• Pastoral care: This member is a multi-faith chaplain from the
hospital’s Department of Pastoral Care who offers on-site
emotional and spiritual support to all patients and family
members attending clinic appointments. The chaplain helps
facilitate resilience and coping skills, operating through
the lens of ambiguous loss, which includes finding the
meaning of experiences and re-framing expectations.
Additionally, we work very closely with cardiologists to create a
well-coordinated plan for each individual survivor.
Implementation of the Initiative
The initiative was implemented to capture all patients admitted to
any of the 99 hospital ICU beds with CA as the admitting diagnosis.
Through daily ICU screening, potential patients were identified
using diagnostic codes and cooling consults sent to the neurological
ICU team. To ensure data-collection process, surrogates of all survivors
and non-survivors are consented and rapport is established.
For survivors with sufficient mental status to engage in an in-person
interview, the coordinator administers cognitive and psychological
screening assessments and provides basic education, as discussed
above, 24 hours prior to hospital discharge. The education provided
is meant to promote awareness and to prevent negative surprises for
patients if they experience any of the extracardiac symptoms (i.e.,
cognitive, psychiatric, functional) unexpectantly.
For all survivors, the coordinator provides information about our
NeuroCardiac Clinic, and if they show interest in the follow-up,
scheduled appointments are entered into their discharge plan by
the responsible physician and reinforced by the nurse while going
over the clinic information sheet as part of their discharge papers.
No later than one week, the patient’s nurse calls the patient and
inquires about their appointments and again re-iterates the importance
of our clinic.
We aim to conduct the first follow-up appointment at three
months, and then at least two more at six and 12 months. When
patients are approaching their follow-up visit date, the authorized
caregivers are first called by the coordinator to re-establish rapport
and remind them of their family member’s clinic appointment.
They are then given a confirmation call by the clinic’s administrative
staff one day prior to their appointment.
Once at clinic, the patients undergo repeat screening by the coordinator.
All clinic team members together then see the patients,
preferably with their caregiver. Caregivers are interviewed separately
to understand the true nature of the deficits in cognitive,
psychiatric and functional recovery. During the initial screening,
if the neuropsychiatrist deems a patient suitable for an individual
psychiatric diagnostic interview, she will see the patient individually
after the group meeting.
Success of the Initiative
There were 34 patients with 106 visits (median: 2, IQR: 1-3 per
patient) during the first year of the NeuroCardiac Clinic initiation.
Twelve patients (35 percent) were diagnosed with a psychiatric
disorder after evaluation by our psychiatrist. Ten (29 percent)
patients received a brain MRI to define cognitive deficits and
detecting secondary, delayed worsening after anoxic brain injury,
including symptoms of Parkinson’s, movement disorders, spasticity
and gait abnormalities. Three (9 percent) patients had an EEG
performed to justify weaning medications. Eleven (32 percent)
patients were sent for referrals to rehabilitation, psychotherapy,
or detailed neuropsychological testing. Medications for persistent
memory disorder, spasticity, depression, anxiety were either started
or managed on eight (23.5 percent) patients.
Because we are still defining the problem of an in-depth exploration
of the post-arrest experience, we have not conducted any
systematic interventions per se. Instead, we define our successes
thus far as normalizing patients’ post-arrest challenges as well as
serving as a source of emotional and informational support.
Translation to Other Settings
A clinic of this format can be appropriate for any condition that
serves as a striking surprise and leaves patients chronically debilitated
(e.g., stroke, acute coronary syndromes, cancer, traumatic
brain injury). Patients and their caregivers can largely benefit from
emotional support from an integrative multi-disciplinary team.
Summary of the Experience and Future Directions
We have taken an important step in promoting education and
awareness of the extracardiac symptoms cardiac arrest survivors
may experience. As we continue to define the post-cardiac experience,
we hope to develop novel interventions in collaboration
with rehabilitation and regeneration, specialists in memory disorder,
and behavioral medicine psychologists to improve clinical outcomes
and quality of life in both survivors and their caregivers.
Additionally, through continued documentation and research, we
hope to continue obtain the attention of patients’ providers during
the acute hospitalization so that they can address the extracardiac
symptoms cardiac arrest survivors could experience.
With limited availability of treatment options for deficits like
severe memory loss or executive functioning, expectation management,
addressing reality and focusing on building resilience is the
key. Achieving acceptable quality of life is the final goal.
Acknowledgements: We acknowledge the NeuroCardiac Comprehensive
Care Clinic (N4C) staff: Jennifer Loftus (Clinic Operations),
Jennifer Caro (Practice Manager), Kerri Natkiel (Revenue
Cycle Director), Evie Sobczak (Research Assistant), and healthcare
providers from all intensive medical and surgical intensive care
units who contributed to the well-being of our survivors.
References
1. Krisel B. First of kind NYC clinic focuses on brain after cardiac
arrest. Washington Heights Patch. April 26, 2018. https://patch.
com/new-york/washington-heights-inwood/first-kind-nyc-clinic
focuses-brain-after-cardiac-arrest. Accessed April 26, 2018.
2. Benjamin EJ, Blaha MJ, Chiuve SE, et al. American Heart Association
Statistics Committee and Stroke Statistics Subcommittee.
Heart Disease and Stroke Statistics-2017 Update: A Report
from the American Heart Association. Circulation. 2017 Mar
7;135(10):e146-e603.
3. Schaaf KPW, Artman LK, Peberdy MA, et al. Anxiety, depression,
and PTSD following cardiac arrest: a systematic review
of the literature. Resuscitation. 2013;84(7):873-877.
4. Lloyd-Jones DM, Hong Y, Labarthe D, et al. American Heart
Association Strategic Planning Task Force and Statistics Committee.
Defining and setting national goals for cardiovascular
health promotion and disease reduction: the American Heart
Association’s strategic Impact Goal through 2020 and beyond.
Circulation. 2010 Feb 2;121(4):586-613.
5. Sawyer KN, Brown F, Christensen R, et al.
Surviving Sudden Cardiac Arrest: A Pilot
Qualitative Survey Study of Survivors. Ther Hypothermia
Temp Manag. 2016 Jun;6(2):76-84.
12
/first-kind-nyc-clinic-focuses-brain-after-cardiac-arrest
/first-kind-nyc-clinic-focuses-brain-after-cardiac-arrest
