4. Discussion
Cardiac arrest is a rare but highly fatal presentation
in the ED. Often with little time to prepare, the resuscitation bay can
be a chaotic environment where planned or simulated protocols break
down. This makes high-fidelity quality improvement difficult, but
greatly needed. CoVeRT utilizes video review as a quality improvement
tool to improve metrics associated with increased survival in OHCA, to
enhance resident education, and to develop interdisciplinary team
dynamics in the ED.
Data from Jiang et al. suggests that video review can identify
deficiencies in CPR in the
ED.15
Rolston et al. went further by showing that video review can improve
outcomes and found an associated increased rate of
ROSC.11
We are the first to have demonstrated that video review of OHCA
resuscitation can not only identify areas in need of improvement, but
also enact change and increase compliance with AHA quality metrics. For
example, our data suggest that the video review process was associated
with a significant improvement in pulse check times. The AHA recommends
limiting pulse checks to less than 10 seconds, however, many
resuscitation teams struggle to meet this
metric.17,18
Our data indicate that, with video review, we reduced pulse checks over
time. Although, the overall average of our pulse check time was still
greater than10 seconds. Furthermore, our results indicate an association
between our interventions and a significant increase in CCF. The AHA
recommends a total CCF of greater than 0.80, meaning that chest
compressions occur more than 80% of total resuscitation time. Prior
literature demonstrates improved survival with CCF of 0.6-0.8 in
patients with cardiac arrest due to ventricular
fibrillation.19Our data indicates not only that CCF improved over time with the
establishment of CoVeRT, but also that only one case had a CCF less than
the recommended 0.80.
Time to IV access and time to placement of the monitor are not AHA
quality metrics, and there is no published data on these metrics in CA
resuscitation. However, we consider them important to measure given that
they represent essential components of a well-run resuscitation. Our
data suggests that there was no significant change in these data points
over time. Many patients arrive with an IV already in place.
Additionally, time to IV access is more likely patient- and
operator-dependent. Monitor placement is an essential aspect of any
resuscitation and is one that our nurses and technicians prioritize.
Finally, regarding education, resident members of CoVeRT presented a
total of 14 Grand Rounds lectures. Topics ranged from leadership and
communication, to advanced resuscitation topics such as dual sequential
defibrillation and the use of tPA in cardiac arrest. Group video review
supplemented each lecture in order to allow open discussion of different
perspectives on which aspects went well for each case and which could be
improved upon. Additionally, feedback was sent to each resuscitation
team regarding the metrics for each case. It has been demonstrated that
such audit-feedback techniques are associated with improved performance
by healthcare providers, and, specifically in resuscitation, improved
chest compression performance.20–22