redefining resuscitation
TRANSCRIPT
Ken Hillman
REDEFINING RESUSCITATION
Don Harrison Perpetual Lecture,
Spark of Life Conference, Perth.
7th-10th April 2011
HISTORY OF
RESUSCITATION
LIFE-SAVING AFTER NEAR-DROWNING
HOLLAND 1767 – Society for resuscitation of the drowned
BRITAIN 1774 – Society for the recovery of persons apparently drowned
Royal Humane Society for the Apparently Dead
2/0179
RESUSCITATION Trespassing the boundary between life
and death
Scientifically possible (sometimes)
Religious - only the Creator could give or
Ethical take life
2/0190
RESUSCITATION – rekindling the
flame of a taper by blowing gently –
MEDICINE’s work
RE-ANIMATION – bringing a corpse
back to life after the spark is fatally
extinct – GOD’s work
2/0161
EARLY RESUSCITATION
TECHNIQUES
• Warming
• Rolling body over barrel
• Rubbing the body
• Tickling throat with a feather
2/0191
UP UNTIL WORLD
WAR II
• Fogging on mirror over mouth –
warm
• No fogging on mirror – SILVESTER
or SCHAFER resuscitation
techniques
2/0165
CPR
Combination of
• Open airway
• Mouth to mouth respiration
• External cardiac compressions
2/0168
1968 – INCONSISTENT ARTIFICIAL
VENTILATION – GERMAN STUDY 1968
Aim to compare ventilatory effect of:
Howard-Thomsen
Holger Nielsen Chest compression
Silvester-Brosch Arm lift
Mouth-to-nose Exhaled air
Mouth-to-mouth
Acta Anaesth Scand 1968; suppl XXIX
GA – pentobarbitone
Paralysed with methyl-curare
Ventilation with Ambu bag + Ruben valve
Femoral artery catheter
ECG
End exp CO2 %
Pulse rate
Acta Anaesth Scand 1968; suppl XXIX
“LATIN SQUARE” SEQUENCE Volunteers Methods
1+6 A C B E D
2+7 D A E C B
3+8 B D C A E
4+9 C E D B A
5+10 E B A D C
A – Mouth to nose
B – Mouth to mouth
C – Howard-Thomsen
D – Holger Nielsen
E – Silvester-Brosch
Acta Anaesth Scand 1968; suppl XXIX
ABG - normal ventilation
Apnoea - 60 secs
Then one of the 5 ‘methods’
• ABGs/30 sec for 3 min
• The ‘method’ for 9 min
Acta Anaesth Scand 1968; suppl XXIX
ABG - Clark electrode
pH & PaCO2 - Astrup
O2 sat - slide rule designed by
Severinghaus
Acta Anaesth Scand 1968; suppl XXIX
CPR
• Initially for anaesthesia – induced
cardiac arrest
• “Miraculous, effective, simple”
Kovwenlioven NEJM 1960;173:1064
2/0062
CPR “Anywhere….. Anytime”
Universally applicable to
death and dying – no matter
what the cause
2/0170
CPR
• Intimately linked to the practice of
medicine
• Associated with acute medicine through
the media
2/0033
HOSPITAL CPR
• Most die in hospital
• Half of all survivors have
significant decrease in
functional status Arch Int Med 2000;160:1969
2/0068
REDEFINING
RESUSCITATION IN ACUTE
HOSPITALS
• Where and why do patients have
cardiac arrests?
• Moving from CPR to patient centered
resuscitation
• The role of DNR?
• The future?
2/0078
WHY DO PATIENTS HAVE
CARDIAC ARRESTS IN
HOSPITAL?
Up to 80% of all so-called ‘arrests’ are
preceded by at least 8 hours of slow
deterioration in vital signs
2/0013
Schein et al Chest 1990;98:1388
WHY DO PATIENTS HAVE
CARDIAC ARRESTS IN
HOSPITAL?
Silo based hospital function
Medical specialisation
Vital sign measurement
Nurses are trained to measure not act
Doctors act on them in hierarchical way
Poor resuscitation training
2/0013
SICK PATIENT
NURSE OBSERVES BUT CAN’T ACT
TRAINEE DOCTORS ACT BUT NOT
TRAINED
SPECIALIST – TRAINED BUT NOT IN
ACUTE MEDICINE
EVENTUALLY MULTIORGAN
FAILURE/CARDIAC ARREST AND
ADMITTED TO ICU
Systems to
connect first
signs with
acute care
specialists
1.2/0073
SINGLE CENTRE STUDIES
ALL SHOW A REDUCTION
IN CARDIAC ARRESTS
AND DEATHS
• System implementation is different from
drug and procedural implementation
• A large Hawthorn effect is essential
2/0017
BEFORE/AFTER
MET
50% reduction in CARDIAC ARRESTS
after casemix adjustment odds ratio
0.5: 95% CI 0.35-0.73
BMJ 2002;324:387
2/0039
BEFORE/AFTER MET STUDY
Before After Difference RR
95% CI 95% CI
Cardiac arrests 63 22 41(23-59) 0.35(0.22-0.57)
Deaths from cardiac
arrests 37 16 21(7-35) 0.43(0.26-0.70)
No. days in ICU>C.arrest 163 33 130(110-150) 0.20(0.13-0.33)
No.days in hospital
>C.arrest 1353 159 1194(1119-1269) 0.11(0.70--.79)
Inpatient deaths 302 222 80(37-123) 0.74(0.70-0.79)
MJA 2003;179(6):283-287
2/0040
CONFOUNDERS
• Over 30% of calls in control
hospitals were ‘MET’ calls –
contamination
• Large variability in MET
hospitals
2/0017
CONFOUNDERS Less than half of all events
had vital signs criteria
documented in the eight
hours beforehand
Lancet 2005;365:2091-2097
CONFOUNDERS In patients with documented
MET criteria followed by an
event, only a minority of
patients overall had an actual
MET call made
1.4/0122 Lancet 2005;365:2091-2097
PROPORTION OF MISSING VITAL
SIGNS WITHIN 24 h OF SERIOUS
ADVERSE EVENT
Respiratory rate - approx 25%
Heart rate - approx 8%
BP - approx 6%
Resuscitation 2009;80:35
INTERVENTIONS
Emergency Team Calls (ie non-cardiorespiratory arrest)
512 control hospitals
1864 MET hospitals
Only 5 of these were not critical care interventions
Only 1 had an assessment/examination
Resuscitation 2010;81:25
META ANALYSIS
30% reduction in paediatric mortality
and cardiac arrest rates
30% reduction in adult cardiac arrest
rates
Not achieved by any other intervention
Chen et al 2010;170(1):18-26
RAPID RESPONSE
SYSTEMS
• Majority of US hospitals – IHI
• Majority of Canadian hospitals
• UK – mandatory outreach and now RRSs
• Scandinavia – spreading
• Holland – national implementation underway
• Sporadic – Mexico, Subcontinent, remainder of Europe
RAPID RESPONSE
SYSTEMS - AUSTRALIA
• NSW – being rolled out in every acute hospital
• Australia – implementation guidelines being developed by the Australian Commission on Safety and Quality in Health Care
REDEFINING
RESUSCITATION
Is about system implementation
as well as
Individual clinical skills
2/0017
EFFECTIVE IMPLEMENTATION
OF RAPID RESPONSE SYSTEMS
1. Triggering criteria
2. Response – 24/7 of at least one person with advanced resuscitation skills
3. Ownership and administration within a hospital
4. Education • Awareness – EVERYONE
• Basic resuscitation – NURSES AND ON-SITE MEDICAL STAFF
• Advanced resuscitation – MINIMUM 1 PERSON 24/7
5. Key performance Indicators (KPIs) • Measure problem
• Track implementation and maintenance
• Measure effectiveness
ALL IMPLEMENTED SIMULTANEOUSLY
REDEFINING RESUSCITATON
MOVE FROM:
CARDIAC ARREST TEAMS
SYSTEM BUILT AROUND AT-RISK PATIENTS – 24/7 system to identify all at-risk patients
– Patient centred triage according to level of illness
– Small 24/7 teams skilled in ALL aspects of managing the seriously ill, including CPR
2/0113
HOSPITAL CARDIAC ARRESTS
ARE SENTINAL EVENTS
- SHOULD BE SUBJECT TO
DETAILED ANALYSIS
• Most are potentially preventable
• Many should have been DNR
• Few are sudden and unexpected
REDEFINING
RESUSCITATION
• CPR has a low survival rate
• CPR works best in witnessed arrests
with sudden arrhythmia
• CPR almost never works at the natural
end of life in a dying person- witnessed
or non witnessed.
2/0017
• IF CPR UNLIKELY TO BE
– appropriate
– successful
• WHY WRITE DNR ORDERS?
• DISCUSS DYING AND HOW IT IS
TO BE MANAGED
2/0090
THINKING DNR?
Catalyst to begin honest discussions:
• Medical condition
• Therapeutic options
• Prognosis
2/0097
DNR = Diagnosis of dying
= Medicine has no more to offer
= Change thrust of care
HONESTY AND PALLIATION
2/0050
SERIOUSLY ILL AT-RISK
PATIENT vs CARDIAC ARREST
PATIENT
“The seriously ill at-risk patient”
is a syndrome similar to the
“coronary artery syndrome”
2/0178
PATIENT-CENTRED
RESUSCITATION
This is not waiting until the
patient’s heart has stopped
and instituting CPR
2/0017
COMMUNITY
EXPECTATIONS
Sophisticated
and well organised systems to
guarantee patient safety at all
times
2/0140
CONTINUING WARD CARE DEFINITIONS
FOR TRIAGE
NOT FOR RESUSCITATION
STEP DOWN UNIT
ICU & SPECIALISED UNITS
TRIAGE
Resuscitation
Early
identification
of seriously
ill at-risk
patients
2/0135
REDEFINING
RESUSCITATION
• Resuscitation is not only CPR
• Resuscitation is a complex set of skills
and experience used to stabilise acutely
ill patients
• Require at least one person at all times
in a hospital with appropriate advanced
skills, knowledge and experience 2/0017