5/26/2014 1 Creating a High-Performance Resuscitation System Paris Hotel and Casino Las Vegas, Nevada Joseph P. Ornato, MD, FACP, FACC, FACEP Professor & Chairman, Dept. of Emergency Medicine Professor, Internal Medicine (Cardiology) Virginia Commonwealth University Health System Operational Medical Director Richmond Ambulance Authority Richmond Fire & EMS Henrico County Division of Fire Richmond, VA Disclosure Information Joseph P. Ornato, MD, FACP, FACC, FACEP Creating a High-Performance Resuscitation System FINANCIAL DISCLOSURE: Cardiac Co-Chair & Consultant: NIH Resuscitation Outcomes Consortium (ROC) American Editor, Resuscitation Advisory Board, Key Technologies, Inc. (Transnasal Cooling Device) UNLABELED/UNAPPROVED USES DISCLOSURE: Wriskwatch™, Emergency Medical Technologies How are we going to reduce the mortality from OOH-CA meaningfully? Accurate data Prevention Implementing effective community systems of care Changing research funding priorities Breakthrough approaches Detecting unwitnessed OOH cardiac arrest Effective therapy for pulseless electrical activity (PEA) Adapting principles & practices from high performance industries Accurate Data Cardiac arrest data No national U.S.registry Data sources NIH Resuscitation Outcomes Consortium (ROC) 8 U.S., 3 Canadian sites Research sites Epistry CDC Cardiac Arrest Registry to Enhance Survival (CARES) 46 communities in 31 states & DC Voluntary sites ROC CARES Public Health Burden of Cardiac Arrest Heart Disease and Stroke Statistics Go et al. Circulation. 2013;127:e6-e245 10 x more deaths/year from OOH-CA than MI Out-of-hospital Cardiac Arrest Acute Myocardial Infarction 720,000 cases per year in the USA 21% of these are “silent” 73% of MI deaths occur out-of- hospital (i.e., cardiac arrests) In-hospital mortality rate= 4.6% In-hospital deaths/year Out-of-hospital deaths/year 359,400 out-of-hospital cardiac arrest cases per year in the USA 23% have an initial documented CA rhythm of VF Out-of-hospital mortality rate= 90.5% MI Cardiac Arrest 32,959 0 100,000 200,000 300,000 400,000 325,257 0 100,000 200,000 300,000 400,000 You created this PDF from an application that is not licensed to print to novaPDF printer (http://www.novapdf.com)
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Ornato - Plenary on the future of resuscitation · Name Type Design N Status 1 Cardiac Arrest Epistry Cardiac Observational 179,310 Ongoing 2 Trauma Epistry/PROPHET Trauma Observational
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5/26/2014
1
Creating a High-PerformanceResuscitation System
Paris Hotel and Casino Las Vegas, Nevada
Joseph P. Ornato, MD, FACP, FACC, FACEP
Professor & Chairman, Dept. of Emergency MedicineProfessor, Internal Medicine (Cardiology)
Virginia Commonwealth University Health System
Operational Medical DirectorRichmond Ambulance Authority
Richmond Fire & EMSHenrico County Division of Fire
Richmond, VA
Disclosure Information
Joseph P. Ornato, MD, FACP, FACC, FACEP Creating a High-Performance Resuscitation System
Consortium (ROC) American Editor, Resuscitation Advisory Board, Key Technologies, Inc.
(Transnasal Cooling Device)
UNLABELED/UNAPPROVED USES DISCLOSURE: Wriskwatch™, Emergency Medical Technologies
How are we going to reduce the mortality from OOH-CA meaningfully?
Accurate data Prevention Implementing effective
community systems of care Changing research funding priorities Breakthrough approaches Detecting unwitnessed OOH cardiac arrest Effective therapy for pulseless electrical activity (PEA) Adapting principles & practices from high
performance industries
Accurate Data
Cardiac arrest data
No national U.S.registryData sourcesNIH Resuscitation Outcomes
Consortium (ROC)8 U.S., 3 Canadian sitesResearch sitesEpistry
CDC Cardiac Arrest Registry to Enhance Survival (CARES)46 communities in 31 states & DCVoluntary sites
ROC
CARES
Public Health Burden of Cardiac ArrestHeart Disease and Stroke StatisticsGo et al. Circulation. 2013;127:e6-e245
Regional Systems of Care for Out-of-Hospital Cardiac Arrest: A Policy Statement from the American Heart Association
Task Force convened to explore addition of Cardiac Resuscitation quality improvement efforts to current M:L Program
Overlapping clinical conditions
Common providers and procedures
Well-documented effectiveness of regionalized STEMI systems
Development of Ideal systems for Cardiac Arrest
Launch of STEMI and Cardiac Resuscitation Systems of Care Mission: Lifeline program
April 2012
AHA Mission Lifeline Ideal System
Patient centered care High quality care that is safe, effective, and timely Stakeholder consensus on systems infrastructure Increased operational efficiencies Measurable patient outcomes Evaluation mechanism to ensure that quality of care
measures reflect changes in evidence-based research A role for local community hospitals so as to avoid a
negative impact that could eliminate critical access to local healthcare
Reduction in disparities of healthcare delivery
Guiding Principles for Regionalization of Post-Arrest Care
Richmond EMS system
2-3 min fire AED first response
6 min all-ALS system
12-lead ECGs, capnography,pulse oximetry, AutoPulse™, wireless internet, GPS automated vehicle locators on all units
Resuscitation strategy approach
Optimize blood flow/oxygen delivery• Vasopressin 40u IV alternating with
epinephrine 1 mg IV every 5 min• Autopulse™ CPR (2 min) before DF with
continuous chest compression– No interruptions of CPR for defibrillation
Shorten the time to airway & drug therapy• King LTS™• EZ-IO™
Protect the brain & heart• Pre-hospital therapeutic hypothermia
during & post-arrest
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dvanced esuscitation ooling herapeutics ntensive are
ARCTIC Alert from field VCU never on diversion for ARCTIC
pts ARCTIC Team ED physician and nurse ARCTIC attending (only 5) CCU / interventional fellow CCU NP RN Coordinator Inclusion criteria for ARCTIC Comatose or unable to follow verbal
commands Initial rhythm VF, or Initial rhythm witnessed PEA or ASYS Exclusion criteria DNAR, terminal illness Shock unresponsive to vasopressors Uncontrolled bleeding
dvanced esuscitation ooling herapeutics ntensive are
“Induction Center Concept”
0102030405060708090
100
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
VCU ARCTIC Patients/Year
EM focuses on stabilizing patientInitiates early goal directed therapy
CICU/cath team places cooling catheter and continues standardized post-arrest careEndovascular cooling strategy with 5
dedicated machinesContinuous EEGs with aggressive seizure Rx
Patients admitted to only one ICU (CICU) with specially trained, dedicated ARCTIC nurse staffingElectronic order sets & personal checklists72-hour pathway for goal directed therapyFull time RN ARCTIC coordinatorCICU NP
Clinical consistency Multidisciplinary ongoing education process EMS and satellite hospital feedback on all
cases Continuous quality review of data and ongoing
evidence based system changes
Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) Immediate memory
List learning Store memory
Visuospatial / constructional orientation Complex figure copy / trail making Line orientation
Need for Cardiac Arrest ResearchOrnato JP, Becker LB, Weisfeldt ML, Wright BA. Circulation 2010:1876-9
NIH Resuscitation Outcomes Consortium (ROC) 2005-15 First large-scale,
governmentally-sponsored, North American effort to conduct definitive pre-hospital, randomized clinical trials in out-of-hospital cardiac arrest (OHCA) and severe traumatic injury
Focus is on very early delivery of interventions by EMS providers, when there is optimal potential for benefit
ROC
ROC focus areas
Primary Pre-hospital, randomized clinical trials that test very early (i.e., field
or ED) administration of promising drugs, devices, and strategies with a goal of improving outcomes in victims of cardiac arrest or severe traumatic injury
Breakthrough Approaches:Adapting Principles & Practices from High Performance Industries
Aviation vs. resuscitationOrnato JP, Peberdy MA. Resuscitation 2014; 85:173-6
Aviation ResuscitationPreflight checks Code cart/equipment checksPreflight crew brief Delegation of tasksTake-off/climb Initiate CPR/DF/airway/IVCruise Continue CPR/DF/drugsDescent/landing ROSC or cease resuscitationPost-flight checks Stabilization, post-resusc careCrew debriefing Team debriefing
Phases of Flight Phases of Resuscitation
Aviation & resuscitation are team effortsOrnato JP, Peberdy MA. Resuscitation 2014; 85:173-6
Aviation ResuscitationPerson in charge Pilot in Command Team LeaderLives at stake Up to hundreds 1Multiple phases Yes YesDidactic training Flight School BCLS, ACLS, PALSScenario-based training Flight Simulator Code SimulationStandard setting organization FAA AHAStandardized approach Checklists AlgorithmsConsistent standardization Absolutely No
What’s different about aviation?Ornato JP, Peberdy MA. Resuscitation 2014; 85:173-6
Pilots understand that flying is a privilege
Aviation functions in a rigorous culture of safety
Skills & procedures are standardized
Teamwork is the daily routine
Pilots anticipate, train, plan & brief for emergencies
Summary Accurate data Prevention Implementing effective
community systems of care Changing research funding priorities Breakthrough approaches Detecting unwitnessed OOH cardiac arrest Effective therapy for pulseless electrical activity (PEA) Adapting principles & practices from high
performance industries
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