Objectives Designing a Cardiac Surgery Nurse-Driven Resuscitation - - PDF document

Designing a Cardiac Surgery Nurse-Driven Resuscitation Protocol C524

2017 ANCC National Magnet Conference

Thursday, October 12, 2017, 9:30-10:30 Presented by: Melanie Roberts DNP, RN-BC, CNS, CCNS, CCRN UCHealth, Medical Center of the Rockies Loveland, CO

Objectives

• Describe the development and implementation of the

nurse-driven Cardiac Surgery Resuscitation Protocol based on the evidence-based European Resuscitation Council guideline (Dunning et al., 2009; Soar et al., 2010, Truhlar et al., 2015)

• Identify key elements of the PRISM Implementation

Model (Feldstein and Glascow, 2008) used to develop and implement the new resuscitation protocol in collaboration with the cardiothoracic surgeons.

• Discuss the process and outcome measures used to

determine successful implementation and efficacy of the new resuscitation protocol.

Medical Center of the Rockies

Tertiary care facility in Loveland, CO 174 beds, Level II Trauma and Cardiac Service Line Opened 2007 First hospital to implement the Cardiac Surgery European Resuscitation guideline in the state/ region

Problem Background/Significance

• 350,000 cardiac surgeries are performed annually in

the U.S.(Centers for Disease Control and Prevention, 2015)

• MCR does 450-500 cases per year
• Incidence of perioperative arrest is 1.5%-5.2% with an

associated survival to hospital discharge rate of 48%- 83% (LaPar et al., 2014; Mazeffi et al., 2014; Ngaage & Cowen, 2009)

• MCR had an incidence of arrest of 2.8%
• MCR had a survival to discharge of 43%
• Variability exists in both the incidence of

cardiopulmonary arrest and survival to hospital discharge rates among different hospitals (LaPar et al., 2014;

Mazeffi et al., 2014)

Problem Background/Significance

ACLS No standard resuscitation protocol exists in the U.S. that addresses the unique needs of the cardiac surgery population:

• American Heart Association specifically

states cardiac surgery is a special population with specific resuscitation needs, but does not provide a guideline

(Vanden Hoek et al., 2010).

• An international survey of cardiothoracic

surgeons found only 32% of surgeons follow current resuscitation recommendations (ACLS) and 25% have never read the current guidelines (Adam et al.,

2009).

Not ACLS

Design of the Project

• IOWA Model of Evidence-Based Practice to Promote

Quality of Care

• Titler et al., 2001
• Overarching model for planning the project
• Process steps
• Identify the impetus for the practice change
• Determine if the topic is a priority for the organization
• Assemble and critique the evidence to determine if it

supports the practice change

• Pilot the practice change
• Evaluate the pilot to determine if the practice change should be

widely adopted

Design of the Project

PRISM (Practical, robust implementation and sustainability):

• Feldstein and Glascow, 2008
• Model designed for translation of

research into practice in healthcare

• Guided the specific steps for

process development

• Key domains for the project
• The intervention
• Implementation and sustainability

infrastructure

• Organization recipients
• Evaluation (RE-AIM)

Review of Literature

• The European cardiac surgery resuscitation guidelines

were originally published by Dunning et al., 2009:

• An international, systematic review of the literature reviewed by

the European Association for Cardio-Thoracic Surgery (EACTS).

• Case controls and exposed cohort studies
• Surveyed cardiothoracic surgeons for expert opinion (Adam et al.,

2009)

• Guidelines were developed using the existing evidence and

clinical expert opinion.

• Cardiac Surgery Advanced Life Support course

teaches the guideline (Dunning et al., 2006)

• Guidelines were tested by several expert clinicians in

simulated ICU environments for feasibility and usability.

Review of the Literature

• The guideline was subject to peer review when it was

published in the European Resuscitation Council Guideline for Resuscitation 2010: Section 8 --Cardiac 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.

Review of the Literature

Risk Adjusted Mortality Post-Arrest Range: 49 – 69%

LaPar et al, 2014

Cardiac Surgery Unit-Advanced Life Support versus ACLS

CSU-ALS ACLS Ventricular fibrillation and pulseless ventricular tachycardia 3 sequential defibrillations within 1 minutes of the dysrhythmia 1 defibrillation followed by 2 minutes of chest compressions Asystole Emergency pacing within 1 minute External chest compressions and epinephrine Symptomatic bradycardia Emergency pacing Atropine, pacing External compressions Rate 100-120, SBP greater than 60 mmHg Rate of 100-120, at least 2-2.4 inches depth Epinephrine None unless ordered by CT surgeon, smaller doses 1 mg every 3-5 minutes for any pulseless rhythm Chest re-opening Within 10 minutes if suspect bleeding/ tamponade Not addressed

Why Change Practice?

• Impetus to change practice:
• Knowledge-focused trigger (Dang et al., 2015; Titler, 2001)
• Discovery of new evidence
• Problem-focused trigger
• Organization context
• Patient population
• Compiled and analyzed data from 2012-2014
• The strength of the evidence is moderate to support

the practice change.

MCR Data: Incidence of Arrest and Mortality

Average incidence of arrest = 2.8% Average survival to discharge= 42.8% Of the patients reviewed, 85% would qualify for CSU-ALS 2012 2013 2014 Total number of cardiac surgery patients 283 325 391 Total number of cardiac surgery patients who suffer ARREST 12 7 9 Incidence of ARREST 4.24% 2.15% 2.3% Number of patient who expired with ARREST 8 3 5 Percent survival to discharge for those who suffer arrest 33% 57% 44%

MCR Cardiac Surgery Data

4 16 4 2 OR CICU PCU 3 SOUTH Number of Patients Location by Unit

Incidence of Cardiac Arrest by Location

7 3 2 3 3 2 8 1 2 3 4 5 >6 Number of Patients Post Op Day

Incidence of Cardiac Arrest by POD

7 5 15 5 PVT/VF ASYSTOLE/BRADY PEA Primary Event

Primary Event of Cardiac Arrest

Number of Patients Tamponade/Bleeding

Project Objectives

• Develop a nurse-driven cardiac surgery resuscitation

protocol based on the most recent evidence

• Develop a database to track cardiac surgery patient

arrests

• Evaluation of process and outcome measures
• Go live for the practice change, February 15, 2016

Organization Characteristics (Recipients)

• Financial commitment of the organization to the

project

• Cardiovascular Service Line Director and Clinical

Director for Critical Care

• Required for the project to move forward
• Approximate cost of the project $16,600
• Education of staff
• Clinical leadership (providers and administration)
• Management support

Organization Perspective (Intervention)

• Strength of the evidence
• Organizational readiness
• Alignment with organization’s strategic goals, mission,

and stage of development

• Barriers of the front line staff
• Focus groups to define workflow
• Usability and adaptability
• Debriefs to make any necessary changes
• Trialability and reversibility
• Observability (dashboard)
• Burden (complexity and cost)
• Coordination across departments

Organization Approval Process

Time DiscussionwithSurgical DirectorforCardiovascular Surgery(Oct,2014) DiscussionwithCritical CareServicesDirector& CardiovascularServiceLine SeniorDirector(Aug,2015) DiscussionwithCritical CareServicesDirector (Mar,2015) CardiovascularSurgeons groupmeeting (Aug,2015) CardiovascularService LineQualityCommittee (Sept,2015) MeetwithChiefMedical OfficerandChiefQuality Officer(Oct,2015) CardiovascularService LineSteering Committee(Oct,2015) CodeBlueCommittee (ResuscitationCommittee, Oct,2015) CriticalCareCommittee (Nov,2015)

Cardiovascular Service Line Critical Care Services

Project Design (August-December 2015)

Implementation and sustainability

• A dedicated team (CNS, Cardiovascular NP)
• Adopter training and support
• 8 hour course
• Modified course
• Provider training
• Mock codes
• Financial resources
• Key personnel & stakeholders
• IRB

Project Design (August- December 2015)

Implementation and sustainability (cont)

• Adaptable protocols and procedures developed in

collaboration with the cardiothoracic surgeons

• Development of cardiac surgery resuscitation procedure
• Workflow
• Resuscitation roles
• Developed Cardiac Surgery Code Team
• Emergency sternotomy equipment/cart
• Resuscitation orders embedded in the postoperative

cardiac surgery order set

Evaluation

• Reach
• Efficacy
• Survival to discharge, goal of 65%
• Incidence of arrest
• Unintended consequences
• Adoption
• Not measured, all clinicians did not have the opportunity
• Implementation
• Time to intervention (simulated and clinical environment)
• Statistical analysis for pre-course/post-course times
• Debriefs and interviews
• Maintenance
• Process and outcome measures

Results: Time to Intervention

SIMULATION ENVIRONMENT

Case Scenario Pre- course mean Pre- course median Pre- course range Post- course mean Post- course median Post- course range

Asystole 77.67 66 51-180 20.11 12* 6-58 pVT/VF 185.56 190 146-223 40.11 37* 7-69 PEA #1 60.75 58.5 30-87 42.67 42 32-51 PEA #2 185.56 198 176-228 128.56 123* 105-165

Note: All times are in seconds; the (*) denotes post-course times significantly lower than pre-course times in seconds; PEA= pulseless electrical activity; pVT/VF= pulseless ventricular tachycardia/ventricular fibrillation.

Statistical Analysis

Group Statistical Results

Asystole V=45, p=0.0039 pVT/VF V=45, p=0.0091 PEA #1 V=45, p=0.0547 PEA #2 V=32, p=.0039

• Wilcoxon signed rank test was used because of the

small sample (n=9) did not meet the assumption of normality of the dependent t test.

• Pre-course and post-course times were compared

within the same group, testing for change

Results: Time to Intervention

Mock Codes

Intervention Mean time to intervention Median time to intervention

Defibrillation #1 20.71 18.5 Defibrillation #2 31.69 28 Defibrillation #3 42.77 37 Epinephrine dosing 66.77 60 Chest reopening 191.64 180

Note: All times are in seconds.

Results: Time to Intervention

Clinical Environment

Process Measures # of patients who received intervention # of pts who required intervention Compliance rate Average time to intervention

Pacing for bradycardia 9 9 100% 24 sec Epinephrine 100 mcg for extreme hypotension 9 9 100% UTA Defibrillate 200 joules x 3 1 1 100% UTA Appropriate chest compressions 2 4 50% 20 sec Chest reopening NA

MCR Data: Incidence of Arrest and Mortality

2012 2013 2014 2015 2016 Total number of cardiac surgery patients

283 325 391 389 374

Total number of cardiac surgery patients who suffer arrest

12 7 9 9 6

Incidence of ARREST

4.24% 2.15% 2.3% 2.3% 1.60%

Number who expired with arrest

8 3 5 4 6

Percent survival to discharge for those who suffer ARREST

33% 57% 44% 55% 0%

Total number of cardiac surgery patients who suffer an EVENT

NA NA NA 2 13

Survival to discharge for cardiac surgery patient EVENTS

NA NA NA 50% 100%

Total survival to discharge for events and arrests

NA NA NA NA 68%

(13/19)

MCR Data: 2015 & 2016 Drilldown

2015 n (%) 2016 n (%) Total number of cardiac surgery PATIENTS suffering arrest or events

11 19

Number of ARRESTS

15 6

Number of EVENTS

2 18

Pulseless electrical activity

8 (47%) 5 (21%)

Asystole

2 (12%) 1 (4%)

pVT/VF

5 (29%) 1(4%)

Respiratory

1 (6%)

Bradycardia with hypotension

1(6%) 10 (42%)

Hypotension

7 (29%)

Chest compressions (per PATIENT)

8 (73%) 6 (32%)

Chest compressions (per EVENT)

14 (82%) 6 (25%)

Note: Prior to CALS training severe bradycardia and hypotension was not documented unless it was the precursor to PEA or asystole.

Evaluation of the Change

• Maintenance refers to the extent to which the practice

becomes part of routine practice (Glascow et al., 2015)

• The most important criteria to determine maintenance

was the effectiveness of the practice change:

• Reach
• Time to interventions in the clinical setting
• Decrease incidence of arrest (1.60% from 2.8%)
• Decrease percentage of patients receiving chest

compressions

Implications/Summary

• The most important implication is the ability
• f the nurse to avert arrest with the nurse-

driven protocol.

• Discovery of the actual time to intervention

in the critical care units and the implications in future resuscitation science.

• Further data analysis is needed to

determine the “survivability” of the patient’s suffering cardiac arrest after cardiac surgery.

• Collaboration and teamwork were required

to implement this complex practice change.

• Expansion of the practice change within the
• rganization and the system.

Questions?

References

Adam, Z., Safwaan, A., Everngam, R.L., Oberteurffer, R.K., Levine, A., Strang, T, …Dunning, J. (2009). Resuscitation after cardiac surgery: Results of an international study. European Journal of Cardio- Thoracic Surgery, 36, 29-34. doi:1016/j.ejcts.2009.02.050. Centers for Disease Control and Prevention 2015 FastStats Inpatient SurgeryCenters for Disease Control and Prevention. (2015, April 29). FastStats Inpatient Surgery. Retrieved fromhttp://www.cdc.gov/nchs/fastats/inpatient- surgery.htm Dunning, J., Fabbri, A., Kolh, P. H., Levine, A., Lockowandt, U., Mackay, J.,...Nashef, S. A. (2009). Guideline for resuscitation in cardiac arrest after cardiac surgery. European Journal of Cardio-Thoracic Surgery, 36, 3-28. DOI:10.1016/j.ejcts.2009.01.033. Dunning, J., Nandi, J., Arrifiin, S., Jerstice, J., Danitsch, D., & Levine, A. (2006). The Cardiac Surgery Advanced Life Support Course (CALS): Delivering significant improvements in emergency cardiothoracic care. Annals of Thoracic Surgery, 81, 1767-1772. DOI:10.1016/j.athoracsur.2005.12.012. Feldstein, A. C., & Glasgow, R. E. (2008). A Practical, Robust, Implementation and Sustainability Model (PRISM) for integrating research findings into practice. The Joint Commission Journal

• n Quality and Patient Safety, 34(4), 228-242.

Khera, R., Chan, P.S., Donnino, M.W., &Girotra, S. (2016). Hospital variation in time to epinephrine for non-shockable, in-hospital cardiac arrest. Circulation, 134, 2105-2114. DOI: 10.1161/CIRCULATIONAHA.116.025459.

References

LaPar, D. J., Ghanta, R. K., Kern, J. A., Crosby, I. K., Rich, J. B., Speir, A. M.,...Ailawadi, G. (2014). Hospital variation in mortality from cardiac arrest after cardiac surgery: An opportunity for improvement. Annals of Thoracic Surgery, 98, 534-

• 540. DOI: 10.116/j.athoracsur.2014.03.030.

Mazzeffii, M., Zivot, J., Buchman, T., & Halkos, M. (2014). In-hospital mortality after cardiac surgery: Patient characteristics, timing, and association with postoperative length of intensive care and hospital stay. Annals of Thoracic Surgery, 97, 1220-1226. DOI: 10.1016/j.athoracsur.2013.10.040 Ngaage, D. L., & Cowen, M. E. (2009). Survival of cardiorespiratory arrest after coronary artery bypass graft and aortic valve

• surgery. Annals of thoracic surgery, 88, 64-69. DOI: 10.1016/j.athoracsur.2007.12.035

Soar, J., Perkins, G. D., Abbas, G., Alfonzo, A., Barelli, A., & Bierens, J. J.,...Nolan, J. P. (2010). European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances. Resuscitation, 81, 1400-

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Titler, M., Kleiber, C., Steelman, V., Rakel, B. A., Budreau, G., Everett, L.Q….Goode, C.J. (2001). The Iowa model of evidence-based practice to promote quality care. Critical Care Nursing Clinics of North America, 13(4),497-509. Truhlar, A., Deakin, C. D., Soar, J., Khalifa, G.E., Alfonzo, A., Bierens, J., …Nolan, J. P. (2015). European Resuscitation Council guidelines for resuscitation 2015: Section 4. Cardiac arrest in special circumstances. Resuscitation, 95, 148-

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