Do You Know the Quality of Your CPR? Utilizing Feedback to Improve CPR Quality Cindy Ruiz MS, APN CNS, CCRN Objectives Describe the importance of measuring CPR rate, depth & chest compression fraction to improve CPR quality in hospital resuscitation. Discuss ways to provide feedback and training to staff on CPR quality to improve performance. Northwest Community Hospital 489 bed hospital Located in Arlington Heights, IL More than 350,000 outpatient visits a year and more than 20,000 annual patient admissions Three time holder of the prestigious Magnet designation Comprehensive Stroke Center Earned the Joint Commission s Gold Seal of Approval in 2015 for quality and safe patient care 1
2015 ACLS/BLS Guidelines Recommendations: High quality CPR Compress 100 120 bpm (Class IIa) Depth 2 to 2.4 inches (Class I) Feedback devices (Class IIb) Chest compression fraction (CCF) at least 60% (with an unprotected airway) (Class IIb) Capnography (Class I) Early debrillation Compression Rate Too Slow (Before 2010) 100 120 per minute Too Fast (After 2010) 2
Chest Compression Fraction Time spent providing compressions Also be called compression ratio Chest compression fraction (CCF) should be as high as possible A minimum of 60% Goal: At least 80%! HUGE issue in hospitals Too many interruptions! How Do You Implement Change? You cannot change what you do not measure. Northwest Community Hospital s Story Code Blue Committee focused on high quality CPR Recent code critiques revealed issues No way to assess CPR quality Inconsistent use of ETCO2 Looking to purchase new defibs CPR data from our defibs Baseline data 3
Feedback CPR Report Card CPR Report Card December 2014 Case #1 4
Case #1 20 sec Case #2 Case #3 Continued issues with CC rate 5
Case #3 Case #4 Pre shock pause issues 38 second pre shock pause Work to Improve Shared CPR Report Cards with staff and physicians Purchased new defibs with metronomes and ETCO2 Started Mock Codes on all units Focused on first responder activities: o Activating the code o Starting compressions o Quality of compressions o Airway o AED o Suction 6
Case #5 2 mos Later Improvement 8 second pulse check Case #6 Minimized pre & post shock pauses 2 sec Case #7 Overall HUGE improvement!!! 7
Case #7 Improvement 8 Sec Case #7 Rhythm check 8
More Work to Improve In situ mock codes revealed staff fumbled to find to CPR mask Red stickers were posted on the drawer containing the mask But we wanted to do more to recognize their efforts!!! More Staff Recognition We created the LifeSaver Award! 3 teams received the first awards One unit for most improved One unit for using the AED prior to the code team arrival And one to the following team: 9
How long is too long to attempt resuscitation? 58 y/o male admitted to the ortho unit post laminectomy 8 hours post op he suffered a 70 min Vfib arrest ETCO2 remained in the 30 40s during the code Taken to cath lab & stented The next day he was awake & alert but remained intubated Discharged to home on day 7 fully intact A grateful patient and the importance of capnography! In conclusion High Quality CPR is one of the most important aspects of successful resuscitation! Focus on minimizing interruptions in compressions Defibrillate early with minimal pre/post shock pauses Use ETCO2 You will not improve what you don t measure!!! 10
Next steps Maintain our compression rates Begin to monitor depth Focus ventilation rates References Idris, A., Guffey, D., Pepe, P., et al (2015) Chest compression rates and survival following out of hospital cardiac arrest. Critical Care Medicine. 43, (4) 840 https://eccguidelines.heart.org/ index.php/american heartassociation/ Morrison, L., Neumar, R., Zimmerman, J., et al (2013) Strategies for improving survival after in hospital cardiac arrest in the United States: 2013 consensus recommendations. Circulation, 127, 1 26. Herbers, M. and Heaser, J. (2016) Implementing an in situ mock code quality improvement program. American Journal of Critical Care. 25, (5) 393 399. Thank you! Cindy Ruiz, MS, APN CNS, CCRN cruiz@nch.org MS, APN CNS, CCRN 11