WHERE You Live Shouldn’t Determine IF You Live: EMS Strategies for Improving Cardiac Arrest Survival
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This webcast will focus on strategies that can be used by the EMS community to improve survival from out-of-hospital cardiac arrest. The American Heart Association (AHA) Guidelines for CPR and Emergency Cardiovascular Care (ECC) are based on evidence evaluation from the 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations (CoSTR 2010), of which the American Heart Association was a founding member. During this presentation, you’ll learn: •Evidence based strategies for improving survival from out of hospital cardiac arrest •AHA programs and products for use by the Emergency Medical Services community •How to develop a localized action plan to improve outcomes The recommendations in the AHA Guidelines for CPR and ECC confirm the safety and effectiveness of many approaches, acknowledge that other approaches may not be optimal, and recommend new treatments that have undergone evidence evaluation. Our science, products and programs are designed to help you increase the probability of prompt bystander CPR and improve the quality of resuscitation provided by rescuers. LINK TO AUDIO: http://yourlisten.com/channel/content/16907692/AHA_EMS_Webcast_Recording
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WHERE You Live Shouldn’t Determine IF You Live: EMS Strategies for Improving Cardiac Arrest Survival
- 1. Where You Live Shouldn’t Determine If You Live: EMS Strategies for Cardiac Arrest Survival Monday May 21st 1 pm EDT 1
- 2. Rod Kimble EMT-P • Sr. Account Manager CPR & ECC Programs • 23 yrs in Fire Service and EMS • Flight Paramedic - HealthNet Aeromedical Services, Morgantown, WV • Passion in curriculum development and systems of care improvement.
- 3. David Hiltz, NREMT-P • 14 years as Account Manager for CPR & ECC Programs • Special interest in emergency medicine and resuscitation • Implementation of AHA initiatives such as Operation Heartbeat and Operation Stroke.
- 4. 4
- 5. You Will Learn • Strategies for increasing survival rates for out- of-hospital cardiac arrest • AHA programs and products for use by the Emergency Medical Services community • Development of localized action plan to improve outcomes
- 7. Poll Question Is the EMS Community best suited for ownership of localized efforts to improve the system of care and outcomes for Out-of-Hospital Cardiac Arrest?
- 8. Approach to Improving Outcomes Many Systems Ideal System No Data Data Collected No Plan Quality Improvement Plan Fragmented Efforts Holistic Approach Partially Fully Implemented Implemented Guidelines Guidelines
- 9. A Systems Approach 9
- 10. Issues CPR Component Challenges to Improving Quality Recognition Failure to recognize gasping as sign, unreliable Pulse Detection Initiation of CPR Low Bystander CPR response Rate, Incorrect Dispatch instructions Compression Rate Slow compression Rate Compression Depth Shallow compression Depth Chest Wall Recoil Rescuer Leaning on Chest 10
- 11. Issues (cont’d) CPR Component Challenges to Improving Quality Compression Interruptions Excessive interruptions for pulse check, Ventilations, defibrillation, intubation, IV access, other Ventilations Ineffective ventilations, prolonged interruptions in compressions , excessive ventilations (especially with airway) Defibrillation Prolonged time to defibrillator avail, prolonged interruptions in chest compressions pre- and post shocks Team Performance Delayed rotation, leading to rescuer fatigue and decay in compression quality, poor communication among rescuers leading to unnecessary interruptions in compressions 11
- 13. Guideline Implementation IMPROVED SURVIVAL
- 14. Tale of Two Communities 14
- 16. Call to Action Emergency Medical Services should develop localized plans to optimize survival. These plans will be based on data and address individual links in the chain of survival, as well as all the links together.
- 17. Link 1: Immediate Recognition and Activation • Failure to recognize gasping • Unreliable pulse detection • Delayed 9-1-1 activation
- 18. Tools and Resources >>insert banner from http://www.heart.org/HEARTORG/News/PublicServi ceAnnouncements/Public-Service- Announcements_UCM_312002_SubHomePage.jsp# <<
- 20. Call to Action EMS agencies can access existing print, radio, and video Public Service Announcements to use in their communities to increase awareness, response and 9-1-1 activation.
- 21. Link 2: Early CPR • Low bystander CPR response rates • Incorrect dispatch instructions
- 23. Tools and Resources 23
- 24. Call to Action EMS providers and agencies should use tools such as Hands-Only™ CPR; self-instructional and certification programs to support community education.
- 25. Link 3: Rapid Defibrillation • Delayed time to defibrillator use • Interruptions in chest compressions pre- and post-shocks
- 27. Call to Action EMS providers and agencies should use tools such as the AED Implementation Guide and Scientific Statements to support rapid defibrillation
- 28. Link 4: Effective ACLS • Slow compression rate • Shallow compression depth • Rescuer leaning on the chest
- 29. Link 4: Effective ACLS • Compression interruptions • Excessive interruptions for: Rhythm/Pulse Checks, Ventilations, Defibrillation, Intubation, and Intravenous Access
- 30. Iterative Process Appropriate education G2010 Competency Evidence, eLearning Structured & Simulation & Supported frequency of Debriefing training
- 31. 31
- 32. Feedback and Debriefing • Provider focused • Assist in improving performance • Improved adherence to Guidelines • Higher rate of ROSC 32
- 34. Maintenance of Competency • Emerging trends supporting continuous maintenance of competence • Evidence that basic and advanced life support skills decay rapidly • Optimal mechanism for maintenance of competence is not known 34
- 35. CPR Fractions 35
- 36. Call to Action EMS providers and agencies should practice resuscitation skills and team performance, incorporating the measuring of CPR fractions and debriefing as methods for improving quality and outcomes.
- 37. Link 5: Post-Cardiac Arrest Care • Therapeutic Hypothermia • Post ROSC 12-lead ECG • Transport to Cardiac Arrest Center
- 38. Tools and Resources Part 9: Post Cardiac Arrest Care: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Regional Systems of Care for Out-of- Hospital Cardiac Arrest: A Policy Statement From the American Heart Association.
- 39. Call to Action EMS providers and agencies are integral to the advancement of post resuscitation care and evolving systems of care. The importance of your role at all levels of implementation is immeasurable.
- 40. The Next best thing to preventing Sudden Cardiac Arrest: PREPARING FOR IT! Mission: Lifeline and Cardiac Arrest Systems of Care www.heart.org/missionlifeline 40
- 42. Summary 42
- 44. 44
- 45. Appendix You’re the Cure You don't have to be a lobbyist to call on lawmakers - just an advocate passionate about heart and stroke issues. In just a few moments, you can make a huge difference. We'll make it easy for you to email, phone or even visit your legislators. And we'll keep you informed on the progress you're making as one of the very important voices for the cure. http://www.heart.org/HEARTORG/Advocate/ActionCenter/Action-Center_UCM_001134_SubHomePage.jsp http://www.resuscitationacademy.com/index.php/resources/registry/ Importance and Implementation of Training in Cardiopulmonary Resuscitation and Automated External Defibrillation in Schools A Science Advisory From the American Heart Association http://circ.ahajournals.org/content/123/6/691.full.pdf Response to Cardiac Arrest and Selected Life-Threatening Medical Emergencies The Medical Emergency Response Plan for Schools A Statement for Healthcare Providers, Policymakers, School Administrators, and Community Leaders http://www.heart.org/idc/groups/heartpublic/@wcm/@ecc/documents/downloadable/ucm_425826.pdf Debriefing and Cardiac Arrest Quality Improvement — Document http://www.slideshare.net/Hiltz/debriefing-and- cardiac-arrest-quality-improvement-8692570 45
- 46. CPR and ECC Science Read more about 2010 AHA Guidelines and Statements. http://www.heart.org/HEARTORG/CPRAndECC/Science/Science_UCM_001125_SubHomePage.jsp Emergency Medical Service Dispatch Cardiopulmonary Resuscitation Prearrival Instructions to Improve Survival From Out-of-Hospital Cardiac Arrest A Scientific Statement From the American Heart Association http://circ.ahajournals.org/content/early/2012/01/09/CIR.0b013e31823ee5fc How EMS Systems are Changing for the better http://www.ems1.com/cardiac-care/articles/1210274-How-EMS-systems-are-changing-for-the-better/ Law Enforcement Role in Response to Sudden Cardiac Arrest — Presentation http://www.slideshare.net/Hiltz/law-enforcement-role-in-response-to-sudden-cardiac-arrest Opportunity for law enforcement agencies to save lives — Document Transcript http://www.slideshare.net/Hiltz/opportunity-for-law-enforcement-agencies-to-save-lives Reducing Barriers for Implementation of Bystander-Initiated Cardiopulmonary Resuscitation A Scientific Statement From the American Heart Association for Healthcare Providers, Policymakers, and Community Leaders Regarding the Effectiveness of Cardiopulmonary Resuscitation http://circ.ahajournals.org/cgi/content/extract/117/5/704 46
- 47. LAW ENFORCEMENT AGENCY DEFIBRILLATION (LEA-D):POSITION STATEMENT AND BEST PRACTICES RECOMMENDATIONS FROM THE NATIONAL CENTER FOR EARLY DEFIBRILLATION http://www.naemsp.org/pdf/lead.pdf Medical Emergency Response Planning Schools — Presentation http://www.slideshare.net/Hiltz/medical- emergency-response-planning-schools Medical Emergency Response Planning Schools — Podcast http://ems12lead.com/2011/10/aeds-and-emergency- response-plans-in-schools-syncope-and-sudden-death-in-student-athletes-part-3-ems-12-lead-podcast-episode-3- monica-kleinman-m-d/ Regional Systems of Care for Out-of-Hospital Cardiac Arrest A Policy Statement From the American Heart Association http://circ.ahajournals.org/cgi/content/abstract/121/5/709 Q & A Medical Emergency Response Plan for Schools (MERPS) Medical Emergency Response Plan for Schools (MERPS) Sample Plan One Medical Emergency Response Plan for Schools (MERPS) Sample Plan Two CPR Statistics - CPR & Sudden Cardiac Arrest (SCA) 47
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- First off, we would like to take a moment to say thank you to all those who are involved in our emergency medical services system and to the providers who help keep our communities safe.The American Heart Association values the Emergency Medical Services community as inseparable partners in emergency cardiovascular care management. We are proud to recognize the efforts of all EMS providers and agencies during Emergency Medical Services Week. Our entire organization is grateful for your commitment to patients and saving lives. The Emergency Cardiovascular Care Committee and AHA staff acknowledges and shares in the EMS community’s goal of improving patient outcomes through the development and delivery of the highest quality prehospital care available. We appreciate your collaboration, input, and interaction with the American Heart Association. The American Heart Association remains committed to a renewed, strengthened partnership with the EMS community that achieves the mission of saving lives. Further, we are confident that together we can globally improve our relationships and create an even more collaborative environment that fosters synergy and enables a convergence of our common goals.
- Welcoming remarks and review of objectivesUpon the conclusion of this webcast, participants should be able To explain evidence based Strategies for increasing survival rates for out of hospital cardiac arrestTo identifyAHA programs and products for use by the Emergency Medical Services community To develop a localized action plan to improve outcomes We hope to provide webcast participants with pragmatic strategies that can be used by the Emergency Medical Services Community to improve survival from out of hospital cardiac arrest as well as provide access to AHA science, products and programs that are specifically designed to help increase the probability of prompt bystander initiated CPR, and improve the quality of resuscitation provided by rescuers.Return to a prior quality of life and functional state of health is the ultimate goal of a resuscitation system of care.
- Despite many improvements in the chain of survival associated with pre-hospital care of sudden cardiac arrest patients, survival is still poor — less than 12 percent.Translating Resuscitation Science Into Practice seems to be where things begin to come apart, and therefore the likely key to improved outcomes.
- Let’s use the polling feature to see how we all feel about ownership of efforts to improve out of hospital cardiac arrest survival.Please answer the following question:Is the EMS Community best suited for ownershipoflocalized efforts to improve the system of care and outcomes for Out of Hospital CardiacArrest?
- In this chart, we contrast between a majority of systems with that of an ideal, or more optimized EMS system. Regretfully, many systems do not collect meaningful data relating to cardiac arrest, employ fragmented efforts to improve survival, and often lack substantive plans.The American Heart Association would like to help. Full implementation of Guidelines, with data collection, planning and implementation of a broad based strategy is the best recommendation for improving survival from sudden cardiac arrest, acute coronary syndromes such as ST-elevation MI, and acute stroke.
- There is wide community and hospital variability in cardiac arrest survival. High-performing systems haveused this continuous quality improvement approach with great success, as have systems that have more recentlyadopted this strategy. These successes have occurred in a variety of systems, suggesting that all communities andhospitals can substantially improve care and outcomes.Since each system has different characteristics and challenges, there is no single prescriptive strategy for improvement.However, each system has an obligation to address the fundamental principles of quality improvement: measurement,benchmarking, and feedback and change.A conceptual appreciation of this system and its working components is illustrated here. Improving care requires assessment of performance. Only when performance is evaluated can participants in a system effectively intervene to improve care. This process of quality improvement consists of an iterative and continuous cycle of(1) systematic evaluation of resuscitation care and outcome,(2) benchmarking with stakeholder feedback, and(3) strategic efforts to address identified deficiencies.The process of simply measuring and benchmarking care can positively influence outcome. However, ongoing review and interpretation are necessary to identify areas for improvement. Local data may suggest the need to increase bystander CPR response rates, improve CPRperformance, or shorten the time to defibrillation. Useful strategies might include programs targeting citizen awareness, education and training for citizens and professionals, and various technologic solutions. These programs need to be continually re-evaluated to ensure that potential areasfor improvement are fully addressed.Although future discoveries will offer opportunities to improve survival, we currently possess the knowledge and tools—represented by the Chain of Survival—to address many of these care gaps.
- Thisexcellent summary table which continues on the following slide, outlines the key challenges to improve CPR quality and improve survival. As you can see, the challenges span recognition, initiation of CPR, compression rate and depth, incomplete recoil, ADVANCE SLIDEventilation, defibrillation and team performance. Each issue is significant, and if not addressed entirely, prevents optimized survival.The Guidelines for CPR and ECC are designed to address each of these challenges, and help improve outcomes.
- …ventilation, defibrillation and team performance. Each issue is significant, and if not addressed entirely, prevents optimized survival.
- Can we say that Guidelines have been fully implemented in our communities? Is Guideline implementation limited to updating your training, equipment and protocols or are those tasks simply a small part of our responsibilities?
- Efforts to improve independent links in the chain of survival should not be dismissed, however, it is important to understand that the potential benefit in survival is limited, unless we can also invoke equal improvements in the other links.
- Synergistic performance and outcomes Body: Bystander CPR predicts 2 times the chance of survivalQuality compressions and monitored ventilation improves 2.5 timesQuality CPR and ITD shows 3 times better resultsQuality CPR, ITD, and therapeutic hypothermia result in over 3.5 times Of course, we could chop some of the words from the slide and put it into the notes as further explanation. Ultimately the best single variable is quality BLS, but we are wanting to show that 2+2+2=10.
- While the Highlights of the 2012 Guidelines for CPR and ECC, illustrated on the right, provide an excellent and quick read, the Guidelines themselves, shown on the left articulate, in depth the best recommendations we can make to improve survival. These Guidelines identify factors with the greatest potential impact on survival. We encourage EMS Medical Directors, Agency Directors, providers and stakeholders to access and utilize these invaluable recommendations in improving understanding through better appreciation of the science as well as in implementation of strategies designed to improve outcomes.Our Guidelines are available in printed format, as well as online as a free downloadable set of PDF documents.
- Emergency Medical Services is well suited to lead in thedevelopment and implementation of localized plans to optimize survival. These plans should be based on data and address individual links in the chain of survival, as well as all the links together.
- Prompt emergency activation and initiation of CPR requires rapid recognition of cardiac arrest. A cardiac arrest victim is not responsive. Breathing is absent or is not normal. Agonal gasps are common early after sudden cardiac arrest and can be confused with normal breathing.Pulse detection alone is often unreliable, even when performed by trained rescuers, and it may require additional time. Consequently, rescuers should start CPR immediately if the adult victim is unresponsive and not breathing or not breathing normally (ie, only gasping).The directive to “look, listen, and feel for breathing” to aid recognition is no longer recommended.ngAs a side note, it is also dissappointing to note that despite efforts, many patients ignore early warning signs, delay activation of 9-1-1, and often self present to hospitals when having an acute coronary syndrome.
- The American Heart Association has a number of public service announcements that are available for use by emergency medical services agencies and systems. We have a wide variety of video, radio and print PSAs that can be used as part of localized campaigns to improve awareness and response. EMS agencies can find additional public service announcements on our YouTube channel. For access to our public service announcements page and link to the American Heart Association’s youtube channel, please refer to our resources links, provided at the end of our webcast.
- Let’s take a quick look at an example PSA from South Dakota’s Mission: Lifeline that was designed to improve 9-1-1 activation by persons experiencing signs and symptoms of acute coronary syndrome, or heart attack.
- Public service announcements can be an effective means of improving awareness, recognition, response and 9-1-1 activation. Your EMS agency can access existing print, radio, and video PSAs and use these important messages in your own communities.These resources are immediately available, but in order to be effective, they need to be shared, broadly within a target population. Additionally, repeated and prolonged exposure to these messages is needed in order to realize a desired effect. There are numerous options for engaging your public, however, it takes effort in order to effectively expose your citizens to these important life-saving messages.
- The prompt initiation of effective chest compressions is a fundamental aspect of cardiac arrest resuscitation. CPR improvesthe victim’s chance of survival by providing heart and brain circulation. Rescuers should perform chest compressions for all victims in cardiac arrest, regardless of rescuer skill level, victim characteristics, or available resources.Updated guidelines are associated with improved survival in those with shockable cardiac arrest…arrests are caused by ventricular fibrillation/tachycardia and they respond to shocks delivered by an AED.However, the percentage of out-of-hospital shockable arrests is declining, and about three-quarters of all such arrests are nonshockable arrhythmias.New evidence shows that most cardiac arrests -- nearly 75 percent -- are due to conditions that don't respond to shocks. In such patients there have been few, if any, life-saving treatments and it was uncertain whether CPR guidelines changes were beneficial. "Now, for the first time, we have seen a treatment that improves survival specifically in these patients," Kudenchuk said. "And that treatment is simply providing the more intense, quality CPR recommended in the new guidelines. You could save 2,500 more lives each year in North America alone by implementing these changes."
- According to a Scientific Statement published January 9, 2012, in the AHA journal, Circulation, more people will survive sudden cardiac arrest with 9-1-1 dispatchers help bystanders assess victims and begin CPR immediately. While the 2010 AHA Guidelines for CPR & ECC advised 9-1-1 dispatchers to provide assistance, this statement provides more specific information about how dispatchers should provide such help and also emphasizes the importance of assessing the dispatcher’s actions. Highlights of the statement include the following recommendations:Dispatchers should help 9-1-1 callers identify cardiac arrest victims and coach callers to provide immediate CPR. If more dispatchers followed these processes, thousands of lives could be saved every year. Communities should regularly evaluate 9-1-1 emergency dispatchers’ performance and the overall emergency response system To support this AHA Scientific Statement, AHA CPR & First Aid has created a Dispatcher CPR web page that includes links to case studies and features actual 9-1-1 calls that allow viewers to listen to calls and try to determine where improvement is needed. I’m very pleased to see this statement published, as efforts to improve dispatcher CPR can make a significant impact toward the AHA’s 2020 Impact Goal of increasing bystander response and ultimately, doubling survival from out-of-hospital cardiac arrest.Let’s take a listen to a call where the emergency dispatcher talk a rescuer through Hands-Only CPR on the phone.After playing:• The victim is not breathing normally, as evident by the agonal breathing heard on the recording. • The dispatcher quickly recognizes a cardiac arrest and instructs the bystander on how to start chest compressions. • As she does this, the bystander notes that the victim begins to breathe again. Then she stops, and the victim stops breathing completely. Cardiac arrest victims commonly have some movements that can be mistaken for seizure activity.• When receiving chest compressions, victims often gasp. When this occurs, unless the victim becomes responsive and has normal breathing, CPR should be continued
- As your trusted partner in resuscitation, the American Heart Association has developed a wide variety of scientificstatements, advocacy tools to improve CPR awareness, support citizen CPR education, and improve willingness to performCPR on collapsed victims.Advocacy is an important component of strategies to improve CPR. With You’re the Cure, an AHA supported grassroots advocacy program, you cansupport important public policy efforts such as those associated with our efforts to make CPR training a high school graduation requirement.Additionally, you should also be aware of our comprehensive Hands-Only CPR campaign that includes messaging, videos, print and radio ads, all available from Handsonlycpr.org. To support education for layrescuers, options include the CPR Anytime Program and kits, and for those who seek certification, our suite of Heartsaver CPR, AED and First Aid programs.
- Although technology, such as that incorporated in automated external defibrillators (AEDs), has contributed to increased survival from cardiacarrest, no initial intervention can be delivered to the victim of cardiac arrest unless bystanders are ready, willing, and able toact. Moreover, to be successful, the actions of bystanders and other care providers must occur within a system that coordinatesand integrates each facet of care into a comprehensive whole, focusing on survival to discharge from the hospital.EMS providers and agencies are uniquely positioned to lead efforts in educating citizens in cardiopulmonary resuscitation. The advent of Hands-Only CPR and self instructional programs like CPR Anytime enable widespread community CPR education.
- The victim’s chance of survival decreases with an increasing interval between the arrest and defibrillation. Thus early defibrillation remains the cornerstone therapy for ventricular fibrillation and pulseless ventricular tachycardia. Community strategies should aggressively work to reduce the interval between arrest and defibrillation.One of the determinants of successful defibrillation is the effectiveness of chest compressions. Defibrillation outcome is improved if interruptions (for rhythm assessment, defibrillation, or advanced care) in chest compressions are kept to a minimum.Talk further about defibrillation deployment strategies.
- In an effort to support effective early defibrillation strategies, and implementation, we have several recommendations including a newly redesigned AED program implementation guide, and our updated Heartsaver CPR, AED, and First Aid products.We have a scientific statement that is specific to medical emergency response plans in schools and a supporting powerpoint presentation on that subject. Additionally, we are making available to you a presentation that was provided at the IACP conference this past year on the role of Law Enforcement as First Responders that addresses early defibrillation by this group of public safety professionals.You will also provided hot links to several videos on the subject of rapid defibrillation at the end of this webcast.
- EMS providers and agencies should use tools such as the AED Implementation Guide and Scientific Statements designed to support rapid defibrillation.The concept of defibrillation by law enforcement personnel may be a particularly effective means of delivering early defibrillation in many communities.
- The foundation of successful ACLS is high quality CPR, and, for VF/pulseless VT, attempted defibrillation within minutes of collapse. For victims of witnessed VF arrest, early CPR and rapid defibrillation can significantly increase the chance for survival to hospital discharge. In comparison, other ACLS therapies such as some medications and advanced airways, although associated with an increased rate of ROSC, have not been shown to increase the rate of survival to hospital discharge. The majority of clinical trials testing these ACLS interventions, however, preceded the recently renewed emphasis on high-quality CPR and advances in post– cardiac arrest care. Therefore, it remains to be determined if improved rates of ROSC achieved with ACLS interventions might better translate into improved long-term outcomes when combined with higher quality CPR and post– cardiac arrest interventions such astherapeutic hypothermia and early percutaneous coronary intervention (PCI).We mustn’t become distracted by therapies that have not been shown to increase the rate of survival to hospital discharge. Rather, we need to focus on compression rates, depth and recoil…limiting delays and interruptions at all times.An example of where we may observe interruptions is during the transition from CPR to defibrillation. This process should not interrupt chest compressions for more than 5 to 10 seconds.Additionally, rescuer fatigue should not be overlooked, and chest compressors rotated frequently during resuscitation.
- Intervention to prevent cardiac arrest in critically ill patients is ideal. When cardiac arrest occurs, high-quality CPR is fundamental to the success of any subsequent ACLS intervention. During resuscitation healthcare providers must perform chest compressions of adequate rateand depth, allow complete recoil of the chest after each compression, minimize interruptions in chest compressions, and avoid excessive ventilation, especially with an advanced airway. Quality of CPR should be continuously monitored. Physiologic monitoring may prove useful tooptimize resuscitative efforts. For patients in VF/pulseless VT, shocks should be delivered promptly with minimal interruptions in chest compressions. The increased rates of ROSC associated with ACLS drug therapy have yet to be translated into long-term survival benefits. However, improved quality of CPR, advances in post– cardiac arrest care, and improved overall implementation through comprehensivesystems of care may provide a pathway to optimize the outcomes of cardiac arrest patients treated with ACLS interventions.
- An iterative process in developing and maintaining competency.
- Our suite of blended and elearning programs can be used to free up time for practice and other educational offerings. Expand or delete slide…
- Debriefing is a learner-focused, nonthreatening technique to assist individual rescuers or teams to reflect on, and improve,performance. In manikin-based studies, debriefing as part of the learning strategy resulted in improved performance inpost-debriefing simulated scenarios, and it improved adherence to resuscitation guidelines in clinical settings.Debriefing as a technique to facilitate learning should be included in all advanced life support courses (ClassI, LOE B).Debriefing of cardiac arrest events, either in isolation or as part of an organized response system, improves subsequentCPR performance in-hospital and results in higher rate of return of spontaneous circulation (ROSC). Debriefing of actual resuscitation events can be a useful strategy to improve future performance (Class IIa, LOE C). Additional research on how best to teach and implement postevent debriefing is warranted.Debriefing has distinctive merits, appears to be easily implemented by virtually any EMS agency, and has yielded not only predictable results, but also a variety of unintended consequences that led to localized adaptation and implementation of strategies to improve outcomes from sudden cardiac arrest.
- Our Structured and Supported Debriefing course educates instructors and clinical leaders how to facilitate an effective debriefing and was designed specifically for the American Heart Association. The course focuses on a learner or providercentered debriefing model, draws on evidence-based findings from behavioral science, focuses on critical thinking and encourages participants to analyze their performance and motivations.The course is self-paced and is completed entirely online. Course content includes:• Methods for conducting debriefing • Creating a supportive environment • Establishing roles and goals of the interaction • Genuine inquiry • Active listening • Organized communication • Generating an accurate record of the events • Dealing with obstacles and challengesWhen taking the course online, you are able to download tools such as the Gather-Analyze-Summarize guide for debriefing.Also look for a hot link at the conclusion of this webcast to an excellent article written by Hiltz and Baumrind on the subject of debriefing in resuscitation quality improvement.
- Reflecting the emerging trends supporting continuous maintenance of competence and continuing professional developmentin the healthcare professions, there is support to move away from a time-related certification standard and toward a more competency-based approach to resuscitation education.There is substantial evidence that basic and advanced life support skills decay rapidly after initial training. Basic skills have been shown to deteriorate when assessed at 1 to 6 months or 7 to 12 months following training.Advanced life support providers demonstrated similar decays in knowledge or skills when assessed at 3 to 6 months,to 12 months, and more than 12 months. These studies were heterogeneous with respect to participant composition,course length, course format, instructor type, and frequency of participant involvement in actual resuscitations.The majority reflected teaching methodologies in use prior to the most recent AHA course design updates in 2005.In one study a 2-hour class was sufficient for participants to acquire and retain BLS skills for an extended time period, provided a brief re-evaluation was performed after 6 months.182 Four studies showed minimal or no deterioration of skills or knowledge at 6, 12, or 17 months after course completion.While the optimal mechanism for maintenance of competence is not known, the need to move toward more frequent assessment and reinforcement of skills is clear. Skill performance should be assessed during the 2-year certification with reinforcement provided as needed (Class I, LOE B). The optimal timing and method for this assessment and reinforcement are not known.The need for additional practice of CPR and team performance is nothing new…but despite recommendations spanning decades, very few providers actually practice or measure CPR performance outside of their biannual training.The time has come for us to realize that additional practice is necessary. Concepts such as high performance, pit crew and or high density CPR offers a framework for this additional practice.
- Using a monitor/defibrillator with novel additional sensing capabilities, the parameters of CPR quality including chest compression rate, compression depth, ventilation rate, and the fraction of arrest time without chest compressions (no-flow fraction) can be recorded, analyzed and used as part of data collection and quality improvement.As many resuscitation leaders have said, "You can't fix what you can't measure“ and “Performing CPR was like driving a car without a speedometer, based more on feel than on feedback”. Devices are now available that record the rate and depth of chest compressions, the rate and volume of ventilations, and the presence or absence of a pulse. They also note when no compressions are being performed and calculates total "no-flow" time, as well as the fraction of time during a cardiac arrest when there is no blood flow.This strategy has been effectively integrated into strategies to improve CPR quality among healthcare providers.
- We know that 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). CPR is the foundation of the resuscitation success. High quality CPR improves the effectiveness of defibrillatory shock. High quality CPR improves the effectiveness of medication treatments. We need to focus on these basic principles, and practice…Practice like we play.
- There is increasing recognition that systematic post–cardiac arrest care after return of spontaneous circulation (ROSC)can improve the likelihood of patient survival with good quality of life. This is based in part on the publication of results ofrandomized controlled clinical trials as well as a description of the post–cardiac arrest syndrome. Post–cardiac arrest care hassignificant potential to reduce early mortality caused by hemodynamic instability and later morbidity and mortality frommultiorgan failure and brain injury. The initial objectives of post– cardiac arrest care are to● Optimize cardiopulmonary function and vital organ perfusion.● After out-of-hospital cardiac arrest, transport patient to an appropriate hospital with a comprehensive post–cardiac arrest treatmentsystem of care that includes acute coronary interventions, neurological care, goal-directed critical care, and hypothermia.● Try to identify and treat the precipitating causes of the arrest and prevent recurrent arrest.Subsequent objectives of post– cardiac arrest care are to● Control body temperature to optimize survival and neurological recovery● Identify and treat acute coronary syndromes (ACS)● Optimize mechanical ventilation to minimize lung injury● Reduce the risk of multiorgan injury and support organ function if required● Objectively assess prognosis for recovery● Assist survivors with rehabilitation services when required
- We have two principle references for post cardiac arrest care with Part 9: Post Cardiac Arrest Care: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care in center stage. This section summarizes our evolving understanding of the hemodynamic, neurological, and metabolic abnormalities encountered in patients whoare initially resuscitated from cardiac arrest, as well as the initial objectives of post– cardiac arrest care. You can find more detailed information and useful references in this very important section of our Guidelines.Additionally, we would like to call your attention to Regional Systems of Care for Out-of-Hospital Cardiac Arrest: A Policy Statement From the American Heart Association.This policy statement describes the rationale for regional systems of care for patients with OOHCA Existing models ofregional systems of care for OOHCA, traumatic injury, ST-elevation myocardial infarction (STEMI), and stroke are critiqued, and the essential components of regional systems of care for patients with OOHCA are discussed. These efforts are aimed at improving outcomes but may not always be feasible because of limited resources or other factors. Changes in care delivery, legislation, and reimbursement are likely necessary to maximize the impact of regional systems of cardiac resuscitation on public health.In these, important factors and strategies are discussed and provide a stable foundation for our efforts relating to Stroke, STEMI, and Cardiac Arrest Systems of Care.
- EMS providers and agencies are integral to the advancement post resuscitation care andevolving systems of care. The importance of your role at all levels of design and implementation is innumerable.Discussions regarding systems of care are occurring across the US. We encourage you to contact your local American Heart Association office to learn where and how you can get involved.
- We are very proud to make you aware of these two programs that are designed to support our efforts to improve baseline knowledge and 12 lead ECG skills among healthcare providers.The AHA’s Learn: Rapid STEMI ID Course has been updated to reflect new science in the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.This self-directed, online course prepares healthcare professionals to evaluate and assess patients with potential symptoms of myocardial infarction, interpret ECGs for signs of STEMI (ST-elevation myocardial infarction) and activate a system of care for rapid reperfusion of an occluded coronary artery.Learn: Rapid STEMI ID supports the efforts of the American Heart Association’s Mission: Lifeline®, a national initiative to improve quality of care and outcomes in heart attack patients by improving healthcare systems’ readiness and response to STEMI patients.No skills session is required to complete the course; however, students will receive a certificate of completion upon successful completion, and physicians, nurses, and EMS will be eligible to apply for continuing education credits. Course content:Understanding STEMI Systems of Care and STEMI recognition Basics of acute coronary syndromes (ACS) and triage of STEMI patients Acquiring high-quality, 12-lead electrocardiograms (ECGs) 12-lead findings that mimic STEMI Coronary anatomy related to 12-lead ECG Indications for activating a Heart Alert System The STEMI Provider Manual is intended for personnel in out-of-hospital and in-hospital, including paramedics, nurses, nurse practitioners, physician assistants and physicians. Also for other STEMI systems of care providers.STEMI clinical information, including steps needed to attain treatment goals • Direction on 12-lead ECG as a key tool in triage and treating Acute Coronary Syndromes (ACS) • Distinguishing ECG findings for identifying patients into three ACS categories • Steps for fibrinolytic therapy and percutaneous coronary intervention (PCI) • Identifying pharmacologic agents for pain relief and reperfusion therapy • Includes ECG ruler as companion tool
- EMS plays a critical role in an integrated approach to improving survival rates for cardiac arrest victims. This includes timely response and providing initial definitive care to victims of cardiovascular emergencies but additionally, being advocates for change, promoting CPR training in the community, guiding effective early defibrillation strategies, and an essential partner in efforts relating to STEMI and cardiac arrest systems of care. Each EMS provider and agency is key to building an effective integrated system by linking the bystander who initiates CPR (and, sometimes, provides defibrillation) with the hospital, where the road to neurologically intact recovery is supported by specialized post-resuscitation care.We have sound guidelines and the tools to implement at hand. But we must develop a plan, and take advantage of what we know, and the available tools and resources. It is possible to save lives, but a coordinated effort is needed.