Download 9/16/2014 ©2010, American Heart Association

9/16/2014
©2010, American Heart Association
1
Get With The Guidelines® – Resuscitation
Webinar: Time to Shock Measure
Best Practices
Tanya Lane Truitt, RN MS
National Consultant- Resuscitation
American Heart Association
9/16/2014
©2010, American Heart Association
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Resuscitation
 Get With The Guidelines-Resuscitation formerly known as National Registry of
Cardiopulmonary Resuscitation (NRCPR) was launched by the American Heart Association in
2000
 It was the first quality improvement database to focus efforts upon the in-hospital resuscitation
events of newborn/neonates, children and adults.
 Get With The Guidelines-Resuscitation joined the other in-hospital quality suite of programs
including Get With The Guidelines-Stroke and Get With The Guidelines-Heart Failure in 2010.
 Over 323 hospitals enter data on Cardiopulmonary Arrest, Acute Respiratory Compromise,
Medical Emergency Team response and our newest form Post Cardiac Arrest Care introduced in
October 2012.
 This program is overseen by in-hospital Resuscitation Experts on the GWTG-Resuscitation
Clinical Working Group
 In-hospital resuscitation data is entered in the Patient Management Tool
 Hospitals enrolled have opportunities to be recognized for their efforts at national events
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Culture of Resuscitation
Quality
Data
Collection
Reporting/
Benchmarking
Training/
Processes
9/16/2014
Feedback
(individual &
organizational)
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Get With The Guidelines® – Resuscitation
Webinar: Time to Shock Measure
Best Practices
Tia T. Raymond, MD, FAAP, FAHA
Pediatric Cardiac Critical Care
Medical City Children’s Hospital
Dallas, Texas
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©2010, American Heart Association
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©2010, American Heart Association
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Incidence of CPR
for IHCA
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©2010, American Heart Association
Chan. Arch Int Med, 2010; Nadkarni. JAMA, 2006; Fiser. J Pediatr 1992; Booth. JAMA 2004.
IHCA Survival Improving
84,625 Adults
45
Survival to Discharge, %
40
35
30
VF and VT
25
20
Asystole and
PEA
15
10
5
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Adj. rate ratio/year: 1.04, 95% CI [1.02-1.05]
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Girotra, et al NEJM 2012
©2010, American Heart Association
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IHCA Survival Improving
1,031 children
Risk-adjusted Survival Rate Increased
14.3% in 2000 to 43.5% in 2009
Adj rate ratio/year 1.08; 95% CI [1.01,1.16]
Girotra, Spertus, Li, Berg, Nadkarni, Chan
Circ Cardiovasc Qual Outcomes 2013
“Delayed time to defibrillation
after in-hospital cardiac arrest”.
Study Cohort
Chan P et al. N Engl J Med 2008;358:9-17
Chan PS. NEJM 2008; 358: 9-17
Baseline Characteristics According to
Time to Defibrillation
Chan P et al. N Engl J Med 2008;358:9-17
Chan PS. NEJM 2008; 358: 9-17
Unadjusted and Adjusted Rates of Survival to
Hospital Discharge According to Time to
Defibrillation
Chan P et al. N Engl J Med 2008;358:9-17
Chan PS. NEJM 2008; 358: 9-17
Opportunity For Improvement
• Delayed defibrillation in 30%
• Survival to discharge related to time to defibrillation
–Defibrillation ≤2 minutes – 39% Survival
–Defibrillation >2 minutes – 22% Survival
Chan PS. NEJM 2008; 358: 9-17
Summary of Study End Points and Adjusted
Survival Rates with Delayed Defibrillation
Chan P et al. N Engl J Med 2008;358:9-17
Chan PS. NEJM 2008; 358: 9-17
Factors Associated with Delayed Time to
Defibrillation in Multivariable Analysis
Chan PS. NEJM 2008; 358: 9-17
Examples of How GWTG-R Can Be Used To
Improve Performance
Survival is decreased if time event recognized until first
defibrillation shock exceeded 3 minutes
Delayed time to defibrillation after in-hospital cardiac arrest. Chan PS,
Krumholtz HM, Nichol G, Nallamothu BK: N Engl J Med 2008; 358: 9-17.
This GWTG-R study established that survival-to-discharge following inhospital cardiac arrest due to ventricular fibrillation/pulseless ventricular
tachycardia is strongly dependent on minimizing time to defibrillation. They
found that delays in the time to defibrillation are common in hospitalized
patients with cardiac arrest due to a ventricular arrhythmia, and identified
several patient- and hospital-related factors associated with delayed time to
defibrillation. Such delays were associated with substantially worse clinical
outcomes, with each additional minute of delay resulting in worse survival.
American Heart Association Guidelines 2010:
Initial Shockable Rhythm, Time to First Shock
Ewy GA, Ornato JP. 31st Bethesda Conference: emergency cardiac care—task
force 1: cardiac arrest. J Am Coll Cardiol 2000;35:832-46
Hospitals should aim for a goal of delivering the first shock
within 2 min of when the arrest was determined in noncritical care
areas.
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• Recognition Measures
– Backed by very strong scientific evidence
• Quality Measures
– Weaker level of evidence, but thought to benefit patient outcome
• Reporting Measures
– May have some benefit, not harmful
• Descriptive Measures
– Provided to assist facilities in understanding event situations
Recognition Measures
Time to first shock ≤ 2 min for
VF/pulseless VT first documented rhythm:
Percent of initially pulseless events with VF/pulseless
VT first documented rhythm with time to shock ≤ 2
minutes
Percent of Events, Initial Shockable Rhythm, with
Time of Event Recognition to First Shock Within 2
Minutes
Example of
a report
graph
3/2/2011
12/8/2010
©2010,American Heart Association
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Time to first shock ≤ 2 min for VF/pulseless
VT first documented rhythm
©2010, American Heart Association
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Time to first shock ≤ 2 min for VF/pulseless VT first
documented rhythm
For patients who arrest in the hospital with an initial rhythm of ventricular fibrillation or
pulseless VT, defibrillation within 2 minutes is associated with a higher likelihood of
survival to discharge.
National Performance
2010-2013
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©2010, American Heart Association
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What about patients where there was a
documented medical reason why a shock was not
provided within 2 minutes?
CPA 4.2 AED and VF/Pulseless VT
Exclude pt.
Updated Data Element & Recognition Measure
Time to first shock ≤ 2 min for VF/pulseless VT first
documented rhythm
•
Updated Recognition Measure will look only at eligible patients
•
We hope this will result in improved performance!
GOAL: Reach 85% and then
exceed it!
Recognition Awards
• BRONZE recognizes performance of 1 calendar quarter.
• SILVER recognizes performance of 1 calendar year
(Jan 1st to Dec 31st).
• GOLD recognizes performance of 2 consecutive calendar
years (Jan 1st to Dec 31st).
•
Retrospectives study of first 500 patients in non-monitored areas treated initially by nursing
staff equipped with AEDs.
•
Evaluation of the efficiency of the existing in-hospital CPR program produced poor results in
the year 2000 an in-hospital first responder AED program was initiated in 2001.
•
Before arrival of the CPR team nurses on duty were on scene as first responders in all
cases.
•
40 biphasic external AEDs, one for each floor and each outpatient clinic were installed. The
AEDs had no ECG display but verbal instructions to guide the first responder through the
resuscitation program.
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©2010, American Heart Association
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Study Cohort
•
This April 2001-Dec 2004 439 patients (61
false alerts) evaluated
•
256 (58%) ROSC, 125 (28%) d/c from
hospital, and 95 (22%) alive at 6 months
after d/c.
•
Among the 73 patients with VF/VT 63 (86%)
had ROSC, 34 (47%) were discharged from
hospital and 28 (38%) were alive after 6
months.
•
Out of 73 patients with VF/VT, defibrillation
was performed by nurses alone in 41, by
nurses and physicians in 10, by physician
only in 10 and by nurses and other
healthcare workers (i.e. midwives, assistant
medical technicians) in 6 patients.
Conclusions
•
This observational study supports the concept of hospital-wide first responder resuscitation
performed by nursing staff before the arrival of the CPR-team.
•
Among these patients survival rate was higher in those with VF/VT defibrillated at an early
stage.
•
Consequently, it may be assumed that patients may die unnecessarily due to sudden cardiac
arrest if proper in-hospital resuscitation programmes are not available.
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Examples of How GWTG-R Can Be Used To
Improve Performance
Data to Consider:
Identify specific problem areas within the facility by reviewing the
Events by Time/Location Report.
Compare median times with your comparison group.
Compare event locations with comparison group: ICU vs. Telemetry vs.
General Floor
Evaluate first pulseless rhythm and compare with comparison group:
shockable vs. non-shockable
Compare percent of witnessed vs. un-witnessed CPA with your
comparison group.
Example of positive organizational changes within member facilities
as a result of related data:
Purchased AEDs for certain areas.
Trained personnel in use of AEDs
Established “First Responder” Protocols
Include use of hands-free pads (which decrease preshock pause)
Increased monitored bed capacity
THANK YOU!
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Get With The Guidelines® – Resuscitation
Webinar: Time to Shock Measure
Best Practices
Tanya Lane Truitt, RN MS
National Consultant- Resuscitation
American Heart Association
9/16/2014
©2010, American Heart Association
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Configurable Measure Descriptions
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©2010, American Heart Association
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CPA: Time to first shock <= 2 min for VF/pulseless VT first documented rhythm: Percent of
initially pulseless events with VF/pulseless VT first documented rhythm with time to first shock <= 2
minutes.
Core Date: CPA Date/Time the need for chest compressions (or defibrillation when initial rhythm was
VF or Pulseless VT) was FIRST recognized
This report is event-based and includes all initially pulseless events with first documented rhythm of
VF/pulseless VT.
NOTE: Apply the “Patient Population” filter with this measure to examine either Adult, Pediatric or
Newborn/Neonate
Events with missing or invalid response times are excluded from interval-based reports. These
intervals, which indicate the time lapse between when a condition was recognized and when
intervention began, are key to improving outcomes and meeting practice guidelines. The time to
defibrillation for events with the initial rhythm ventricular fibrillation/pulseless ventricular tachycardia is
calculated as the interval from the reported time of initial recognition of the cardiac arrest to the
reported time of the first attempted defibrillation. Decreasing time to defibrillation is a key determinant
of positive cardiac arrest patient outcome, survival to hospital discharge
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©2010, American Heart Association
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CPA: Time to first shock <= 2 min for VF/pulseless VT first documented rhythm:
Percent of initially pulseless events with VF/pulseless VT first documented rhythm
with time to first shock <= 2 minutes
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©2010, American Heart Association
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©2010, American Heart Association
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Finding the Patients who
fell out of the measure
Finding the Patients who
fell out of the measure
Finding the Patients who
fell out of the measure
What to look for when determining why a patient
fell out of the measure?
•
Check to see if the time of shock was entered into the PMT and was entered
correctly.
•
Check to see if there was a medical reason the patient was not shocked in the
required timeframe.
Was it a documentation problem?
Was it a time problem?
Was there another issue within the event itself? Did a debrief occur and any
possible cause identified?
•
•
•
–
–
–
–
Leadership
ALS Guidelines not followed
Equipment issues
Supplies missing (defib patches etc.)
Is there a system issue resulting in the delay?
•
The peer review of these events may identify opportunities for improving processes and
outcomes.
•
Hospital teams have developed and tested process and system changes that allowed them to
improve performance related to time to defibrillation. Here are a few examples:
•
Defibrillators include stand-alone automated external defibrillators (AEDs) and AED mode
in manual defibrillators.
•
Assure that stand-alone AEDs and/or AED mode in manual defibrillators are available
throughout the facility.
•
In the event of sudden cardiac arrest a defibrillator should be available within one to two
minutes.
•
Early defibrillation should be available in geographically isolated parts of the hospital where
code team response times are long.
•
Consider placing stand-alone AEDs in non-patient-care areas.
•
All BLS personnel must be trained to operate, be equipped with, and permitted to operate a
defibrillator if in their professional duties they are expected to respond to people in cardiac
arrest
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©2010, American Heart Association
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Contact Information
Wyoming, Oklahoma and Texas Panhandle
Katie Butterfield- [email protected]
Central Texas and Rio Grande Valley
Diana Barrett- [email protected]
Colorado
Julie Blakie- [email protected]
Houston and Greater Gulf Coast
Kate Simpson- [email protected]
New Mexico, El Paso and Lubbock
Dallas/ Fort Worth Metro
Stephanie Chapman- [email protected]
Shanthi Raj- [email protected]
Arkansas
Cammie Marti- [email protected]
9/16/2014
Mid- Market/ Rural Texas
Cherie Boxberger- [email protected]
©2010, American Heart Association
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