The Pulse - February 2025

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1. Code Blue or Code Through? New Rules for Ending Resuscitation for In-Hospital Cardiac Arrest

   New research offers a pragmatic, data-driven approach to deciding when to call it quits during in-hospital cardiac arrests. A Scandinavian study identified four key predictors of non-survival—unmonitored status (no telemetry), unwitnessed arrest, initial rhythm asystole, and ≥10 minutes of resuscitation—wherein patients meeting all criteria had a 0.5% survival at 30 days. Applying this rule could allow clinicians to reasonably stop resuscitation efforts after 10 minutes rather than the average 20 minutes (average within the study), sparing futile efforts while ensuring <1% of potential survivors are missed. While promising, broader validation is needed before this rule becomes standard practice. Holmberg MJ et al. JAMA Intern Med 2025 Jan.

   Study Type: prospective cohort study of 9863 Danish, 12781 Swedish and 1308 Norwegian patients who underwent resuscitation for in-hospital cardiac arrest

   Link: https://doi.org/10.1001/jamainternmed.2024.7814 

2. Delirium Defense: Pre-Op Assessment of Elderly 

   For hospitalists managing older surgical patients (>65 years old), the key to smoother recoveries is tackling delirium risk head-on. Start with a pre-op check for cognitive impairment and frailty. Consider using dexmedetomidine (Precedex) as it was shown to significantly lower post-op delirium and non-significantly lower post-op mortality. Avoid CNS-affecting meds—including benzodiazepines, antipsychotics, anticholinergics, ketamine, corticosteroids, and gabapentin. NSAIDs were in this list of meds to avoid but then later suggested as a way to decrease post-op pain and therefore delirium; the jury is still out as there no RCTs. Sieber F et al. Anesthesiology 2025 Jan. 

   Study Type: ASA Practice Advisory

   Link: https://doi.org/10.1097/ALN.0000000000005172

3. UpToDate? More Like Out-of-Date—ChatGPT & Clinical Decision Making

   Looks like ChatGPT might be gunning for your white coat! In a randomized trial (using clinical vignettes), physicians armed with GPT-4 outperformed those relying on traditional resources like UpToDate and Google when tackling complex clinical vignettes. The real kicker? ChatGPT alone did just as well as the doctors using it—so maybe it’s time to start buttering up your future AI overlord. In all seriousness, the technology is still unproven in live encounters and has been previously shown to be as prone to the same cognitive errors/biases as human physicians (NEJM 2024) if not more. Goh E et al. Nat Med 2025 Feb 5.

   Study Type: prospective, controlled trial in which 92 physicians were randomized to GPT-4 + conventional resources or just conventional resources in order to answer 5 simulated clinical vignettes developed by experts

   Link: https://doi.org/10.1038/s41591-024-03456-y

4. Intensive or Expensive? The Cost of Over-Admitting

   A study of over 2 million VA patient visits found that physicians working in the same ED varied widely in how often they admitted patients (as much as 24% between 90th and 10th percentiles)—even when those patients had similar health statuses. The kicker? Those who were admitted by the more “intensive practice” docs weren’t any less likely to die within 30 days (or even a year). Instead, they were more likely to get sent home within 24 hours, suggesting that plenty of these admissions were just expensive, unnecessary sleepovers. The study hypothesizes that some docs may just have a lower tolerance for uncertainty, meaning more tests, more admissions, and more costs—without better outcomes. And before you blame medical training, that didn’t explain much either. While there might be some non-mortality-related benefits to admission (e.g. patient peace of mind), this habit of erring on the side of admission isn’t doing much beyond straining hospitals and jacking up costs. The bottom line? More admissions ≠ better survival. An editorial in response to this article suggested two possible solutions: (1) the Acute Unscheduled Care Model which incentivizes ED providers to reduce unnecessary admissions through bundled payments, and (2) standardized admission criteria for common conditions. Coussens S et al. JAMA Intern Med 2025 Jan.

   Study Type: observational, cross-section study of 2,137,681 patients visiting VA hospital EDs for either chief complaint of chest pain, shortness of breath, or abdominal pain

   Link: https://doi.org/10.1001/jamainternmed.2024.6925, https://doi.org/10.1001/jamainternmed.2024.7075 (Editorial)

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