CRITICAL ANALYSIS, CRITICAL CARE Editor’s note: This is part of an ongoing series of columns from nurses at the University of Washington that will examine in depth the research related to critical care practices.

By Nicole Kupchik, MN, RN, CCNS, CCRN, PCCN, CMC, and Elizabeth Bridges, PhD, RN, CCNS

Improving Outcomes from In-Hospital Cardiac Arrest Critical areas for improvement highlighted by the 2013 AHA consensus statement.

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Photo by Ashley Gilbertson / New York Times / Redux.


our patient Mr. Jones is complaining of chest pain. While performing an assessment after activating the rapid response team, you notice that Mr. Jones is pale and diaphoretic. Suddenly, he loses consciousness and his pulse is undetectable. Your heart is racing as you ask yourself what you should do first and how you can ensure the best possible outcome for your patient. In 2013, the American Heart Association (AHA) published consensus recommendations addressing inhospital cardiac arrest.1 According to these recommendations, the percentage of patients who survive to discharge after in-hospital cardiac arrest is a dismal 18%. One year after cardiac arrest, that percentage drops to 6.6%, while at three years, only 5.2% of all in-hospital cardiac arrest victims survive. The most common initial in-hospital cardiac arrest rhythms are pulseless electrical activity and asystole. Together these rhythms make up 67% of in-hospital cardiac arrests. Is an 18% survival rate acceptable, or can we improve this number? What can we do to make a difference? The evidence-based recommendations from the AHA identify five critical areas to focus on to improve cardiac arrest response and patient outcome.1 1. Focus on cardiopulmonary resuscitation (CPR) quality. 2. Defibrillate shockable rhythms quickly, with minimal pauses in compressions. 3.  Prevent excessive ventilation. 4.  Incorporate postevent debriefing. 5.  Measure outcomes, practice, and improve. Focus on CPR quality. Compression rate, depth, and recoil. Cardiac resuscitation should be focused on maintaining perfusion to vital organs. In 2010, the AHA strengthened its emphasis on chest compression quality and recommended a compression rate of at least 100 compressions per minute with a two-inch depth.2 Prior to 2010, many providers were compressing at a rate of less than 100 compressions per minute. In the years following publication of the 2010 guidelines, the new mantra became “press fast, press hard.”

Now the pendulum has swung the other way— we may be compressing too fast. The problem with a compression rate greater than 120 compressions per minute is that it may prevent achievement of a two-inch compression depth. Rapid compressions may also not allow for full recoil of the chest and can lead to increased intrathoracic chest pressure, causing decreased venous return and poor coronary perfusion pressure. In addition, compressing at too rapid a rate more quickly leads to provider fatigue. All of these issues may decrease the likelihood of a­chieving return of spontaneous circulation. One way to improve compression rate is to use a metronome device. These are now built into some newer defibrillators. The use of a metronome gives the compressor an auditory cue to prevent compressing too fast or too slow. If your defibrillator does not have a metronome, many metronome apps can be downloaded onto smartphones to assist with providing proper chest compression rates. Another method of achieving the optimal compression rate is to use intraarrest CPR feedback devices. These devices are usually placed on the chest, allowing AJN ▼ May 2015

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the compressor to provide compressions on top of the device. The compressor receives immediate feedback on chest compression rate and depth via a digital display so that corrections can be made instantly. Some feedback devices also have a metronome built in to provide an auditory cue as well as the chest compression rate and depth. Minimizing interruptions. Interruptions in compressions are common during CPR for cardiac arrest, but should be avoided. Often, compressions are interrupted to check for a pulse, or to place an advanced airway or a central intravenous line. It has been estimated that compressions are provided only 40% to 50% of the time during pulselessness.3 There is a newer term—chest compression fraction—which is the percentage of time during pulselessness in which chest compressions are provided each minute. The chest compression fraction goal should be a minimum of 80%,3 but many successful resuscitation programs target a higher goal of 90% to 95%.

placed and provides a continuous measurement of end-tidal carbon dioxide (EtCO2) level—received a Class I, Level A, recommendation from the AHA in 2010 for verification of endotracheal tube placement.2 EtCO2 received a Class IIb, Level C, recommendation as an indicator of chest compression effectiveness. (Class I, Level A, recommendations are supported by evidence from multiple randomized trials or meta-analyses and indicate that the procedure’s benefit is greater than its risk, whereas a Class IIb recommendation indicates that usefulness is less established.) EtCO2 is the amount of carbon dioxide present at the end of exhalation. Normal capnography values range from 35 to 40 mmHg. In a cardiac arrest event, the target EtCO2 value is a minimum of 10 mmHg.2 Since EtCO2 level reflects cardiac output, a value less than 10 mmHg during resuscitation should trigger an assessment of the quality of chest compressions. With compressions of good quality, EtCO2 values

Delays in defibrillation are common with in-hospital cardiac arrest, and are associated with a lower probability of survival. Mechanical compression devices are one way to minimize interruptions in chest compressions. These devices can be easily applied to the patient to provide continuous chest compressions. Other advantages of mechanical devices include their ability to achieve proper compression depth and recoil and the freeing up of staff to focus on other tasks, which can be especially helpful in prolonged resuscitation events. Who should perform compressions? More people than necessary usually respond to an in-hospital cardiac arrest event. Jones and Lee compared CPR performed by male and female nurses in a simulation setting and evaluated the effectiveness of compression quality.4 Overall, the male nurses provided more effective compressions than their female counterparts. However, there are no specific guidelines from the AHA on who should perform compressions, only that compressions be performed correctly and effectively. Many facilities are utilizing step stools to allow for optimal positioning of the hands and arms directly over the patient’s sternum, minimizing leaning at an angle while providing compressions, so that the force of the compression is centered on the sternum. The use of quantitative waveform capnography — which can occur once an advanced airway has been 52

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greater than 10 mmHg are common. If a sharp increase in EtCO2 is detected during compressions, this could be a sign of the return of spontaneous circulation.2 If this increase in EtCO2 is seen, compressions should be continued until the end of the two-minute compression cycle, at which time you should assess for a pulse. Defibrillate shockable rhythms quickly. Shockable rhythms, such as ventricular fibrillation and pulseless ventricular tachycardia, respond best to defibrillation. If the patient presents in a shockable rhythm, the goal is to defibrillate within two minutes of onset.2 A study published in 2008 showed that delays in defibrillation are common with inhospital cardiac arrest, with delays of more than two minutes from collapse to defibrillation occurring more than 30% of the time in patients with ventricular fibrillation or pulseless ventricular tachycardia.5 The authors found that delays in defibrillation were associated with a lower probability of survival, as only 22.2% of patients who experienced a greater than two-minute delay in defibrillation survived compared with 39.3% of patients who did not experience a delay. Every nurse working in a hospital needs to be prepared to quickly apply defibrillator pads and

­ efibrillate a patient. Chest compressions should d be continued while the pads are placed and only ­in­terrupted for rhythm assessment and the actual ­defibrillation. Interruptions in chest compressions are a common problem during defibrillation, with pauses often occurring before and after the shock. Pauses greater than 10 seconds have been linked to decreased survival and shock success.6, 7 Compressions should be provided right up to the point of defibrillation and restarted immediately afterward. This resumption of compressions is a change from the 2005 AHA guidelines, which recommended assessing for a pulse immediately after defibrillation. On units where nurses are not trained to interpret electrocardiogram (ECG) rhythms, the use of automated external defibrillators (AEDs) or manual defibrillators in AED mode should be considered. Nurses who have not been educated in ECG interpretation cannot be expected to analyze rhythms and decide if the patient needs to be shocked. In non–­ telemetry-monitored areas, many programs require the trained resuscitation team to respond with a manual defibrillator that allows for rapid defibrillation and visualization of the ECG. Prevent excessive ventilation. In the 2010 AHA basic life support and advanced cardiac life support guidelines, the focus of initial treatment of cardiac arrest transitioned from airway–breathing–circulation (ABC) to circulation–airway–breathing (CAB).2, 8 Although managing the airway continues to be important, providing chest compressions should be the highest priority. The current target compression-toventilation ratio without the presence of an advanced airway is 30 compressions to two ventilations.2 Once an advanced airway, such as an endotracheal tube, has been placed, one ventilation should be administered every six to eight seconds.2 Maintaining this slow ventilation rate can be extremely challenging, and excessive ventilation rates and volume are common. Excessive ventilation may lead to increased intrathoracic chest pressure, decreased venous return, decreased coronary perfusion pressure, and decreased survival.9 Many capnography devices display the assisted ventilation rate or provide a visual cue when a ventilation should be administered. Assisted ventilation should be provided by administering a small amount of tidal volume. The current recommended AHA ventilation volume goal is 600 mL.2 The optimal tidal volume to administer during resuscitation is unknown. The current recommendation is to provide assisted ventilation for one second, with enough volume to produce chest rise. Incorporate postevent debriefing. Debriefing can be a powerful tool to use immediately after [email protected]

r­ esuscitation events to allow staff to discuss the event, highlight best practices, and consider areas for improvement. It is important to identify a leader on the team who is responsible for debriefing after stressful resuscitation events. Three simple questions can be posed to the team: “What went well?” “What should we do differently next time?” and “Were there any safety or equipment concerns?” Debriefing should be brief and approached in the spirit of highlighting best practices in a blame-free environment. A recent study by Wolfe and colleagues, which focused on cardiac events among pediatric patients

Figure 1. Example of an ICU Debriefing Tool

This tool provides quantitative feedback on the quality of the CPR performed. The compression fraction or “ratio” (A) is the percentage of time per minute spent providing chest compressions while the patient is pulseless. Ideally, this is a minimum of 80%. The average compression rate (B) and average compressions per minute (C) are also shown. (Note that compressions per minute differs from compression rate in that it takes into consideration pauses in compressions during the resuscitation effort.) The initial electrocardiogram rhythm at the time of arrest (D) and the continuous waveform capnography display (E) appear below. Each red line (F) represents one chest compression. The middle column labeled “Compr. Rate” (G) displays minute by minute compression rates. (Note that the rates are consistently in the 140 range, which is too fast.) CODE-STAT CPR report courtesy of Physio-Control. AJN ▼ May 2015

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in an ICU, found that providing debriefing to the interdisciplinary resuscitation team was associated with improved patient survival and better neurologic outcomes.10 This quality improvement trial made use of quantitative feedback obtained from a defibrillator, which recorded information on the quality of CPR in four target areas: rate and depth of compressions, chest compression fraction, and leaning (recoil). (See Figure 1 for a sample debriefing tool.) The defibrillator also audio-recorded the event, and this allowed for postevent review of team dynamics. The results of the quality assessment were presented to the resuscitation team members and to all ICU staff within three weeks of the cardiac arrest. The staff was given the patient’s history, “pertinent prearrest studies” such as radiographs and laboratory results, and the patient outcome and summary, in addition to the quantitative resuscitation data. In the course of the study, information was summarized for the 59 cardiac arrests in the intervention group and outcomes were compared with those of the 60 cardiac arrests in the control group. There was a significant improvement in CPR quality in the intervention group compared with the control group, and the chance of survival with favorable neurologic outcome increased 2.5 times. If your hospital does not have software to review intraarrest data, there are still ways to assess some of these quality markers. For example, many hospitals have assigned a person on the resuscitation team to be in charge of counting the number of compressions and ensuring that the hands-off-the-chest time or number of interruptions in compressions is minimized. Measure outcomes, practice, and improve. Measurement of cardiac arrest outcomes is vital to improvement. Many hospitals participate in national registries or track data and outcomes internally. As seen in the study by Wolfe and colleagues, it is important for members of the resuscitation team to be made aware of outcome data; the AHA recommends that data from the feedback devices or defibrillators used during cardiac arrest be utilized to provide feedback to the team about their performance.1 These data can be used to focus training where it is needed. Mock resuscitation drills are one helpful way to allow staff to practice cardiac arrest response in a safe learning environment. These drills can be done in the actual work environment or in a simulation laboratory. The focus in such drills is typically on practicing as a team while evaluating dynamics and performance in resuscitation. When in-hospital cardiac arrest outcomes are measured, improvement can be made through training 54

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and feedback provided to the resuscitation team and first responders. Important areas of focus to keep in mind are high-quality CPR, early defibrillation, and avoidance of excessive ventilations. The bottom line: we can’t improve what we don’t measure. ▼ Keywords: cardiac arrest, cardiopulmonary resuscitation, in-hospital cardiac arrest, quality improvement

Nicole Kupchik is an independent consultant and a staff nurse at Swedish Medical Center, Seattle. Elizabeth Bridges is a clinical nurse researcher at the University of Washington Medical Center, Seattle, and an associate professor in the University of Washington School of Nursing. Contact author: Nicole Kupchik, [email protected] Elizabeth Bridges also coordinates Critical Analysis, Critical Care: [email protected] Nicole Kupchik is a paid consultant and speaker for Physio-Control, a manufacturer of products discussed in this article; Elizabeth Bridges has disclosed no potential conflicts of interest, financial or otherwise.

REFERENCES 1. Morrison LJ, et al. Strategies for improving survival after inhospital cardiac arrest in the United States: 2013 consensus recommendations: a consensus statement from the American Heart Association. Circulation 2013;127(14):1538-63. 2. Neumar RW, et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2010;122(18 Suppl 3):S729-S767. 3. Christenson J, et al. Chest compression fraction determines survival in patients with out-of-hospital ventricular fibrillation. Circulation 2009;120(13):1241-7. 4. Jones AY, Lee RY. Rescuer’s position and energy consumption, spinal kinetics, and effectiveness of simulated cardiac compression. Am J Crit Care 2008;17(5):417-25; discussion 426-7. 5. Chan PS, et al. Delayed time to defibrillation after in-hospital cardiac arrest. N Engl J Med 2008;358(1):9-17. 6. Edelson DP, et al. Effects of compression depth and pre-shock pauses predict defibrillation failure during cardiac arrest. Resuscitation 2006;71(2):137-45. 7. Sell RE, et al. Minimizing pre- and post-defibrillation pauses increases the likelihood of return of spontaneous circulation (ROSC). Resuscitation 2010;81(7):822-5. 8. Berg RA, et al. Part 5: adult basic life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2010; 122(18 Suppl 3):S685-S705. 9. Bobrow BJ, et al. Passive oxygen insufflation is superior to bag-valve-mask ventilation for witnessed ventricular fibrillation out-of-hospital cardiac arrest. Ann Emerg Med 2009; 54(5):656-62 e1. 10. Wolfe H, et al. Interdisciplinary ICU cardiac arrest debriefing improves survival outcomes. Crit Care Med 2014;42(7): 1688-95.

Improving outcomes from in-hospital cardiac arrest.

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