Sometimes breaking off the rear view mirror and starting down a new path is the way to go. That’s what Daniel Davis, MD, advocates when it comes to improving survival of cardiac arrest patients, preventing events and enabling better neurological outcomes. A unique resuscitative training program at the University of California San Diego (UCSD) has helped increase the survival rate of cardiac arrest to 47 percent—more than triple the national average—as well as decreasing the overall incidence of arrests through surveillance and a rapid response team.
“Everyone recognizes that [resuscitative care] has been a frustrating piece of medicine for a long time,” says Davis, who is the resuscitation director at UCSD and director of the UCSD Center for Resuscitation Science. “Outcomes have not improved consistently, or really at all.”
Resuscitative care is as much an art as a science. Training is key for both. That’s where Davis comes in—an emergency medicine physician, researcher and evangelist who preaches that training methods need to be changed to improve patient outcomes. “There are patients dying who shouldn’t be,” says Davis, who also is medical director for a half-dozen air medical bases in Southern California. “There is a solution that can save a lot of lives, people just need to use it.”
Davis led the change at UCSD in 2007 when they instituted a set of training programs called Advanced Resuscitation Training (ART) and Basic Resuscitation Training (BART). This new resuscitation strategy comes in the form of a template that depends on uninterrupted compressions, frequent training, excellent teamwork and highly intuitive user interfaces with technologies that enable split-second decision-making. Fast work and fast thinking are bringing excellent results. In addition to UCSD increasing the survival rate of cardiac arrest to 47 percent, they simultaneously reduced the rate of cardiac arrests by 50 percent. Training has worked across town, too, at the VA Medical Center where cardiac arrest survival has increased to 44 percent, which is almost three times the national average. Similarly, since implementing the training program in November 2012, the Oxnard, Calif., fire department saw cardiac arrest survival rates increase 50 percent, posting some of the highest survival rates in the world. Several one-day primer training courses for air medical crews across the West and Midwest have shown immediate results with survival for arrest victims more than doubling. As further testament to success, UCSD began expanding the training program to other University of California campuses on July 1st.
ART’s mission is to “prevent the preventable, resuscitate the resuscitatable and recognize the futile.” It includes high-quality CPR: Stay on the chest. Do continuous chest compressions. Do not break compressions to ventilate. Push hard. Push deep. Make sure there is good chest recoil. Many studies demonstrate a correlation between deep compressions with good recoil and survival, likely by increasing perfusion pressure.
The resuscitation program facilitates the integration of intuitive technology into clinical practice, specifically ZOLL equipment with software that displays the depth and rate of the compressions and provides filtered EKGs. The filtered EKG allows the care team to see the patient’s underlying rhythm as they do compressions because the artifacts are filtered out. The necessary pauses to confirm a rhythm or check a pulse are thus shorter.
Access to that critical data is essential to effective treatment, Davis says. “I say you have 1.7 seconds to look at a display that includes over 20 data points and gather all the information that you need. The user interface is so key to resuscitation success. We need the essential information in a highly viewable form.”
Clinician training focuses on a core principle: the prevention of interruptions in compressions at all costs. Compressions should be performed from the moment the arrest begins until return of spontaneous circulation (ROSC) is confirmed. Technology is essential to monitoring compressions and patient response and providing resuscitation metrics to identify needed performance improvement during the code. Reviewing the metrics is an effective way to assist better training for future codes.
The clinical staff of UCSD all receive training from a set of in-house instructors who are consistent in message and method. Staffers take a four-hour class once a year and participate in online as well as hands-on training. Training is specific to the role in the code, such as a physician, nurse, pharmacist or EMT. Roles are carefully delineated and focused on specific tasks during a code.
As a teaching institution, UCSD’s code teams change each month. But consistency is maintained by code nurses who run the codes. This special group of people receives ongoing training and attends monthly meetings to discuss feedback and performance.
“We provide training to optimize resuscitation as well as tools to measure effectiveness,” Davis says. “The chest compressions are the most important, followed by defibrillation, ventilation, and medications. We retain the core elements of our algorithms in the training, with specific techniques and points of emphasis changed based on performance improvement data. It is continual refinement and improvement. The ART curriculum content is uniquely driven by our own performance improvement data.”
Digging into data
Besides tracking the patient during the code, technology also details team performance on how the code was executed for post-code analysis. The team de-briefs shortly after each code and again a week later once they pull together the data from the code and merge it with the patient care record to see how the patient did. The code nurse documents the event in terms of leadership, quality of chest compressions, algorithms and other items that should be addressed and logged, creating a report card and report of what needs to be done in the future.
Metrics show that the UCSD staff stay on the chest 91 percent of time vs. the national average of 60 percent. The compression rate averages 123 per minute, while compression depth averages 2.6 inches. During a pre-shock pause, the team is off the chest for 2.6 seconds. It takes them on average 3.6 seconds to get back on the chest. A perfusion check takes an average of 4.3 seconds. The average ventilation rate is 9.7 per minute, while the end-tidal O2 averages 15.3 mmHg. The fact that these data are available and incorporated directly into training is unique and underscores the power of the ART-driven CQI loop.
Every month, the team at UCSD mines code data, evaluating each Code Blue and every rapid response. They look at why patients are coding and how codes might be preventable—seeking teaching moments for the next code. “We look retroactively at codes to see what improvements we can make to improve patient survival," Davis says. “But we also look proactively at patients who could be declining. Before a patient codes, we know there’s a five-hour window in which he or she is struggling and vital signs show that they are likely to code. We need to catch these patients prior to a code to totally avoid it.”
When the training program started in 2007, about 45 percent of UCSD’s arrests were respiratory arrests. Now most of the rapid responses are called for respiratory problems, with respiratory arrests having dropped to less than a quarter of baseline. UCSD estimates they’ve saved more than 500 lives since starting the new program. They also have the lowest risk-adjusted mortality rate among all hospitals in San Diego among academic hospitals in California. “I feel like we’ve discovered the Midas touch,” Davis says.
“The days of life support training for the sole purpose of meeting Joint Commission requirements are over,” Davis says. Now it’s time to train to improve outcomes—and expand to other community facilities, which is in the works.
“The real meat is on the prevention side, establishing how often people have an arrest.” The benchmark is about six cardiac arrests per thousand hospital admissions. UCSD now has less than half that. And the San Diego VA hospital has decreased non-ICU arrests four-fold since starting the ART program, with survival-to-discharge following an arrest increasing to 44 percent.
The cost of care
Besides good patient outcomes, there’s a growing financial need to improve resuscitative care as well. The healthcare cost of an unexpected death has been estimated at about $50,000, and the burden of an arrest victim with significant post-arrest disability is staggering. Medicolegal costs for these patients can easily reach seven figures, Davis notes. Most recently, Medicare and other insurance payors are rewarding good clinical performance through increasing compensation rates, calculating the ratio of actual mortality against expected mortality based on the acuity of patients in a particular institution.
“Most hospitals have focused on increasing their expected mortality numbers through better documentation,” Davis says. “Nobody thinks you can reduce actual mortality rate, but you can. It is horrifying that one of four hospital deaths may be preventable. There is so much opportunity in resuscitation training.”