Objectives Designing a Cardiac Surgery Nurse-Driven Resuscitation Protocol • Describe the development and implementation of the C524 nurse-driven Cardiac Surgery Resuscitation Protocol based on the evidence-based European Resuscitation 2017 ANCC National Magnet Conference Council guideline (Dunning et al., 2009; Soar et al., 2010, Truhlar et al., 2015) Thursday, October 12, 2017, 9:30-10:30 • Identify key elements of the PRISM Implementation Model (Feldstein and Glascow, 2008) used to develop and Presented by: implement the new resuscitation protocol in Melanie Roberts DNP, RN-BC, CNS, CCNS, CCRN collaboration with the cardiothoracic surgeons. UCHealth, Medical Center of the Rockies Loveland, CO • Discuss the process and outcome measures used to determine successful implementation and efficacy of the new resuscitation protocol. Medical Center of the Rockies Problem Background/Significance Tertiary care facility in • 350,000 cardiac surgeries are performed annually in Loveland, CO the U.S. (Centers for Disease Control and Prevention, 2015) 174 beds, Level II • MCR does 450-500 cases per year Trauma and Cardiac • Incidence of perioperative arrest is 1.5%-5.2% with an Service Line associated survival to hospital discharge rate of 48%- 83% (LaPar et al., 2014; Mazeffi et al., 2014; Ngaage & Cowen, 2009) Opened 2007 • MCR had an incidence of arrest of 2.8% • MCR had a survival to discharge of 43% First hospital to implement the Cardiac • Variability exists in both the incidence of Surgery European cardiopulmonary arrest and survival to hospital Resuscitation guideline in discharge rates among different hospitals (LaPar et al., 2014; the state/ region Mazeffi et al., 2014)
Problem Background/Significance Design of the Project ACLS No standard resuscitation protocol • IOWA Model of Evidence-Based Practice to Promote exists in the U.S. that addresses the Quality of Care unique needs of the cardiac surgery • Titler et al., 2001 population: • Overarching model for planning the project • American Heart Association specifically • Process steps states cardiac surgery is a special population with specific resuscitation • Identify the impetus for the practice change Not ACLS needs, but does not provide a guideline • Determine if the topic is a priority for the organization (Vanden Hoek et al., 2010). • Assemble and critique the evidence to determine if it • An international survey of cardiothoracic surgeons found only 32% of surgeons supports the practice change follow current resuscitation • Pilot the practice change recommendations (ACLS) and 25% have • Evaluate the pilot to determine if the practice change should be never read the current guidelines (Adam et al., widely adopted 2009). Design of the Project Review of Literature PRISM (Practical, robust • The European cardiac surgery resuscitation guidelines implementation and sustainability): were originally published by Dunning et al., 2009 : • Feldstein and Glascow, 2008 • An international, systematic review of the literature reviewed by • Model designed for translation of the European Association for Cardio-Thoracic Surgery (EACTS). research into practice in o Case controls and exposed cohort studies healthcare • Surveyed cardiothoracic surgeons for expert opinion (Adam et al., • Guided the specific steps for 2009) process development • Guidelines were developed using the existing evidence and • Key domains for the project clinical expert opinion. • The intervention • Cardiac Surgery Advanced Life Support course • Implementation and sustainability teaches the guideline (Dunning et al., 2006) infrastructure • Guidelines were tested by several expert clinicians in • Organization recipients simulated ICU environments for feasibility and usability. • Evaluation (RE-AIM)
Review of the Literature Review of the Literature • The guideline was subject to peer review when it was published in the European Resuscitation Council Risk Adjusted Mortality Post-Arrest Guideline for Resuscitation 2010: Section 8 --Cardiac Range: 49 – 69% Arrest in Special Circumstances (Soar et al., 2010): • Case controls and exposed cohorts • The guideline was updated in 2015, no changes in content were made (Truhlar et al., 2015). • The European Resuscitation Council guideline represents the best available evidence regarding the resuscitation of cardiac surgery patients suffering cardiac arrest. LaPar et al, 2014 Cardiac Surgery Unit-Advanced Life Support Why Change Practice? versus ACLS CSU-ALS ACLS • Impetus to change practice: Ventricular fibrillation and 3 sequential 1 defibrillation pulseless ventricular tachycardia defibrillations within 1 followed by 2 • Knowledge-focused trigger (Dang et al., 2015; Titler, 2001) minutes of the minutes of chest o Discovery of new evidence dysrhythmia compressions Asystole Emergency pacing within External chest • Problem-focused trigger 1 minute compressions and o Organization context epinephrine o Patient population Symptomatic bradycardia Emergency pacing Atropine, pacing External compressions Rate 100-120, SBP Rate of 100-120, at o Compiled and analyzed data from 2012-2014 greater than 60 mmHg least 2-2.4 inches • The strength of the evidence is moderate to support depth the practice change. Epinephrine None unless ordered by 1 mg every 3-5 CT surgeon, smaller minutes for any doses pulseless rhythm Chest re-opening Within 10 minutes if Not addressed suspect bleeding/ tamponade
MCR Cardiac Surgery Data MCR Data: Incidence of Arrest and Mortality Incidence of Cardiac Arrest by 2012 2013 2014 POD Total number of cardiac surgery 283 325 391 Number of Patients 8 patients 7 Total number of cardiac surgery 12 7 9 Primary Event of Cardiac Arrest 3 3 3 patients who suffer ARREST 2 2 0 1 2 3 4 5 >6 Incidence of ARREST 4.24% 2.15% 2.3% 15 Post Op Day Number of patient who expired with 8 3 5 7 ARREST 5 5 Incidence of Cardiac Arrest by Percent survival to discharge for those 33% 57% 44% Location PVT/VF ASYSTOLE/BRADY PEA who suffer arrest Primary Event Number of Patients Tamponade/Bleeding Number of Patients 16 Average incidence of arrest = 2.8% Average survival to discharge= 42.8% Of the patients reviewed, 85% would 4 4 2 qualify for CSU-ALS OR CICU PCU 3 SOUTH Location by Unit Project Objectives Organization Characteristics (Recipients) • Develop a nurse-driven cardiac surgery resuscitation • Financial commitment of the organization to the protocol based on the most recent evidence project • Develop a database to track cardiac surgery patient • Cardiovascular Service Line Director and Clinical arrests Director for Critical Care • Evaluation of process and outcome measures • Required for the project to move forward • Go live for the practice change, February 15, 2016 • Approximate cost of the project $16,600 • Education of staff • Clinical leadership (providers and administration) • Management support
Organization Approval Organization Perspective (Intervention) Process Critical Care Services • Strength of the evidence Cardiovascular Service Line Critical � Care � Committee � (Nov,2015) • Organizational readiness Cardiovascular � Service � Code � Blue � Committee � • Alignment with organization’s strategic goals, mission, Line � Steering � (Resuscitation � Committee, � Committee � (Oct,2015) Oct,2015) and stage of development Meet � with � Chief � Medical � Officer � and � Chief � Quality � • Barriers of the front line staff Officer � (Oct, � 2015) Cardiovascular � Service � • Focus groups to define workflow Line � Quality � Committee � (Sept,2015) • Usability and adaptability Cardiovascular � Surgeons � • Debriefs to make any necessary changes group � meeting � (Aug,2015) • Trialability and reversibility Discussion � with � Critical � Care � Services � Director � & � Cardiovascular � Service � Line � • Observability (dashboard) Senior � Director � (Aug � ,2015) • Burden (complexity and cost) Discussion � with � Critical � Care � Services � Director � Discussion � with � Surgical � (Mar,20 � 15) • Coordination across departments Director � for � Cardiovascular � Surgery �� (Oct,2014) Time Project Design (August- December 2015) Project Design (August-December 2015) Implementation and sustainability Implementation and sustainability (cont) • A dedicated team (CNS, Cardiovascular NP) • Adaptable protocols and procedures developed in • Adopter training and support collaboration with the cardiothoracic surgeons • 8 hour course • Development of cardiac surgery resuscitation procedure • Modified course • Workflow • Provider training • Resuscitation roles • Mock codes • Developed Cardiac Surgery Code Team • Financial resources • Emergency sternotomy equipment/cart • Key personnel & stakeholders • Resuscitation orders embedded in the postoperative cardiac surgery order set • IRB
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