The ART of Resuscitation

CURRENT PRACTICES:
EDUCATION SERIES
The ART of Resuscitation
1
I n tr o d u c ti o n
In 2007, the University of California San Diego (UCSD) Medical Center instituted
a novel resuscitation training program known as ART, short for Advanced
Resuscitation Training. Not simply a replacement for traditional training courses,
ART is a template for a new strategy of resuscitation oversight that can be applied
within various institutions.
The training is constructed around a single core principle: the prevention of
interruptions in compressions at all costs. ART emphasizes the simple concept that
compressions should be performed from the moment of arrest until ROSC (return
of spontaneous circulation) is assured. The term codus interruptus was coined to
represent all of the things that interrupt compressions during a code, with a potential
solution identified for each. One aspect of the program was integrating technology
to provide resuscitation metrics that can identify needed performance improvement.
At UCSD, the ART program has improved outcomes from cardiac arrest by
increasing both survival and the rate of good neurological outcomes in an inpatient
population, while decreasing the overall incidence of arrests through surveillance
and a rapid response team.
This booklet is based on a presentation by Sheri Villanueva, an ICU critical
care nurse at UCSD. Villanueva, who works as a code nurse and a rapid response
nurse, is part of the team responsible for training house staff and new code
nurses using ART.
The ART of Resuscitation
New
Model
Cardiac arrest is a heart
taking a nap, and hearts
don’t take naps. So when
someone goes into cardiac
arrest, the job of first
responders is to take over
circulation. We need to jump
in and start CPR in order to
do the heart’s work.
for
R e s u s c itati o n
Figure 1—Stay on the chest!
5
4
Adjusted OR
A
* Adjusted for: age, gender, bystander CPR,
public location, response time, compression rate
14% of
patients
3
2
20% of
patients
1
0
0-20
21-40
41-60
61-80
81-100
Optimal cardiac arrest
Chest Compression Fraction
resuscitation is truly about
high-quality CPR. But how
Based on: Christenson J, et al. Circulation. 2009;120:1241–47.
do you define high quality?
Is it a magic number? Is it a magic rate? It’s neither. It’s as deep as you can, as fast as
you can, as long as you have good recoil.
Let’s look at the main components of high-quality CPR:
•Stay on the chest. Do continuous chest compressions.
Do not take breaks to ventilate.
•Push hard. Push deep—as deep as you can.
•Make sure you have good recoil.
Figure 2—Compression depth matters
50
100
90
40
% Admitted Alive
Shock Success (%)
80
70
60
50
40
30
20
30
20
10
10
0
<26
26-38
39-50
Compression Depth (mm)
Edelson DP, et al. Resuscitation. 2006
Nov;71(2):137–45.
>50
0
lowest quartile
25-50 quartile
50-75 quartile highest quartile
Compression Depth (mm)
Based on: Kramer-Johansen J, et al.
Resuscitation. 2006;71:283–292.
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Figure 3—Perfusion pressure increases with full recoil
Learning from
the past
Based on published
data, we know that
historically, the CPR
that we’ve been
providing is not
adequate. One measure
of CPR quality is the
CPR fraction, the
percentage of time
that compressions
are delivered during
resuscitation. A 2009
pre-hospital study
Aufderheide TP, et al. Resuscitation. 2005;64:353–362.
found that survivability
goes way up if you’re on the chest 81% to 100% of the time (see Figure 1). This
study found that only 14% of patients were getting good compressions, with the
provider staying on the chest more than 80% of the time. For 20% of patients, the
rescuers stayed on the chest only 20% of the time at best.
Two studies from 2006 demonstrate the importance of deep compressions. Deeper
compressions correlate with survivability, as shown in Figure 2. But we have to
achieve a balance because we also need good recoil. If you stay on the chest and
don’t get good recoil, the intrathoracic pressure will be so high that you won’t get
perfusion. Perfusion pressure will increase with full recoil (see Figure 3).
It’s ART
At UCSD, we don’t follow the ACLS [advanced cardiac life support] algorithm. All
of our nurses, physicians, house staff, and nurse assistants receive a specific training
called ART, or BART. ART stands for Advanced Resuscitation Training, and
BART is our basic resuscitation training. ART is a novel resuscitation program that
facilitates the integration of new technology into clinical practice. Our institution
uses ZOLL equipment, with software that displays the depth and rate of the
compressions and also provides filtered EKGs. This is wonderful. A filtered EKG
allows us to see the patient’s underlying rhythm while we are doing compressions
because it filters out the artifact. And, when we stop compressions to confirm a
rhythm or to perform a pulse check the pauses are much shorter.
The ART of Resuscitation
Figure 4—The algorithm created at UCSD
ART: Advanced Resuscitation Training. PART: Pediatric Advanced Resuscitation Training.
.
The ART model is flexible and adaptive. Flexible meaning we actually collect a lot
of data that help us determine why our patients are coding. Is the code preventable?
From month to month, we evaluate every Code Blue, every rapid response, so
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there’s follow-up to address Figure 5—ZOLL OneStep® Resuscitation Electrode with
CPR Sensor
any education pieces that
are missing.
We’re a team and we want
to prevent our patients
from coding. We know that
based on our data, there’s a
five-hour window prior to
a patient actually arresting
where vital signs reflect
the fact that this patient is
going to code. Could we
have done something prior
to the patient coding that
could have stopped it from
happening? Are we coding
patients that are actually futile? These are some questions that we evaluate as an
organization.
The ART Mission
•To prevent the preventable
•To resuscitate the resuscitatable
•To recognize the futile
All of our house staff receive exactly the same
training from a set of instructors that we
train ourselves. If you receive ACLS training,
it can sometimes be confusing because
different instructors might say things in a
different way. But all of our instructors are UCSD trained, and we do this training
in a simulation center at our medical school, where the staff can come in and do
actual Code Blue simulations with other members of the team. Figure 4 shows the
ART algorithm that we use. As you can see, we have an algorithm for a perfusing
patient, so that is similar to the ACLS algorithm, but the rest of it is different.
Integrating technology to improve outcomes
There are many reasons why compressions are stopped in both the hospital and
pre-hospital environments—intubation, line placement, checking to see if there is
an underlying rhythm. But new technology that we have today can measure CPR
quality in real time and retrospectively, and I would like to talk about how we’ve
implemented a lot of this technology at UCSD and the difference that it has made
in our outcomes.
The ART of Resuscitation
Figure 6—Screen display of ZOLL defibrillator showing
Let’s look at some of the
CPR Dashboard™
equipment that we use
as part of ART. We use
ZOLL defibrillators. The
defibrillator electrode
actually has a sensor on it
that measures depth and
rate (see Figure 5). If you
look at the screen of one
of our defibrillators (see
Figure 6), this is how it
appears. I can see from
the bar that my depth is
good, and I can see that
my rate is about 127
compressions per minute on average. And if I’m wondering if I’m staying on the
chest long enough, I can look at the little diamond that tells me how full my pump
is. [This diamond shows the perfusion performance index, or PPI.] This is some
really good real-time feedback. [This data display of depth rate, release, and PPI is
known as CPR Dashboard™ and is made possible by Real CPR Help® technology.]
During a code, you can use it to evaluate whether someone needs to do better chest
compressions or if someone is getting tired.
Treat the patient, not the monitor
The end-tidal CO2 level is one of the main factors that we use to help determine
return of spontaneous circulation. In Figure 7, you see capnography data for a
patient who is in cardiac arrest. Initially, during CPR, the end-tidal CO2 is only at
about 18 [mmHg], so in our algorithm, this person is dead. CPR is stopped to
defibrillate the patient. End-tidal CO2 climbs up into the forties, so we restart CPR.
We’re watching to be sure that the level is maintained in the forties. We hold
compressions; end-tidal CO2 is maintained. We saw a reflection of this in the EKG
Figure 7—Capnography
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rhythm. So this person is
back, and we’re going to
ventilate this patient.
But if we saw a dip in
the end-tidal CO2, we
would jump back on the
chest and continue CPR.
Figure 8—Treat the patient, not the monitor
As a vital sign, pulse
oximetry is something
that we all use. But in
Figure 8, we have a pulse
ox reading of 72%, a
heart rate of 72, and it looks like this patient has some QRS complexes. If you saw
this screen, you might think that this patient is perfusing and has a heart rate of 72,
so he’s alive. But you can see that the end-tidal CO2 level is zero, so this patient can’t
be alive. The pulse oximeter sensor is on an Ambu mask. It sounds obvious, but we
have to remember to treat the patient, not the monitor. You have to take all of the
pieces of technology into account to determine return of spontaneous circulation.
In spite of CPR artifact
If you look at the EKG on the screen of one of our defibrillators, you will
see what I referred to earlier as a filtered EKG. [The technology that makes this
possible is called See-Thru CPR®.] With this technology, pauses are much shorter
when confirming a rhythm or performing a pulse check.
Looking at Screen A in Figure 9, do you know if this person is dead or alive?
I can see that this person is in a V-fib [ventricular fibrillation] arrest. We can also
look at the end-tidal CO2 level, which is only 16. What is alive to me? As a code
nurse, I’m looking at something between 35 and 45. If it’s below 20, I don’t think
this person is alive. This data is telling me that this patient is not doing well, but
that our CPR is pretty good. The depth is about two inches, and the rate is 127.
So, we make a decision to stay on the chest and continue to do what we can.
On Screen B, we see what the monitor shows after the patient receives a shock. It
looks like there are some QRS complexes. But in our algorithm, this patient is still
dead because the heart rate is less than 40. And looking at the end-tidal CO2, if
this person had return of spontaneous circulation, we would want to see this level
greater than 25—hopefully, climbing up into the thirties. We would tell our team
The ART of Resuscitation
Figure 9—Screen displays from a ZOLL defibrillator
Screen A
Screen B
Screen C
Screen D
to stay on the chest. So, CPR would keep going on continuously. On Screen C, we
see a different rhythm, and our end-tidal CO2 is at 31. At this point, you would
say, “Guys, it’s time to do a pulse check. While CPR is going on, I want you all to
get to a pulse point.” We don’t stop CPR while everyone is fishing around to find a
pulse point. We wait until everyone is set. Then we tell them to hold compressions.
If you can feel a pulse and you continue to see the end-tidal CO2 holding, this
person is alive. But if you suddenly start to feel the pulse disappear, you get back on
the chest and continue CPR.
Now look at Screen D. This is what we see when we stop compressions for the
pulse check. We see the pulse ox waveform that correlates with the EKG. We see
that there’s perfusion and that the end-tidal CO2 level is being maintained in
the thirties. This person is alive. This is how we pull all the pieces of integrated
technology into the picture during a code.
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Mining the data after the code
How many times have you run a code and, at the end, wished you knew exactly
what was done when and how well the team did? When did we deliver the shocks?
How long did it take us to get back on the chest after the shock? I wonder if that
person was going too fast, or I wonder if that person was going too slow. What
could we have done better? When you talk about debriefing after your codes, you’ll
hear people say that they don’t have accurate feedback to tell them what really
happened. How do you improve what your team does as a code team if you can’t go
back and look at what you can do to improve?
At UCSD, we do have this information because the same CPR sensor that gives us
all the CPR quality data about the depth and rate of the compressions during the
code also records all of the information for post-code analysis. In Figure 10, you
can see some of the data on depth, rate, and compression quality that was recorded
during one particular code. This individual received three shocks in a row. You can
see from this data that the person who was doing chest compressions started getting
tired. There’s a little break where nobody’s doing CPR. Then someone else jumps
back on the chest. It’s time to deliver a shock. Are you ready to shock? Pause and
confirm shockable rhythm. Shock delivered; back on the chest. Then the machine
is charged again. Stay on the chest until we’re ready to defibrillate. Off the chest,
charge delivered; back on the chest. You can see how CPR continues between each
shock. This is really great information to debrief after the code. If you have good
results, that’s great. If you don’t have good results, you can go back and educate
your staff as to what they could have done better.
Figure 10—CPR data collected from the ZOLL defibrillator code record
The ART of Resuscitation
Figure 11—Second-by-second data for post-code debriefing
Figure 12—More code record data, showing a pause in CPR to perform a C-section
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Figure 13—UCSD CPR statistics
Because UCSD is a
teaching institution, our
Results
code teams switch every
month. But there is one
Chest compression fraction
91%
group of people who
Compression rate
123/min
remain in place and do not
Compression depth
2.6 inches
switch on the code teams
Pre-shock pause
2.6 sec
throughout the hospital:
Post-shock pause
3.6 sec
the code nurses. With the
education that we receive
Perfusion check
4.3
and the feedback that we
Ventilation rate
9.7/min
have, during a post-code
15.3 mmHg
PetCO2
review it is really simple to
say something like, “Did
you realize that this person was PEA [pulseless electrical activity], and you guys
were shocking an unshockable rhythm?” Something like this can be really insightful
in terms of teaching.
Figures 11 and 12 show CPR data from a recent code. We were able to go back
and look at what happened with this woman. This is second-by-second data; you
can see the EKG strip. This patient was in V-fib. The bars are showing compression
depth, and you can see that it was good and that the team kept doing CPR. We
can see that as CPR continued, there was a change in rhythm. Then there was a
period where there was a big block when they weren’t doing compressions. So the
code team goes back and asks what happened during this time. Unfortunately, this
woman was pregnant, so they had to stop compressions to do a C-section.
Measuring the value of ART
At UCSD, we stay on the chest 91% of the time; the national average is 60%.
(See Figure 13.) One of the reasons we can stay on the chest is because of the
software our ZOLL defibrillators have. We can look at filtered EKG rhythms and
are able to watch chest compression quality. Our compression rate averages 123 per
minute; our compression depth is about 2.6 inches. So that’s pretty good. During
a pre-shock pause—that basically means “Everybody clear?"—we’re only off the
chest for 2.6 seconds. It takes us an average of 3.6 seconds to get back on the chest.
These are things that we look at in our CQI [continuous quality improvement]
data. How long does it take to do a perfusion check? For us, it’s 4.3 seconds.
That’s not very long, but when you’re feeling for a pulse, it does feel like forever.
But we know that the coronary perfusion pressure drops really quickly, so the less
The ART of Resuscitation
time off the chest, the better. Our ventilation rate is an average of about 9.7 per
minute, and our end-tidal CO2 averages 15.3 mmHg.
When we look at arrest etiologies at UCSD, the majority of our codes are in
patients that go into respiratory distress first before showing actual cardiac issues.
This is interesting because when we used to train based on the ACLS algorithm, our
focus was on V-fib and V-tach [ventricular tachycardia] patients. But guess what?
Within the hospital, that isn’t how our patients code. When we started our program
back in 2007, 45% of our arrests were respiratory arrests. Educating our staff about
how our patients code has prevented deaths. Most of our rapid responses are called
for respiratory issues, and since instituting the ART program, respiratory arrests
have dropped down to the 20% range.
Our outcomes have been outstanding. Looking at pre-ART training versus postART training in Figure 14, you can see that there has been a huge increase in
survivability and in good neurological outcomes. We are particularly excited about
the data from the non-ICU setting. In the ICU setting, we all know that our
patients are really sick, and there isn’t always a lot that we can do to predict whether
or not they’re going to cardiac arrest. Overall, in the last five years that we’ve been
following the ART program, we have saved over 250 lives from cardiac arrest within
the hospital. When patients die unexpectedly, there is a charge of about $50,000 to
the hospital. So we’ve really done a lot of work in saving money as well.
Figure 14—A comparison of outcomes pre- and post-ART
45
40
Pre
Post
35
Percent (%)
30
25
20
15
10
5
0
Non-ICU
ICU
All
Survival-to-Discharge
Non-ICU
ICU
All
Good Neurological Outcome
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If you compare mortality for all of the hospitals in San Diego, you can see that
UCSD has the lowest rate in San Diego, which is really exciting. (See Figure 15.)
The university is getting a lot of awards for this. And when UCSD is compared to
all of the teaching hospitals in California, again, UCSD is at the very bottom for
mortality. (See Figure 16.)
ART is a great program. I understand there are a lot of differences between ART
and the typical ACLS, but we have the results to prove that it works. We hope that
the ART concepts can be applied in other institutions. If you have the chance to tell
people about it, tell them that the technology works in helping save lives, and that
it’s a great thing to do for resuscitation.
Figure 15—UCSD now has lowest mortality rate of all
San Diego hospitals
Mortality Index (O/E Ratios)
San Diego Area Hospitals, MedPar (Medicare) 2010
1.40
1.20
1.00
0.80
UCSD
0.60
Figure 16—UCSD mortality rate is lowest of all
California teaching hospitals
Mortality Index (O/E Ratios)
California Academics, UHC All Payors, Jan-Oct 2011
1.60
1.40
120
100
0.80
UCSD
0.60
The ART of Resuscitation
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The ART of Resuscitation
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