Jose G. Cabanas

Part 4: Systems of Care and Continuous Quality Improvement 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

The science and recommendations discussed in the other Parts of the 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) form the backbone of resuscitation. They answer the “why”, “what,” and “when” of performing resuscitation steps. In a perfectly controlled and predictable environment, such as a laboratory setting, those answers often suffice, but the “how” of actual implementation depends on knowing the “who” and “where” as well. The ideal work flow to accomplish resuscitation successfully is highly dependent on the system of care as a whole. Healthcare delivery requires structure (eg, people, equipment, education, prospective registry data collection) and process (eg, policies, protocols, procedures), which, when integrated, produce a system (eg, programs, organizations, cultures) leading to outcomes (eg, patient safety, quality, satisfaction). An effective system of care (Figure 1) comprises all of these elements—structure, process, system, and patient outcomes—in a framework of continuous quality improvement (CQI). Figure 1. Taxonomy of systems of care. In this Part, we will focus on 2 distinct systems of care: the system for patients who arrest inside the hospital and the one for those who arrest outside it. We will set into context the building blocks for a system of care for cardiac arrest, with consideration of the setting, team, and available resources, as well as CQI from the moment the patient becomes unstable until after the patient is discharged. The chain of survival metaphor, first used almost 25 years ago,1 is still very relevant. However, it may be helpful to create 2 separate chains (Figure 2) to reflect the differences in the steps needed for response to cardiac arrest in the hospital (in-hospital cardiac arrest [IHCA]) and out of the hospital (out of hospital cardiac arrest [OHCA]). Regardless of where an arrest occurs, the care following resuscitation converges …

Double Sequential External Defibrillation in Out-of-Hospital Refractory Ventricular Fibrillation: A Report of Ten Cases

Abstract Background. Ventricular fibrillation (VF) is considered the out-of-hospital cardiac arrest (OOHCA) rhythm with the highest likelihood of neurologically intact survival. Unfortunately, there are occasions when VF does not respond to standard defibrillatory shocks. Current American Heart Association (AHA) guidelines acknowledge that the data are insufficient in determining the optimal pad placement, waveform, or energy level that produce the best conversion rates from OOHCA with VF. Objective. To describe a technique of double sequential external defibrillation (DSED) for cases of refractory VF (RVF) during OOHCA resuscitation. Methods. A retrospective case series was performed in an urban/suburban emergency medical services (EMS) system with advanced life support care and a population of 900,000. Included were all adult OOHCAs having RVF during resuscitation efforts by EMS providers. RVF was defined as persistent VF following at least 5 unsuccessful single shocks, epinephrine administration, and a dose of antiarrhythmic medication. Once the patient was in RVF, EMS personnel applied a second set of pads and utilized a second defibrillator for single defibrillation with the new monitor/pad placement. If VF continued, EMS personnel then utilized the original and second monitor/defibrillator charged to maximum energy, and shocks were delivered from both machines simultaneously. Data were collected from electronic dispatch and patient care reports for descriptive analysis. Results. From 01/07/2008 to 12/31/2010, a total of 10 patients were treated with DSED. The median age was 76.5 (IQR: 65–82), with median resuscitation time of 51minutes (IQR: 45–62). The median number of single shocks was 6.5 (IQR: 6–11), with a median of 2 (IQR: 1–3) DSED shocks delivered. VF broke after DSED in 7 cases (70%). Only 3 patients (30%) had ROSC in the field, and none survived to discharge. Conclusion. This case series demonstrates that DSED may be a feasible technique as part of an aggressive treatment plan for RVF in the out-of-hospital setting. In this series, RVF was terminated 70% of the time, but no patient survived to discharge. Further research is needed to better understand the characteristics of and treatment strategies for RVF.

Epidemiology of Out-of Hospital Pediatric Cardiac Arrest due to Trauma

Abstract Objective. To determine the epidemiology and survival of pediatric out-of-hospital cardiac arrest (OHCA) secondary to trauma. Methods. The CanAm Pediatric Cardiac Arrest Study Group is a collaboration of researchers in the United States and Canada sharing a common goal to improve survival outcomes for pediatric cardiac arrest. This was a prospective, multicenter, observational study. Twelve months of consecutive data were collected from emergency medical services (EMS), fire, and inpatient records from 2000 to 2003 for all OHCAs secondary to trauma in patients aged ≤18 years in 36 urban and suburban communities supporting advanced life support (ALS) programs. Eligible patients were apneic and pulseless and received chest compressions in the field. The primary outcome was survival to discharge. Secondary measures included return of spontaneous circulation (ROSC), survival to hospital admission, and 24-hour survival. Results. The study included 123 patients. The median patient age was 7.3 years (interquartile range [IQR] 6.0–17.0). The patient population was 78.1% male and 59.0% African American, 20.5% Hispanic, and 15.7% white. Most cardiac arrests occurred in residential (47.1%) or street/highway (37.2%) locations. Initial recorded rhythms were asystole (59.3%), pulseless electrical activity (29.1%), and ventricular fibrillation/tachycardia (3.5%). The majority of cardiac arrests were unwitnessed (49.5%), and less than 20% of patients received chest compressions by bystanders. The median (IQR) call-to-arrival interval was 4.9 (3.1–6.5) minutes and the on-scene interval was 12.3 (8.4–18.3) minutes. Blunt and penetrating traumas were the most common mechanisms (34.2% and 25.2%, respectively) and were associated with poor survival to discharge (2.4% and 6.5%, respectively). For all OHCA patients, 19.5% experienced ROSC in the field, 9.8% survived the first 24 hours, and 5.7% survived to discharge. Survivors had triple the rate of bystander cardiopulmonary resuscitation (CPR) than nonsurvivors (42.9% vs. 15.2%). Unlike patients sustaining blunt trauma or strangulation/hanging, most post–cardiac arrest patients who survived the first 24 hours after penetrating trauma or drowning were discharged alive. Drowning (17.1% of cardiac arrests) had the highest survival-to-discharge rate (19.1%). Conclusions. The overall survival rate for OHCA in children after trauma was low, but some trauma mechanisms are associated with better survival rates than others. Most OHCA in children is preventable, and education and prevention strategies should focus on those overrepresented populations and high-risk mechanisms to improve mortality.

Variability in discharge instructions and activity restrictions for patients in a children's ED postconcussion

Objective The objective of this study was to describe discharge instructions given to school-aged patients evaluated in a children’s emergency department (ED) following concussion. Methods This was a retrospective cohort study of children 6 to 18 years evaluated in a dedicated children’s ED at a level I trauma center in 2008 following acute head trauma regardless of mechanism, identified by any of 27 International Classification of Disease, Ninth Revision diagnoses for head injury, concussion, or skull fracture. Included were those presentations consistent with the Zurich definition for concussion. Excluded were hospital admission, death before admission, evidence of intoxication, or structural abnormality on imaging. Univariate and multivariate analyses determined adjusted odds ratios (ORs) for receipt of concussion-specific discharge instructions and activity restrictions. Results Of 350 eligible patients, the 218 included patients were mostly male (68%) with mean age 12.8 (SD, 3.4) years. Injury characteristics included sports-related, 42%; fall, 23%; loss of consciousness, 33%; headache, 75%; dizziness, 29%; amnesia, 25%; and vomiting, 19%. Most patients underwent imaging (81%). Discharge characteristics included concussion stated in final diagnosis, 31%; concussion-specific instructions, 62%; and activity restrictions, 34%. Concussion-specific discharge instructions were more likely for loss of consciousness (OR, 1.7; 95% confidence interval [CI], 1.22–2.36), and activity restrictions were more likely for sport-related injury (OR, 1.31; 95% CI, 1.02–1.76) and amnesia (OR, 1.42; 95% CI, 1.01–1.98). Conclusions Most children meeting diagnostic criteria for concussion were discharged without concussion-specific diagnoses or activity restrictions. Given the risks associated with untimely return to both physical and cognitive activity after concussion, improved awareness and standardization of disposition are imperative for the management of these young patients in the ED.

Prehospital endotracheal intubation vs extraglottic airway device in blunt trauma

OBJECTIVE The objective of the study is to compare outcomes in blunt trauma patients managed with prehospital insertion of an extraglottic airway device (EGD) vs endotracheal intubation (ETI). The null hypothesis was that there would be no difference in mortality for the 2 groups. METHODS This is a retrospective study of blunt trauma patients with Glasgow Coma Scale score less than or equal to 8 transported by ground emergency medical services directly from the scene of injury to a single urban level 1 trauma center. Patients managed with only noninvasive airway techniques were excluded, leaving patients undergoing either EGD placement or ETI. Outcomes included in-emergency department (ED) traumatic arrest and hospital mortality. Multivariable logistic regression was used to control for the potential confounding effects of demographic and clinical variables. For all analyses, P < .05 was used to establish statistical significance. RESULTS In bivariate analysis, patients managed with EGD were more likely than those managed with ETI to have an in-ED traumatic arrest (36.5% vs 17.1%; P = .005), but eventual hospital mortality did not significantly differ between the 2 groups (75.7% vs 67.1%; P = .228). After controlling for demographic and clinical characteristics, patients managed with EGD were no more likely than patients managed with ETI to experience traumatic arrest in the ED (adjusted odds ratio, 1.67; 95% confidence interval, 0.72-3.89), and there was also no difference in overall hospital mortality (adjusted odds ratio, 0.912; 95% confidence interval, 0.36-2.30). CONCLUSION In this preliminary, retrospective analysis, we found no difference in overall survival among trauma patients managed with prehospital EGD and those managed with prehospital ETI.

Elite Motorcycle Racing: Crash Types and Injury Patterns in the MotoGP Class

BACKGROUND Crashes are a small but regular feature of elite motorcycle racing. These crashes provide a novel opportunity to benchmark and analyze motorcycle crash mechanics, crash types, and associated injuries at high speeds in a cohort of riders who are well protected and in a controlled environment. PURPOSE The purpose was to benchmark the prevalence of injuries, categorize crash subtypes, and determine associated injury patterns. METHODS This was an institutional review board-approved, prospective observational cohort study of MotoGP riders for 1 racing season in 3 venues. Accident type was determined by race-marshal report and visual analysis of race footage for each crash. Accident types were defined as lowside (falling toward the inside of the turn), highside (falling over and toward the outside of the turn), and topside (going over the handlebars of the motorcycle). Specific injuries and hospital admission data were collected using a standardized data collection form. Basic descriptive statistics were performed on all categorical variables. We used the exact binomial test examine the association between accident type and retirement from race, transport to medical building, transport to hospital, and injuries sustained. RESULTS Crash prevalence was 9.7 per hundred rider hours. There were 78 crashes: 58 lowsides, 13 highsides, 2 topsides, and 5 indeterminate. In the lowside group (n = 58), 19 (95% confidence interval [CI], 0.21-0.46) riders retired, 0 required emergent transportation to the track facility or to the hospital, and 1 (95% CI, <0.1-0.9) significant injury was noted. In the highside group (n = 13), 10 (95% CI, 0.46-0.95) retired, 9 (95% CI, 0.39-0.91) were transported to the track medical facility, and 3 (95% CI, 0.05-0.54) were admitted to the hospital. In the highside group, there were 7 (95% CI, 0.25-0.81) significant injuries. In the topside group, both riders were retired with 1 hospital admission. Lowside crashes had a lower rate of retirement from race, emergent transport, and significant injuries compared with highside crashes. CONCLUSIONS Lowside crashes are lower risk than highside crashes. Most highside crashes are caused by oversteering to prevent an impending lowside crash. Strategies to reduce oversteering to prevent a lowside crash may reduce highside crashes, enhance the safety for riders in MotoGP racing, and be applicable to recreational motorcycle riding.

Derivation and initial application of a standard population for out-of-hospital cardiac arrest (SPOHCA)

AIM While adjusting data for age, sex, race and/or socio-economic status is well established in out-of-hospital cardiac arrest (OHCA) research, there are shortcomings to reporting and comparing population-based OHCA outcomes. The purpose of this study was to derive a case-based standard population specific to EMS treated adult OHCA (SPOHCA) in the U.S., and demonstrate its application. METHODS The proposed SPOHCA was developed from three sources of multi-site OHCA data: the Cardiac Arrest Registry to Enhance Survival (CARES); the National EMS Information System (NEMSIS); and a published report from the Resuscitation Outcomes Consortium (ROC). OHCA data from a single EMS system were then used to demonstrate the application of SPOHCA. We report raw survival, population-based survival adjusted to the U.S. population, and the new SPOHCA-adjusted survival. RESULTS Observed raw survival was 12.3%. Adjustment to the demographic make-up of the adult U.S. population produced an adjusted incidence of 94.2 OHCA per 100,000 p-y, with a survival rate of 9.8 per 100,000 p-y. Using the proposed SPOHCA to adjust survival data produced an adjusted survival rate of 12.4%. CONCLUSION A case-based standard population provides for more practical interpretation of reported OHCA outcomes. We encourage a more widespread effort involving multiple stakeholders to further explore the effects of adjusting OHCA outcomes using the proposed SPOHCA instead of population-based demographics.

Evaluation of an Integrated Rescue Task Force Model for Active Threat Response

Abstract Objective: An integrated response to active threat events is essential to saving lives. Coordination of law enforcement officer (LEO) and emergency medical services (EMS) roles requires joint training, as maximizing survival is a shared responsibility. We sought to evaluate the performance of an integrated LEO-EMS Rescue Task Force (RTF) response to a simulated active shooter incident utilizing objective performance measures. Methods: Following prior didactic training, we conducted a series of evaluation scenarios for EMS providers and patrol officers in our urban/suburban advanced life support EMS system (pop. 1,000,000). The scenario-tested command staff, LEOs tasked with neutralizing an active shooter threat, and two RTFs of LEOs and EMS providers each tasked with triage and treatment of 11 simulated casualties scattered over 2 office building floors totaling 13,000 square feet. Trained evaluators recorded performance on 30 objective data elements related to LEO-EMS operations/communication, time intervals, and trauma care. Data were analyzed using descriptive statistics and t-tests for between group comparisons. Results: Over 18 days, 69 scenario events evaluated 388 EMS providers and 468 LEOs. Overall median (90th percentile) times in minutes from dispatch were: unified command established 4.1 (5.5), RTF assembled 9.4 (13.5), first victim contact 11.9 (16.5), first victim to internal casualty collection point (CCP) 16.6 (20.8), all victims ready for evacuation 21.6 (26.0). Life-saving interventions included tourniquet placed: 96% (95% CI 92–99) and LEO placed tourniquet: 88% (79–94). Clinical delays included inappropriate chest decompression: 4% (2–9) and unnecessary initial treatment: 17% (12–25). Correct operational actions included communication with LEO to ensure EMS was safe to treat: 70% (61-77) and appropriate CCP selection: 84% (74–91). Incorrect operational actions included failure to maintain protective LEO-EMS formation: 49% (45–62) and inappropriate single patient evacuation: 20% (14–28). Limitations included the lack of a pre-training control group for this novel program. Conclusions: We described the performance of an integrated LEO-EMS Rescue Task Force response to a simulated active shooter event in a large city. In general, clinical care was appropriate while operational targets can be improved. Objective measurement of response goals may be used for benchmarking and performance improvement for active threat events.

Acute Crisis Care for Patients with Mental Health Crises: Initial Assessment of an Innovative Prehospital Alternative Destination Program in North Carolina

ABSTRACT Objective: Emergency Departments (ED) are overburdened with patients experiencing acute mental health crises. Pre-hospital transport by Emergency Medical Services (EMS) to community mental health and substance abuse treatment facilities could reduce ED utilization and costs. Our objective was to describe characteristics, treatment, and outcomes of acute mental health crises patients who were transported by EMS to an acute crisis unit at WakeBrook, a North Carolina community mental health center. Methods: We performed a retrospective cohort study of patients diverted to WakeBrook by EMS from August 2013–July 2014. We abstracted data from WakeBrook medical records and used descriptive statistics to quantify patient characteristics, diagnoses, length of stay (LOS), and 30-day recidivism. Results: A total of 226 EMS patients were triaged at WakeBrook. The median age was 38 years, 55% were male, 58% were white, and 38% were uninsured. The most common chief complaints were suicidal ideation or self-harm (46%) and substance abuse (19%). The most common diagnoses were substance-related and addictive disorders (42%), depressive disorders (32%), and schizophrenia spectrum and other psychotic disorders (22%). Following initial evaluation, 28% of patients were admitted to facilities within WakeBrook, 40% were admitted to external psychiatric facilities, 18% were stabilized and discharged home, 5% were transferred to an ED within 4 hours for further medical evaluation, and 5% refused services. The median LOS at WakeBrook prior to disposition was 12.0 hours (IQR 5.4-21.6). Over a 30-day follow-up period, 60 patients (27%) had a return visit to the ED or WakeBrook for a mental health issue. Conclusions: A dedicated community mental health center is able to treat patients experiencing acute mental health crises. LOS times were significantly shorter compared to regional EDs. Successful broader programmatic implementation could improve care quality and significantly reduce the volume of patients treated in the ED for acute mental health disorders.

Out-of-hospital cardiac arrest outcomes with “pit crew” resuscitation and scripted initiation of mechanical CPR

Objective: To compare OHCA outcomes in patients managed with mechanical versus manual CPR in an EMS system with a “pit crew” approach to resuscitation and a scripted sequence for the initiation of mechanical CPR. Methods: Through a year‐long quality improvement effort we standardized the initial resuscitative efforts for OHCA, prioritizing a “pit crew” approach to high quality manual CPR, early defibrillation and basic airway management ahead of a scripted sequence for initiating mechanical CPR. We then analyzed outcomes for adult, non‐traumatic OHCA attended in the following year (2016). We used a propensity score matched analysis to compare ROSC, survival to discharge, and neurologic status among patients managed with manual versus mechanical CPR while controlling for patient demographics and arrest characteristics. Results: Of 444 eligible OHCAs, 217 received manual and 227 received mechanical CPR. Crude ROSC (39.2% vs. 29.1%) and survival to discharge (13.8% vs. 5.7%) were higher with manual CPR. In the propensity matched analysis (n = 176 manual CPR; 176 mechanical CPR), both ROSC (38.6% vs. 28.4%; difference: 10.2%; CI: 0.4% to 20.0%) and survival to discharge (13.6% vs. 6.8%; difference: 6.8%; CI: 0.5% to 13.3%) remained significantly higher for patients receiving manual CPR. Conclusions: In this EMS system with a standardized, “pit crew” approach to OHCA that prioritized initial high‐quality initial resuscitative efforts and scripted the sequence for initiating mechanical CPR, use of mechanical CPR was associated with decreased ROSC and decreased survival to discharge.