Survival and recovery continue long after resuscitation.

Editor’s note: This is an early release of a web exclusive article for the May 2021 issue of American Nurse Journal. 

According to Sawyer and colleagues, only 11% of patients who experience a sudden cardiac arrest (SCA) outside of the hospital will survive to discharge. When it occurs in the hospital, the chance of survival is still only 26%. These numbers may seem low, but survival after resuscitation has increased over the past decade thanks to standardized post-cardiac arrest care and delaying withdrawal of life-sustaining therapies.

Recovery after SCA extends well after discharge, and a supportive structure is necessary to ensure optimal care. Survivors have experienced a sudden and profound life-altering event, as have their family, friends, and caregivers. Many patient outcomes after cardiopulmonary resuscitation are described from a healthcare-centric perspective (return of spontaneous circulation, survival at discharge, Modified Rankin Scale score). These data are important, but they don’t take into account the patient’s perspective. Nurses can combine insights about the patient’s needs with the nursing process and critical thinking skills to provide holistic, patient-centered care.

No guidelines addressing SCA survivorship currently exist, but the American Heart Association (AHA) 2020 Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care updates include the addition of “recovery” within the chain of survival. In addition, other disease states, such as stroke, have standards addressing similar issues faced by patients who survive SCA. This article draws on the AHA updates as well as standards for other disease states (such as stroke) to provide acute-care nurses with suggestions for supporting these patients.

Focus on the survivor

Think about the recovery process (from the initial SCA to 3 to 6 months after discharge) from the patient’s perspective. To help guide the treatment plan, ask the patient, “What does recovery look like to you?” “Where do you hope to be 3 months from now?” For example, a patient’s sense of wellness may be sitting at home watching sports. Or it may be that they want to return to work and support their family. Initially, the patient may not be able to participate in this discussion, but family or friends can help establish a baseline recovery expectation.

Assess for post-intensive care syndrome

Unexpected critical illness can have long-term consequences for patients months to years after the event. Post-intensive care syndrome (PICS) describes the collection of psychological, cognitive, and physical impairments that can occur after prolonged hospitalization in an ICU, especially for those requiring mechanical ventilation. The healthcare team must be vigilant to PICS signs, which include muscle weakness and delirium. Currently, no screening or assessment exists to determine who might develop PICS, but several strategies are recommended. For example, the ABCDEF bundle (assess for pain, breathing trials daily, choose appropriate and minimal analgesia and sedation, monitor for delirium, early mobility even on the ventilator when stable enough to do so, family engagement and empowerment), handoff tools for care continuity, minimal use of invasive lines and restraints, and bundling care interventions to allow for rest can help prevent or reduce many of its debilitating effects. (A full discussion of PICS is beyond the scope of this article; refer to the reference list for more information.)

Address physical impact

Resuscitation efforts in response to SCA can be brutal, and over half of survivors experience painful chest injuries (such as rib and sternal fractures) as a result of CPR. Other interventions (including intubation and mechanical ventilation) can cause pain and injuries, and prolonged bed rest can lead to muscle stiffness and discomfort.

Intubation is associated with oral trauma and vocal cord injuries, and mechanical ventilation can weaken tracheal muscles and the diaphragm, leading to difficulty removing the ventilator, swallowing, and speech. Prolonged ICU stays can lead to musculoskeletal impairment due to stress-induced catabolic state, inflammation, and immobilization. Associated complications include skin breakdown and pressure injuries, urinary stasis and incontinence or retention, and urinary tract infections. Retained secretions from immobility can lead to pneumonia.

To aid recovery from physical impact, start physical therapy and occupational therapy early in the hospital stay. Begin passive range-of-motion exercises; for those who can’t actively participate, create a turning schedule. Also, prioritize regular breathing exercises with incentive spirometry after extubation and early removal of invasive catheters and lines. A speech and language pathology consultation can help ensure safe extubation and prevent aspiration while eating and drinking. Start tube feeding under the guidance of a clinical dietician as soon as possible, and continue it until a normal diet can resume.

Work with patients to set expectations, and develop goals to ensure they understand their physical impairments and the anticipated recovery trajectory. In addition, explain the importance of pain control and how to achieve it, including pharmacotherapy and splinting with pillows when coughing. Sufficient pain control helps survivors participate in rehabilitation activities and ensures they can collaborate in care decisions.

Address cognitive impact

Cognitive impairment is common in patients who survive an SCA but may not be discernible during the acute care phase. Family and friends may help shed some light on how the SCA and subsequent interventions have altered their loved one, but specifics will be lacking until the patient is discharged home and engages in more regular activities. Tools such as the Montreal Cognitive Assessment (MoCA) or the Saint Louis University Mental Status (SLUMS) may be helpful in the hospital setting; however, it’s important that a patient’s cognitive status is assessed in the primary care setting.

Limited evidence exists to suggest what types of patients might experience cognitive impairment after SCA. For example, age doesn’t appear to be an independent contributing factor. Some older patients recover to baseline cognitive function, whereas some teenagers develop severe cognitive impairment after SCA. Patients may experience memory loss, difficulty learning new concepts, lack of concentration, or indecisiveness. Typically, cognitive deficit improvement occurs within the first 3 months after the SCA; after that, the chances of improvement are minimal. Targeted temperature management has been shown to help reduce cognitive impairment.

Because little information exists to help predict whether survivors will experience cognitive impairment, assessing a patient for their general ability to complete self-care activities is important to determine appropriate care needs after discharge. For example, survivors may be started on new medications for cardiac muscle weakening, reduced ejection fraction, or valvular dysfunction, which are new to their self-care regimen. A study by Mekonnen and colleagues showed that half of patients discharged from acute care experienced a medication error when they went home. Increased vigilance and additional support are necessary with new medications in general, especially in patients with new cognitive impairment.

If CPR is delayed or inadequate, lack of blood flow to the brain increases the risk of neurologic injury. Watch for seizures and stroke symptoms, and talk to the family and medical power of attorney about necessary support if severe cognitive issues are suspected. After discharge from the ICU, movement disorders such as rapid muscle contractions and balance and gait difficulties may become apparent. Coach, educate, and emotionally support the survivor to reset expectations and plan for rehabilitation partners to help improve function over time.

Address psychosocial impact

Some survivors may have difficulty adapting to life after SCA, especially if they have psychological or cognitive impairment. They may focus on what life was like before the SCA and become overwhelmed and paralyzed by fear and a sense of vulnerability. A major impact on emotional well-being is the survivor’s dependence on others after the event. Many find it difficult to ask for help. If the survivor was the sole provider for a family, this change in family dynamics may affect overall family well-being. Whenever possible, include household members the patient sees as key to their happiness and adjustment in conversations about care plans and recovery.

Some survivors will change perceived bad habits, move toward healthier lifestyles, and take on a positive outlook. They may appear almost euphoric at their new chance at life. These attitudes and expectations may cause frustration or irritation for family members who are asked to make changes along with the survivor. Some survivors have near-death experiences they relate to a supreme being or previously deceased family member. Allow them to discuss their experiences without judgement or interpretation so they can come to terms with their meaning. Every survivor will be different, and we must meet them where they are with support and acceptance.

SCA survivors may need or want to return to work. Identify any alterations that may impact work–life balance, and prioritize solutions. Recommend that survivors set goals with rehabilitation services that include an occupational focus. Mutual goal setting will allow the team to focus on interventions that prepare the patient for the physical or cognitive skills needed to resume work. If necessary, encourage energy-conservation strategies such as a slower pacing, task delegating, and pre-planning to ease survivors back into the work setting.

Offer prevention strategies

The healthcare team should conduct a thorough history and physical to identify the most likely cause of the SCA. All reversible and treatable contributing factors (such as myocardial ischemia or infarction, drug toxicities, electrolyte abnormalities, toxin exposures, aberrant conduction pathways, and infections) should be addressed before discharge. Some patients may have multiple contributing factors. Exploring all possible etiologies will aid in coordinating the best intermediate and long-term management strategies and offer the patient and family a sense of control.

Offering CPR classes to the family may or may not be well-received. Some will be too frightened to even consider taking on that responsibility. Others may demand the training. Foster open and honest communication about improved outcomes of early CPR for patients who’ve experienced SCA. Engage the family early by keeping them informed, involving them in decision-making, and maintaining a clear understanding of the concepts of illness to promote family- and patient-centered care. This focus can ease anxieties and increase trust that establishes bidirectional communication between families and the healthcare team over time. Regardless of the family’s willingness to discuss the topic of CPR, ensure that the family has written material that aids any verbal discussion and leaves the family feeling empowered to discuss it with the healthcare team when they’re ready.

Nurses’ role in recovery

The holistic approach embedded in nursing practice supports recovery in the updated SCA chain of survival. Nurses’ role in caring for and supporting survivors includes identifying individualized self-management interventions, encouraging survivors to share their personal experiences, and serving as a resource for support information.

Discharge planning should begin when the survivor enters the hospital. Nurses can help ensure that care coordination expectations are met and the survivor and family are adequately prepared for discharge. Nurses have a unique opportunity to gain insight into survivor and caregiver concerns, which they can share with the healthcare team for developing and implementing change strategies. A 1-year roadmap to recovery can help guide the focus of intervention for survivors across the healthcare system. (See Recovery plan.)

When the survivor is discharged from the hospital, recovery should focus on interventions that address treatment, surveillance, and rehabilitation needs, as well as caregiver and survivor support. These needs include managing symptoms and new disabilities, monitoring indicators associated with the SCA, managing medications, implementing nutrition and healthy lifestyle changes, and engaging in collaborative healthcare provider appointments.

Community programs for social support can be beneficial to improving all aspects of a survivor’s health and well-being. Provide them with access to resources that meet their individual needs. For example, some survivors may prefer in-person groups, whereas others may prefer online forums; some may want survivor-only groups, others may want to include family.

Prepared for the future

Surviving cardiac arrest is just the first step in a delicately complex journey to a survivor’s achievement of optimal health and well-being. Nursing care doesn’t end when the acute phase of care is completed. Applying your knowledge about potential complications and associated needs beyond discharge prepares survivors and families to leave the hospital feeling confident and equipped to begin life after SCA.

Danette Culver is a clinical nurse specialist at Norton Healthcare in Louisville, Kentucky.

References

Davidson JE, Hopkins RO, Louis D, Iwashyna TJ. Post-intensive care syndrome. Society of Critical Care Medicine. 2013. sccm.org/MyICUCare/THRIVE/Post-intensive-Care-Syndrome

Ely WE. The ABCDEF bundle: Science and philosophy of how ICU liberation serves patients and families. Crit Care Med. 2017;45(2):321-30. doi:10.1097/CCM.0000000000002175

Grady PA, Gough LL. Self-management: A comprehensive approach to management of chronic conditions. Am J Public Health. 2014;104(8):e25-31. doi:10.2015/AJPH.2014.302041

Mekonnen AB, McLachlan AJ, Brien JE. Pharmacy-led medication reconciliation programmes at hospital transitions: A systematic review and meta-analysis. J Clin Pharm Ther. 2016;41(2):128-44. doi:10.1111/jcpt.12364

Sawyer KN, Camp-Rogers TR, Kotini-Shah P, et al. Sudden cardiac arrest survivorship: A scientific statement from the American Heart Association. Circulation. 2020;141(12):e654-85. doi:10.1161/CIR.0000000000000747

Society of Critical Care Medicine. ICU Liberation Bundle (A-F). sccm.org/ICULiberation/Home/ABCDEF-Bundles

Twibell KR, Petty A, Olynger A, Abebe S. Families and post-intensive care syndrome. Am Nurse Today. 2018;13(4):6-11.