Quality Improvement in Cardiopulmonary Resuscitation How to Definite

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Quality Improvement in Cardiopulmonary Resuscitation 顧孝文醫師

Quality Improvement in Cardiopulmonary Resuscitation 顧孝文醫師

How to Definite the “CPR Quality” ? Most studies defined it as the compliance

How to Definite the “CPR Quality” ? Most studies defined it as the compliance to the latest guidelines in chest compression rate, depth, ventilation rate, and interruptions during resuscitation.

CPR Guidelines: Past Remedies for Resuscitation ~by Herholdt and Rafn in 1800 n n

CPR Guidelines: Past Remedies for Resuscitation ~by Herholdt and Rafn in 1800 n n n n n Cleanse the mouth and nose Compress the chest Insufflate the lung with air If this proves impossible, perform a tracheotomy. Apply electric shocks to the heart Place bladders filled with hot water on the stomach and feet. Administer a stimulant clyster Shake the victim vigorously Continue remedies above for hours. Finally, apply red-hot irons to the feet or other sensitive places. ~ Baskett PJ. Resuscitation. 2003; 58: 283 -8.

Does CPR Training Work? n Despite the major reassessment and publication of new CPR

Does CPR Training Work? n Despite the major reassessment and publication of new CPR and ECC guidelines every 5~8 year for the past 3 decades, survival from cardiac arrest remains unacceptably low (between 4~9% in most countries). ~ Fries M and Tang W. Curr Opin Crit Care. 2005 Jun; 11: 200 -203.

What’s Wrong? n Although the causes of poor patient outcome are still under discussion,

What’s Wrong? n Although the causes of poor patient outcome are still under discussion, the issues of inadequate provision of “ good-quality CPR” has been the focus of renewed attention!

Does the Quality of CPR Makes a Difference in Patient Outcomes? No RCT to

Does the Quality of CPR Makes a Difference in Patient Outcomes? No RCT to answer this question!

Observational Studies: Animals n Pause for ventilation: When animals received realistic 16 second pauses,

Observational Studies: Animals n Pause for ventilation: When animals received realistic 16 second pauses, 24 -hour neurologically intact survival was 13% compared with 80% in the group receiving continuous chest compressions. 9. n ~ Kern et al. Circulation. 2002; 105: 645 - Pause for AED analysis: Longer pause of chest compression related to worse ROSC rate and postresuscitation myocardial function; 100% of animals receiving more than 80 c. p. m. were resuscitated whereas only 10% of those receiving fewer than 80 c. p. m. survived. ~Yu T et al. Circulation. 2002; 106: 368 -72.

Observational Studies: Humans n Patients receiving good bystander CPR had significantly better hospital discharge

Observational Studies: Humans n Patients receiving good bystander CPR had significantly better hospital discharge rate than those who had no or poor CPR (26% vs 3% vs 1%). ~Resuscitation 1994; 28: 195 -203. n Suboptimal compression rates during CPR were significantly correlated with poor ROSC(90± 17 vs. 79± 18; p=0. 003). 34. ~ Circulation. 2005; 111: 428 -

Does rescuers perform CPR according to the latest guidelines?

Does rescuers perform CPR according to the latest guidelines?

Laypersons and Medical Students n Laypersons taught single-rescuer CPR take n Medical students needed

Laypersons and Medical Students n Laypersons taught single-rescuer CPR take n Medical students needed 14 seconds to an average of 16 seconds for each ventilation pause. ~Resuscitation. 2000; 45: 7 -15. deliver 2 ‘rapid-breaths’ during CPR and delivered only (43± 1) c. p. m. after standard AHA-CPR training because of pauses for ventilations; while uninterrupted compression resulted in (113± 2) c. p. m. ~Resuscitation. 2004; 62: 283 -289.

Health Care Professionals n Skills involved in the performance of basic life support (BLS)

Health Care Professionals n Skills involved in the performance of basic life support (BLS) are poorly acquired and poorly retained by healthy professionals as well as laypersons. -23. n ~Crit Care Med. 1986; 14: 620 ~J Adv Nursing 1996; 23: 1016 In actual CPR: Lower chest compression rates (37% resuscitation time segment < 80 c. p. m in a 97 -case in-hospital CPR) and high ventilation rates (30± 3. 2 v. p. m in a 13 -case OHCA CPR) when CPR is performed by health care professionals. 13. -5. 34. ~Acad Emerg Med. 1995; 2: 708~ Circulation 2004; 109: 1960 ~ Circulation. 2005; 111: 428 -

Real CPR: In-hospital n Abella BS et al. : CPR performed by welltrained hospital

Real CPR: In-hospital n Abella BS et al. : CPR performed by welltrained hospital staff were deficient in too shallow compression depth(37%<38 mm), too slow compression rate (28%<90/min) and over ventilation (61%>20/min) ~JAMA. 2005; 293: 305 -10. n Chiang WC et al. : Averaged Hands-off time during actual CPR was 17 seconds per minute; hands-off time occupied 28% of total CPR time. 301. ~ Resuscitation. 2005, 64: 297 -

Real CPR: Out-ofhospital n Wik L, et al. : inadequate chest compressions rate (mean

Real CPR: Out-ofhospital n Wik L, et al. : inadequate chest compressions rate (mean 64/min) and depth (mean 34 mm); too much hands-off time (48% resuscitation time). Ventilations were given 11/min in average. AED analysis and defibrillation accounted for only small parts. 304. n ~JAMA. 2005 Jan 19; 293(3): 299 - Ko PCI, et al. : based on analysis of AED records, the quality of prehospital CPR was judged as adequate only in 29% of the consensus, associated with a greater likelihood of survival in witnessed VF. -169. ~Resuscitation. 2005; 64: 163

No one perform CPR according to guidelines, either in manikin scenario or in real

No one perform CPR according to guidelines, either in manikin scenario or in real practice! Clearly, the quality of real-world CPR must be improved!

How to Improve the CPR Quality? 1. 2. 3. 4. 5. 6. Limitation of

How to Improve the CPR Quality? 1. 2. 3. 4. 5. 6. Limitation of Interruptions (Hands-off) Provision of Audio-Prompt in CPR Avoidance of Hyperventilation Accessory Mechanical Device Optimal Timing of Defibrillation Simplification of Guidelines

1. Limitation of Interruptions n Interruptions of CPR negatively affects survival form cardiac arrest.

1. Limitation of Interruptions n Interruptions of CPR negatively affects survival form cardiac arrest. ~ Curr Opin Crit Care. 2005 Jun; 11: 2003. n Hands-off in CPR: – CPR before or during attachment of electrodes – Minimal delay between chest compression and subsequent defibrillation – Minimal delay after interruptions due to procedures – Manual vs. AED defibrillation – Electronic signal filtering technique incorporated in AEDs – Not to check for pulse immediately after a shock ~ Resuscitation 2003; 58: 271 -5.

Analysis of Hands-off time n Causes in Hands-off in NTUH-ER CPR n Averaged in

Analysis of Hands-off time n Causes in Hands-off in NTUH-ER CPR n Averaged in (16. 9± 7. 9) in every CPR Averaged (273± 153) seconds in every resuscitations (mean 998± 294 ) seconds ~ Resuscitation. 2005, 64: 297 -301.

How to Improve the CPR Quality? 1. 2. 3. 4. 5. 6. Limitation of

How to Improve the CPR Quality? 1. 2. 3. 4. 5. 6. Limitation of Interruptions (Hands-off) Provision of Audio-Prompt in CPR Avoidance of Hyperventilation Accessory Mechanical Device Optimal Timing of Defibrillation Simplification of Guidelines

2. Provision of Audio. Prompt (AP) n Proven to improve adhesion to guidelines in

2. Provision of Audio. Prompt (AP) n Proven to improve adhesion to guidelines in teaching scenarios, simulation, or retention of CPR skills in laypersons, students, nurses, and EMTs. ~Resuscitation. 2001; 50: 167 -72. ; ~Resuscitation. 2003; 57: 57 -62. ~Emerg Med J. 2005; 22: 140 -143. ~Resuscitation. 2005 Aug; in press.

AP in Real CPR : Pioneer in PICU n Berg RA et al. :

AP in Real CPR : Pioneer in PICU n Berg RA et al. : – A small clinical trial (6 babies) in the pediatric intensive care units (PICU) – Audio-prompted rate guidance resulted in higher end-tidal carbon dioxide partial pressure, suggesting improved CPR performance. ~ Acad Emerg Med. 1994; 1: 35 -40.

How to Improve the CPR Quality? 1. 2. 3. 4. 5. 6. Limitation of

How to Improve the CPR Quality? 1. 2. 3. 4. 5. 6. Limitation of Interruptions (Hands-off) Provision of Audio-Prompt in CPR Avoidance of Hyperventilation Accessory Mechanical Device Optimal Timing of Defibrillation Simplification of Guidelines

Avoidance of Hyperventilation n Lower Compression / Ventilation (C/V) ratio: – – increased intra-thoracic

Avoidance of Hyperventilation n Lower Compression / Ventilation (C/V) ratio: – – increased intra-thoracic pressure decreased venous flow and blood pressure decreased coronary flow and cerebral O 2 delivery worsen neurological outcome in animal model n Optimal ratio: unknown (hyper vs. normal vs. hypo? ) n A discrepancy between recommended and the ‘real-world CPR’ related to flat survival rate in OHCA. ~ Curr Opin Crit Care. 2005 Jun; 11: 20411.

How to Improve the CPR Quality? 1. 2. 3. 4. 5. 6. Limitation of

How to Improve the CPR Quality? 1. 2. 3. 4. 5. 6. Limitation of Interruptions (Hands-off) Provision of Audio-Prompt in CPR Avoidance of Hyperventilation Accessory Mechanical Device Optimal Time of Defibrillation Simplification of Guidelines

4. Accessory Mechanical Device n ACD+ITD n – RCT; n=210 OHCA. – Improvement in

4. Accessory Mechanical Device n ACD+ITD n – RCT; n=210 OHCA. – Improvement in ROSC, 1 - and 24 -hour survival rates (vs. manual CPR) Auto-Pulse CPR – Case-control; n=162 OHCA; improvement in shortterm survival. – FDA approved ~Curr Opin Crit Care 2005; 11: 219 -23.

The RCT support: ACD + ITD n n The only RCT with positive result

The RCT support: ACD + ITD n n The only RCT with positive result in CPR device! Improved vital organ blood flow (> X 3 increase) during cardiac arrest. Improve short-term survival rate for OHCA “Window of opportunity” for successful CPR can be extended by enhancing circulation with ACD+ITD ~Circulation 2003; 108: 2201 -5.

How to Improve the CPR Quality? 1. 2. 3. 4. 5. 6. Limitation of

How to Improve the CPR Quality? 1. 2. 3. 4. 5. 6. Limitation of Interruptions (Hands-off) Provision of Audio-Prompt in CPR Avoidance of Hyperventilation Accessory Mechanical Device Optimal Timing of Defibrillation Simplification of Guidelines

5. Optimal Timing of Defibrillation n VF early defibrillation (Class I) “Defibrillation as soon

5. Optimal Timing of Defibrillation n VF early defibrillation (Class I) “Defibrillation as soon as possible” !? Time-sensitive progression of resuscitation physiology which in turn requires time-critical intervention! <4 Min Electrical phase 4 -10 Min Circulatory phase >10 Min Metabolic phase ~Weisfeldt ML and Becker LB. JAMA 2002; 288: 3035 -8.

RCT: Early defibrillation vs. CPR ~ 200 OHCA-VFs in Oslo. JAMA. 2003; 289: 1389

RCT: Early defibrillation vs. CPR ~ 200 OHCA-VFs in Oslo. JAMA. 2003; 289: 1389 -1395.

Delaying shock for CPR? n n n Current guidelines call for rapid defibrillation as

Delaying shock for CPR? n n n Current guidelines call for rapid defibrillation as the most important ‘link’ in the ‘chain of survival’. Most EMS response time within 5~8 mins for most ventricular fibrillation patients who have professional rescuers arrive, while immediate defibrillation is likely to be ineffective! Should we change? – – Witnessed VF DC shock first! Un-witnessed VF CPR first!

How to Improve the CPR Quality? 1. 2. 3. 4. 5. 6. Limitation of

How to Improve the CPR Quality? 1. 2. 3. 4. 5. 6. Limitation of Interruptions (Hands-off) Provision of Audio-Prompt in CPR Avoidance of Hyperventilation Accessory Mechanical Device Optimal Timing of Defibrillation Simplification of Guidelines

6. Simplification of Guidelines n n The ACLS course as become dramatically more complex

6. Simplification of Guidelines n n The ACLS course as become dramatically more complex than it was 20 years ago. The unintended consequences of the complex BLS/ACLS algorithms are too many interruptions in chest compressions, too many rescue breaths, not enough compressions, and not enough survivors. 2005; 293: 363 -5. n ~Sanders AB and Ewy GA. JAMA Modified CPR instruction protocols for emergency medical dispatchers has been recommended at some area. (100: 2 C/V or non-V in untrained layperson). 10. ~Roppolo LP et al in Dallas, Texas. Resuscitation 2005; 65: 203 -

What’s new in Nov. 2005? ? ? n It’s time to return to the

What’s new in Nov. 2005? ? ? n It’s time to return to the core mission: to provide the most important initial steps for patients in cardiac arrest and simplify the message to both laypersons and health care professionals. ~JAMA 2005; 293: 363 -5. n Most significant changes in CPR including priority of defibrillation timing, CPR devices, CPR pharmacology and organ protection. ~ by Prof. Tang W. TSEM Annual Session on July 3, 2005.

Recommended Readings n Curr Opin Crit Care this month (Jun 2005. ) had four

Recommended Readings n Curr Opin Crit Care this month (Jun 2005. ) had four essential reviews on updated BLS concepts: – Delaying shock for cardiopulmonary resuscitation: does it save lives? – How does interruption of cardiopulmonary resuscitation affect survival from cardiac arrest? – What is the optimal chest compression-ventilation ratio? – Mechanical devices for cardiopulmonary resuscitation.

How to improve CPR Quality of your team NOW ? Take Action NOW!

How to improve CPR Quality of your team NOW ? Take Action NOW!

Push harder and push faster on the center of the chest without interruption, defibrillate

Push harder and push faster on the center of the chest without interruption, defibrillate promptly, and don’t provide too many rescue breaths per minute… If CPR device or audio prompt apparatus is available, you may try it…