The Quality-Cost Connection: Review resuscitation and outcomes
Review resuscitation and outcomes
Address data collection, improvement challenges
By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR
In response to recommendations from the Ameri-can Heart Association (AHA), in 1999 the Joint Commission on Accreditation of Healthcare Organizations added a requirement for review of cardiopulmonary resuscitation (CPR) to the hospital performance improvement standard. In 2004, this requirement is found in Standard PI.1.10 — the organization collects data to monitor its performance. Although the requirement has been around for several years, hospitals still encounter data collection and improvement challenges. While the standards do not specify exact data collection and reporting requirements, the greatest benefit can be gained from reviewing all key aspects of CPR as well as the outcomes.
By analyzing resuscitation processes and outcomes, the health care team can identify improvement opportunities. In addition, areas of potential liability risk can be identified and corrected. For example, noncompliance with approved advanced cardiac life support (ACLS) protocols and/or failure to initiate early defibrillation could pose a liability risk to the facility. The International Liaison Com-mittee on Resuscitation recommends that resuscitation personnel be authorized, trained, equipped, and directed to operate an automated external defibrillator if their professional duties require them to respond to persons in cardiac arrest. This recommendation includes all first-responding medical personnel, whether physicians or nurses.
Several key clinical issues can be evaluated in the management of cardiopulmonary arrest. The first is airway management. Are intubations successful? How often is bag/mask ventilation required after failed intubations? If mask ventilation is not successful, are rescue procedures such as cricothyrotomy or laryngeal mask airway used? Once the airway is secure, is the adequacy of the patient’s ventilation assessed? Be sure to regularly monitor how quickly defibrillation is initiated (delays are frequent allegations in liability claims). Evaluate whether the drugs and dosages used are consistent with AHA guidelines. Once the patient has been stabilized, appropriate post-resuscitation management should be provided. Disease-specific treatment should be started. Evaluating how patients are managed post-resuscitation can be a part of the medical staff CPR review process.
Evaluations of CPR events should include an analysis of the conditions that may have caused the patient to arrest. Myocardial infarction, pulmonary embolism, hypovolemic shock, drug overdose, metabolic acidosis, and hypothermia are common causes of a cardiac arrest. Often, review of CPR cases primarily focuses on what happened when the patient was found to be in cardiac arrest; however, an important factor to consider is what precipitated the arrest and how it could have been prevented. A research team in England found that in-hospital unexpected cardiac arrests usually are preceded by signs of clinical instability characterized by deterioration in the patient’s airway, circulation, or respiratory system for at least one hour before their cardiac arrest.1 Clinicians at this hospital were able to decrease the incidence of cardiac arrests by creating a medical emergency team that intervenes when patients meet predefined clinical criteria such as:
- Respiratory rate > 30/minute
- Respiratory rate < 6/minute
- SaO2 < 90% on oxygen
- Blood pressure < 90 mmHg despite treatment
- Pulse rate > 130/minute
- Repeated or prolonged seizures
The addition of the medical emergency team as a pre-emptive response team to manage these patients resulted in a 50% reduction in the incidence of unexpected cardiac arrests.
Hospitals should have established policies and procedures governing CPR. According to the AHA, recertification of basic life support (BLS) and advanced cardiac life support is recommended every two years. Be sure that employees in your facility have properly maintained certifications. Many hospitals have incorporate automated external defibrillator training into their BLS courses.
Caregivers should respond quickly to a cardiac arrest victim and assess the patient’s status. The likelihood of survival to hospital discharge doubles if CPR is administered within four minutes of collapse. Every person who provides direct patient care must be familiar with the cardiac arrest procedure and how to initiate the code team. Nurses and technicians should know where emergency equipment (e.g., oxygen, suction, defibrillator/ECG unit, and code cart) is located in their department. Review of CPR cases could include an evaluation of the timeliness of switchboard operator contact, initiation of CPR, and arrival of the code team.
All hospitals have a designated code team of specially trained nurses, respiratory therapists, anesthesia personnel, and physicians who are expected to respond to codes immediately. A crash cart may be brought to the scene of the code if one is not already available. The crash cart contains emergency equipment, medications, and intravenous supplies and solutions. CPR evaluation should include an assessment of the response time by the code team and any issues involving the crash cart that may have created problems for the code team (e.g., missing supplies, outdated drugs, delay in arrival of cart).
In emergency situations, the outcome can depend on the cooperative actions of the code team and on quick decision making and actions. One factor that should be evaluated is the number of people at the scene. Too many people responding to the code can often lead to disorder and diffusion of responsibility. Researchers recommend that one physician, knowledgeable about cardiac resuscitation, should take the lead and assign tasks related to the resuscitation to team members. The lead physician should direct the resuscitation process and make the clinical decisions without directly performing procedures whenever possible. The leader should involve team members in decision making by soliciting suggestions from team members and ensuring everyone is in agreement about a decision to stop the resuscitation attempt. The leader should facilitate a debriefing once resuscitation is completed/terminated so that everyone can learn from the experience. This debriefing should occur even though a multidisciplinary committee will review the event later. Insights gained during the immediate post-resuscitation discussion should be communicated to the committee respond for overseeing resuscitation practices in the hospital.
In most hospitals, crash carts are available on all nursing units and in specialized departments such as radiology, minor procedure, and outpatient respiratory and cardiac treatment centers. The crash cart should be checked routinely according to policy and restocked following a code. A nurse usually is responsible for making routine crash cart checks. If this responsibility is rotated among staff, people can stay familiar with what supplies are available on the crash cart. The cart check should include ensuring appropriate supplies are available, sterile, and within the expiration dates. All equipment is examined and tested for proper functioning. Staff should complete a checklist as they review the crash cart. The checklist helps to ensure that items won’t be overlooked and provides documentation that the check was completed. In addition to the regular crash cart checks, clinical or bioengineering personnel should make periodic rounds to make sure the defibrillator/AED/pacer equipment is functioning properly. Compliance with these maintenance checks should be monitored.
Most hospitals have a committee that is responsible for developing policies and procedures for CPR training and equipment maintenance and conducting post-arrest evaluations. The committee includes physicians, anesthesiologists, critical care nurses, and respiratory therapists. To fulfill their responsibilities, the committee should receive regular performance reports covering the key aspects of resuscitation, including compliance with policies and procedures and CPR survival rates. In some hospitals, this committee also is responsible for evaluating the physician aspects of care. In other hospitals, these issues are identified by the multidisciplinary committee and referred to one of the medical staff peer review committees for more in-depth evaluation.
The second part of this article covers the data-collection aspects of CPR evaluation and performance measures that routinely can be assessed by the committee responsible for resuscitation review.
Reference
1. Buist MD, Moore GE, Bernard SA, et al. Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: Preliminary study. BMJ 2002; 324:387-390.
In response to recommendations from the Ameri-can Heart Association (AHA), in 1999 the Joint Commission on Accreditation of Healthcare Organizations added a requirement for review of cardiopulmonary resuscitation (CPR) to the hospital performance improvement standard.
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