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A p p ro a c h e s t o I m p ro v i n g
R e s u s c i t a t i o n Eff e c t i v e n e s s
Ian J. Barbash,
MD
, Jeremy M. Kahn,
MD, MS
a,b,c,
KEYWORDS
Cardiac arrest Resuscitation Simulation Quality improvement Patient safety
Hospital systems
KEY POINTS
Improved resuscitation outcomes require not just advances in the understanding of
bedside physiology but also advances in the organization of resuscitation care.
Organizational targets for improving in-hospital resuscitation include three main domains:
(1) monitoring and alerts, (2) resuscitation teams, and (3) quality improvement.
Organizational approaches for monitoring include improved electronic health records that
incorporate novel prediction models for recognizing physiologic deterioration and telemedicine for improving alert interpretation.
Organizational approaches for resuscitation teams include formal rapid response/medical
emergency teams based on managerial principals that emphasize leadership, team work,
and organizational effectiveness.
Organizational approaches for quality improvement include real-time data management
strategies that feedback process and outcome data to the resuscitation team, enabling
implementation of evidence-based approaches to correct specific quality deficits.
Future research should be directed at developing novel predictive models for physiologic
deterioration, improving interactions between physiology-based alarms and bedside providers, identification of the ideal components of an effective resuscitation team, and
developing novel quality improvement strategies through information technology and
organizational science.
Disclosures: Dr I.J. Barbash has no conflicts to disclose. Dr J.M. Kahn reports receiving in-kind
research support from the Cerner Corporation, a health information technology corporation;
and receiving consulting fees from the United States Department Veterans Affairs for consulting on the topic of intensive care unit telemedicine.
a
Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of
Medicine, 3459 Fifth Avenue, 628 Northwest, Pittsburgh, PA 15213, USA; b Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Pittsburgh,
PA 15261, USA; c Department of Health Policy & Management, University of Pittsburgh Graduate School of Public Health, 130 De Soto Street, Pittsburgh, PA 15261, USA
* Corresponding author. Scaife Hall, Room 602-B, 3550 Terrace Street, Pittsburgh, PA 15261.
E-mail address: kahnjm@upmc.edu
Crit Care Clin 31 (2015) 165176
http://dx.doi.org/10.1016/j.ccc.2014.08.008
criticalcare.theclinics.com
0749-0704/15/$ see front matter 2015 Elsevier Inc. All rights reserved.
166
INTRODUCTION
Fig. 1. Conceptual model for the organization of resuscitation care. Effective resuscitation
requires three key components: (1) monitoring and identification of arrests, (2) effector
teams for initiation of timely and high-quality resuscitation, and (3) feedback mechanisms
for outcome measurement and improvement.
patients at risk for deterioration and prevent patients from progressing to cardiac
arrest. After detection of physiologic deterioration, the resuscitation teams of the
efferent limb are required to initiate timely, high-quality, evidence-based care,
including administration of intravenous fluids and vasoactive agents thought to be
associated with survival.3 For patients not in the ICU, resuscitation teams need to
accurately triage patients, moving those at high risk for further worsening to an ICU.
Finally, feedback mechanisms must exist to accurately measure the processes and
outcomes and design performance improvement interventions to refine, update,
and enhance the entire system. As described in the following sections, each of these
domains can be a target for improving resuscitation outcomes by improving the organization and management of care.
ORGANIZATIONAL TARGETS FOR IMPROVING RESUSCITATION EFFECTIVENESS
Monitoring and Alerts: the Afferent Limb
The first step in an effective resuscitation is the timely detection of physiologic deterioration; high-quality clinicians, either by themselves or as part of a RRT, are irrelevant
Table 1
Organizational approaches to improving resuscitation effectiveness
Domain
Limb
Approaches
Afferent
Resuscitation teams
Efferent
Quality improvement
Feedback
Simulation training
Real-time feedback
Outcome measurement
National quality improvement programs
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if they are not alerted to patient events. Traditionally, monitoring systems were only
useful in detecting cardiac arrest through telemetry.14 However, more recently monitoring systems are used to detect deterioration well before arrest, providing time for
active intervention. Thus, these systems may allow for earlier treatment and allow
at-risk patients to be moved to environments in which they can be resuscitated
more effectively.
Outside of the ICU, physiologic monitoring may consist of centralized cardiac telemetry, continuous pulse oximetry, and intermittent noninvasive blood pressure measurement. However, most hospitalized patients do not have these monitors in place.
For example, although respiratory decompensation is an important and preventable
cause of in-hospital death, only a small minority of hospital patients have respiratory
monitors in place.15 In many hospitals, standard medical and surgical wards do not
have the capacity to continuously monitor patients, reserving continuous monitoring
for telemetry wards that typically focus on patients at cardiac risk. Indeed, standard
guidelines for the use of telemetry may overestimate risk in some patients and underestimate it in others, leading to false alarms in the former and missed arrhythmias in
the latter.16 Early detection models can help identify at-risk patients who may benefit
from closer monitoring, either in situ or by a move to a higher level of care.
Although monitoring itself is not truly an organizational intervention, the act of
applying prediction models to monitoring data and presenting the results of these
models to providers has strong organizational underpinnings. Multiple prediction
models exist, with varying inputs, weighting, and resultant differences in sensitivity
and specificity for detecting deterioration (Table 2).17 Several models include variations on the Early Warning Score, and others include the Medical Early Response
Intervention and Therapy and the Cardiac Arrest Risk Triage. These models
Table 2
Accuracy, sensitivity, and specificity of prediction modeling for cardiac arrest
Prediction Model
and Score Cutoff
IHCA Accuracy
Composite Accuracy
MEWS
0.76 (0.710.81)
0.75 (0.740.76)
Sensitivity, %
Specificity, %
>3
67
80
>5
20
96
>3
55
85
>5
19
97
>8
60
83
>10
29
95
>16
61
84
>24
35
95
SEWS
ViEWS
CART
0.76 (0.710.81)
0.77 (0.720.82)
0.83 (0.790.86)
0.76 (0.750.77)
0.75 (0.740.76)
0.78 (0.770.79)
Composite accuracy reflects receiver-operating characteristics area under the curve (95% confidence interval) for a composite measure of cardiac arrest, intensive care unit transfer, and
mortality.
Abbreviations: CART, Cardiac Arrest Risk Triage; IHCA, in-hospital cardiac arrest; MEWS, Modified
Early Warning System; SEWS, Standardized Early Warning System; ViEWS, VitalPAC Early Warning
System.
Data from Churpek MM, Yuen TC, Edelson DP. Risk stratification of hospitalized patients on the
wards. Chest 2013;143(6):1762, 1763.
In recent decades interest emerged in team-based care for patients with trauma,
myocardial infarction, and stroke, because evidence indicated that early intervention
for these conditions could improve patient outcomes. Following the publication of
early goal-directed treatment strategies for sepsis, it became apparent that an
increasing number of hospitalized patients might benefit from intervention early in
the course of clinical deterioration.3 In the 2000s, RRTs emerged to help these patients. These teams are typically composed of physicians, nurses, and respiratory
therapists, at least some of whom have training in advanced cardiovascular life
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support and critical care.27 In 2005, the Institute for Healthcare Improvement included
RRTs as one of six recommendations to improve health care quality.28 The years after
this recommendation saw rapid proliferation of RRTs throughout hospitals in developed countries.
Although it seems intuitive that these teams would help to improve outcomes, the
data on RRTs are complex, with most available evidence showing that RRT strategy
has reduced the incidence of cardiac arrest outside of the ICU without necessarily
altering overall hospital mortality.12 These studies face significant methodologic challenges. Most use a before-and-after design following implementation of a hospitalwide RRT. Before-and-after studies are notoriously difficult to interpret, because
they are confounded by temporal trends and difference in case-mix between the before
and after periods. Perhaps most importantly, it is difficult to reliably capture the extent
to which rapid response systems contribute to early goals-of-care discussions,
thereby preventing the need for resuscitation in patients who are unlikely to derive
long-term benefit. At least one study demonstrated that changes in the goals of care
frequently occur after RRT calls,29 although the degree to which this occurs on a large
scale is unknown. Despite these inconsistencies in the RRT literature, most hospitals in
the United States continue to adopt RRTs based on their strong conceptual rationale.
Given the limitations of RRTs, a second organizational approach is education and
leadership training to improve resuscitation effectiveness (ie, efforts to make response
teams better, be they formal RRTs or informal resuscitation teams). Well-trained
resuscitation teams can improve resuscitation outcomes by facilitating aggressive
fluid resuscitation and other evidence-based treatments. Here, several lessons can
be drawn from the literature on in-hospital cardiac arrest, in which two of the most
important predictors of mortality are delayed defibrillation and interruption of chest
compressions.30 Compared with ad hoc teams, those with prespecified leadership
and organized roles perform earlier defibrillation and maintain greater hands-on
time during simulated arrests.31 Other simulation studies indicate that initial resuscitation by nonphysician first responders may delay defibrillation in arrest.32 Other
important factors may include effective communication or well-defined roles.33 These
findings are supported by observations from in situ surprise simulations of cardiac
arrest on hospital wards, which demonstrate improved quality of cardiopulmonary
resuscitation after arrival of a code team compared with the resuscitation efforts of
the first responder hospital staff.34 The major conclusion from these studies is that it
is not enough for resuscitation teams to simply exist and respond to cardiac arrest;
rather, they must function with good leadership and effective communication.35,36
The strong conceptual model for an impact of high-functioning teams on the quality
of resuscitation efforts begs the question of why this beneficial effect has been difficult
to demonstrate or detect in clinical practice. First, there is a difference between resuscitation from cardiac arrest and triage or treatment of a deteriorating patient, which is
the more typical situation encountered by a RRT. Cardiac arrest care is highly protocolized and algorithm-based, whereas nonarrest resuscitation requires intellectual
nuance that resists protocolization. Another possible explanation often suggested in
the RRT literature is that the monitoring systems in place during the studies may not
identify those patients who would most benefit from care from an RRT. As a result,
RRTs may be called on the wrong patients, or may be called too late to have an
impact. Thus, an important strategy may be to reduce the cultural barriers to calling
an RRT; if bedside nurses are uncomfortable calling for help or afraid of repercussions
from unnecessary calls, an opportunity for early intervention may be missed.37
Another important aspect of the resuscitation team is the leader, who should have
appropriate time, training, and expertise to manage a complex resuscitation.
Substantial data suggest that the presence of a trained intensivist physician is associated with improved outcomes in the ICU.38 Although the exact mechanism of intensivist physician staffing is unknown, it may in part be caused by improved
resuscitation at the bedside.39 For example, adding intensivist physicians to the ICU
increased the chance of receiving a sepsis resuscitation bundle, although these
effects were not statistically significant.40
Here, telemedicine may also play a role. A resuscitation team might have all the
necessary components to deliver high-quality care, but lack an effective leader for coordination and key decision making. Telemedicine could be used to remotely bring an
experienced leader to the team. This approach would be analogous to stroke telemedicine, in which expertise required but not readily available at all hospitals is delivered
remotely as needed rather than all the time.22 If the technology required could be
deployed rapidly, team leaders could review data, coordinate care, and make key
decisions from a remote location, expanding access to this essential component of
hospital-based critical care.
The Feedback Limb: Quality Improvement
The third major organizational approach to improving resuscitation outcomes is quality improvement. Broadly defined, quality improvement is a systematic, data-driven
approach to improving health care processes and outcomes. Quality improvement
in resuscitation systems requires multiple components: data to measure quality
through the process of care (ie, timely arrival and treatment) and outcomes of care
(ie, postresuscitation survival and functional status); feedback mechanisms to present
that data on processes and outcomes back to providers in ways that are meaningful
and actionable; and organizational-based approaches to improve quality based on a
critical interpretation of the data.
The first step is obtaining datathat which cannot be measured cannot be
improved. Without reliable outcome data it is impossible to know whether interventions are having their intended effect. Therefore, all hospitals should ideally maintain
accurate and up-to-date databases of clinical outcomes. Hospitals with RRTs should
maintain data on the frequency of calls, the reasons for the calls, the actions of the
team, and the subsequent outcomes of the patients. These databases are important
for not only broadly measuring resuscitation effectiveness but also identifying targets
for quality improvement, the so-called needs assessment part of the quality
improvement process.13 For example, one hospital seeking to improve outcomes
might find that the RRT teams are not consistently called before arrest, whereas
another hospital might find that fluids are not administered in a timely fashion. These
different findings would lead to different interventions.
In addition to such hospital-wide databases, technologies exist that can provide
real-time quality to resuscitation teams. In cardiac arrest, investigational devices
can be used to monitor the effectiveness of chest compressions and ventilation in
simulated and actual hospital code environments.41 These devices provide immediate
feedback to providers, allowing them to improve the quality of their resuscitation
efforts. This technology is still experimental, and has not yet shown an improvement
in return of spontaneous circulation or survival to hospital discharge. However, early
data suggest that real-time quality monitoring is an important frontier for improving
resuscitation effectiveness.
Another source of data on resuscitation effectiveness is through surveys of
providers. Most simply take the form of semistructured interviews designed to elicit
opportunities for improvement from the perspectives of front-line practitioners.
More advanced approaches involve the used of validated scoring systems for team
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Box 1
Principles for demonstrating and teaching effective leadership
Effective leadership principles
Evaluate existing leadership before interjecting with new leadership
Identify progress aloud and elicit contributions
Identify problems by asking questions that highlight them
As a team leader, avoid direct, hands-on involvement; assign tasks
Facilitate open and effective communication (affirmative statements, closed-loop
communication)
Effective leadership teaching
Explain the importance and impact of leadership
Demonstrate difference in leadership styles
Monitor adherence to leadership principles and algorithms; provide feedback
Facilitate open and effective communication
Speak clearly and concisely
Adapted from Hunziker S, Johansson AC, Tschan F, et al. Teamwork and leadership in cardiopulmonary resuscitation. J Am Coll Cardiol 2011;57(24):23818. http://dx.doi.org/10.1016/j.jacc.
2011.03.017; with permission.
The conceptual model outlined in this article (that of a sensorimotor loop requiring
sensing, action, and feedback) provides a framework for a systems-based approach
to improving resuscitation outcomes. The existing literature lends support to this
model and its components, providing some concrete targets for organizational
approaches to improve resuscitation effectiveness. However, many questions remain
and should be the focus of future research.
Monitoring and Alerts
Although it is tempting to seek improvement in patient outcomes via new, and often
expensive, medical technologies, simple systems-based interventions frequently yield
equal if not greater changes. For decades, critical care research focused on understanding and altering the physiology of sepsis, investing millions of dollars in trials
of various investigational agents. In the end, early and appropriate antibiotics, early
restoration of the circulation, prevention of ICU complications, and the systems
needed to address the failure to achieve those goals proved the most important
aspects of improving outcomes for patients with septic shock. Thus, although the
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last decade has seen a rapid expansion in the understanding of resuscitation physiology, we must not lose sight of the systems necessary to complement innovations
in resuscitation science and improve patient outcomes. This effort requires systems
that identify patients at risk, resuscitation teams with effective leaders who can rapidly
implement high-quality evidenced-based, and feedback mechanisms that identify
changes in patient outcome and facilitate quality improvement in resuscitation
systems.
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