steven brooks md mhsc frcpc, principal investigator laurie morrison md msc frcpc, co-principal...

Steven Brooks MD MHSc FRCPC, Principal InvestigatorLaurie Morrison MD MSc FRCPC, Co-Principal Investigator

“Resuscitation is just the beginning…”

Post Arrest Consult Team PACT

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Funding

St. Michael’s Hospital AFP Innovation Fund

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Rationale for PACT

• High mortality after OHCA resuscitation • Post Cardiac Arrest Syndrome

• Hospital survival rates vary • E.g. 25%-30% locally vs. 50-60% in US and

Europe

• Local data shows care is not standardized

• Studies from elsewhere show improved survival with champions and a standardized, multi-faceted approach

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Barriers

• Process concerns due to low volume of OHCA

• Lack of a standardized approach

• Difficulty gaining experience

• The disjointed patient journey

• Access to specialized services – (ICU, PCI, EP)

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Post Arrest Consult Team (PACT)

• Building on other Centres of Excellence models– Trauma, stroke, STEMI etc

• Building on the CCRT model– Dedicated consult service of RN/RT/MD to

assist MRPs and primary nurses with complex/high risk patients

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Post Arrest Consult Team (PACT)

• Guidelines inspired• Evidence based• Standardized clinical pathways

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PACT Process

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PACT Activation

• Single page PACT activation through locating• Automated prehospital alert to PACT RN text

pager from upload of electronic ambulance call report from Toronto EMS

• MDs will have cell phone/pager registered with communications with call schedule

• RNs will have a PACT text pager which is passed on to the PACT RN on call

• We will be tracking activation rates and missed cases

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Goal directed gas exchange and hemodynamics

• Hyperoxia is bad– minimize FiO2 for oxygen saturation ≥ 94%

• Hypocarbia is bad– ventilate to ETC02 of 35-40 mmHG or PaCO2

levels of 40-45 mmHG

• Hypotension is bad– MAP goal specified in pre-printed order set

• Best evidence suggests these are urgent issues

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Therapeutic hypothermiaWhere PACT can have an IMPACT

• Cooling more eligible patients• Appropriate core temperature monitoring• Facilitating rapid decline in temperature through

the “danger zone” (quickly to 33.5)– Proper placement/replacement of ice bags – RAPID infusion of cold saline – Shivering prevention/treatment

• Encouraging aggressive sedation, analgesia and paralytic (PRN) as per hospital protocol

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Therapeutic hypothermiaWhere PACT can have an IMPACT• Use of the trouble-shooting checklist when

cooling rates are too slow

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Be aware of potential complications during induction of hypothermia

• Shivering– Will slow cooling– Increase in metabolic rate and oxygen demand

• Volume depletion• Electrolyte abnormalities

– Hypokalemia, Hypomagnesemia, hypophospatemia

• Glucose resistance

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PACT MD PACT MD Roles and ResponsibilitiesRoles and Responsibilities

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PACT MD

• 24-hour availability. • In house M-F 9-5 with callback ASAP and

bedside assessment ASAP with a target of within 15 minutes of consult.

• Home call for telephone consult after-hours with discretionary bedside assessment

• For the ICU physicians call schedule synchronized with ICU call

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PACT MD

• Interaction with the PACT RN modeled after the CCRT– PACT RN will discuss case details, clinical assessment

and plan with the PACT MD after initial contact with the patient is made

– A collaborative plan with the PACT RN will be determined

– Similar to a resident to staff exchange

• PACT MD will provide “suggest” orders as needed and discuss them immediately with the MRP or their delegate at the time of assessment

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PACT MD

• Initial involvement directed towards items in the PACT clinical pathways that are urgent

– Gas exchange and hemodynamic goals

– Trouble-shooting therapeutic hypothermia to ensure goal temperature reached

– Need for urgent coronary reperfusion?

– Making appropriate sub-specialty consultations

– Encouraging delayed neuroprognostication

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PACT MD

• Subsequent bedside follow-up daily during acute phase of care

– Support maintenance of hypothermia– Support safe, controlled rewarming at 24 hours– Support neuroprognostication pathway– EP involvement as per protocol– Consider etiology in collaboration with primary

team

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PACT MD

• Clinical note expected for each consult• Detail clinical assessment and management

plan, highlighting the important features related to the PACT clinical pathways

• Hand-over PACT patient consult list to on-coming PACT MD for continuity of follow-ups

• Sign-off from patients when acute post arrest issues are resolved (~72 hours?)

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PACT MDs

• Dr. Andrew Baker

• Dr. Chris Hayes

• Dr. Jan Friedrich

• Dr. Sara Gray

• Dr. Paul Dorian

• Dr. Neil Fam

• Dr. Laurie Morrison

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PACT RN PACT RN Roles and ResponsibilitiesRoles and Responsibilities

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PACT RNPACT RN

• 24 hour in-hospital presence for PACT• Goal: Respond to page for consultation and attend

patient bedside as soon as possible to assist the primary care team in the implementation of best practices for the post-arrest patient

• PACT will only consult on out-of-hospital arrest patients; requests for in-hospital post cardiac arrest patients will be politely refused

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PACT RNPACT RN

An advocate for the patient and an ambassador for the PACT

• Communication with primary MD, ED RN’s and PACT MD and the RT’s

• WILL NOT take over primary nursing responsibilities Review PACT eligibility

• OHCA• Comatose (not responding to verbal commands)• ROSC

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The PACT RN as a Champion

• The PACT RN is expected to have the greatest impact related to optimizing the induction of therapeutic hypothermia

accurate temp measurement

surface cooling

sedation & analgesia

cold fluids-FAST

NMBA’s

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Therapeutic HypothermiaTherapeutic Hypothermia

• SMH Pre-printed Therapeutic Hypothermia orders

ED

ICU

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Therapeutic HypothermiaTherapeutic Hypothermia

Pre-Printed Orders TH ED Pre-Printed Orders TH ICU

•MD administer neuromuscular blocking agents

•RN administer sedation & analgesia to target Sedation Agitation Score (SAS) 1 prior to induction of neuromuscular blockade

•RN to obtain a baseline Train of Four (TOF) measurement (if available). Administer neuromuscular blocking agents (NMBA) as ordered below.

•MD in the ICU would give the first dose

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TH Potential ConcernsTH Potential Concerns

PACT TH Trouble Shooting Checklist

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Cooling Equipment

• Pre-printed orders and quick reference

• Ice packs (freezer)• Cold fluids – saline • zip lock bags • Esophageal probe

– Guide for esophageal probe placement

– Paper measuring tape

• Note ED does not have a cooling blanket

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The PACT RN as a Champion

The PACT RN will also play a major role in assessing the patient with respect to the other clinical pathways • Goal directed gas exchange/ Hemodynamics• 12-lead ECG-urgent PCI • EPS• Neuroprognostication

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Hemodynamic Optimization and Hemodynamic Optimization and Gas ExchangeGas Exchange

RT collaboration to help facilitate the gas exchange targets

Minimize FiO2 to maintain O2 saturation of 94-96%

Ventilate ETCO2 to levels of 35 – 40 mmHg OR

Maintain PaCO2 levels of 40 – 45 mmHg

Maintain MAP goal specified in pre-printed order set

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Coronary Angiography Coronary Angiography Assessment Assessment

• Check to see if 12-lead ECG completed by the attending team– If not done, work with ED RN to

complete• Review the ECG with the MRP in the

ED and/or PACT MD to determine possible STEMI

• If possible STEMI, discuss activation of Code STEMI protocol

• Follow up with primary care team after patient returns from Cath Lab

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Electrophysiologist AssessmentElectrophysiologist Assessment

• Collaborate with PACT MD / MRP to call for Electrophysiologist consult

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Patient Follow-Up Patient Follow-Up

• If a patient has come in after hours please provide Karen or Tessa with a patient debrief, via email of in person.

• Karen Wannamaker and Tessa Diston as PACT RNs will complete a follow up after 12 hours of ED admission to monitor cooling.

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PACT RN Coverage

8:00 to 16:00 hrs Monday to Friday Karen Wannamaker or Tessa Diston will be the on call PACT RN.

16:00 hrs to 8:00 Monday to Friday and 24 hours weekend coverage, the CCRT nurse will be the on call PACT RN.

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PACT RN Communication Tools

Pager and iPAD

Two pagers with the same number have been set up with locating for PACT

iPAD has the electronic version of the Case Report Form (eCRF)

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PACT RN Hand Over

After the PACT RN shift has ended

Contact the next on call PACT RN

Transfer pager (only applicable for CCRT nurses)

Provide a debrief of any PACT patient that may have been admitted to Karen and Tessa for 12 hour follow up

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Working Together… to COOL!

“You may have the greatest bunch of stars in the world, but if they don’t play together, the club won’t be worth a dime.”

Babe Ruth

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A PACT Case

• 52 yr old male• Acute onset chest pain followed by collapse

outside home– Witnessed – Bystander CPR initiated

• 911 call @ 20:32

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EMS Treatment

• Toronto Fire– First on scene– Confirmed VSA, continued CPR– AED applied – 1st shock

Analysis: started

Prompt: don't touch patient, analyzing

20:37:43 20:37:44 20:37:45 20:37:46 20:37:47 20:37:48 20:37:49Defib mode: Auto defib

Grid size is 0.20 s x 0.50 mV at Gain x1ECG

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EMS Treatment

• Toronto EMS– Bradycardic PEA, continued CPR– Course V-fib – 2nd shock– ROSC– Intubation

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SMH Emergency Department

• Patient brought into a resuscitation bay• Assessment by emergency RNs, ER residents

and MD– BP 80/50, HR 110 Sinus Tachy, BVM ventilations

(apneic), O2 100% on FiO2 100%, Temp 36

• Tube position confirmed with colorimetric ETCO2, RT paged, cxray ordered, blood drawn, additional IVs established

• 12-lead ECG ordered• Order for dopamine give for a BP 80/40• ER puts in right femoral central line

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SMH Emergency Department

• Pre-printed post arrest therapeutic hypothermia orders signed by emerg staff MD

• Several ice bags placed around patient• Critical Care paged through locating• PACT team activated

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A PACT Case

• After hours paging protocol – PACT RN

• PACT RN – Calls back to emergency– Attends ASAP– Determines eligibility– Undertakes a focused assessment of the

patient

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A PACT Case

• PACT-focused problem based approach using the checklist and pathways– Pt is comatose (not responding to voice or

painful stimuli)– Intubated on vent. RT at bedside.– On emergency cardioresp monitor– BP 80/50, HR 110 Sinus Tachy, Vented O2

100% on FiO2 100%, Temp 36 (tympanic)– Ice bags at neck and groin

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A PACT Case

• PACT RN actions?

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PACT RN Actions

• Discussed gas exchange goals with RT and obtained orders from MRP or PACT MD– Requested end-tidal CO2 monitor from RT

• Identified hypotension as an issue and advocated for fluids/pressors/central line by primary team– Pre-printed orders support this

• Ensured 12-lead ECG was done and assessed by MRP– Draw attention to PCI pathway if indicated

• Helped bedside nurses place an esophageal temp probe• Assisted bedside nurses with proper ice bag placement

and reminded about hourly replacement

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PACT RN Actions

• Started 2L cold saline bolus as per pre-printed orders with pressure bags

• Encouraged sedation/analgesia and paralytic PRN as per pre-printed orders

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PACT RN Actions

• At completion of initial assessment and management, contacted the PACT MD through locating to discuss the case– Focus on:

• Hx and focused physical assessment• Review eligibility• Review interventions/investigations prior to PACT• Review any PACT interventions• Discussion with RN/MD around issues requiring attention by

PACT MD

• After MD contact, the PACT RN completed the eCRF on iPAD

• Brief PACT RN note in chart

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PACT MD actions

• Reviewed case with the PACT RN over the phone

• Provided verbal “PACT Suggest” orders for ventilation parameters

• After review with PACT RN, contacts MRP to discuss the suggest orders and discuss the ECG/PCI pathway

• Assessment for PCI• Assessment for EP involvement acutely

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PACT RN Actions

• One hour later – PACT RN follows up with emerg– BP 120/70 on 10 mcg/kg/min– HR Sinus at 95

– Ventilated FiO2 40% O2 sats 95% ETCO2 40

– Temp (esophageal) 36 degrees

• Action?

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THANK YOU