In Hospital: Clinical Solutions & Best Practices
Improving cardiac arrest outcomes is about more than improved team performance; it includes involving stakeholders and selling your product to convince code team members why and how their participation can save lives!
PURPOSE: High-quality cardiopulmonary resuscitation (CPR) for in-hospital cardiac arrest (IHCA) is the primary component influencing return of circulation (ROSC) and survival to hospital discharge, but few hospitals regularly track these metrics. Other studies have demonstrated significant improvements in survival after IHCA events following implementation of a dedicated code team training program. Therefore, we developed a Code Team Training (CTT) course, and evaluated its post-implementation effect on CPR quality and post-IHCA patient outcomes at our institution.
METHODS: CPR quality data was prospectively collected for quality improvement purposes once our institution had that capability, with 12-months pre-CTT and 21 months post-CTT. Pre-CTT data shaped the elements of the four-hour CTT course that included didactics, small group sessions, and high-fidelity simulation exercises. A total of 456 multi-professional code team members were trained in 22 courses. Data collection included CPR quality and translational outcomes for events where CPR was performed, except the ED. CodeNet® software was used for CPR quality measures, cardiac rhythm, defibrillation metrics, use of continuous waveform capnography, and pauses in compressions. Target metrics for CPR quality were based on 2015 AHA guidelines. Key translational outcomes measures included event location, ROSC, and survival to hospital discharge. Matched pre- and post- Likert-based evaluations were completed by participants to determine the perceived impact and utility of the course in terms of attitudes and confidence.
RESULTS: CPR quality was obtained from 140 of 230 (61%) in- and out-of-hospital pulseless adult cardiac arrest events over 33 months (50 [36%] before CTT and 90 [64%] following the first course). There was no significant difference between groups in terms of event location within the hospital nor initial event rhythm. A total of 116,908 chest compressions were evaluated. Median compressions in target rate improved from 32% before CTT to 49% after CTT (p < 0.05). When accounting for target rate and depth, the median compressions rate improved to 38% post-CTT compared to 31% pre-CTT (p < 0.05). While compression depth had a non-statistically significant decline (90.8% pre-CTT and 83.4% post-CTT), mean rate and median rate-in-target improved from 119.99 +/- 15.6 cpm and 32.4% pre-CTT to 113.7 +/- 16.1 cpm and 48.6% post-CTT (p < 0.05). The rate of ROSC improved from 60% (30 of 50) to 78% (70 of 90) after implementation of CTT (p=0.003), excluding IHCA in the ED. Index IHCA survival rate for our institution improved from 26% to 33% before and after CTT [p-value NS], which far surpasses the national average (23.8%). 283 CTT participants [146 Nurses (RN), 49 Physicians (MD), 37 Respiratory Therapists (RT), 36 Technicians (Tech)] completed pre- and post-evaluations, and 235 (92.5%) reported that their confidence in code team participation improved as a result of the course. Following the course, all groups also felt more confident in their CPR skills (RN, p < 0.0001; MD, p=0.03; RT, p < 0.0001; Tech, p=0.0008) and in the importance of a dedicated code team to improve IHCA outcomes (RN, p < 0.0001; MD, p=0.0145; RT, p < 0.0001; Tech, p=0.0096).
CONCLUSIONS: After the initiation of a CTT course targeting key code team member personnel, CPR quality significantly improved, which was associated with an increase in ROSC and a trend towards increased survival for in-hospital cardiac arrest patients. The CTT course also resulted in an improvement in course participant confidence and attitudes regarding the program, which further strengthened the change in culture at our institution. This could be a model for other institutions attempting to improve CPR quality and IHCA outcomes.
DISCLOSURE: The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, the Department of the Air Force, or the Department of Defense or the U.S. Government.