Cardiopulmonary resuscitation practices in the Netherlands: results from a nationwide survey

In-hospital cardiac arrest (IHCA) is a major adverse event for hospitalized patients with a reported incidence of 1.6/1000 admissions in European countries [1]. Cardiopulmonary resuscitation (CPR) is started to restore circulation, but survival rates are low and vary across various countries and hospitals [2‐4]. Recent guidelines call for research on long-term and patient-centred outcomes, as well as strategies to help improve survival of IHCA [5, 6]. Much research is done on early recognition of patients at risk for IHCA and post-resuscitation care. The role of resuscitation practices itself and inter-hospital differences is far less examined, but is a growing focus in current research [7‐9].

Survival after out-of-hospital cardiac arrest is relatively high in the Netherlands and we have learned from large cohort studies that optimisation of pre-hospital resuscitation care leads to higher survival [10]. The current European Resuscitation Council guidelines have several recommendations with regard to life support training of healthcare workers and strategies for prevention of cardiac arrest through Rapid Response Teams (RRT) [6]. Previous studies have demonstrated that quality characteristics such as team training and adherence to Advanced Life Support (ALS) guidelines are related to a higher survival probability for patients [9]. Furthermore hospital characteristics like teaching status, size and urban location are associated with differences in mortality after IHCA [11‐15]. Knowledge about CPR practices might be useful for further research to optimise the chain of survival for IHCA.

The Resuscitation Outcome in the Netherlands (ROUTiNE) project is a nationwide initiative aimed at describing outcome of IHCA. Part of this project is a survey on CPR characteristics focussed on use of guidelines, training and organisation in Dutch hospitals. The goal of this survey is to describe the current resuscitation practices in the Netherlands.

Of the 77 hospital organisations, 71 (92%) hospital organisations responded to the survey. These hospitals represent 99 hospital locations.

This nationwide survey covering 92% of all Dutch hospital organizations shows that CPR practices differ between hospitals. Although almost all hospital locations reported following the most current European guidelines for ALS, there are differences between hospitals in CPR training frequencies, the availability of ALS certified medical doctors during day and night and constitution of the CPR teams.

The current European Resuscitation Council Guidelines recommend a CPR (re) training more than once a year, because ALS knowledge and skills deteriorate within 6 to 12 months after ALS training [6, 16]. Previous studies showed improved survival from IHCA when the responding emergency team included ALS-trained individuals [17‐19]. In our study, 94% of all hospital locations report that CPR team members received routine resuscitation training, but only 57% of all hospitals reported round the clock availability of an ALS certified medical doctor. Ten per cent reported not having ALS certified medical doctors employed, although we do not know if other training was provided.

The importance of CPR practices have not yet been fully elicited, however a recent publication finds that top-performing hospitals with regard to survival rates after IHCA show several common practices [9]. The first is a formally organized team composed of members from diverse disciplines. These members had delineated roles and responsibilities. They speak of strong communication, leadership and a focus on training and education. In our own study these features are clearly depicted. All responding hospitals have a designated CPR team. In general there is no formal organization of CPR teams, however they always consist of medical professionals (residents or specialists) who are trained a field of acute care. As this was not a qualitative study, we cannot make statements about strong communication. We can state that training and education is mostly according to ERC guidelines and 94% of hospitals train their personnel at least once a year.

In previous self-reported survey studies, conducted in 2009 and 2015 in the US, Germany, Austria and Switzerland, only 52–62% of hospitals reported offering routine training for CPR team members [20, 21]. Another survey in the UK showed that 49% of junior doctors participating in CPR team not had ALS training, but would like to do so. These differences with our findings may be due to the fact that surveys of Siebig et al. and Morgan et al. were anonymous [21, 22]. Furthermore, the routine use of resuscitation officers in the Netherlands may contribute to this difference. This is in line with the survey of Edelson, who stated that less than half of the responding hospitals reported the presence of a resuscitation officer, which is correlated with routine CPR training [20]. Our study shows that CPR teams trained more than once a year in 41% of the cases, which is in line with our neighbouring countries [21].

Our results showed that CPR team physicians consisted of cardiologists, anaesthetists, intensivists and physicians from the emergency department. A German survey from 2009 reported that 80% of the physicians in the resuscitation team worked on an intensive care. Furthermore they reported that 55% of the physicians in the CPR team had a specialist qualification [21]. A survey conducted in the UK, reported the team leader is in 73–82% of cases represented by an emergency consultant [23]. In the present study we found comparable results: in the roles of team leader, airway manager and circulation manager the participation of residents and medical specialist was almost equally distributed. When stratified by hospital type, residents were most often participating in CPR teams in university hospitals and least often in non-teaching hospitals. This corresponds with findings of Edelson et al. [20]. An exploratory study showed that junior physicians are competent overall in managing resuscitation attempts but partly failed in the role of team leader [24]. We found a relatively low number of anaesthetists performing airway management. This finding should be elicited by the fact that intensive care medicine in the Netherlands is performed by anaesthetists or internists with a focus in ICU-medicine, Based on local protocol airway management service is therefore provided by either the department of anaesthesia or the ICU. The total number of team members per CPR team in our survey is comparable with results reported by Porter el al., who stated resuscitation teams consisted in 64–69% of cases of four to six members [23].

In our study, 91% of the responding hospital locations reported to have a Rapid Response System (RRS) in place, which is in line with previous Dutch studies and also with findings of a survey in the US [20, 25]. However, in 2008, the implementation of RRS was mandated by the Dutch government. Reasons for not having an RRS implemented yet are unclear.

The majority of Dutch hospitals follow the ERC guidelines but there are differences in the presence of an ALS certified physician, intensity of training and participation of medical specialties in the fulfilment of roles within the CPR-team. Knowledge on resuscitation practices and learning from best practice can be useful in improving CPR quality and can be of interest in future research.