Several critical paradigms lie at the heart of the ART program. The ART Matrix represents a strategy to categorize etiology for each at-risk patient. This facilitates a systematic approach to reducing preventable deaths within each category by targeting prevention as well as effective resuscitation. The Matrix also allows for consolidation of multiple hospital-based patient safety initiatives: sepsis, perioperative respiratory depression and sleep apnea, occult hemorrhage, dysrhythmias, deep venous thrombosis/pulmonary embolus detection and treatment, respiratory distress, neurological emergencies, and general critical care. This integration is crucial for effective hospital leadership, outcomes tracking, and training efficiency. The Matrix is based on the ART Integrated Model of Physiology, which identifies three physiological processes – oxygenation, ventilation perfusion– that define the optimal approach to clinical practice, CQI data collection, technology, and training. Early detection of deterioration is critical for arrest prevention \cite{Nolan_2010}. Most approaches involve a critical tradeoff between sensitivity and specificity, with a measurable incidence of over- or under-utilization of rapid response team resources, limiting overall effectiveness. The ART model employs a stepwise approach to early detection that maximizes both sensitivity and specificity and integrates clinical data, technology, and hospital processes. Each Matrix category is associated with specific static and dynamic risk factors, which in turn suggest particular strategies for vital sign assessment and sensors/technology. Concerning patterns suggesting deterioration trigger a targeted diagnostic and therapeutic approach to both improve specificity and potentially reverse deterioration.
The integrative nature of the ART program is a key component to its effectiveness. In addition to integrating clinical practice, science, technology, CQI, and training, ART also brings together multiple hospital initiatives as discussed above. This allows leadership integration and enhances efficiency. Finally, ART training opportunities provide a conduit to address institutional resuscitation and patient safety needs via regular access to all clinical providers.
The ART program has been successfully implemented at the UCSD as well as the VA Medical Center in San Diego. As a direct result of ART program implementation, arrest incidence has been reduced to 50 percent of baseline values and survival following arrest has doubled and tripled.
Leadership Plan
- Hospital administration and clinical leadership must commit to supporting the development and maintenance of an institutional AIR program, including support for program leadership as well as commitment to provider training.
- AIR Steering Committee (AIRSC): A multi-disciplinary institutional group should be designated as primarily responsible for the program. This group should have both ownership and accountability for outcomes and should have access to afferent data and input into the efferent response.
- Reporting from the institutional AIRSC 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
- Oxygenation
- 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®).
- Perfusion goes here ( copy and paste function did not work sorry)
- Could consider putting in AOVIPPS resuscitation nemonic here
- 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
Arrest Related Death
Arrest Related Death (ARD) is defined as patients not surviving to hospital discharge who receive resuscitative efforts (either CPR or defibrillation).
Outcome Measure Formula
Numerator: Total number of Arrest Related Deaths
Denominator: Total number of admissions
Rate is typically displayed as ARDs/admissions *1000
Metric Recommendations
Direct Impact: Any patient receiving resuscitative efforts
Lives Spared Harm: