“Putting It All Together” to Improve Resuscitation Quality
Section snippets
Current state of resuscitation performance
Recent resuscitation literature, assisted by CPR-recording devices, large cardiac arrest event registries, and high-fidelity ACLS simulation studies, have focused on and provide a significant amount of objective data regarding rescuer performance during actual and simulated cardiac arrests. Unfortunately, a common theme from these studies was that resuscitation performance frequently does not meet established care guidelines during IHCA, OHCA, and simulated cardiac arrests. Even more troubling,
Improving performance improves outcomes
Although numerous studies have documented that resuscitation quality frequently does not meet established care guidelines, it also appears that this substandard care is adversely affecting hemodynamics during, and outcomes from, cardiac arrest resuscitation. For example, increasing chest compression depth to the AHA Guideline standard results in favorable hemodynamic changes, such as an increased arterial blood pressure, in adult humans30 and an increase in coronary blood flow in mature pigs.31
Before: resuscitation training
Because the quality of CPR is directly related to survival outcomes,23, 35, 36 several studies have implicated the existing educational programs for teaching CPR skills as a prime target for interventions to improve survival after cardiac arrest. Although most hospitals in the United States require either basic life support or ACLS certification for most care providers, this is often the only resuscitation training practitioners receive, and there is a growing body of literature supporting the
During: monitoring CPR quality with titration to patient physiology
The evaluation of the effectiveness of ongoing CPR efforts has proven difficult. Several methods that are used commonly (eg, presence of femoral or carotid pulsations, pulse oximetry) have not correlated with successful resuscitation and may even mislead rescuers. The following is a discussion of real-time audiovisual feedback systems, arterial blood pressure monitoring, and end-tidal carbon dioxide (CO2) capnography as methods to guide resuscitation quality.
After: performance debriefing
Health care debriefing is defined as a facilitator-led participant discussion of events with reflection and assimilation of learning into practice. Structured debriefing can trace its origins back to the military in World War II. General George Marshall ordered soldiers under his command to give an account of their experience on return home from a mission. Although the initial intent was to gather tactical information or strategize for future battles, he noticed that debriefings were also
Evidence that putting it all together improves outcomes
Although this article is focused on techniques to improve resuscitation performance (eg, innovative training methods, monitors to enable providers to titrate the resuscitation to arrest physiology, real-time feedback-enabled CPR monitoring defibrillators, and a systematic post-cardiac arrest debriefing process), it is likely that a bundled approach incorporating two to several of these techniques will be necessary to improve long-term patient outcomes. As a promising recent example, the “Take
Summary
In spite of the remarkable progress made in resuscitation science since Kouwenhoven's112 original description of closed chest cardiac massage, survival from cardiac arrest continues to be very low. The reader should be convinced that this could be attributed, in part, to the poor performance of resuscitation care. Furthermore, it should be clear that resuscitation of the cardiac arrest victim is a highly complex task requiring coordination between multiple levels and disciplines of care
Acknowledgments
The authors would like to thank Dr Robert A. Berg and Dana Niles for their help in preparation of this article. We would also like to acknowledge Marion Leary, Lori Boyle, and Jessica Leffelman, who have supported resuscitation science at the University of Pennsylvania and Children’s Hospital of Philadelphia.
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Cited by (33)
Implementation of a Low-Dose, High-Frequency Cardiac Resuscitation Quality Improvement Program in a Community Hospital
2019, Joint Commission Journal on Quality and Patient SafetyProviders with Limited Experience Perform Better in Advanced Life Support with Assistance Using an Interactive Device with an Automated External Defibrillator Linked to a Ventilator
2015, Journal of Emergency MedicineCitation Excerpt :Previous data have shown poor compliance with CPR guidelines for out-of-hospital and in-hospital CPR (4,6–11). Various approaches have been implemented to increase the quality of the CPR process, including awareness campaigns, comprehensive introduction of AEDs, additional training of medical personnel, visible and audible feedback systems during CPR performance, active chest compression-decompression assist devices, instructor supervision of the ALS provider, dispatch-assisted CPR, and a telemedicine network (12–22). The hypothesis of the present study was that CPR quality of inexperienced ALS providers would be improved using a process that incorporated visible and audible instructions for using a respirator with an integrated and synchronized AED.
Chest compression release velocity: Association with survival and favorable neurologic outcome after out-of-hospital cardiac arrest
2015, ResuscitationCitation Excerpt :Encouragingly, CPR quality is a modifiable factor with previous studies demonstrating that CPR quality can be improved.5,21 Differences in CPR quality likely play a role in the large reported variations in outcomes for OHCAs.6,21,33–35 Previous literature demonstrates that CC depth, rate, and fraction as well as the preshock pause impact survival from OHCA.5–7,11,12,21,27,33,36
Medical students do not adversely affect the quality of cardiopulmonary resuscitation for ED patients
2014, American Journal of Emergency MedicineA review of chest compression interruptions during out-of-hospital cardiac arrest and strategies for the future
2013, Journal of Emergency MedicineCitation Excerpt :If EtCO2 levels are low, it can be presumed that compressions are either poor in quality or this could signal that the patient may not be viable; however, if the EtCO2 is high, compressions are likely quite adequate and ROSC may be imminent. Furthermore, it has been found that a sharp rise in EtCO2 levels during chest compressions correlates well with ROSC, and some authors feel this information can be used strategically to minimize unnecessary pulse checks (48). Mechanical CPR devices are marketed worldwide to potentially remove the human factor errors that likely result in poor CPR quality during manual chest compressions, such as provider fatigue.
Financial Disclosures or Conflicts of Interest: Vinay Nadkarni receives unrestricted research grant support from the Laerdal Foundation for Acute Care Medicine. Robert Sutton is supported through a career development award from the Eunice Kennedy Shriver National Institute of Child Health & Human Development (K23HD062629). Benjamin Abella receives research funding from Philips Healthcare, the American Heart Association, and the Doris Duke Foundation, and has received speaking honoraria from Philips Healthcare.