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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 3 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 4 Culture of Resuscitation Quality Data Collection Reporting/ Benchmarking Training/ Processes 9/16/2014 Feedback (individual & organizational) 5 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 9/16/2014 ©2010, American Heart Association 6 9/16/2014 ©2010, American Heart Association 7 Incidence of CPR for IHCA 9/16/2014 ©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] 9/16/2014 Girotra, et al NEJM 2012 ©2010, American Heart Association 9 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. 9/16/2014 ©2010, American Heart Association 19 • 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 9 Time to first shock ≤ 2 min for VF/pulseless VT first documented rhythm ©2010, American Heart Association 24 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 9/16/2014 ©2010, American Heart Association 25 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. 9/16/2014 ©2010, American Heart Association 30 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. 9/16/2014 ©2010, American Heart Association 32 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! 9/16/2014 35 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 36 Configurable Measure Descriptions 9/16/2014 ©2010, American Heart Association 37 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 9/16/2014 ©2010, American Heart Association 38 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 9/16/2014 ©2010, American Heart Association 39 9/16/2014 ©2010, American Heart Association 40 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 9/16/2014 ©2010, American Heart Association 45 9/16/2014 ©2010, American Heart Association 46 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 47