Youve Got To Know When To Holdem, Know When to Foldem: Methods for Assessing System Performance in t

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Youve Got To Know When To Holdem, Know When to
Foldem Methods for Assessing System
Performance in the Hospital Setting Mary E.
Mancini RN, PhD, CNA, FAANProfessor - Associate
DeanThe University of Texas at Arlington --
School of NursingCONFLICT OF INTERESTChair,
NRCPR Science Advisory Board
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This Presentation.

• Present an Organized Process for Review and
  Evaluation of In-Hospital Resuscitation Systems
• Structure
• - Equipment
• - Policies and procedures
• Processes
• - Training
• - Gold Process Variables
• Outcomes

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Ive done it a thousand times, what could
possibly go wrong?
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Five Rights for EQUIPMENT

• Having The RIGHT Equipment
• In The RIGHT Place
• At The RIGHT Time
• For Use By The RIGHT Person
• Who Has Been Trained To Use It RIGHT
• ..CONSISTENTLY

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NRCPR-CPA by Location - Adult
Version 5.0 / 6.0 data as of 12/31/2007
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THE GOLDILOCKS RULE

• NOT TOO MUCH.
• NOT TOO LITTLE.
• JUST RIGHT!

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POLICIES - PROCEDURES

• Are there SPECIFIC policies and procedures that
  address
• Resuscitation response
• - Does it include first responder
  defibrillation?
• - Are there documentation forms that include
  prompts?
• Evaluation of resuscitation efforts
• - Are there planned and systematic debriefings?
• - Are there established targets - benchmarking?
• - Are there consistent retrospective reviews?

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Training
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Training
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Quality of Chest Compressions
Wik et al. JAMA 2005 293299-304
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Training

• WHO DO WE TRAIN IN HOSPITALS?
• IS IT TIME TO TRANSFORM THE QUEST FOR THE CARD TO
  THE QUEST FOR COMPETENCY?

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Definition of Terms

• COMPETENT - Paper trail affirms an individual has
  the necessary education and experience for the
  job.
• COMPETENCE - An individuals assessed capacity to
  perform a defined function.
• COMPETENCY - The demonstrated ability to do a job
  consistently.

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Quality of CPR

• Stages of Growth Through Training
• Unconsciously Incompetent
• Consciously Incompetent
• Consciously Competent
• Unconsciously Competent
• Michael DeVita

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In-Hospital Chain Of Survival

• EARLY RECOGNITION and/or prevention of the event
• EARLY CPR provided according to guidelines
• EARLY DEFIBRILLATION by first responders
• EARLY ADVANCED Care including evidence-based
  post-resuscitation care

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Outcomes. (thru 12/31/07)
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In-Hospital Cardiac Arrest Survival

• 44 ROSC rate
• 30 Survival at 24 hours
• 18 Survive to hospital discharge

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NRPCR Post Pulseless Index Event Mean LOS

• Died in hospital Adult 1.6 6.8 days
• Ped 2.9 12.3 days
• Survived to discharge Adult 14.2 16.3 days
• Ped 27.7 37.4 days

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DNAR / Life Support Withdrawn (thru 12/31/2007
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Are we resuscitating the right people?

• Scots believe death is imminent.
• Canadians, on the other hand,
• believe death in inevitable.
• Americans believe death is optional.
• And our individual approaches
• to heath care reflect these points of view.

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Do Not Resuscitate ?
ARE WE RESUCITATING THE RIGHT PEOPLE??
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SUMMARY

• USING DATA TO IMPROVE PERFORMANCE, ENHANCE
  PATIENT SAFETY, AND OUTCOMES

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Biochemical Events During and After Cardiac
ArrestProposed by Safar, et al 1995
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Changing culture

• The challenge isnt
• getting new ideas into
• our heads.
• Its getting the
• old ideas out!

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Lewins Change TheoryUnfreeze --gt Move To A New
Level --gt Refreeze

• Create a sense of discomfort with the status quo
• Provide motivation to change
• Assess driving and restraining forces
• Support driving forces
• Neutralize restraining forces
• Implement the change
• Integrate the change into ongoing behavior

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Measure What Matters

• Survival to discharge
• Percentage of arrests that are unmonitored and/or
  unwitnessed
• Time to defibrillation
• Variance in outcomes by time of day and/or day of
  week

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To achieve greatness

• Start where you are.
• Use what you have.
• Do what you can.
• Arthur Ashe

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Never believe a handful of people cannot change
the world, for indeed, this is how all change has
happened. Margaret Mead
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