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