In-Hospital Resuscitation: Implementation of the AutoPulse as part of

In-Hospital Resuscitation: Implementation
of the AutoPulse® as part of a process
improvement bundle.
Presented By:
Melanie Roberts MS, APRN, CCRN,
CCNS
Cri ti c a l Ca re Cli ni c a l N u rse Sp ec i a li st
M edi c a l Center of th e Roc ki es
L ovela nd, Colora do
m g r @ pvh s . o rg
OBJECTIVES
 Articulate the importance of high quality CPR.
 Discuss the limitations of manual CPR in providing
optimal perfusion.
 Discuss the benefits and challenges of mechanical
cardiac support.
 Share real life experience with program development
and implementation, utilizing mechanical cardiac
support during in-hospital resuscitation.
MANUAL CPR
 Emphasis on improving basic CPR.
 American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care, 2005 updates, (Class I):
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30:2, rate of 100 compressions per minute
Compression depth of 1.5-2 inches
If multiple rescuers, change CPR providers every 2 minutes
Minimal interruptions, less than 10 seconds
Class I recommendation: high level prospective studies, potential benefit outweighs harm
MANUAL CPR – How good is it?
 Prospective, observational study, 67 patients, in-hospital cardiac
arrest using monitor/defibrillator with sensing capabilities
 40.3 % ROSC (27 patients), 10.7% (7) survived to discharge
 Analysis of first 5 minutes revealed inconsistent CPR that did not
meet guidelines
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Depth too shallow 37.4%
Ventilation rate too high 61%
Rate 90/min 28%
Mean no-flow was 0.24 (a 10 second pause each minute would yield a noflow fraction of 0.17)
Abella B et al. Quality of cardiolpulmonary resuscitation during in-hospital cardiac arrest. 2005 JAMA;293(3):305310.
MANUAL CPR
 Retrospective, observational study
 435 patients before 2005 ACLS changes, 481 patients
after
 Improved CPR:
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Decreased pre-shock pauses
Decreased hands off time
Appropriate compression and ventilation rates
 Survival 11% and 13 %
 Quality of CPR improved after implementation of
2005 Guidelines with only a weak trend toward
improved survival to discharge.
Olasveengen TM, et al. Effect of implementation of new resuscitation guidelines on quality of
cardiopulmonary resuscitation and survival. 2009 Resuscitation;80(4):407-11.
MANUAL CPR
 Challenges with providing high quality CPR during a
resuscitation
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Inconsistency of performance
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Resuscitation 2009, CPR feedback/prompt devices for training/?
Clinical practice
Fatigue of providers
Resuscitation, 2009
 Resuscitation, 2009
 Resuscitation, 2009
 Resuscitation, 2010
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chest compressions depth decay
change providers every 1 min
low back pain and ideal height for performance
CPR best position on floor
Chaos of switching providers every 2 minutes
BENEFITS OF MECHANICAL
CARDIAC SUPPORT
 High quality, effective CPR is required for the patient to
have an opportunity to survive, it does NOT ensure
survival.
 Mechanical cardiac support does not have to produce
better outcomes than manual CPR, it has to be as good
as manual CPR and no increased harm.
BENEFITS OF MECHANICAL
CARDIAC SUPPORT
 Pilot, clinical study
 In hospital arrest, 31 patients
 After 10 minutes of failed ACLS, catheters were placed to
measure coronary perfusion pressure during alternating manual
CPR and AutoPulse mechanical compressions
 AutoPulse created higher peak aortic pressure, peak right atrial
pressure, higher CPP
 Previous research has shown in an increased CPP is correlated
with increased coronary blood flow
Timerman S. et al. Improved hemodynamic performance with a novel chest compression device during
treatment of in-hospital cardiac arrest. 2004. Resuscitation;61:273-280.
MECHANICAL CARDIAC SUPPORT
 Multicenter, randomized trial, out-of-hospital cardiac arrest
 Manual CPR= 517, AutoPulse = 554
 Primary end point was survival to 4 hours post arrest, secondary end
points were survival to discharge and neurologic status
 No difference in the primary end point
 Survival to hospital discharge
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9.9% in manual CPR group
5.8% in AutoPulse group (P=.06)
 Neurologic status, cerebral performance category of 1 or 2 at hospital
discharge
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7.5 % in manual CPR group
3.1% in AutoPulse group (P= .006)
Hallstrom A. et al. Manual Chest Compression vs Use of an Automated Chest Compression Device During
Resuscitation Following Out-of-Hospital Cardiac Arrest. 2006. JAMA ;295(22):2620-2628.
MECHANICAL CARDIAC SUPPORT
 Observational, cohort
 783 adult, out-of-hospital cardiac arrests, manual CPR=499,
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AutoPulse =210
Outcome ROSC, secondary outcome survival to hospital
admission, discharge, and neurologic status on discharge
ROSC and survival to discharge was greater with AutoPulse
No difference in neurologic outcomes for survivors in either
group
The number needed to treat for the adjusted outcome survival to
discharge was 15 (95% CI, 9-33).
Ong M. et al. Use of an Automated, Load-Distributing band Chest Compression Device for Out-of-Hospital
Cardiac Arrest Resuscitation. 2006. JAMA;295(22):2629-2637.
MECHANICAL CARDIAC SUPPORT
 Prospective, observational study, out-of-hospital cardiac arrest
 46 patients, resuscitated with the AutoPulse device
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54.3% had ROSC
39.1% were admitted to ICU
21.8% were discharged from ICU
End-tidal C02 significantly higher in patients with ROSC
Mean time for set-up of the device was 4.7+ 5.9 min but activation of the
device was possible within 2 minutes or less (67.4% of cases)
No injuries were detected
Henning K. et al. Out-of-hospital cardiopulmonary resuscitation with the AutoPulse system: A prospective
observational study with a new load-distributing band chest compression device. 2007. Resuscitation 73;8695.
MECHANICAL CARDIAC SUPPORT
 Multicenter, manikin study
 Primary endpoints hands-off fraction and timing of ALS tasks
 Hands-off fraction (HOF) was increased with the Autopulse at
the site with the lowest fraction with manual CPR. The HOF
improved with the Autopulse at the two sites with the highest
HOF with manual CPR.
 Initial defibrillation was delayed with the Autopulse versus
manual CPR
 There were some issues with the multiple sites following the
study protocol.
Tomte O, et al. Advanced life support performance with manual and mechanical chest compression in a
randomized, multicenter manikin study. 2009 . Resuscitation; 80:1152-1157.
MECHANICAL CARDIAC SUPPORT
 Phased, before-after cohort evaluation, out-of-hospital cardiac
arrests
 Outcome median no-flow time defined as a sum of all pauses
between compressions longer than 1.5 seconds in the first 5
minutes of CPR
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First 5 minutes: manual no-flow time 85 seconds, AutoPulse 104
seconds
5-10 minutes: manual no-flow time 85 seconds, AutoPulse 52 seconds
Average time to apply the AutoPulse 152 seconds
 Greater no-flow time with the AutoPulse in the first 5 minutes,
but improved later in the resuscitation.
Ong M. Cardiopulmonary resuscitation interruptions with use of a load-distributing band device during
emergency department cardiac arrest. 2010 Annals of Emergency Medicine (article in press).
BENEFITS OF MECHANICAL
CARDIAC SUPPORT
 Why don’t we have more research available?
 Undertaking large scale, RCT, large samples, long term follow-up
for outcomes requires more resources than are available to most
researchers. Difficult to get multiple centers to follow a study
protocol.
 Cost
 Resuscitation is complicated with confounding variables.
 Potential for harm of mechanical chest compression devices
compared to manual chest compressions, it is unclear if there is
excess harm associated with the mechanical device.
Jacobs I. Mechanical chest compression devices—will we ever get the evidence? Resuscitation 2009
(80): 1093-1094.
BENEFITS OF MECHANICAL
CARDIAC SUPPORT
 Potential benefits not studied
 Teamwork
Increased “hands off ‘ time (needs further study)
 Increased “think” time of the team, allowing team to consider causes
and definitive treatment earlier
 Decreased team members required for the resuscitation
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Increased perfusion
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Ability to defibrillate while compressions are in progress
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Generates systolic BP 90-140 mmHg
Decreasing the time without compressions
Decreased work-related injuries due to providing CPR
Implementing a Program with a
Mechanical Cardiac Support Device
 In this fiscal environment, how do you get a
mechanical cardiac support device?
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How many nurses injure their backs doing CPR?
How much does it cost to train an RN to work in the ICU ?
How many employees does it take to run a resuscitation
currently?
 Mechanical Cardiac Support only has to be as good as
manual CPR, may not be better due to multiple
variables affecting the outcome of a resuscitation.
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Not all interventions will have Level I evidence to support use.
Is there sufficient evidence to show it is not harmful?
 Ask ZOLL for an evaluation period
USING THE AUTOPULSE™
Implementation of the AutoPulse into the in-house
resuscitation team: Our Experience
Implementing a Program with a
Mechanical Cardiac Support Device
 Strategic placement is the key
 Place the Autopulse where it will be maintained and checked
routinely
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Code Blue Team access
Base number on response time of Code Blue Team
Determine number needed without excess
Who will place the device?
Autopulse™
Transport
 Mounted below
defibrillator
 Handle to facilitate
pulling or pushing
 Taken with in-house
team when activated
 Keys to elevator
Implementing a Program with a
Mechanical Cardiac Support Device
 Develop a procedure
 Define what patients populations can and can not have the
AutoPulse
 Who can place the AutoPulse
 Clearly define how to use the AutoPulse
 Clearly define how to change the Life Band ®
 Clearly define how to clean the AutoPulse and have it ready for
use – hygiene barrier
 Daily maintenance
Check belt
 Change battery
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Documentation regarding AutoPulse during code
Implementing a Program with a
Mechanical Cardiac Support Device
 Simulate placement of the AutoPulse
 Don’t use a manikin, use real people. The manikin is too light.
 Drill OFTEN, it is a complex skill in a resuscitation
At least quarterly
 Practice precision, placement less than 30 seconds
 Standardize the process
 Time the process
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 Review problems with the AutoPulse real time
Implementing a Program with a
Mechanical Cardiac Support Device
 AutoPulse placement
 Start manual CPR, placement of the Autopulse does not have to
be immediate.
 Remove AutoPulse from transport device and turn it on.
 Continue manual CPR, have staff position themselves on each
side of the patient. When everyone is in position and ready, the
person with the AutoPulse does the count.
 On the count of three, the patient is lifted to a sitting position, the
AutoPulse slides in behind the patient (round end to the butt).
 The patient is lowered onto the AutoPulse, ensure positioning is
appropriate, bring LifeBand around chest.
 Pull LifeBand up, start AutoPulse
Pausing AutoPulse
 Pauses should be kept to a minimum
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Checking for shockable rhythm
 When shock is advised, the AutoPulse can continue
compressions during the shock
Medical Center of the Rockies Experience
YEAR
Number
Actual
Codes
Codes
with
AutoPulse
Initial Rhythm
PEA/Asystole
VT/VF
Survival to
Discharge
2007
45
19
(42%)
53%
(24/45)
16%
(17/45)
43%
(17/40)
2008
33
14
(42%)
76%
(25/33)
6%
(2/33)
33%
(9/27)
2009
58
25
(43%)
64%
(37/58)
31%
(18/58)
44%
(21/48)
Medical Center of the Rockies Experience
 AutoPulse is one component of a bundle to improve
outcomes with resuscitation:
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Pharmacist added to the team
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Increased training of Code Blue Team
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Simulation training focusing on teamwork, communication
Rapid Response Team decreased Code Blue calls outside
ICU
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1999 study, 35% of all US admissions, statistically significant lower mortality,
32% hospitals utilize pharmacists on their teams.
1029 hospitals, 18 fewer deaths in the hospitals with pharmacists
participating on the teams, extrapolated to all hospitals, 67,000 lives saved
per year
15% of Code Blue calls outside of ICU
Induced Hypothermia (NNT 6-8)
Medical Center of the Rockies Experience
 Lessons Learned
 Learning curve with use of the AutoPulse (longer than expected)
 Placement has to be quick and efficient for the Code Blue team to
see the benefit of the AutoPulse
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Practice is imperative for placement
The AutoPusle has to become an efficient, planned, and practiced part of
the process of the in-hospital resuscitation, with timing of placement
based on the clinical situation.
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PEA/Asystole about 40% of these codes
VT/VF only about 5% of these codes
In our experience, it is utilized in longer codes, short ones the patient has
ROSC before placement can occur.
Placement is after the first two minutes of CPR, sometimes at the 4 or 6
minute checks depending on circumstances.
Placing the AutoPulse should NEVER delay defibrillation.
Medical Center of the Rockies Experience
 Lessons Learned
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Critical thinking required about patient physiology and
AutoPulse function
Hypertrophic cardiomyopathy patient (Amyloidosis)
 Femoral pulses
 Palpation of brachial/radial (SBP 90-140)
 Pulmonary Edema
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MCR uses the AutoPulse on open heart surgery patients, several
have had their chests explored after the AutoPulse was used, no
injuries were found.
Medical Center of the Rockies Experience
 Case Report
 53 yo man, cardiac arrest at home, EMS finds patient in VF (Nov)
 10 minutes of manual CPR, 27 minutes Lucas device, 60 minutes
with the AutoPulse
 CCL, 100% LAD, PTCA/Stent, defibrillated 12 times in CCL, IABP
 Induced hypothermia in the CICU, with 2 more arrests
 Day 3 returns to normothermia, awakens from sedation within
12 hours
 Patient asked if he could hear us to give a thumbs up, the pt did
 Left the hospital 10 days later, completely neurologically intact
 Visited the CICU in running shorts at Christmas
Medical Center of the Rockies Experience
 Case Report
 76 yo man, VF arrest at home, lives next to fire station, manual
CPR within 3 minutes of collapse
 AutoPulse during transport to MCR (35 minutes)
 CCL, PTCA/Stent, IABP, Induced hypothermia
 Returned to normothermia, slow to awaken but once awake,
follows commands
 Discharge home, neurologically intact
Summary
 Literature reports the following for survival to
discharge:
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PEA/Asystole 12%
VT/VF 37%
Overall 0-29%
Meaney P, et al. Rhythms and outcomes of adult in-hospital cardiac arrest. Critical Care Medicine 2009;38(10:1-8.
 Our experience, survival to discharge has increased
from 15%-21% (prior to 2007) to 33% -44%
(PEA/Asystole 60%) with the AutoPulse
implementation as part of a resuscitation improvement
bundle.
Summary
 The AutoPulse is a tool, there are times when it is
advantageous and times when it isn’t.
 The ability of the team to place the device quickly,
correctly, and efficiently will determine if outcomes
will improve. Placement of the AutoPulse CAN NOT
delay ACLS interventions.
QUESTIONS