high performance cpr and resuscitation quality improvement

WHAT IS HIGH PERFORMANCE CPR?IS IT REALLY WORTH THE TROUBLE?

PRESENTED BY: DAVID B. HILTZ

THIS IS NOT AN AHA PRESENTATION.THIS IS NOT A RESUSCITATION ACADEMY

PRESENTATION.PRODUCTS SHOWN ARE NOT ENDORSED

BY THE PRESENTER, THE AHA, THE RESUSCITATION ACADEMY, OR KING COUNTY MEDIC ONE.

INTRODUCTORY REMARKS

OBJECTIVESCPR Quality Consensus Statement

Compliance vs. CompetencyKey Quality Challenges

Science ReviewConcept of Pit Crew CPRAHA Quality CPR eBook

Reaffirmation-Q&A

“Poor-quality CPR should be considered a preventable harm. In healthcare environments, variability in clinician performance has affected the ability to reduce healthcare associated complications, and a standardized approach has been advocated to improve outcomes and reduce preventable harms. The use of a systematic continuous quality improvement (CQI) approach has been shown to optimize outcomes in a number of urgent healthcare conditions.”

“Despite this evidence, few healthcare organizations apply these techniques to cardiac arrest by consistently monitoring CPR quality and outcomes. As a result, there remains an unacceptable disparity in the quality of resuscitation care delivered, as well as the presence of significant opportunities to save more lives.”

QUESTION FOR AUDIENCE:HOW MANY OF YOU PRACTICE CPR?

(OUTSIDE OF YOUR AHA CLASS)

SOME CHOICE WORDS!

WE CAN’T EXPECT TO WIN “RACES” WITHOUT MEANINGFUL PRACTICE

AND AN ONGOING ITERATIVE PROCESS OF MEASURING AND IMPROVING…

BEGINNERS PERMIT

DON’T THROW OUT THE BABY WITH THE BATH WATER!

YOUR STANDARDIZEDTRAINING IS IMPORTANT!

TOO MANY PEOPLE ARE GOING HERETOO EARLY!

SURVIVAL IS theBENCHMARK forEMS PERFORMANCE

A QUICK REVIEWOF RELATED SCIENCE

SystoleDiastole

DUTY CYCLE

DELAYS AND INTERRUPTIONS KILL!

DEATH BY HYPERVENTILATION

A COMMON EXPERIENCE IN CARDIAC ARREST

TRANSITION TIME-NO FLOW-

FOR DEFIBRILLATION

WATCH YOUR TRANSITION

FROM MANUAL TO

MECHANICAL CPR IF THESE DEVICES ARE

USED

•Perceived performance does not always match observed performance.

•Aufderheide et al. showed that duty cycle, chest compression depth and complete recoil were performed significantly less well when directly observed than EMT perceptions of their performance.

•Wik et al. showed that chest compression rate and depth were both significantly below AHA guidelines by trained EMS providers, and no flow time (when there was neither a pulse nor CPR being given) was almost 50% in directly observed performance evaluations.

•The likelihood of ROSC increases significantly with higher mean chest compression rate (in a hospital study 75% of patients achieved ROSC with 90 or more chest compressions/minute compared to only 42% with 72 or fewer chest compressions/minute).

THE PAINFUL TRUTH

REPORT CARD?

HAVING QUALITY TIME ON THE CHESTIS ESSENTIAL

DISTRACTIONS AROUND

EVERY CORNER

TUNNEL VISION AND ALTERATIONS

IN SITUATIONAL AWARENESS DURING RESUSCITATION

Eastern Airlines 401 crashed into the Everglades in

December of 1972 as a result of the flight crew's failure

to recognize a deactivation of the autopilot during their

attempt to troubleshoot a malfunction of the landing

gear position indicator system (an indicator light).

Fatigue and poor crew resource management (CRM)

contributed to the accident.

EA 401 gradually lost altitude while the flight crew was

preoccupied and eventually crashed.

The effect of this crash on the airline industry continues

today and has resulted in the development of Crew

Resource Management (CRM). CRM is a technique that

requires air crews to divide the work in the cockpit

amongst available crew ensuring that someone

continues focusing on flying the plane while

troubleshooting continues.

DO YOUR CARDIAC ARRESTSLOOK LIKE A BULL RUN IN MADRID?

OR A WELL CHOREOGRAPHEDDANCE SCENE LIKE THIS?

“Quality CPR is a means to improve survival from cardiac arrest. Scientific studies demonstrate when CPR is performed according to guidelines, the chances of successful resuscitation increase substantially. Minimal breaks in compressions, full chest recoil, adequate compression depth, and adequate compression rate are all components of CPR that can increase survival from cardiac arrest. Together, these components combine to create high performance CPR (HP CPR)”

DISCUSSION OF DRUGS WITH PROVEN BENEFIT FOR CARDIAC ARREST

WOW! THAT WAS QUICK!

http://www.youtube.com/watch?v=w32PUDL2lb8

Compress

> 2 inches

Minimize interruptions

Full recoil

Rate between 100 and 120/min

Improved survival

Switch compressors every 2 min. Hover hands

Prioritize compressions

C-A-B

Rapid rhythm analysis

Minimize pauses

Administer drugs

Intubation IV placement

EMT CPR Foundation

Paramedic Advanced Life

Support

•EMTs own CPR•Minimize interruptions in CPR at all times•Ensure proper depth of compressions (>2 inches)•Ensure full chest recoil/decompression•Ensure proper chest compression rate (100-120/min)•Rotate compressors every 2 minutes •Hover hands over chest during shock administration and be ready to compress as soon as patient is cleared•Intubate or place advanced airway with ongoing CPR•Place IV or IO with ongoing CPR•Coordination and teamwork between EMTs and paramedics

10 PRINCIPLES

•C-A-B•Minimize interruptions in compressions•Compress at least 100/min•Allow complete chest wall recoil/decompression between compressions•Rhythm assessment every 2 minutes•Rotate compressors every 2 minutes•Hover over patient with hands ready during defibrillation so compressions can start immediately after the shock (or analysis) has occurred

ALWAYS TRUE!

HOVERING

BREAK TIME?DO WE NEED TO RUSH TO ADVANCED AIRWAYS?

ARE WE BRINGING THE RIGHT EQUIPMENT

TO THE PATIENT?

CPR DURINGTRANSPORT?

Pictures are for presentation purposes only. The American Heart Association does not endorse any particular products, models or manufacturers.

EACH PERSON HAS AN ASSIGNED ROLE

AND PRACTICES AGAIN AND AGAIN!

1

2

3

4

5

6

PIT CREW LEADERAIRWAY LEADERDEFIB-IV/IO-MEDSCPR CHIEFCPR DEPUTY CHIEF

*VARIABLE PLAYER

PRE-ASSIGNED ROLES

1

3

24

56

BOSS

ACCESSMEDS

MONITOR

CPR 1

CPR 2

AIRWAYVENTILATION

AIRWAYASSISTANT

RESUSCITATIONPIT CREW MODEL

FEEDBACK?

PRACTICELIKEYOUPLAY

LIVE DEMO OF AHA RQI TOOLS

A continuous process evaluates and improves clinical care and generates new guidelines and therapy.

Meaney P et al. Circulation 2013;128:417-435

Copyright © American Heart Association

Illustration of proposed resuscitation “report cards.” Routine use of a brief tool to document resuscitation quality would assist debriefing efforts and quality improvement efforts for

hospital and emergency medical services systems.

Meaney P et al. Circulation 2013;128:417-435

Copyright © American Heart Association

THIS IS WHERE IT IS AT

CONTEXTUALIZETRAINING

MEASURETIME

VIDEO TAPEPRACTICE

USEINSTRUMENTED

MANIKINS

FREQUENCY OF

PRACTICE

eLearningCAN BUY TIME

FOR MORE PRACTICE

NON-PUNITIVE QI

CARE TO LOOK AT A VIDEO?

"Eisenberg has done a remarkable job in articulating the steps to be taken for communities to improve survival from sudden cardiac arrest. Resuscitate! is a 'best in class' and one of a kind guide that provides inspiration as well as direction in translating resuscitation science into practice. It is essential for all those who seek to establish strategies to improve survival and quality of life for cardiac arrest victims whose hearts are 'too young to die.'" - David B. Hiltz, EMT-P Resuscitation Academy Alumni

www.heart.org/cprquality

www.resuscitationacademy.org

FINAL RECOMMENDATIONS

QUESTIONS - ANSWERS

THANK YOU!

david.hiltz@heart.org