This presentation was used to facilitate a discussion of the AHA CPR Quality Consensus Statement, CPR compliance vs. competency, key quality challenges, review of related science, the concept of “pit crew” CPR, and RQI tools and processes.
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HIGH PERFORMANCE CPR and RESUSCITATION QUALITY IMPROVEMENT
6. “Poor-quality CPR should be considered a
preventable harm. In healthcare environments,
variability in clinician performance has affected the
ability to reduce healthcare associated
complications, and a standardized approach has
been advocated to improve outcomes and reduce
preventable harms. The use of a systematic
continuous quality improvement (CQI) approach
has been shown to optimize outcomes in a number
of urgent healthcare conditions.”
7. “Despite this evidence, few healthcare organizations
apply these techniques to cardiac arrest by consistently
monitoring CPR quality and outcomes. As a result,
there remains an unacceptable disparity in the quality
of resuscitation care delivered, as well as the presence
of significant opportunities to save more lives.”
10. WE CAN’T EXPECT TO WIN “RACES”
WITHOUT MEANINGFUL PRACTICE
AND AN ONGOING ITERATIVE PROCESS
OF MEASURING AND IMPROVING…
25. THE PAINFUL TRUTH
•Perceived performance does not always match observed performance.
•Aufderheide et al. showed that duty cycle, chest compression depth and
complete recoil were performed significantly less well when directly observed
than EMT perceptions of their performance.
•Wik et al. showed that chest compression rate and depth were both
significantly below AHA guidelines by trained EMS providers, and no flow time
(when there was neither a pulse nor CPR being given) was almost 50% in
directly observed performance evaluations.
•The likelihood of ROSC increases significantly with higher mean chest
compression rate (in a hospital study 75% of patients achieved ROSC with 90
or more chest compressions/minute compared to only 42% with 72 or fewer
chest compressions/minute).
30. Fatigue and poor crew resource management (CRM)
contributed to the accident.
EA 401 gradually lost altitude while the flight crew was
preoccupied and eventually crashed.
The effect of this crash on the airline industry continues
today and has resulted in the development of Crew
Resource Management (CRM). CRM is a technique that
requires air crews to divide the work in the cockpit
34. “Quality CPR is a means to improve survival from
cardiac arrest. Scientific studies demonstrate
when CPR is performed according to guidelines,
the chances of successful resuscitation increase
substantially. Minimal breaks in compressions, full
chest recoil, adequate compression depth, and
adequate compression rate are all components of
CPR that can increase survival from cardiac arrest.
Together, these components combine to create
high performance CPR (HP CPR)”
40. •EMTs own CPR
•Minimize interruptions in CPR at all times
•Ensure proper depth of compressions (>2 inches)
•Ensure full chest recoil/decompression
•Ensure proper chest compression rate (100-120/min)
•Rotate compressors every 2 minutes
•Hover hands over chest during shock administration
and be ready to compress as soon as patient is cleared
•Intubate or place advanced airway with ongoing CPR
•Place IV or IO with ongoing CPR
•Coordination and teamwork between EMTs and paramedics
41. •C-A-B
•Minimize interruptions in compressions
•Compress at least 100/min
•Allow complete chest wall recoil/decompression between
compressions
•Rhythm assessment every 2 minutes
•Rotate compressors every 2 minutes
•Hover over patient with hands ready during defibrillation so
compressions can start immediately after the shock (or
analysis) has occurred
46. Pictures are for presentation purposes only. The American Heart Association does not endorse any particular products, models or manufacturers.
67. "Eisenberg has done a remarkable job in articulating the steps to be
taken for communities to improve survival from sudden cardiac arrest.
Resuscitate! is a 'best in class' and one of a kind guide that provides
inspiration as well as direction in translating resuscitation science into
practice. It is essential for all those who seek to establish strategies to
improve survival and quality of life for cardiac arrest victims whose
hearts are 'too young to die.'"
- David B. Hiltz, EMT-P Resuscitation Academy Alumni
Perceived performance does not always match observed performance.Aufderheide et al. showed that duty cycle, chest compression depth and complete recoil were performed significantly less well when directly observed than EMT perceptions of their performance.Wik et al. showed that chest compression rate and depth were both significantly below AHA guidelines by trained EMS providers, and no flow time (when there was neither a pulse nor CPR being given) was almost 50% in directly observed performance evaluations.The likelihood of ROSC increases significantly with higher mean chest compression rate (in a hospital study 75% of patients achieved ROSC with 90 or more chest compressions/minute compared to only 42% with 72 or fewer chest compressions/minute).
The 2010 AHA Guidelines for CPR and ECC once againemphasize the need for high-quality CPR, including• A compression rate of at least 100/min (a change from“approximately” 100/min)• A compression depth of at least 2 inches (5 cm) in adults• Allowing for complete chest recoil after each compression• Minimizing interruptions in chest compressions• Avoiding excessive ventilation
The quality of unprompted CPR in both in-hospital and out-of–hospital cardiac arrest events is often poor, and methods shouldbe developed to improve the quality of CPR delivered to victimsof cardiac arrest.73,91–93,287 Several studies have demonstratedimprovement in chest compression rate, depth, chest recoil,ventilation rate, and indicators of blood flow such as end-tidalCO2 (PETCO2) when real-time feedback or prompt devices areused to guide CPR performance.72,73,80,288–293 However, there areno studies to date that demonstrate a significant improvement inpatient survival related to the use of CPR feedback devicesduring actual cardiac arrest events. Other CPR feedback deviceswith accelerometers may overestimate compression depth whencompressions are performed on a soft surface such as a mattressbecause the depth of sternal movement may be partly due tomovement of the mattress rather than anterior-posterior (AP)compression of the chest.62,294 Nevertheless, real-time CPRprompting and feedback technology such as visual and auditoryprompting devices can improve the quality of CPR (Class IIa,LOE B).