The Quality-Cost Connection: Gathering and reporting CPR performance data
Gathering and reporting CPR performance data
By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR
Trending of resuscitation survival rates and other cardiopulmonary resuscitation (CPR) measures of performance can help caregivers pinpoint potential problem areas. The Joint Commission’s standards are somewhat vague with regard to what CPR factors should be monitored regularly. At a minimum, hospitals should be evaluating CPR survival rates; however, to ensure high-quality patient care and reduce liability concerns, all of the key issues affecting in-hospital resuscitations should be evaluated regularly. In part 1 of this 2-part series, the important aspects of resuscitation were described. This column details techniques for gathering CPR performance data and what should be reported to the committee responsible for evaluating resuscitation and its outcomes.
Much of the information related to compliance with hospital policies on CPR training, code cart checks, and maintenance already is being documented. It is merely a matter of gathering the data from logs, checklists, and staff education files. It may take a little more work to gather information about the code event itself and post-resuscitation patient management.
Pre-designed CPR or code sheets help to make documentation easier and more consistent.
Documentation should begin at the time the code is called. Usually one person is designated to document on a code sheet that ultimately becomes part of the patient’s record. A separate code critique form can be used to gather additional information for post-code evaluations. This form is not part of the patient’s record. Both of these documents serve as the primary source of information for CPR performance data.
To enable complete documentation of the CPR event and allow for collection of information that will be used to create event-related performance measures, the code sheet should contain the following minimum data elements:
- Patient identification information
- Status of the patient, e.g., inpatient, outpatient, ED, volunteer, visitor
- Where the code was called
- Who called the code
- Whether or not the code was witnessed
- Date and time the code was called
- Date and time resuscitation was started
- Time and watt seconds used for each electrical defibrillation
- Cardiac rhythm at time of defibrillation
- Tube size, time, name, and title of the person who intubated the patient
- Dosage and time medications were given
- Patient’s level of consciousness throughout the code with changes in the patient’s condition clearly documented and timed
- Site of each IV fluid, amount, rate, and time administered
- Equipment used during the code
- Names of staff who assisted at the resuscitation
- Patient outcome and disposition
The hospital should have policies about where blank code sheet are kept (e.g., on every patient unit, on crash cart). The policy also should state who is responsible for recording the information during the code. The recorder is responsible for documenting the events as they happen. Since the events of resuscitation happen quickly, someone should assume the role of recorder as soon as safely possible.
Copies of the code sheet can be distributed to various departments or groups in the hospital. Be sure to remove patient identifiers before sharing copies with people who don’t need patient-specific information. The pharmacy department may want a copy for purposes of restocking code cart medications and charging. A copy to central processing may help them determine what code cart equipment needs replacing. Risk management may receive a copy to investigate areas of potential liability. The quality department can use a copy of the code sheet to collect performance data. If the team completes a code critique form or documents debriefing notes, the original should be forwarded to the risk management or quality department. Critique forms or notes should not be kept as a permanent part of the patient’s record.
Several types of CPR performance measures can be used to evaluate patient resuscitation events. Examples include:
- Complication rates
- Average length of time from initiation of the code until the start of resuscitation
- Average length of time from the start of resuscitation until the end of the code
- Appropriateness of the code, e.g., Did patient have "do-not-resuscitate" orders? Had patient actually arrested when the code was called?
- Average length of time for specific disciplines to respond to the code
- Percent of codes with reported equipment problems
- Percent of codes in which medications or supplies were not available when needed
- Percent of codes in which code cart items specific to the needs of the patient were not available, e.g., pediatric medication doses or equipment necessary for newborn resuscitations
- Percent of codes in which staff or physician reported problems
- Percent of codes in which endotracheal intubation could not be accomplished
- Percent of defibrillations in which paddles were properly placed
- Percent of defibrillations in which no shock was delivered on first attempt
- CPR survival rates
CPR survival rate is the most common performance measure used by hospitals to evaluate resuscitation efforts. However, survival rates are difficult to benchmark without a good understanding of patient variables. Studies of CPR outcomes show wide disparity in survival rates. The worldwide average CPR survival-to-discharge rate has been reported to be 15.2%, with rates ranging from 3% to 27%. Researchers in Canada studied all records of adult cardiopulmonary arrests that occurred at three main teaching hospitals in Edmonton between Jan. 1, 1997, and Jan. 31, 1999. Medical staff witnessed 58% of the 247 arrests that occurred during the study period. Of these arrests, 48% of patients were resuscitated successfully. But only 22% of them lived long enough to be discharged from hospital.
To more accurately evaluate your hospital’s CPR survival rate, it’s important to stratify the results into meaningful categories. For example, studies have shown that patients with ventricular tachycardia or fibrillation are more likely to survive resuscitation than those with asystole or pulseless electrical activity. Thus, it may be worthwhile to report CPR survival rates for patients having each type of condition. Researchers also have found that emergency department and coronary care unit patients are more likely to survive a code than intensive care unit and general ward patients. Other factors related to better survival rates are respiratory arrest, witnessed arrest, absence of comorbidity, and short duration of CPR. Survival rates can be correlated with any of these pre-arrest and intra-arrest factors to help caregivers judge the results. By monitoring survival trends for different categories of patients, caregivers can identify improvement opportunities. For example, if CPR survival rates appear to be high in relation to published study results, it may be an indication of inappropriate codes, e.g., CPR initiated for nonarrest situations. If CPR rates appear low, it may be a quality-of-care issue or it may be that do-not-resuscitate orders are underutilized or advanced directives are not being considered prior to starting resuscitation.
The notes from debriefings done immediately post-resuscitation also can be valuable sources of information. Some of the things that can go wrong during a code often are not clearly identifiable on the resuscitation record. Often, errors relate to leadership, teamwork, or procedural skills. If several physicians were present at the code, was a lead physician clearly identified? Were team members reluctant to question the person in charge, even if that person’s decision was in error (e.g., failure to question an incorrect epinephrine dose)? Did the team have access to the patient’s complete clinical history, or were there delays in obtaining the hospital chart? Were members of the team distracted or fatigued? Provide a brief synopsis of debriefing notes along with the results of performance measures.
The committee responsible for monitoring CPR survival rates also should receive information about related CPR performance data, e.g., compliance with training and code cart checks, problems identified during code situations, etc. Those nonclinical aspects of resuscitation can affect survival rates.
One of the more serious and clinically important adverse events is unexpected cardiac arrest. That’s the primary reason why the Joint Commission standards require that all resuscitations be reviewed for appropriateness of care and analysis of the events leading up to the arrest. Despite the availability of cardiac arrest teams and advances in cardiopulmonary resuscitation, the risk of death from such an event has remained largely static at 50% to 80%. By reviewing the clinical aspects of patient care in addition to CPR processes, hospitals can identify ways to prevent arrests as well as improve patient outcomes following an arrest. CPR reviews also can identify underutilization of "do not resuscitate" orders for patients receiving palliative care.
Trending of resuscitation survival rates and other cardiopulmonary resuscitation (CPR) measures of performance can help caregivers pinpoint potential problem areas. The Joint Commissions standards are somewhat vague with regard to what CPR factors should be monitored regularly. At a minimum, hospitals should be evaluating CPR survival rates; however, to ensure high-quality patient care and reduce liability concerns, all of the key issues affecting in-hospital resuscitations should be evaluated regularly.
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