AHA Resuscitation Quality Improvement Overview

Cardiac Arrest Incidence & Outcomes

• Estimated 209,000 in-hospital cardiac arrests (IHCA) each year– (4 per 1000 admissions – Chen 2013, JAMA Intern Med. –

GWTG-R)

• Culture of hopelessness in outcomes from IHCA may stem from the lack of knowledge and uniform reporting standards

• Estimated IHCA Survival Rates– 19% Adult Survival (AHA 2020 Goal: 38%)– 35% Pediatric Survival (AHA 2020 Goal: 50%)

Variability in Survival from IHCA

• Significant variability in outcomes even after risk adjustment

• 2014 Study of 135,896 IHCA - GWTG-R (468 hospitals) – 8.3% - 31.4% unadjusted survival rates– 12.4% - 22.7% risk adjusted survival rates– The hospital of admission may influence survival by 42%– Differences in patient case-mix or hospital characteristics had

no impact on variation

Merchant 2014, J Am Heart Association

• Hospitals that performed better on publically reported outcomes (AMI, HF, Pneumonia) did not necessarily have better cardiac arrest survival

Chen 2013, 700 – GWTG-R

• High-quality CPR (HQCPR) is the primary component in influencing survival from cardiac arrest

– When rescuers compress at a depth of <38 mm, survival-to-discharge rates after out-of-hospital arrest are reduced by 30%

– When rescuers compress too slowly, return of spontaneous circulation (ROSC) after IHCA falls from 72% to 42%

Stiell et al. 2012

Metrics of HQCPR to include compressions, ventilations, rates, and chest compression fraction are primary influencers in survival rates

Click Here to View AHA Consensus on CPR Quality

High-Quality CPR Saves Lives

Presenter

Presentation Notes

The variations in performance and survival described in these studies provide the resuscitation community with an incentive to improve outcomes. To maximize survival from cardiac arrest, the time has come to focus efforts on optimizing the quality of CPR specifically, as well as the performance of resuscitation processes in general.

• Psychomotor skills decline rapidly over time

• Current two-year course completion card model does not lend itself to the maintenance of competency

• RQI provides performance data for key resuscitation quality metrics

• RQI implements QI measures in training and clinical performance

“Poor-quality CPR should be considered a

preventable harm.

In healthcare environments, variability in clinician performance

has affected the ability to reduce healthcare-

associated complications….”

Meaney et al.Circulation. 2013;128:417-435.

CPR Psychomotor Skills Rapidly Decay

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Presentation Notes

CPR is inherently inefficient; It provides only 10% to 30% of normal blood flow to the heart and 30% to 40% of normal blood flow to the brain even when delivered according to guidelines. This inefficiency highlights the need for trained rescuers to deliver the highest-quality CPR possible. Poor-quality CPR should be considered a preventable harm. There remains an unacceptable disparity in the quality of resuscitation care delivered, as well as the presence of significant opportunities to save more lives.

• There is significant misalignment in perception of providers’ proficiency for HQCPR and reality

• 75% of healthcare providers believe they perform quality CPR

• Only 26% self-report they are compliant to AHA Guidelines in their CPR performance

• Studies show CPR performance is often low

Lpsos Survey, 2009

Nearly two-thirds (64 percent) of

American drivers rate themselves as "excellent" or "very

good" drivers2011 Financial Dynamicssurvey for Allstate Insurance

CPR Skills Misperceived

Biennial Training Does Not Sustain HQ CPR

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Presentation Notes

The concept of Resuscitation Quality Improvement goes back to the ECC business model, which historically has been based on biennial training. Every two years, healthcare providers and others need to re-take or renew their training to maintain their course completion card status. And then once every five years, we release new CPR and ECC Guidelines, which may include changes in the way AHA recommends that CPR be done, so there may be a refresher of content and skills required with those changes to our Guidelines. Years ago, we theorized this may not be the most effective way to maintain CPR competency. You can see from this graphic that the competency of a providers decreases over time if they don’t frequently practice and use their skills.

AHA Guidelines Recommend More Frequent Training

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We hypothesized that a high frequency, low dose type of training solution might be more effective in maintaining healthcare providers’ competency in performing what is largely a psychomotor skill.

• The RQI Program requires an active course completion card to enter

• RQI Program users then continuously reinforce skills through regular, self-directed assessments

• User engagement with RQI provides a perpetual renewal of credential

RQI Program

Entering the RQI Program

What is the RQI Program?

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This graphic illustrates how this RQI system works. In essence, it is a maintenance of competency solution, where the course completion card is a perpetual one, based on quarterly skills sessions that are usually about 10 minutes each. They are comprised of a cognitive portion (a video or eLearning segment) followed by a skills evaluation on a sophisticated feedback manikin and simulation scenario on the RQI skills station. This enables us to do many things we weren’t able to do before. Giving real-time feedback to the provider to allow them to adjust and learn their skills is significantly more impactful from a learning standpoint. And we’re able to provide updates more frequently and quickly when we have electronic, rather than Instructor-led training solutions in place.

BLS for Healthcare Provider

Q2 Q4Q3 Q2 Q3Q1 Q4

Psychomotor Skills Sessions (Approx. 48min total)

Cognitive Content Modules (Approx. 57min total)

Q1

High Frequency & Low Dose

Year 1 Year 2Introduction to RQI (2)2-Rescuer Adult BLS (3)2-Rescuer Adult BLS Patient Case 1 (10)1-Rescuer Adult BLS (3)Adult/Child Choking (3)

2-Rescuer Adult BLS Patient Case 2 (10)1-Rescuer Child BLS (10)2-Rescuer Infant BLS (5)1-Rescuer Infant BLS (10)Infant Choking (3)

Adult / ChildCompressionsVentilations



Adult / Child1 – Rescuer

CPR


InfantCompressionsVentilations


Infant1 – Rescuer

CPR

6-8 min 6-8 min 6-8 min 6-8 min 6-8 min 6-8 min 6-8 min 6-8 min

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Presentation Notes

High Quality CPR – AHA RQI is a program to develop high-quality resuscitation (HQ CPR) through competency-based learning and skills assessment system. Maintaining Competence – A learning management approach, didactic sessions, quarterly maintenance of competence sessions designed to address the rapid degradation of skills. Simulations – Simulation brought to work areas to assimilate into normal work behaviors and provide convenient access to practice. Adaptive learning – A system that allows supplementing cognitive and psychomotor sessions based on performance measures. Efficiency in ROI – RQI provides a more efficient method for on-going maintenance of certification for compliance by bringing practice to providers while automatically managing all records and completion certificates.

BLS for HCP and ACLS Combined

Psychomotor Skills Sessions (Approx. 48min total)

Cognitive Content Modules (Approx. 233min total)

High Frequency & Low Dose

Year 1 Year 2Self-Assessment module (15)Team Dynamics Lesson (10)BLS and ACLS Surveys (25)IO Insertion (2)Adult BLS (15)Adult/Child Choking (3)1-Rescuer Child BLS (10)2-Rescuer Infant BLS (10)1-Rescuer Infant BLS (5)Infant choking (3)

ACLS Tutorial and Patient Case (15)Acute Coronary Syndromes (25)Cardiac Arrest Patient Case (10)Stroke (23)Stroke Patient Case (10)Ventricular Tachycardia Patient Case (10)Bradycardia Patient Case (10)Respiratory Arrest Patient Case (10)Megacode Patient Case 1 (10)Megacode Patient Case 2 (10)

Q2 Q4Q3 Q2 Q3Q1 Q4Q1




Adult / Child1 – Rescuer

CPR


InfantCompressionsVentilations


Infant1 – Rescuer

CPR

6-8 min 6-8 min 6-8 min 6-8 min 6-8 min 6-8 min 6-8 min 6-8 min

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Presentation Notes


Video tutorials, eHandbook, simulation, audio-visual feedback during skills assessment

Robust Interactive User Experience

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Presentation Notes

The RQI Program provides comprehensive self-serve guidance, such as video tutorials and e-handbook reference, and real-time feedback with voice-prompts during skills assessments

Psychomotor Skills – RQI Station

You can only improve what you measure

Quality CPR Feedback

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Presentation Notes

AHA-condoned method of assessing CPR skills performance -Objectively considers total skill performance per Guidelines -Provides real-time visual and voice prompts -Permits student to repeat skills assessment

• RQI attests to the competence for single rescuers to demonstrate high-quality CPR skills

• Approved mock codes and team resuscitation training are encouraged to enhance the RQI program:– Can be used for quarterly RQI activity and completion requirement for

ongoing BLS and ACLS training

• Skill station(s) can be used to support mock codes for local simulation– Adult manikins can be placed on bed and connected wirelessly to tablet for

collection of performance data

• RQI learning events are intended to support the HQ resuscitation efforts to sustain optimal team dynamics

Mock Codes for Team Dynamics

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Presentation Notes

We strongly encourage sites to also utilize mock codes to sustain HQ team dynamics in their resuscitation. These can be completed as learning events in place of the quarterly prescribed psychomotor skills practice.

• Students enter the program with an active course completion card

• Every quarter that is successfully completed automatically updates the expiration date of student’s course completion card by 90 days

Perpetual Course Completion

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Presentation Notes

A “perpetual ecard” is provided through participation in the RQI Program. Through low-dose/high-frequency learning the Student ecard is constantly renewed for as long as the Student participates in the Program and completes assignments. If the Student leaves the Program then the “life” remaining on card is the same as when the Student entered the program. As long as learners stay in the Program, they never have to sit in a classroom CPR course again EXAMPLE: If a learner enters the Program with 9 months on her card, participates for 2 years and leaves, her card stills has 9 months life remaining

Virtual Course Completion Card (eCard)• Available from RQI eCard

website; provides eCard as shown at right that may be printed locally

Benefits• Simplifies card management• Eco-Friendly • Convenient authentication in

AHA eCard system• Providers have self-serve

access to card replacement• Can be printed by participants

and managed by administration for compliance purposes

AHA eCards

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Presentation Notes

Physical Card May be ordered online through the program interface AHA is promoting eCards which the RQI Program provides as part of the annual RQI Program subscription fee. Traditional printed “wallet cards” are available for purchase if desired. **

• Three pilot sites ran a rudimentary version of the program that began in 2012:– Ohio State University– University of Chicago– Kaiser Permanente San Diego

• Surveys of participants revealed a high level of satisfaction with program outcomes

RQI Pilot Success

• Independently conducted cost-benefit analysis resulted in significant savings over conventional life support training programs

• RQI positioned as a core institutional value with a goal to save more lives

• Over 2,500 participants with 99% compliance

“With 24/7 access to the mobile skills station, the

program supports

autonomous, self-directed

learning” – Texas Health Dallas

RQI Implementation Success

• The RQI Program offers significant overall institutional savings when compared to conventional BLS and ACLS programs

• Program activities in work areas provide less program administration and operational expense; price is based on number of participants

• Case studies using current eLearning methods demonstrate decreased BLS/ACLS program administration costs and savings by eliminating time off the floor

• The greatest value is improved patient safety and resuscitation outcomes

The Savings of the RQI Program

• The RQI Program is a service delivery platform; organizations do not purchase RQI like traditional products

• RQI is a subscription based on the number of students and carts within the program:– Ongoing simulation practice brought to work areas to

assimilate into normal work day – 24/7 access – Drive for quality, not course completion cards– Facilitation of self-directed CPR training so educators can

focus on high-quality events like mock codes and team building exercises

Key Features of Subscription

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Presentation Notes

Maintenance, repair and replacement of equipment (not including consumables, such as BVM or cleaning supplies) is included in subscription. Site is not responsible for this cost. A toll-free support line is provided for RQI customers The benefits of RQI are quality-focused and Guidelines driven to engage and incentivize each healthcare provider to embrace the responsibility to be ready to deliver HQCPR at any moment. Having a “wallet card” is no longer sufficient.

• Organizations who value quality in resuscitation improvement initiatives and who are looking for solutions to improve performance and patient outcomes are ideal for the RQI Program

• Characteristics common to ideal RQI sites:– Maintenance of competence strategies – Utilization of Simulation – High-quality CPR focus– Regular mock codes and team training– Resuscitation committees focused outcomes– High importance on tracking of IHCA outcomes

Is Your Organization Prepared to Improve Resuscitation Quality?

• High-quality CPR is the single most influential factor that has been shown to improve survival from cardiac arrest

• The RQI Program supports sustaining the skills to perform high-quality CPR for improved patient safety and outcomes

• The RQI Program’s low-dose, high-frequency education model with simulation brought to the work area offers increased efficiency and focuses on resuscitation quality

In Summary

Slide Appendix:

The remaining slides provide an overview of key research in support of the RQI program

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Presentation Notes


Edelson et al. Resuscitation 2006

Clinical effects of compression depth and pre-shock pause

AHA Consensus Statement: CPR Quality

Return To Presentation

Optimized CCF can be sustained in clinical practice through maintenance of competency, focusing on performance skills and team training, mock codes, and clinical debriefings

Vaillancourt Resuscitation 2011

Chest Compression Fraction vs. ROSC in Non-VF/VT


Mean compression depth:Exp. Group > Control (p=0.03)

Performance over time:Exp. Group – no changeControl - ↓after 9 mos (p=0.004)

Oermann, M.H., Kardong-Edgren, S., & Odom-Maryon, T. (2011). Effects of monthly practice on nursing students¹ CPR psychomotor skill performance.Resuscitation, 82, 447-453. doi:10.1016/j.resuscitation.2010.11.022.

2010 CPR Skills Study


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Presentation Notes

So in 2010, we commissioned a study to look at this method. This study involved 606 BLS-trained 1st-yr nursing students were randomized to: Experimental (9-minute monthly BLS skills practice), OR Control (no monthly practice) A sample of 50 trainees from each group was assessed every three months and removed from further participation. All subjects remaining after the 12-month assessment were re-trained with BLS HCP classroom and assessed (the “12R” time point). This chart shows the performance in compression depth of the experimental group (in black) who received monthly practice compared to the control group (in grey) who received no monthly practice. The differences in compression depth between students who had brief monthly practices on a VAM and the control group were significant (F=4.77 [1, 592], p = 0.03). In the experimental group, students’ mean compression depths were within the accepted range (between 38 and 51mm), with no loss of this skill over the 12 months (p = 0.31). The control group, however, had a significant loss of ability to compress with adequate depth between 9 (M = 39.6, SD = 6.8 mm) and 12 (M = 36.5, SD = 7.7 mm) months (p = 0.004).

Mean ventilation volume:Exp. Group > Control (p=0.001)

Performance over time:Exp. Group – continual ↑Control – < recommended for

all 12 months

Oermann, M.H., Kardong-Edgren, S., & Odom-Maryon, T. (2011). Effects of monthly practice on nursing students¹ CPR psychomotor skill performance.Resuscitation, 82, 447-453. doi:10.1016/j.resuscitation.2010.11.022

2010 CPR Skills Study


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Presentation Notes

There were also statistical differences between the experimental and control groups for mean ventilation volumes, F = 35.26 (1, 592), p < 0.0001. Students in the experimental group improved steadily in their ability to ventilate with an adequate volume (500–800ml). In the control group, the mean ventilation volumes remained less than the recommended minimum throughout the 12 months.

AHA Resuscitation Quality Improvement Overview

Health & Medicine

Transcript of AHA Resuscitation Quality Improvement Overview