arrest recovery takes time. Like months. Really you should look at how these patients do a year from their arrest. Even if you follow them up to their discharge, you often get the situation that everyone is condemned to a life of trach/PEG/SNF. But if you either have good long term follow up data in your own system, or look at folks who have published their long term data, you will see these numbers pretty consistently across a number of settings, both in the US and internationally.

I would challenge you to keep track of your cardiac arrest patients that survive to get admitted to the ICU and call them on their one year arrest anniversary. I think you will be pleasantly surprised about how well people do.

Really the travesty of cardiac arrest care is that prognostication is so poorly understood by many intensivists, and about 20% of the time care is withdrawn on patients due to expected poor neurologic outcome that would have ended up CPC1 (we know this from cohorts of patients who refused withdrawal of therapy for religious reasons). Systems where poor prognostication practices are rampant see much worse outcomes.

 

[emergentmd]

Lots of misunderstanding and outdated information about cardiac arrest survivorship in this thread.

For context, I am an EM trained neurointensivist, and my area of interest is cardiac arrest.

While outcomes vary somewhat across locales and hospital systems, the rate of survival to ICU admission for out of hospital arrest for non traumatic arrests in the typical hospital system should be in the 10-30% range. Pretty wide, but obviously varies with cohort, typical transport times, etc. If you are getting numbers outside of that range, your experience is atypical and/or your system is doing something unusual.

For those that do survive to ICU admission (again, this varies by hospital system somewhat, but not as much as you'd think):
-about 30-40% survive with a good neurologic outcome (CPC 1 (back to work) or CPC 2 (independent in daily life, can work in a modified environment))
-another 30-40% die during their admission (80% of those from withdrawal of life sustaining therapy)
~10% survive with a poor neurologic outcome
~10% progress to brain death (and should end up getting counted among the dead, as they are in fact legally dead)

This shocks a lot of ER docs and (non-neuro) intensivists, because cardiac arrest recovery takes time. Like months. Really you should look at how these patients do a year from their arrest. Even if you follow them up to their discharge, you often get the situation that everyone is condemned to a life of trach/PEG/SNF. But if you either have good long term follow up data in your own system, or look at folks who have published their long term data, you will see these numbers pretty consistently across a number of settings, both in the US and internationally.

I would challenge you to keep track of your cardiac arrest patients that survive to get admitted to the ICU and call them on their one year arrest anniversary. I think you will be pleasantly surprised about how well people do.

Really the travesty of cardiac arrest care is that prognostication is so poorly understood by many intensivists, and about 20% of the time care is withdrawn on patients due to expected poor neurologic outcome that would have ended up CPC1 (we know this from cohorts of patients who refused withdrawal of therapy for religious reasons). Systems where poor prognostication practices are rampant see much worse outcomes.

Good to know and I have a myopic short term view. If 30% gets a decent quality of life and I admit about 30% with ROSC, then this actually makes me feel I am doing some good for the world. Thanks for the pick me up.

 

[Tipsy McStagger]

Interesting. I used to staff a post ICU clinic and was astounded at 12 and 18 months how poor outcomes were. Not just from cardiac arrest but even things like septic shock, intubation etc. The number of patients with debilitating functional status, weakness, memory loss, PTSD, inability to hold down a job is striking. Lots of these patients didn't even arrest. The cardiac arrest patients I saw at 12-18 months usually were very unhappy with their quality of life, despite having an improved neurologic outcome than they had when they left the hospital, many of them said they'd rather be dead.

Numbers tell part of the story, but the PICS clinic really opened my eyes to the reality of day to day life for a lot of people. Of course it's possible that clinic selects the worst cases, we're still learning about it.

Patient selection for CPR is also important. You can't fix multiorgan failure, metastatic cancer etc with CPR. Witnessed arrest with reversible cause is an entirely different beast than what many ICU patient's arrest from.

 

[PianoMedic]

There is likely significant heterogeneity in practices across hospital systems and regions that would affect post-ROSC outcomes. I have witnessed some major differences in physical therapy treatment, which I personally think if started early once safe could have significant impact on critical illness myopathy and other long term sequelae of icu care. One hospital I rotated through as a student had PT, RT, and the nurse walk patients that were below a certain threshold on pressors (like low dose) and/or undergoing vent weaning. Yea, patients were using their vent hooked to portable oxygen as a walker in the ICU. They found significant improvements in their times to hospital discharge and were also not having as much critical illness myopathy. Anecdotal, so not data at all. But early mobility protocols I’ve heard do have some data behind them. More study needed for sure.

To the OP, 10% or less ROSC for me when they come in from the field. Arrest in the ED it’s much higher for me, id say at least 30-40+% with ROSC. I also seem to be involved in super weird cases. I’ve had three patients at three different hospitals where I’ve been involved in the case, all were v fib, that had excellent neuro outcomes. Like the longest time to full recovery was 14 days for one of them (family walked into house and found them dead on the floor, then fireman’s carried/ran them 1/4 mile or more to the ED with no CPR, two shocks to ROSC somehow). Had one self extubate after cath recently who was in refractory v fib for almost a half hour. Was walking around CVICU within two hours post cath, ICU nurses were having a conniption. Non v fib I’d guess my in ED outcomes are at that 10% or maybe even lower mark.

 

[Tipsy McStagger]

There is likely significant heterogeneity in practices across hospital systems and regions that would affect post-ROSC outcomes. I have witnessed some major differences in physical therapy treatment, which I personally think if started early once safe could have significant impact on critical illness myopathy and other long term sequelae of icu care. One hospital I rotated through as a student had PT, RT, and the nurse walk patients that were below a certain threshold on pressors (like low dose) and/or undergoing vent weaning. Yea, patients were using their vent hooked to portable oxygen as a walker in the ICU. They found significant improvements in their times to hospital discharge and were also not having as much critical illness myopathy. Anecdotal, so not data at all. But early mobility protocols I’ve heard do have some data behind them. More study needed for sure.

To the OP, 10% or less ROSC for me when they come in from the field. Arrest in the ED it’s much higher for me, id say at least 30-40+% with ROSC. I also seem to be involved in super weird cases. I’ve had three patients at three different hospitals where I’ve been involved in the case, all were v fib, that had excellent neuro outcomes. Like the longest time to full recovery was 14 days for one of them (family walked into house and found them dead on the floor, then fireman’s carried/ran them 1/4 mile or more to the ED with no CPR, two shocks to ROSC somehow). Had one self extubate after cath recently who was in refractory v fib for almost a half hour. Was walking around CVICU within two hours post cath, ICU nurses were having a conniption. Non v fib I’d guess my in ED outcomes are at that 10% or maybe even lower mark.

Early mobility is a core metric in ICU. We frequently walk vented patients if able, if not they get PT at bedside. At my previous hospital we walked ECMO patients who were able. It's crucial

 

[PianoMedic]

Early mobility is a core metric in ICU. We frequently walk vented patients if able, if not they get PT at bedside. At my previous hospital we walked ECMO patients who were able. It's crucial

The other hospitals I rotated through either as student or resident didn’t have the PT manpower to do that kind of mobility in a coordinated fashion. So they would move patients in bed and such and have them sit up at bedside and call that “early mobility”. Glad to hear that isn’t standard everywhere, and getting patients out of bed is more the standard.

 

[emergentmd]

I have told my family if I need chest compressions/intubation/PEG tube then just let me go. I have seen too much bad outcomes to roll that dice

 

[Rekt]

Lots of misunderstanding and outdated information about cardiac arrest survivorship in this thread.

For context, I am an EM trained neurointensivist, and my area of interest is cardiac arrest.

While outcomes vary somewhat across locales and hospital systems, the rate of survival to ICU admission for out of hospital arrest for non traumatic arrests in the typical hospital system should be in the 10-30% range. Pretty wide, but obviously varies with cohort, typical transport times, etc. If you are getting numbers outside of that range, your experience is atypical and/or your system is doing something unusual.

For those that do survive to ICU admission (again, this varies by hospital system somewhat, but not as much as you'd think):
-about 30-40% survive with a good neurologic outcome (CPC 1 (back to work) or CPC 2 (independent in daily life, can work in a modified environment))
-another 30-40% die during their admission (80% of those from withdrawal of life sustaining therapy)
~10% survive with a poor neurologic outcome
~10% progress to brain death (and should end up getting counted among the dead, as they are in fact legally dead)

This shocks a lot of ER docs and (non-neuro) intensivists, because cardiac arrest recovery takes time. Like months. Really you should look at how these patients do a year from their arrest. Even if you follow them up to their discharge, you often get the situation that everyone is condemned to a life of trach/PEG/SNF. But if you either have good long term follow up data in your own system, or look at folks who have published their long term data, you will see these numbers pretty consistently across a number of settings, both in the US and internationally.

I would challenge you to keep track of your cardiac arrest patients that survive to get admitted to the ICU and call them on their one year arrest anniversary. I think you will be pleasantly surprised about how well people do.

Really the travesty of cardiac arrest care is that prognostication is so poorly understood by many intensivists, and about 20% of the time care is withdrawn on patients due to expected poor neurologic outcome that would have ended up CPC1 (we know this from cohorts of patients who refused withdrawal of therapy for religious reasons). Systems where poor prognostication practices are rampant see much worse outcomes.

I mean you’re downplaying that range quite a bit. There’s a significant difference between 0-1 out of 10 getting rosc vs 3-4. You have to realize your vision is very skewed from the reality of the average EM doc. My hospital covers more than ten counties. I get arrests from 30-45 mins away sometimes even. A bunch of mine arrive bluer than a Smurf. Vomit filled airways. Fumbled tubes. Many non profusing compressions. Grey and green skin tone arrivals. Esophageal tubes. No access. Questionable meds. Most pts with medical history list >20 things barely hanging to life as it is. My EMS crews range from Billy who put his volunteer hat on to flight crews that can drop tubes and lines easily.

I’d say arrest outcome has almost nothing to do with what happens in the ED. I wouldn’t bat an eye of a rosc % less than 10.

 

[SpacemanSpifff]

I mean you’re downplaying that range quite a bit. There’s a significant difference between 0-1 out of 10 getting rosc vs 3-4. You have to realize your vision is very skewed from the reality of the average EM doc. My hospital covers more than ten counties. I get arrests from 30-45 mins away sometimes even. A bunch of mine arrive bluer than a Smurf. Vomit filled airways. Fumbled tubes. Many non profusing compressions. Grey and green skin tone arrivals. Esophageal tubes. No access. Questionable meds. Most pts with medical history list >20 things barely hanging to life as it is. My EMS crews range from Billy who put his volunteer hat on to flight crews that can drop tubes and lines easily.

I’d say arrest outcome has almost nothing to do with what happens in the ED. I wouldn’t bat an eye of a rosc % less than 10.

Right - your system is on the 10% side because of certain unmodifiable (or challenging to modify) factors, namely EMS crew variability and prehospital transport times. Compare that to Seattle, which exists closer to the 30% side. I think @gro2001 isn’t saying that the ED is the source of this variance, or that this difference is insignificant.

I completely agree that most physicians, including EM folks, usually have too much pessimism surrounding cardiac arrest. Does that mean that I tell families in the ICU that their loved one is going to be back at work in 1 month? Definitely not. But the attitude that none of these patients go on to live meaningful lives after their arrest is also not helpful, especially the shockable rhythms with a reversible cause.

 

[gro2001]

Interesting. I used to staff a post ICU clinic and was astounded at 12 and 18 months how poor outcomes were. Not just from cardiac arrest but even things like septic shock, intubation etc. The number of patients with debilitating functional status, weakness, memory loss, PTSD, inability to hold down a job is striking. Lots of these patients didn't even arrest. The cardiac arrest patients I saw at 12-18 months usually were very unhappy with their quality of life, despite having an improved neurologic outcome than they had when they left the hospital, many of them said they'd rather be dead.

Numbers tell part of the story, but the PICS clinic really opened my eyes to the reality of day to day life for a lot of people. Of course it's possible that clinic selects the worst cases, we're still learning about it.

Patient selection for CPR is also important. You can't fix multiorgan failure, metastatic cancer etc with CPR. Witnessed arrest with reversible cause is an entirely different beast than what many ICU patient's arrest from.

The poor neurologic outcomes among patients admitted for septic shock have been well documented. I suspect part of it is pathology related, but part of it is that neuromonitoring/neuroprotective strategies just have not had much penetration to non-neuroICUs. Even basic stuff like ABCDEF/ICU liberation bundles are far, far from universally applied.

 

[Tipsy McStagger]

My ICU experience has been limited to roughly 4 different hospitals of varying quality. I've never not seen these bundles applied, but for sure that doesn't mean they aren't. I also staff a neuro icu (in addition to CICU, CVICU and MICU), but these seem to be universally applied from my experience. Not saying it doesn't happen, but it's definitely not something unique to a neuro ICU that I've seen. Again it's just my personal experience so not solid data or anything.

 

[FiremedicMike]

AHA says 9%.

CPR Facts and Stats

Read the latest stats and CPR facts, survival rates, success of CPR, and why training more Americans in high-quality CPR is so important to the AHA.

cpr.heart.org

I do believe 9% is for out of hospital. The last I checked, patients who arrest in hospital are between 15-25% depending on age group.

 

[dchristismi]

...and when they have rotted at Kindred for 4 months and the family has FINALLY decided that maybe, just maybe that last round of Fosfomycinogorillicillin didn't kill the 4 multidrug resistant organisms in their lungs, but they wanted to wait until after someone's birthday, then it's time for me (inpatient Hospice) because none of the vent weaning trials have worked. Or just nothing has worked and they're persistently encephaopathic. Or someone finally got through to them that grandma isn't gonna get better.

I see a lot of post-ROSCs and they definitely fall into a bimodal distribution: the "we spent 1-2 weeks in the ICU" vs the "we spent 2-4 months at the LTAC after a month in the ICU." I also do a lot of family debriefing and education about what the families experience in the hospital and/or LTACs. ICU stays can absolutely induce PTSD and I'm certain their families experience some of that too. Especially with some of the really intense cases - getting the families into bereavement/counseling/therapy is an underutilized part of hospice care, but essential when it's that sort of situation. I mean, because my patients, well, by definition don't survive.

 

[Janders]

I feel like, as other posters mention, most of this depends on the pre-arrest setting which is largely out of our control--
(1) Made it to the ED alive, arrested in the ED or in the ambulance bay... I get ROSC on a lot of these, and many have solid outcomes. I think we all have had chest pain patients that suddenly VF in front of us, and those people have a solid chance of neuro-intact outcome.
(2) Witnessed arrest at home / work / school, immediate EMS call, EMS there rapidly, work them well... usually EMS is getting the ROSC, but when they transport quickly (been staying and playing more lately...) and they are still in arrest on arrival, I'd say I get >10% to ROSC. Most of our transport times are 5-10 min, dense sub-urban environment.
(3) "noted to be unresponsive" at local SNF. You ALL know the SNF I'm talking about. Odds of me getting ROSC 1% at best. Usually they've been down >1hr prior to 9-1-1 and appear to get minimal CPR until EMS arrives.

I don't deal with things like LONG pre-hospital transport in my job, so that also skews my POV...