Tag Archives: 2015 AHA ECC Guidelines

Dispatcher

2015 AHA ECC Guidelines – Part 2

This is the second post of a multi-part series reviewing the 2015 AHA ECC Guidelines.

Reference Part 5: Adult Basic Life Support and Cardiopulmonary Resuscitation Quality

Epidemiology of sudden cardiac arrest

The guidelines make this sobering observation: 70% of out-of-hospital cardiac arrests occur in the home and 50% are unwitnessed. Only 10.8% of patients who receive resuscitative efforts by EMS survive to hospital discharge.

My department’s survival rate for unwitnessed cardiac arrest is 0% and I suspect that’s the case for the majority of EMS systems.

Basic life support is still the foundation of resuscitation

The chain-of-survival for out-of hospital cardiac arrest remains unchanged from 2010 with a few updates.

There is a greater emphasis on dispatcher recognition of sudden cardiac arrest with early CPR instructions (sometimes referred to as telephone CPR or T-CPR).

The guidelines reiterate the importance of high quality CPR.

  • Ensuring adequate rate (100-120)
  • Ensuring adequate depth (2 to 2.4” or 5 to 6 cm)
  • Allowing full chest recoil (avoid leaning)
  • Minimizing interruptions to chest compressions
  • Avoiding excessive ventilation

This update recognizes the value of a highly choreographed approach that allows simultaneous approach to chest compressions, ventilations, airway management, rhythm detection, and shocking “by an integrated team of highly trained rescuers in appropriate settings.”

There is an acknowledgement that survival rates for witnessed VF can be as high as 50% in top performing EMS systems but vary from 5% to 50% — a 10 fold difference!

Clearly we would not accept this much variation in operative mortality.

Dispatcher recognition of cardiac arrest and CPR instructions

This may be one of the most important statements in the new guidelines:

“When dispatchers ask bystanders to determine if breathing is present, bystanders often misinterpret agonal gasps or abnormal breathing as normal breathing. This erroneous information can result in failure by dispatchers to identify potential cardiac arrest and failure to instruct bystanders to initiate CPR immediately. An important consideration is that brief, generalized seizures may be the first manifestation of cardiac arrest.”

Dispatcher

Image credit: Wikipedia

Quality Improvement in the Dispatch Office

Performing QA/QI on the call intake process for sudden cardiac arrest is extremely important and it’s much harder than you may realize. It is doubtful that the QA/QI tools that come with Emergency Medical Dispatcher (EMD) software packages are adequate.

The CARES registry has an optional T-CPR module that measures various benchmarks for dispatcher performance including recognition of the need for CPR, how long it takes for the dispatcher to begin CPR instructions, and how long it takes for the bystander to begin compressions.

This represents a huge culture shift for dispatch and there is likely to be push back, especially if this type of monitoring occurs without appropriate training, or is implemented in a way that is punitive. However, it’s an often-neglected area of system performance.

As reported by the CARES Registry:

“One recent T-CPR initiative implemented guideline-based protocols, training, and feedback to staff at three regional dispatch centers. This “bundle of care” doubled the number of cases where bystanders started dispatch-directed compressions and reduced the time those compressions started by 80 seconds.”

That’s significant! This is simply not an area we can afford to ignore if we want to be good at resuscitation.

Do we want to be good at resuscitation?

If so, then these issues demand our time and attention. Once you’ve optimized on-scene performance (and hopefully realized some significant gains) you will plateau or perhaps even regress if you don’t find new opportunities to improve the chain-of-survival.

Updated recommendation for dispatchers

“It is recommended that emergency dispatchers determine if a patient is unresponsive with abnormal breathing after acquiring the requisite information to determine the location of the event. If the patient is unresponsive with abnormal or absent breathing, it is reasonable for the emergency dispatcher to assume that the patient is in cardiac arrest. Dispatchers should be educated to identify unresponsiveness with abnormal breathing and agonal gasps across a range of clinical presentations and descriptions.”

Will we pay attention to this recommendation?

I must admit that I find it a bit troubling that so many of my colleagues are saying “there’s nothing new in the 2015 guidelines.” This emphasis on the importance of the call intake process is critically important in my estimation and deserves to be taken seriously.

I hope I’m wrong but it almost reminds me of the 2000 AHA ECC Guidelines when it was first suggested that paramedics may not have enough experience to be proficient at tracheal intubation, and that alternate airways like the LMA might be more appropriate.

We simply did not like the message and many of us still don’t. We’re still arguing about it 15 years later although even the most stubborn of us have, at a minimum, admitted that tracheal intubation should not significantly interrupt chest compressions.

Anecdotally, having reviewed between 50 and 100 cardiac arrest calls using CODE-STAT for CPR analytics, it seems to me that most paramedics will not interrupt chest compressions for more than 10 or 15 seconds for the first attempt. However, if they miss the first attempt, all bets are off, and it is not uncommon for the second attempt to interrupt compressions for 15 to 30 seconds.

Because I know this tends to happen I have asked our paramedics to concentrate on expertly performed BLS for the first 5 cycles (10 minutes) of the cardiac arrest. A 30 second delay in chest compressions, while obviously not desirable, is more palatable at the 10 or 15-minute mark than during the “sweet spot” of the code.

I hope that many years from now (long after I am gone) others in our profession won’t look back and realize that we missed a huge opportunity to strengthen the chain-of-survival in our communities.

Again, I don’t suggest this will be easy. In fact, I’m certain it will be difficult. But with this recommendation it’s a good time to try.

Update: Click here to listen to Robert Lawrence interview Ben Bobrow, M.D. about dispatcher recognition of cardiac arrest and CPR instructions. Here’s the most important part:

“We have to look at this intervention as something we can quantify. So it’s not a binary thing. It’s not a yes or no…it’s not like a 9-1-1 system does this or they don’t, because almost every 9-1-1 system if you ask…answers that they do provide this life-saving service. But when you actually ask them how they train, what protocols they use, if they have a set protocol, how they measure it, what their performance standards are, it’s all over the board. So I think one of the main concepts, besides turning the public into an army of first responders, is that we need to measure, and have performance standards, for giving pre-arrival CPR instructions.”

High Performance CPR training at EMS Today 2015

High Performance CPR training at EMS Today 2015

 

 

 

 

 

 

 

 

 

 

Consideration of the likely cause of the cardiac arrest

I personally found this update to be interesting:

“[I]t is realistic for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrest. For example, if a lone healthcare provider sees an adolescent suddenly collapse, the provider may assume that the victim has had a sudden arrhythmic arrest and call for help, get a nearby AED, return to the victim to use the AED, and then provide CPR.”

In my mind it is linked to the next issue.

Delayed positive pressure ventilation

Consider these recommendations:

“For witnessed OHCA with a shockable rhythm, it may be reasonable for EMS systems with priority-based, multitiered response to delay positive-pressure ventilation by using a strategy of up to 3 cycles of 200 continuous compressions with passive oxygen insufflation and airway adjuncts.”

And:

“We do not recommend the routine use of passive ventilation techniques during conventional CPR for adults. However, in EMS systems that use bundles of care involving continuous chest compressions, the use of passive ventilation techniques may be considered as part of that bundle.”

Setting aside the qualifiers (we could debate what it means to provide “priority-based, multitiered response” or to use “bundles of care”), the guidelines now acknowledge two important facts.

  • Professional rescuers are capable of discerning between run-of-the-mill sudden cardiac arrest and asphyxial arrest which could potentially change how we approach the situation.
  • Positive pressure ventilation is probably unnecessary during the first 6 minutes for witnessed VF/VT arrest.

This to me is a big change in the guidelines. Even though many EMS systems (including my own) have been using a form of Pit Crew CPR which is a hybrid between cardiocerebral resuscitation and 30:2, it’s nice to see the guidelines officially recognize the practice.

I have a suspicion that switching to continuous chest compressions with “passive oxygen insufflation” for the first 3 cycles (6 minutes or so) has the potential to save a lot of lives, especially in those EMS systems that have been waiting for the AHA to endorse the practice.

Rhythm checks and defibrillation

Rhythm checks and defibrillation

The guidelines reinforce that a defibrillator should be used as soon as possible and that chest compressions should be performed while the defibrillator is “being retrieved and applied.”

The evidence shows no survival benefit for a prescribed interval of 1.5 to 3 minutes of chest compressions prior to the first shock (when compared to a control group where chest compressions are performed while the defibrillator is being prepared).

However, I know from conducting time trials in my own department that it takes a good minute to turn on the defibrillator, extend the cables, attach the pads, apply the pads to the patient, charge the capacitor, and deliver the first shock.

So unless you’re by yourself there’s no reason the patient should not receive 100 chest compressions while all of this is happening.

2015 AHA ECC Guidelines – Part 1

This is the first post of a multi-part series reviewing the 2015 ECC Guidelines.

The eagerly awaited 2015 AHA ECC Guidelines have been published (see also ERC Guidelines 2015) and the internet is buzzing as paramedics, nurses, and physicians all over the world comment about what has changed and what has stayed the same.

2015 AHA ECC Guidelines

Image credit: Wikimedia Commons

Whatever your opinion about the routine administration of epinephrine for patients in cardiac arrest, one thing that is new is a section dedicated to systems of care and continuous quality improvement.

I think the ECC committee should be applauded for making this change.

It’s one thing to know what we’re supposed to do. It’s another thing to make our systems perform in such a way that we deliver those results on a routine basis.

That does not happen by accident! As they say in the Resuscitation Academy, “It’s not complicated but it’s not easy.”

Reference: Part 4: Systems of Care and Continuous Quality Improvement

The guidelines now recognize two distinct systems of care with separate chains of survival: one for out-of-hospital cardiac arrest and one for in-hospital cardiac arrest.

Out-of-Hospital Cardiac Arrest

  • Early 9-1-1
  • Early CPR
  • Early Defibrillation
  • Effective Advanced Life Support
  • Post-Cardiac Arrest Care

In-Hospital Cardiac Arrest

  • Surveillance and Prevention
  • Prompt Notification and Response
  • Early CPR
  • Early Defibrillation
  • Post-Cardiac Arrest Care

You can see the new “chains of survival” by clicking here.

In-Hospital Cardiac Arrest

Patients with in-hospital cardiac arrest require a system of surveillance and prevention so that prompt action can be taken.

Pre-Arrest Rapid Response Systems

The guidelines recommend various strategies to prevent delayed recognition of patient deterioration and the development of Rapid Response Teams (RRT) or Medical Emergency Teams (MET) to facilitate early intervention in the hopes of preventing cardiac arrest from occurring.

The guidelines also recommend increased use of Do Not Attempt Resuscitation (DNAR) orders and palliative care services for patients who have reached end of life and for whom resuscitation attempts are likely to be futile or inconsistent with their goals of care.

These discussions should, whenever possible, occur before the cardiac arrest occurs.

My wife is an Acute Care Nurse Practitioner who works as a Hospitalist, so I am aware of how difficult, time consuming, and emotionally draining these conversations can be.

Perhaps this is why we have historically avoided them. Regardless, these are conversations we need to have with patients and their families.

Challenges Associated With In-Hospital Cardiac Arrest

The guidelines note that even in high risk areas cardiac arrest is relatively infrequent and members of the care team may be different for every cardiac arrest (note the similarity to commercial aviation).

This highlights the importance of interdisciplinary collaborative planning and practice to ensure a well-choreographed, high-quality resuscitation attempt.

Crisis Resource Management

The guidelines include a discussion of Crisis Resource Management (CRM) and mention the importance of leadership, communication, checklists, and cross-checks during a resuscitation attempt to improve performance.

Although the guidelines do not explicitly mention it, the authority gradient in medicine can interfere with optimal team performance when members of the care team to not feel empowered to speak up, share opinions, or take action without explicit direction from the physician.

Dedicated resuscitation teams, simulation, and debriefing can all improve the effectiveness of in-hospital resuscitation.

Post-Cardiac Arrest

The guidelines note that post-cardiac arrest syndrome plays a significant role in cardiac arrest mortality and that survival of patients who experience ROSC after in-hospital cardiac arrest ranges from 32-54% with higher volume and teaching hospitals having a higher survival rate.

Our patients require and deserve a collaborative and multidisciplinary team of providers, including cardiologists, interventional cardiologists, cardiac electrophysiologists, intensivists, neurologists, nurses, respiratory therapists, and social workers.

In the absence of these services the guidelines recommend interhospital transfer to ensure access to these resources.

Out-of-Hospital Cardiac Arrest

The guidelines indicate that out-of-hospital cardiac arrest affects 326,000 patients annually in the United States with an annual incidence of 132/100,000. That means you should see 1.32 cardiac arrests per year for every 1,000 people in your community.

Most EMS systems ought to be able to obtain data from their PCR systems with the standardization of the NEMSIS data set, but this is an alternate way to estimate the epidemiology of cardiac arrest in your community.

Public Access Defibrillation

The guidelines encourage public service access points (PSAPs) to know the locations of AEDs in the community so that dispatchers can direct bystanders to the nearest AED and assist in their use whenever possible.

There is more than one way to accomplish this task (including crowdsourcing) but one obvious step is the development of an AED registry.

Dispatcher Recognition of Cardiac Arrest

Dispatcher Recognition of Cardiac Arrest

Image credit: Wikimedia Commons

Sudden cardiac arrest is often mistaken for falls, syncope, seizures, or other less serious medical conditions. As a result CPR can be delayed.

The guidelines recommend that dispatchers be specifically trained to identify abnormal breathing and agonal gasps.

When a patient is unconscious with abnormal or absent breathing it is reasonable to assume that the patient is in cardiac arrest.

Dispatchers should provide chest compression-only CPR instructions to callers for adults with suspected out-of-hospital cardiac arrest.

Use of Social Media to Summon Rescuers

The guidelines indicate that given the low risk of harm it “may be reasonable” to utilize social media based technologies to summon rescuers in close proximity to possible cardiac arrest victims.

The guidelines do not endorse a particular product or service but one of the best known notification apps is PulsePoint. They have two outstanding videos here and here. (No conflict of interest.)

PulsePoint

Citizen rescuers awaiting notification from the PulsePoint app in Alameda County, CA (Image credit: Richard Price from the PulsePoint Foundation)

Out-of-Hospital Cardiac Arrest Quality Metrics

The guidelines encourage data collection using a simplified Utstein template. My department uses the CARES Registry.

This data collection allows EMS systems to find out how many cardiac arrests occur in their jurisdiction, how often the collapse is witnessed, how often bystanders perform CPR, and how often an AED is used.

In addition, it tracks the initial arrest rhythm, how often return of spontaneous circulation (ROSC) is achieved, and most importantly, how many patients survive to hospital discharge with a CPC score of 1 or 2 (neurologically good outcome).

ACS and STEMI

Only 40-60% of STEMI patients contact 9-1-1 with the remainder self-reporting to the hospital.

Patients with possible ACS should receive rapid assessment that includes a prehopsital 12-lead ECG with an emphasis on early identification of acute STEMI and consideration of the method of reperfusion.

ACS and STEMI

That may include prehospital fibrinolysis, notification to the hospital for early in-hospital fibrinolysis, and/or activation of the cardiac cath lab for primary percutaneous coronary intervention (PCI).

Transport to Specialized Cardiac Arrest Centers

The guidelines state that a regionalized approach to out-of-hospital cardiac arrest “may be considered” that includes transport to “cardiac resuscitation centers”.

Features of a cardiac resuscitation center:

  • Evidence-based practice in resuscitation
  • PCI capability 24 hours/day, 7 days/week
  • Targeted temperature management
  • Cardiorespiratory and systems support
  • Adequate annual volume of cases to maintain proficiency
  • Culture of continuous quality improvement

Continuous Quality Improvement

The guidelines discuss the importance of goal setting, measurement, and accountability.

Continuous Quality Improvement

Creative Commons: Diagram by Karn G. Bulsuk (http://www.bulsuk.com)

Many different scientific problem-solving methods exist which can be used to reduce variation and eliminate waste. They include:

  • Lean
  • Six Sigma
  • Total Quality Management
  • Plan, Do, Check, Act (or Adjust)
  • Plan, Do, Study, Act

The exact method used is less important than having a system in place and developing a culture of continuous quality improvement.

As Mickey Eisenburg, M.D. likes to say, “Measure, improve. Measure, improve.”