Editor's note: Since it's all over the news that Seattle's "save rate" for cardiac arrest (witnessed collapse, presumed cardiac etiology, shockable rhythm) is over 50%, I asked Dave Hitlz of the HEARTsafe Community page on Facebook if I could re-post an article he and Mathias Duschl wrote about their experience at the Resuscitation Academy. He graciously agreed.
High Performance CPR: Seattle Style!
Mathias Duschl, from Gattikon, Switzerland
David B. Hiltz, from Westerly, Rhode Island
Recently, the two of us had the tremendous opportunity to attend the Resuscitation Academy, whose mission is to improve survival from out of hospital cardiac arrest.
The Academy, conducted by Seattle Medic One and King County EMS, convenes EMS managers, EMS directors and EMS medical directors in a “mini-fellowship” program that consists of Pre-Fellowship assigned readings, a 4-day intensive and immersive experience discussing Quality Improvement (QI), education, science and leadership in system approaches to optimizing outcomes from out of hospital cardiac arrest (OOHCA), and post-fellowship QI projects.
The experience was remarkable, and provided both of us with improved knowledge, understanding and perception of complex subjects relating to the public health issue of cardiac arrest. Despite having people from different continents, we all had the same mind set and came together to work on strategies that can help save more lives in our communities.
The evolution of discussions at the Academy led to the identification of deliberate approaches to optimizing outcomes from OOHCA. We truly believe that the experience gained through the mini-fellowship program to be highly beneficial and we encourage agencies, EMS systems, local governments and administrations (like county boards of health in the U.S.) to send representatives to the Academy with a goal of developing localized strategies to save lives.
Among the essential components of a system of care for cardiac arrest victims is “high performance CPR” (HP-CPR) and we have decided to share this, our perspective, on the subject. Neither of us intends to portray ourselves as experts and all-knowing, but simply applying one viewpoint on one subject in a cardiac arrest QI montage.
High quality resuscitation and improved outcomes are highly dependent on a foundation of high quality CPR by prehospital care providers. Advanced cardiac life support must be positioned in a way that does not get in the way of, but instead enables this high quality CPR. The approach requires a teamwork approach by EMS systems, agencies and providers alike.
The American Heart Association has released the revised BLS for HCP course. In Europe, the European Resuscitation Council ERC provides PowerPoint presentations, posters etc. about the new BLS strategies as downloads in several languages via their website. These materials, in the hands of qualified instructors, will continue to be a cornerstone in resuscitation education for countless providers. But AHA-ERC certification is just the beginning…not an end point in our efforts to save more lives.
Resuscitation training and education should not be thought of as a course or single “event”, but rather a long-term progression in development of CPR quality and an ongoing quest for better insight on the science, practice and performance of resuscitation. Continuity in education and repetitive training in CPR can lead to better results in real-life situations. A goal of highly choreographed HP-CPR is extremely desirable, but like most things, it won’t happen through desire alone. Action is required if we are to expect improvement.
One potential method to improve CPR is to develop a “team strategy” with clear roles and is translated into “team practice” of HP-CPR. View the videos from the Resuscitation Academy, where a team approach is portrayed. Whether you call it Choreographed CPR, HP-CPR, Crisis Resource Management in CPR or use of an Incident Command strategy at the scene of a cardiac arrest, the essential goal is improved teamwork, and teamwork requires PRACTICE.
Initiating team practice does not have to be elaborate or complicated. Informal and formal practice sessions are both reasonable and recommended strategies to improve future performance. Use of observers with equipped with stopwatches, checklists, video recorders, and/or instrumented manikins along with practiced and non-punitive debriefing skills will improve results.
Use a “let’s just do it” approach. Don’t wait for an overly-detailed plan to begin the process of quality improvement. Read the Guidelines for CPR and ECC and understand the science Make resuscitation quality a priority (culture of excellence) Use courses like the AHA BLS HCP course to establish baselines Begin practicing HP CPR Collect CPR performance data through observation or instrumentation.
Ongoing and routine debriefing regarding CPR performance
All personnel involved in practice should have an opportunity to contribute to the QI process. Exercise facilitators should use a structured and consistent approach to debriefing of rescuers. The practice of clinical event debriefing can also be very valuable in the QI process and development of HP CPR.
Improving OOHCA outcomes is challenging to say the least. Individual clinical excellence is just one factor in a life-saving formula…but at the same time an integral and core component in a process that involves the implementation of strategies to optimize recognition, response, care and outcomes for cardiac arrest patients. The incremental value of ongoing system quality improvement (public health surveillance), early recognition and emergency number activation, pre-arrival instructions, bystander initiated CPR, really fast “shock strategies”, HP- CPR, and regional systems of care (incorporating therapeutic hypothermia and other evidence based recommendations) is essential.
Performing high quality CPR, with minimal delays and interruptions is a core strategy to improving outcomes. Quality improvement strategies should aim to encourage, enable, and direct the ongoing practice and pursuit of high performance CPR. High Performance CPR is not, and should not be complicated. In fact, we believe it is relatively easy to implement. It does however require action in order to get the process going, commence practice, and begin the process of developing a culture of excellence.
“Measure, improve, measure, improve, measure, improve”- Dr. Mickey Eisenberg.