Cardiovascular disease is the leading cause of death in the United States. In-hospital cardiac arrest outcomes are very poor, with a less than a 20 percent survival to discharge rate. Hospitals should establish a systems approach to in-hospital resuscitation rather than depend on the skills of individual professionals. Strong consideration should also be given to expanding training to non-clinical staff. We know that that when CPR is performed, even by healthcare professionals, excessive ventilation is provided during CPR for victims with advanced airways, with a resulting decrease in cardiac output; compressions are interrupted too frequently, with a resulting drop in coronary perfusion pressure and worse outcomes; and chest compressions are often too slow and too shallow.
Methods are needed to improve the quality of CPR delivered at the scene of cardiac arrest by healthcare providers (Class IIa). Possible strategies include education, training, assistance or feedback from biomedical devices, mechanical CPR, and electronic monitoring. Components of CPR known to positively affect hemodynamics include ventilation rate and duration, compression depth, compression rate and number, complete chest recoil, and minimal interruptions or hands-off time. Hospitals should implement continuous quality improvement processes that include monitoring the quality of CPR delivered, other process-of-care measures such as initial rhythm, CPR, and response intervals, etc. and patient outcome through hospital discharge. This data should be used to maximize the quality of resuscitation delivered.
Much of the basis for our recommendations are drawn from scientific papers, reports, and published guidelines. By providing guidance regarding resuscitation training, it is hoped that the care for those who require resuscitation in the hospital will be improved and that ultimately the number of people who survive a cardiopulmonary arrest will increase. The intention of CIHRO is to provide best practice recommendations. We have not directly addressed the question of funding for initial and ongoing training and equipment. We feel, however, that funding for resuscitation education and services should be an institutional responsibility and not the individual clinicians or employees themselves.
The chain of survival, first conceptualized for out-of-hospital sudden cardiac arrest, applies well to in-hospital arrest. Successful resuscitation in a hospital or on its campus is dependent on early detection, early activation of the code team, early CPR, early defibrillation when indicated, and early advanced life support (ALS). Hospitals should work to establish a coordinated, multidisciplinary approach to treating patients with cardiac arrest or cardiopulmonary emergencies. Written policies and procedures that address and facilitate this coordinated and multidisciplinary response is highly recommended. Hospital administrators should ensure that appropriate training policies and infrastructure are in place and supported. Those who provide resuscitation education should receive specialized training to prepare them for their role. The American Heart Association provides such programs for ECC instructors AHA Instructor . Funding should be provided to maintain the highest standards of training and practice in resuscitation throughout the institution.
At the time of the 2005 Consensus Conference, there were no published in-hospital randomized trials of AEDs versus manual defibrillators. Evidence from 1 study of fair quality and a case series indicated higher rates of survival to hospital discharge when AEDs were used to treat adult VF or pulseless VT in the hospital. See Section >>insert<< for more information regarding campus wide defibrillation. Defibrillation is often delayed when patients develop SCA in unmonitored hospital beds and in outpatient and diagnostic facilities. In these areas several minutes may elapse before more traditional response teams arrive with the defibrillator, attach it, and deliver a shock. Despite limited evidence, we believe that AEDs should be considered for the hospital setting as a way to facilitate early defibrillation (a goal of ≤3 minutes from collapse), especially in areas where staff have no rhythm recognition skills or defibrillators are used infrequently. When hospitals deploy AEDs, first-responding personnel should also receive authorization and training in their use. The goal is to provide the first shock for any SCA within 3 minutes of collapse. The objective is to make goals for in-hospital use of AEDs consistent with those established for the out-of-hospital setting. Early defibrillation capability should be available in ambulatory care facilities as well as throughout hospital inpatient areas.
As previously mentioned in section >>insert<<, resuscitation data should be audited to maintain and improve standards of practice. We encourage ongoing communication between resuscitation committees and those who are responsible for providing resuscitation training and education.
Training and practice are necessary to acquire competency in resuscitation. Theoretical training alone without actual hands on practice in a simulated environment, for example on training manikins, is of limited value. The use of manikins should therefore be mandatory. Resuscitation skills dilution occurs rapidly and regular updates or retraining using manikins are necessary to maintain adequate performance levels. Formal studies have shown that repeated instruction and practice is the most successful method of learning and retaining skills in resuscitation.
All those in direct contact with patients should be trained in BLS and related resuscitation skills such as CPR for victims of all ages, two rescuer CPR, use of a bag mask device, and the to use an AED. The American Heart Association Basic Life Support for Healthcare Provider course is ideal for this clinical group. Additionally, the American Heart Association now provides alternative ways for healthcare providers to receive initial or renewal certification for Basic Life Support (BLS). More information is available at AHA E-Learning . Other personnel, such as security personnel and receptionists, may also be trained in CPR and the use of an AED. These staff are nearly always available, particularly in non-clinical areas and may be able to respond before more highly trained help is available. The CIHRO believes that it is unacceptable for patients who sustain a cardiopulmonary arrest to await the arrival of select personnel before basic resuscitation is initiated.
The Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) has revised standards for individual in-hospital resuscitation capabilities to include evaluation of resuscitation policies, procedures, processes, protocols, equipment, staff training, and outcome review. Applying data and insight gained from processes for continuous quality improvement to training and education is essential for the success of resuscitation programs. Because of the correlation between QI and training, we recommend that hospitals establish policies that support the inclusion of resuscitation educators as part of their critical care and/or code committees.
In 2000 the American Heart Association established the National Registry of Cardiopulmonary Resuscitation (NRCPR). The NRCPR is a national database of in-hospital resuscitation events. It is the first Quality Management tool that thoroughly evaluates the care and outcomes of in-hospital resuscitation events, including Medical Emergency Teams (MET). The Mission of the American Heart Association’s NRCPR Hospital Safety Program is to reduce disability and death from cardiac and respiratory emergencies by providing an evidence-based, quality improvement program of patient safety, medical emergency team response, effective resuscitation, and post-emergency care. The objectives of the registry are to develop a well-defined database to document resuscitation performance of hospitals over time. This information can establish the baseline performance of a hospital, target its problem areas, and identify opportunities for improvement in data collection and the resuscitation program in general. For further information visit NRCPR .
During tough economic times, hospitals often find it difficult to balance profitability with expanding the mission of saving lives. This problem is not unique to the hospital industry. The entire US workforce is challenged with doing more with less and exploring alternative methods of delivering content faster, better and more cost effectively. We know that students, instructors, and administrators need alternatives to traditional training courses to better meet the realities of everyday working life, challenges with schedules and facilities, while still maintaining quality training. In response to those needs, the American Heart Association has actively sought additional ways to deliver its educational and training programs, providing healthcare professionals with more options for training. OnlineAHA allows hospitals to train more students in less time, and often at a cost savings. Online courses enable institutions to offer a comprehensive training experience, from high-quality online materials, to hands-on practice and testing with instructors, to monitoring students’ progress.
LEARNING OPTIONS FOR HEALTHCARE STAFF CARING FOR INFANTS AND CHILDREN Pediatric Advanced Life Support (PALS) The PALS Course provides information to recognize infants and children at risk of cardiopulmonary arrest, and strategies to prevent cardiopulmonary arrest in infants and children. It also teaches the cognitive and psychomotor skills to resuscitate and stabilize infants and children in respiratory failure, shock, or cardiopulmonary arrest. PALS Pediatric Emergency Assessment Recognition, and Stabilization (PEARS) PEARS bridges the gap between providers who regularly provide pediatric intensive care and those who do not, but still need training in skills that help identify the signs and symptoms of a pediatric victim in cardiopulmonary distress. It is an intermediate course that equips students to recognize and begin stabilization early and then contact the next level of care. PEARS Course Catastrophic Illnesses in Children An interactive case-based module to be taught in a small group format, this PowerPoint presentation on CD can be used either as a freestanding module or as a part of the PALS Course.
PREPARATORY TRAINING FOR HEALTHCARE STAFF Based on the 2005 AHA Guidelines for CPR and ECC and further research, additional courses have been created that are important for healthcare providers to be able to give quality care. Airway Management This course provides a modular design for enhancing airway management skills used in resuscitation, including ventilation foundations, proper bag-mask use, and advanced airway techniques. To learn more visit Airway Management Course . ECG & Pharmacology The ECG & Pharmacology Course focuses on specific ECG recognition skills, drug treatment knowledge and the practical application of rhythm knowledge and pharmacology in the ACLS algorithms. Visit ECG and Pharmacology to learn more. Learn Rhythm Adult The Learn Rhythm–Adult is part of AHA’s eLearning program and is designed to introduce healthcare providers to the normal cardiac rhythms and prepare them to recognize basic cardiac arrhythmias in clinical practice. This module is ideal for healthcare providers preparing for ACLS, telemetry staff or ambulatory care personnel. -Directed LEARNING and eLearning IMPROVEMENT PROGRAMS Learn Rapid STEMI ID ST-Elevation Myocardial Infarction, STEMI heart attack, occurs when there is a prolonged period of blocked blood supply to the heart. The damage can be severe as it affects a large area of the heart muscle. However, thousands of patients with STEMI fail to receive critical treatment in a timely fashion, some not receiving the care they need at all. As a result, the American Heart Association/Laerdal Medical Alliance has created Learn Rapid STEMI ID™ to better prepare healthcare professionals when dealing with this kind of heart attack.
The training and education goals of CIRHO are to provide suggestions to improve clinical and operational practices around resuscitation, and help improve outcomes through an increased quantity and frequency of education. These recommendations and practices should do much to increase adherence to evidence based treatment guidelines and improve outcomes in the hospital environment.
