Executive Summary Checklist
Reducing preventable deaths requires a multi-disciplinary, multi-specialty collaborative team. In order to implement a program that will optimize anticipation, identification and resuscitation (AIR) of at-risk patients, an implementation plan to complete the following actionable steps should be followed:
- A multi-disciplinary institutional group, the Resuscitation Outcomes Steering Committee (ROSC; would consider changing the name ROSC to the AIR program as resuscitation comes after anticipation and identification of the at-risk patient to identify what type of resuscitation is needed), should be designated as primarily responsible for the AIR program.
- Early event detection has the greatest impact on outcomes thus the bedside clinicians (afferent arm) education, training, is the first and most important component of reducing failure to rescue.
- A formal mechanism for input data (Afferents) should be identified. This should include both external sources of information, such as guidelines and scientific literature, as well as internal (institutional) data.
- The institutional AIRSC should have input into the Efferent actions in response to Afferent data and perceived institutional resuscitation needs.
- An effective AIR program will engage individual providers and enhance their personal sense of ownership and accountability. Ultimately, this program should become the primary vehicle to reduce preventable deaths and ensure an institutional culture of safety.
- Outcome data should be presented to the hospital medical executive board monthly.
- An organized approach to data collection and performance improvement should target various etiologies of cardiopulmonary arrest with regard to reducing arrest incidence, increasing arrest survival and improving end-of-life discussions with patients and families.
- Institutional resuscitation protocols should consider available evidence, technology, and performance improvement data.
- Provider training should ensure optimal AIR performance and be specific to provider type and clinical unit.
- In the event of Cardiopulmonary arrest, resuscitation should emphasize optimal chest compressions and controlled ventilations as recommended by the AHA in their ACLS protocol.
- Post-resuscitative care should focus on optimizing supportive critical care and consideration of targeted temperature management and early coronary revascularization.
- End-of-life discussions should provide patients and families with compassionate but realistic expectations regarding goals of therapy and various therapeutic options.
- Cardiopulmonary arrest prevention should emphasize early recognition of the deteriorating patient by technology that can present an early warning system.
- Perfusion technologies include sphygmomanometry, ECG, capnometry, clinical assessment (mental status, capillary refill, pulse quality, extremity temperature), pulse oximetry including related perfusion indices, laboratory measures of acidosis (pH, base deficit, lactate, anion gap), and newer modalities (near-infrared spectroscopy, orthogonal polarization, heart-rate variability).
- Oxygenation technologies include pulse oximetry, blood gas analysis, near-infrared spectroscopy, and clinical assessment.
- Ventilation technologies include respiratory volumetrics (tidal volume, respiratory rate), blood gas analysis, capnometry, capnography, apnea monitoring, and clinical assessment.
The Performance Gap
The Institute of Medicine 2001 report on quality in healthcare identified failure to rescue as a key opportunity for improving patient safety, decreasing preventable deaths, and reducing healthcare expenditures \cite{2001}. The recognition that many in-hospital deaths are preventable has resulted in a myriad of patient safety efforts targeting a variety of clinical scenarios and disease states. While some of these have demonstrated promise, hospitals are often overwhelmed with the selection, implementation, and coordination of these efforts. In addition, healthcare professionals are facing an increasing number of required training modules, but with a concerning lack of engagement in each. The segregation or “siloing” of these efforts limits their clinical effectiveness, effectively devolving them into a regulatory requirement driving so-called “compliance innovation” instead of a truly coordinated effort to improve clinical outcomes \cite{Blind}.
The ultimate consequence of failure to rescue is unexpected cardiopulmonary arrest \cite{Schmid_2007}. The primary mechanism for maintaining resuscitation competency remains the American Heart Association life support training courses: Advanced Cardiac Life Support (ACLS) and Basic Life Support (BLS)\cite{20956224}. These courses have several limitations, particularly for in-hospital providers \cite{23479672,or6}:
- ACLS/BLS curricula are heavily based on out-of-hospital cardiac arrest. However, recent evidence documents important differences between out-of-hospital and in-hospital arrest etiologies.
- ACLS/BLS curricula cannot be modified to address institutional continuous quality improvement (CQI) needs.
- Treatment algorithms upon which the ACLS/BLS courses are based cannot incorporate the variety of new technologies that offer tremendous potential to improve outcomes. Finally, there is no emphasis on arrest prevention, which is where the most opportunity exists for improving clinical outcomes in the hospital setting.
An institutional AIR program should target preventable deaths for a particular hospital or healthcare organization. Thus, each of the core elements described below (Steering Committee, Afferents, and Efferents) should reflect and be adapted to that institution. In addition, the core elements should be linked together in an institutional closed-loop performance improvement system.
Advanced Resuscitation Training (ART)
Advanced Resuscitation Training (ART) was developed in 2007 at the University of California at San Diego (UCSD) and represents the archetype for an institutional resuscitation program. The ART program represents a comprehensive system of care that targets the reduction of preventable deaths in both the out-of-hospital and in-hospital environments.6 The ART model links scientific evidence, continuous quality improvement (CQI) data, technology, institutional treatment algorithms, and training (Figure 1). Ownership and accountability are transferred to the institution, enhancing both relevance and engagement.