A Conceptual Framework to Reduce Inpatient Preventable Deaths.

BACKGROUND: Efforts to reduce preventable deaths in the in-hospital setting should target both cardiopulmonary arrest (CPA) prevention and optimal resuscitation. This requires consideration of a broad range of clinical issues and processes. A comprehensive, integrated system of care (SOC) that links data collection with a modular education program to reduce preventable deaths has not been defined. METHODS: This study was conducted in two urban university hospitals from 2005 to 2009. The Advanced Resuscitation Training (ART) program was implemented in 2007, incorporating hands-on resuscitative skills and in-hospital-specific training with an institutional resuscitation database. Linkage between the database and training modules occurs via the ART Matrix, which classifies all CPA events into the following etiologies: sepsis, hemorrhage, pulmonary embolus, heart failure, tachyarrhythmias, bradyarrhythmias, acute respiratory distress syndrome, non-intubated pulmonary disease, obstructive apnea, traumatic brain injury, ischemic brain injury, and intracranial mass lesions. This taxonomy was validated using descriptive statistics, before-and-after analysis evaluating CPA incidence, and multivariate logistic regression to predict CPA survival. RESULTS: A total of 336 inpatients suffered a cardiopulmonary arrest during the study period-187 in the pre-ART period and 149 in the post-ART period. The vast majority of CPA events were categorized using the ART Matrix with high inter-observer reliability. As anticipated, changes in CPA incidence and survival were observed for some Matrix categories but not others following ART implementation. In addition, multivariate logistic regression revealed strong independent associations between taxonomy classifications and outcome. CONCLUSION: A novel SOC using a unique taxonomy for arrest classification appears to be effective at reducing inpatient CPA incidence and outcome.

Preliminary report of a mathematical model of ventilation and intrathoracic pressure applied to prehospital patients with severe traumatic brain injury.

BACKGROUND: Inadvertent hyperventilation is associated with poor outcomes from traumatic brain injury (TBI). Hypocapnic cerebral vasoconstriction is well described and causes an immediate and profound decrease in cerebral perfusion. The hemodynamic effects of positive-pressure ventilation (PPV) remain incompletely understood but may be equally important, particularly in the hypovolemic patient with TBI. OBJECTIVE: Preliminary report on the application of a previously described mathematical model of perfusion and ventilation to prehospital data to predict intrathoracic pressure. METHODS: Ventilation data from 108 TBI patients (76 ground transported, 32 helicopter transported) were used for this analysis. Ventilation rate (VR) and end-tidal carbon dioxide (PetCO2) values were used to estimate tidal volume (VT). The values for VR and estimated VT were then applied to a previously described mathematical model of perfusion and ventilation. This model allows input of various lung parameters to define a pressure-volume relationship, then derives mean intrathoracic pressure (MITP) for various VT and VR values. For this analysis, normal lung parameters were utilized. Separate analyses were performed assuming either fixed or variable PaCO2-PetCO2 differences. Ground and air medical patients were compared with regard to VR, PetCO2, estimated VT, and predicted MITP. RESULTS: A total of 10,647 measurements were included from the 108 TBI patients, representing about 13 minutes of ventilation per patient. Mean VR values were higher for ground patients versus air patients (21.6 vs. 19.7 breaths/min; p < 0.01). Estimated VT values were similar for ground and air patients (399 mL vs. 392 mL; p = NS) in the fixed model but not the variable (636 vs. 688 mL, respectively; p < 0.01). Mean PetCO2 values were lower for ground versus air patients (30.6 vs. 33.8 mmHg; p < 0.01). Predicted MITP values were higher for ground versus air patients, assuming either fixed (9.0 vs. 8.1 mmHg; p < 0.01) or variable (10.9 vs. 9.7 mmHg; p < 0.01) PaCO2-PetCO2 differences. CONCLUSIONS: Predicted MITP values increased with ventilation rates. Future studies to externally validate this model are warranted.

Preoxygenation reduces desaturation events and improves intubation success.

OBJECTIVE: Oxygen desaturation occurs frequently in the course of prehospital rapid sequence intubation (RSI) and is associated with increased morbidity and mortality. Preoxygenation with positive pressure ventilation by bag valve mask may delay the onset of desaturation. The purpose of this study was to evaluate implementation of a targeted preoxygenation protocol including the use of positive pressure ventilation on desaturation events and intubation success during air medical RSI. METHODS: The RSI air medical program airway training model was modified to target an oxygen saturation as measured by pulse oximetry value of ≥ 93% before initial laryngoscopy. A review of oxygen saturation as measured by pulse oximetry tracings was performed for 2 years before and 2 years after implementation of this protocol. The incidence of desaturation events and overall intubation success rates were compared before and after the intervention. RESULTS: One hundred fifty-five RSI procedures were evaluated over the study period. Desaturation events decreased from 58% in the 2 years before algorithm changes to 28% in the first year and 14% in the second year after implementation (P < .01). Intubation success rates increased from 89% to 98% (P < .01). There were no self-reports of aspiration events during the study period. CONCLUSION: A preoxygenation protocol dramatically reduced the incidence of desaturation events and increased intubation success without an increase in the number of reported aspiration events.

Assessment of the addition of prehospital continuous positive airway pressure (CPAP) to an urban emergency medical services (EMS) system in persons with severe respiratory distress.

BACKGROUND: The use of continuous positive airway pressure (CPAP) assisted ventilation in the emergency department(ED) has been well described. OBJECTIVES: The purpose of this study was to measure the efficacy of adding pre-hospital CPAP to an urban emergency medical service (EMS) respiratory distress protocol on persons with respiratory distress. METHODS: A historical cohort analysis of consecutive patients between 2005 and 2010. Groups were matched for severity of respiratory distress. Physiologic variables were the primary outcome obtained from first responders and upon triage in the ED. Additional outcomes included endotracheal intubation rate, hospital mortality, overall hospital length of stay(LOS), intensive care unit (ICU) admission, and ICU length of stay (ICU LOS). RESULTS: There were 410 consecutive patients with predetermined criteria for severe respiratory distress, 235 historical controls matched with 175 post-implementation patients. Average age was 67 years, 54% being male. There were significant median differences in heart and respiratory rates favoring the historical cohort (p < 0.05). There were no significant differences in intubation rate, overall hospital LOS, ICU admission rate, ICU LOS, and hospital mortality (p > 0.05).Patients that were continued on noninvasive ventilatory assistance had a significantly improved rate of intubation and ICU LOS (p < 0.05). CONCLUSIONS: The addition of CPAP to our pre-hospital respiratory distress protocol did not improve physiologic variables.There were no differences in overall and ICU LOS between groups. Persons with apparent continued ventilatory assistance appeared to have improved rates of intubation and ICU LOS [corrected].

Latency of pulse oximetry signal with use of digital probes associated with inappropriate extubation during prehospital rapid sequence intubation in head injury patients: case examples.

BACKGROUND: Endotracheal intubation remains the definitive skill needed for airway management of both medical and surgical patients treated in the prehospital and hospital arenas. Subsequently, rapid sequence intubation (RSI) protocols have been established for various first-line emergency service providers. Because RSI results in the paralysis of skeletal muscles, with a subsequent period of apnea and an increased potential for oxygen desaturation, the accuracy of pulse oximetry (SpO(2)) data is critical in guiding pre-oxygenation efforts and indicating abandonment of intubation attempts to avoid hypoxic injury. Latency of up to 120 s has been demonstrated in conditions producing peripheral vasoconstriction. The influence of peripheral oximetry on the decision-making process during the establishment of a definitive airway has not, to our knowledge, been previously investigated in the prehospital setting. OBJECTIVE: To demonstrate how signal latency may manifest itself as a perceived oxygen desaturation with a subsequent premature abortion of a primary RSI attempt or erroneous extubation. CASE EXAMPLES: We document endotracheal extubation associated with pulse oximetry signal latency during prehospital RSI with the use of digital SpO(2) probes. Two case examples are presented that are taken from a retrospective analysis of pre-hospital RSI data recorded by the City of San Diego Emergency Medical Services. CONCLUSION: To avoid the possibility of mistaking oximetry signal latency for oxygen desaturation during pre-hospital RSI, we propose a conservative approach of aggressive pre-oxygenation to SpO(2) values≥94%, and the use of quantitative continuous capnometry for decision-making regarding whether the endotracheal tube is correctly placed. In cases of hypoxemia despite a properly placed tube, focus should be turned to other causes of post intubation hypoxemia.

Gender differences in scene time, transport time, and total scene to hospital arrival time determined by the use of a prehospital electrocardiogram in patients with complaint of chest pain.

BACKGROUND: Recent studies have described a gender bias against women in the setting of acute coronary syndrome (ACS). OBJECTIVES: We sought to measure the impact that a prehospital electrocardiogram (PH ECG) has on prehospital total scene time to hospital arrival time, comparing men and women with the complaint of chest pain (cCP). METHODS: This study retrospectively analyzed San Diego Emergency Medical Services (EMS) runsheets of patients with cCP before and after implementation of the PH ECG protocol. The average scene time (ST), transport time (TT), and total scene-to-arrival-at-hospital time (STH) were compared. After stratification by gender, times were compared in patients with ST-elevation myocardial infarction (STEMI) to those without STEMI. RESULTS: Of 21,742 EMS activations for patients with cCP, there were no significant differences overall. When stratified by gender, there was a significant reduction of ST (00:19:16 min vs. 00:20:48 min, p<0.001, 95% CI 00:01:17-00:01:48) and STH (00:33:22 min vs. 00:35:44 min, p<0.001, 95% CI 00:01:21-00:02:24) favoring men in cases without STEMI. In cases of STEMI, men had a significant reduction in ST (00:17:27 min vs. 00:20:29 min, p<0.001, 95% CI 00:01:24-00:04:40) and STH (00:30:30 min vs. 00:34:25 min, p<0.01, 95% CI 00:01:23-00:06:26) times compared to women. CONCLUSION: Prehospital ECG implementation led to no significant differences in pre- and post-implementation times. In cases of STEMI, men had significantly reduced scene time and scene-to-hospital time when compared to women. The precise reason for these disparities remains unknown.

Addition of Audiovisual Feedback During Standard Compressions Is Associated with Improved Ability.

INTRODUCTION: A benefit of in-hospital cardiac arrest is the opportunity for rapid initiation of "high-quality" chest compressions as defined by current American Heart Association (AHA) adult guidelines as a depth 2-2.4 inches, full chest recoil, rate 100-120 per minute, and minimal interruptions with a chest compression fraction (CCF) ≥ 60%. The goal of this study was to assess the effect of audiovisual feedback on the ability to maintain high-quality chest compressions as per 2015 updated guidelines. METHODS: Ninety-eight participants were randomized into four groups. Participants were randomly assigned to perform chest compressions with or without use of audiovisual feedback (+/- AVF). Participants were further assigned to perform either standard compressions with a ventilation ratio of 30:2 to simulate cardiopulmonary resuscitation (CPR) without an advanced airway or continuous chest compressions to simulate CPR with an advanced airway. The primary outcome measured was ability to maintain high-quality chest compressions as defined by current 2015 AHA guidelines. RESULTS: Overall comparisons between continuous and standard chest compressions (n=98) were without significant differences in chest compression dynamics (p's >0.05). Overall comparisons between +/- AVF (n = 98) were significant for differences in average rate of compressions per minute (p= 0.0241) and proportion of chest compressions within guideline rate recommendations (p = 0.0084). There was a significant difference in the proportion of high quality-chest compressions favoring AVF (p = 0.0399). Comparisons between chest compression strategy groups +/- AVF were significant for differences in compression dynamics favoring AVF (p's < 0.05). CONCLUSION: Overall, AVF is associated with greater ability to maintain high-quality chest compressions per most-recent AHA guidelines. Specifically, AVF was associated with a greater proportion of compressions within ideal rate with standard chest compressions while demonstrating a greater proportion of compressions with simultaneous ideal rate and depth with a continuous compression strategy.

A focused investigation of expedited, stack of three shocks versus chest compressions first followed by single shocks for monitored ventricular fibrillation/ventricular tachycardia cardiopulmonary arrest in an in-hospital setting.

BACKGROUND: In cases of in-hospital-witnessed ventricular fibrillation/ventricular tachycardia (VF/VT) arrest, it is unclear whether cardiopulmonary resuscitation prior to defibrillation attempt or expedited stacked defibrillation attempt is superior. METHODS: Retrospective, observational study of all admitted patients with continuous cardiac monitoring who suffered VF/VT arrest between July 2005 and June 2013. In the stacked shock period (2005-2008), institutional protocols advocated early defibrillation with administration of 3 stacked shocks with brief pauses between each single defibrillation attempt to confirm sustained VF/VT. During the initial chest compression period (2008-2011), the protocol was modified to perform a 2-minute period of chest compressions prior to each defibrillation, including the initial. In the modified stack shock period (2011-2013), for a monitored arrest, defibrillation attempts were expedited with up to 3 successive shocks administered for persistent VF/VT. In unmonitored arrest, chest compressions and ventilations were initiated prior to defibrillation. The primary outcome measure was survival to hospital discharge. RESULTS: Six hundred sixty-one cardiopulmonary arrests were recorded during the study period, with 106 patients (16%) representing primary VF/VT. The incidence of VF/VT arrest did not vary significantly between the study periods (P= 0.16) Survival to hospital discharge for all primary VF/VT arrest victims decreased, then increased significantly from the stacked shock period to initial chest compression period to modified stacked shock period (58%, 18%, 71%, respectively, P < 0.01). Specific group differences were significant between the initial chest compression versus the stacked and modified stacked shock groups (all P < 0.01). CONCLUSION: Data suggest that monitored VF/VT should undergo expeditious defibrillation with use of stacked shocks.

A novel configuration of a traditional rapid response team decreases non-intensive care unit arrests and overall hospital mortality.

BACKGROUND: In-hospital cardiopulmonary arrest (CPA) accounts for substantial morbidity and mortality. Rapid response teams (RRTs) are designed to prevent non-intensive care unit (ICU) CPA through early detection and intervention. However, existing evidence has not consistently demonstrated a clear benefit. OBJECTIVE: To explore the effectiveness of a novel RRT program design to decrease non-ICU CPA and overall hospital mortality. METHODS: This study was conducted from the start of fiscal year 2005 to 2011. In November 2007, our hospitals implemented RRTs as part of a novel resuscitation program. Charge nurses from each inpatient unit underwent training as unit-specific RRT members. Additionally, all inpatient staff received annual training in RRT concepts including surveillance and recognition of deterioration. We compared the incidence of ICU and non-ICU CPA from first complete preimplementation year 2006 to postimplementation years 2007 to 2011. Overall hospital mortality was also reported. RESULTS: The incidence of non-ICU CPA decreased, whereas the incidence of ICU CPA remained unchanged. Overall hospital mortality also decreased (2.12% to 1.74%, P < 0.001). The year-over-year change in RRT activations was inversely related to the change in Code Blue activations for each inpatient unit (r = -0.68, P < 0.001). CONCLUSION: Our novel RRT program was associated with a decreased incidence of non-ICU CPA and improved hospital mortality.