R.M.Y.Cheong, J.Burke, P.T.Morley. Royal Melbourne Hospital, the University of Melbourne, Victoria, Australia

Transcription

1 Cardiopulmonary Resuscitation (CPR) in a Quaternary Teaching Hospital: Performance Component Quality and Impact on Patient Outcomes. An observational study. R.M.Y.Cheong, J.Burke, P.T.Morley Royal Melbourne Hospital, the University of Melbourne, Victoria, Australia

2 Background CPR is a recognised cornerstone for cardiac arrest treatment Published literature suggests link between high-quality CPR and better outcomes High-quality CPR = Qualitative factors + Quantitative factors Novel defibrillators technology currently allows for Retrospective analysis of CPR performance Real-time CPR performance audiovisual feedback

3 Introduction Cardiac arrests occur in approximately 1 in 1000 patients admitted at the Royal Melbourne Hospital (RMH) Survival rates from cardiac arrests in the wards at the RMH are good The RMH has previously not been able to objectively quantify the quality of CPR performed This study has the potential to improve our practice and patient outcomes at the RMH

4 Objectives In patients experiencing a cardiac arrest at the RMH: Describe the quality of various quantitative CPR performance parameters Compare patient-related factors and CPR performance components with patient outcomes Intensive Care Unit (ICU) General Wards

5 Methodology Patient: - Inclusion criteria: Age 18yo, in-hospital cardiac arrest (IHCA), CPR with ZOLL defibrillator attached, complete electronic defibrillator data with 30 compressions, allrhythm cardiac arrests, complete patient electronic data - Exclusion Criteria: Electronic defibrillator data with <30 compressions, incomplete patient data Outcome: - Primary: Quality of chest compression (CC) depth, rate, fraction, interruption (perishock pause), chest compression release velocity (CCRV), ventilation rate, end-tidal carbon dioxide - Secondary: Return of Spontaneous Circulation (ROSC), Survival to Hospital Discharge (STHD), discharge destination Time: 1 July December 2017

6 Methodology Data collected from ZOLL defibrillators, code blue forms and electronic discharge summaries Patient Admission System Code call summaries Chart review Data analysis by specific manufacturer software (ZOLL Online)

7 Methodology Initial Event Number 51 Total events for analysis 15 Excluded 3 27 Electronic Recorded Data <30 Compressions 10 Incomplete patient data

8 Results General Ward Data (For Full Resuscitation) Survival to Hospital Discharge /24 (54%) 2 Shockable 22 Non-shockable /34 (50%) /32 (34%) Survival to Hospital Discharge Survived

9 Results ZOLL Online Software

10 Results

11 Results Patient Demographic: 11/15 (73.3%) female 10/15 (66.7%) Age 65 years old Median age 68 years old 8/15 (53.3%) have a previous diagnosis of cardiac disease 14/15 (93.3%) have 3 co-morbidities 10/15 (66.7%) in the ICU

12 Results Guideline-recommended targets: 4/15 (26.7%) average CC depth 5-6cm 2428/14355 (16.9%) of all compressions 6/15 (40%) average CC rate compressions/min 3559/14355 (24.8%) of all compressions 3/15 (20%) CCF >0.80 (Median CCF= 17.8%) 0/15 (0%) average CC Pauses <10 seconds 3/4 (75%) Pre-shock pause <10 seconds 5/15 (33.3%) average CCRV >400mm/s

13 Results Cardiac arrest outcomes: 13/15 (86.7%) ROSC 9/15 (60%) 24-hour survival 1/15 (6.7%) STHD Discharge destination: Home

14 Results ICU General Wards 8/10 (80%) Female 3/5 (60%) Female 3/10 (30%) initial shockable rhythm 0/5 (0%) initial shockable rhythm 2649/7942 (33.4%) guideline-recommended CC rate 910/6413 (14.2%) guideline-recommended CC rate 1841/7942 (23.2%) guideline-recommended CC depth 587/6413 (9.1%) guideline-recommended CC depth 1/10 (10%) guideline-recommended CCF >0..8 2/5 (40%) guideline-recommended CCF >0.8 3/10 ((30%) average CCRV >400mm/s 2/5 (40%) average CCRV >400mm/s 2/3 (66.6%) guideline-recommended pre-shock pause <10s 1/1 (1000%) guideline-recommended pre-shock pause <10s 9/10 (90%) ROSC 4/5 (80%) ROSC 5/10 (50%) 24-hour survival 4/5 (80%) 24-hour survival 1/10 (10%) STHD 0/5 (0%) STHD

15 Discussion Preliminary analysis suggests Predominantly female patients Poor adherence to guideline-recommended CPR metric targets Better adherence to guideline in the ICU Ongoing study High ROSC rate but low rates of STHD Skewed data set two-third are ICU patients

16 Discussion Issues encountered during research process thus far Limited data Absence of ZOLL defibrillators on certain wards Better processes to collect data ICU General wards Lack of a local IHCA database for future research

17 Discussion Going forward Continued recruitment of patients Data on CPR provider Association with patient survival outcomes Real-time audiovisual feedback devices CoSTR 2015 Real-time feedback devices as an overall systems strategy to improve CPR quality Weak level of evidence for improving ROSC and survival

18 Summary CPR quality metrics generally not within the Australian guideline recommended ranges Strategies to improve performance of CPR quality parameters individual, team, system A bundle of strategies may be essential CPR refresher courses, simulation training, post-event debriefing Larger prospective trials are necessary to validate results

19 References Meaney PA, Bobrow BJ, Mancini ME, Christenson J, de Caen AR, Bhanji F, Abella BS, Kleinman ME, Edelson DP, Berg RA, Aufderheide TP, Menon V, Leary M. CPR quality: Improving cardiac resuscitation outcomes both inside and outside the hospital. Circulation [Internet] Jul [cited 2016 Sep 20]; 128 (4): DOI: /CIR.0b013e31829d8654. Kleinman ME, Brennan EE, Goldberger ZD, Swor RA, Terry M, Bobrow BJ, Gazmuri RJ, Travers AH, Rea T. Part 5: Adult basic life support and cardiopulmonary resuscitation quality. Circ. 2015;132(suppl2):S ANZCOR Guideline 8 Cardiopulmonary Resuscitation (CPR) [Internet]. Australia: Australian Resuscitation Council; 2016 Jan [cited 2017 Apr 25]. Available from: Perkins GD, Travers AH, Berg RA, et al. Part 3: Adult basic life support and automated external defibrillation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resus 2015;95:E ZOLL User Manual Guide

20 Acknowledgement A/Prof Peter Morley, Supervisor Jennifer Burke, Deteriorating Patient Program Nurse Daniel Hadley, Clinical Nurse Manager

21 Thank You