Leadership Plan
- Hospital administration and clinical leadership must commit to supporting the development and maintenance of an institutional resuscitation program, including support for program leadership as well as commitment to provider training.
- Resuscitation Outcomes Steering Committee (ROSC): A multi-disciplinary institutional group should be designated as primarily responsible for the resuscitation program. This group should have both ownership and accountability for resuscitation outcomes and should have access to afferent data and input into the efferent response.
- Reporting from the institutional ROSC should be upward to institutional leaders; horizontal to other committees, hospital units, and service lines; and downstream to providers.
- ART program implementation is based on the principles of the Society of Hospital Medicine’s Mentored Implementation Program, which has demonstrated effective change management in multiple patient safety initiatives.\cite{APSS10Cite8}
- Of note, the UCSD ART program – including support for MD and RN leaders –reduced life support expenditures by 25 percent.
- Additional infrastructure support may be provided by patient safety and risk management entities.
- Clinical leadership, particularly for critical care, nursing, and emergency services, must endorse the general principles of the ART program and commit their providers to regular training.
- Financial support should be provided by administration. This may exist as supplemental training, which would require new expenditures.
- Alternatively, tremendous cost savings may exist with reallocation of existing life support and other training toward an ART program.
- An effective resuscitation program will engage individual providers and enhance their personal sense of ownership and accountability. This can be accomplished by engagement and public support of the institutional ROSC and their activities by hospital leaders, broad representation on the institutional ROSC by various hospital groups, effective modification of training content to address provider-specific needs and issues, and routine feedback of institutional resuscitation data. Ultimately, this program should become the primary vehicle to reduce preventable deaths and ensure an institutional culture of safety.
Practice Plan
- The ART philosophy is of “adaptive” training, which allows provider subgroups – based on provider type (MD, RN, pharmacist, RT) and practice unit – to receive training relevant to their patient population, resources, and role expectations.
- Develop an institutional treatment algorithm and simulation training help reintegrate providers who have received this adaptive training.
- The treatment algorithm is based on institutional capabilities, technology, CQI needs, and clinical leader interpretation of scientific evidence.
- Simulation combines cognitive and psychomotor skills and allows integration and teamwork training, including optimal communication.
- The ART approach to CQI defines specific data elements that identify opportunities for training and algorithm modification. In addition, CQI efforts document clinical outcomes, which are relayed back to providers to enhance ownership and accountability.
- Various aspects of critical care, technical procedures, and surveillance should be recalibrated to utilize ART paradigms and terminology. This affords efficiencies with regard to training and enhances clinical performance and recall during stressful resuscitation events.
- The ART approach to risk factor assessment – both static and dynamic – should be embedded into patient care records and hospital policies and procedures to “institutionalize” the integrated approach to surveillance and monitoring.
Technology Plan
Suggested practices and technologies are limited to those proven to show benefit or are the only known technologies with a particular capability. As other options may exist, please send information on any additional technologies, along with appropriate evidence, to info@patientsafetymovement.org. - One of the core ART philosophies is the integration of technology into clinical practice, CQI, and training.
- In this regard, the ART program has been highly effective not only in facilitating this integration but also in documenting clinical effectiveness.
- An institutional resuscitation program facilitates modification to clinical algorithms based on available technology as well as training to optimize clinical application. This is critically important in resuscitation, where time is limited to interpret and respond to vital sign and sensor data. This underscores the importance of user interfaces that assist clinical interpretation of data and pattern recognition as well as response to therapy.
- Integration of physiological data with the institutional operational response is also important to assure optimal and timely allocation of clinical resources and prevention of morbidity and mortality. This is another critical element of an ART program.
- The ART Integrated Model of Physiology identifies three physiological processes that provide a framework for clinical practice, training, CQI data collection, and technology:
- Perfusion
- 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).
- Adhesive pulse oximetry sensor connected with pulse oximetry technology proven to accurately measure through motion and low perfusion to avoid false alarms and detect true physiologic events, with added importance in care areas without minimal direct surveillance of patients (in a standalone bedside device or integrated in one of over 100 multi-parameter bedside monitors).\cite{Taenzer_2010,Shah_2012}
- Oxygenation technologies include pulse oximetry, blood gas analysis, near-infrared spectroscopy, and clinical assessment.
- Implement noninvasive and continuous hemoglobin monitoring.\cite{APSS10Cite11,APSS10Cite12} SpHb® adhesive sensors connected to Masimo® Radical-7® with SpHb, or a multi-parameter patient monitor with SpHb, including but not limited to the Dräger® M540/Infinity Acute Care System, Welch Allyn® CVSM, Fukuda Denshi® 8500, Saadat® Aria and Alborz monitors, BMEYE® ccNexfin, and more.
- Ventilation technologies include respiratory volumetrics (tidal volume, respiratory rate), blood gas analysis, capnometry, capnography, apnea monitoring, and clinical assessment.
- Ability to accurately measure changes in respiratory rate and cessation of breathing with optimal patient tolerance and staff ease of use in order to avoid false alarms, with added importance in care areas without minimal direct surveillance of patients (such as Masimo® rainbow Acoustic Monitoring or sidestream end tidal carbon dioxide monitoring such as Oridion®, Phasein®, or Respironics®).
- Integration of various vital signs and sensor data is facilitated through ART education, which identifies various patterns associated with deterioration from Matrix-specific categories.
- Remote monitoring with direct clinician alert capability compatible with pulse oximetry technology compatible with recommended pulse oximetry technology (Masimo® Patient SafetyNet™ or comparable multi-parameter monitoring system).
- Direct clinician alert through dedicated paging systems or hospital notification system.
- Future technologies should focus on the user interface for monitors/sensors to facilitate pattern recognition as well as measuring the therapeutic response in real time.
Metrics
Topic 1
Arrest Incidence Rate
Incidence of patients suffering cardiopulmonary arrest (typically expressed per 1000 admissions)
Outcome Measure Formula
Numerator: Number of patients with an arrest (excluding non-admitted ED patients and arrests occurring in the OR) x 1000
Denominator: Number of admissions over the same time period
Metric Recommendations
Indirect Impact: All admitted patients
Direct Impact: All admitted patients
Lives Spared Harm:
\(\frac{Lives\ =\ \left(Arrest\ Incidence\ Rate_{baseline}\ -\ Arrest\ Incidence\ Rate_{measurement}\right)\ x\ Admissions_{baseline}}{1000}\)
Notes:
An arrest is defined as the loss of vital signs requiring either CPR or defibrillation in a patient who is not “Do Not Attempt Resuscitation” at the time of the arrest. An arrest does not require Code Blue team activation. Patients surviving an initial resuscitation attempt but with a later change in code status should be included. Each patient should only be counted once per admission—even if multiple arrest events occur prior to discharge or death.
Data Collection:
Electronic capture from electronic medical record and/or chart review.
Topic 2