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Creating a High-Performance Resuscitation System

Paris Hotel and Casino  Las Vegas, Nevada. Joseph P. Ornato , MD, FACP, FACC, FACEP Professor & Chairman, Dept. of Emergency Medicine Professor, Internal Medicine (Cardiology) Virginia Commonwealth University Health System Operational Medical Director Richmond Ambulance Authority

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Creating a High-Performance Resuscitation System

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  1. Paris Hotel and Casino  Las Vegas, Nevada Joseph P. Ornato, MD, FACP, FACC, FACEP Professor & Chairman, Dept. of Emergency Medicine Professor, Internal Medicine (Cardiology) Virginia Commonwealth University Health System Operational Medical Director Richmond Ambulance Authority Richmond Fire & EMS Henrico County Division of FireRichmond, VA Creating a High-PerformanceResuscitation System

  2. Disclosure Information Joseph P. Ornato, MD, FACP, FACC, FACEP • Creating a High-Performance Resuscitation System FINANCIAL DISCLOSURE: • Cardiac Co-Chair & Consultant: NIH Resuscitation Outcomes Consortium (ROC) • American Editor, Resuscitation • Advisory Board, Key Technologies, Inc. (Transnasal Cooling Device) UNLABELED/UNAPPROVED USES DISCLOSURE: • Wriskwatch™, Emergency Medical Technologies

  3. Creating a High-Performance Resuscitation System • Accurate data • Prevention • Implementing effective community systems of care • Changing research funding priorities • Breakthrough approaches • Detecting unwitnessed OOH cardiac arrest • Effective therapy for pulseless electrical activity (PEA) • Adapting principles & practices from high performance industries

  4. Accurate Data

  5. Cardiac arrest data ROC • No national U.S.registry • Data sources • NIH Resuscitation Outcomes Consortium (ROC) • 8 U.S., 3 Canadian sites • Research sites • Epistry • CDC Cardiac Arrest Registry to Enhance Survival (CARES) • 46 communities in 31 states & DC • Voluntary sites CARES

  6. Public Health Burden of Cardiac ArrestHeart Disease and Stroke StatisticsGo et al. Circulation. 2013;127:e6-e245 Acute Myocardial Infarction Out-of-hospital Cardiac Arrest • 720,000 cases per year in the USA • 21% of these are “silent” • 73% of MI deaths occur out-of-hospital (i.e., cardiac arrests) • In-hospital mortality rate= 4.6% • 359,400 out-of-hospital cardiac arrest cases per year in the USA • 23% have an initial documented CA rhythm of VF • Out-of-hospital mortality rate= 90.5% In-hospital deaths/year Out-of-hospital deaths/year Cardiac Arrest MI 10 x more deaths/year from OOH-CA than MI

  7. Prevention

  8. Challenges in SCD PreventionMyerburg et al. JACC 2009; 54:747-63 MADIT I, MUSTT AVID, CIDS, CASH MADIT II, SCD-HeFT

  9. Implementing Community Systems of Care

  10. Regional variation in OOH-CA survival Resuscitation Outcomes Consortium (ROC)Nichol et al. JAMA 2008; 300:1423-31

  11. ROC all-site survival over time(Unadjusted) WitnessedVT/VF VT/VF EMS treated PEA Asystole

  12. Guiding Principles for Regionalization of Post-Arrest Care • Patient centered care • High quality care that is safe, effective, and timely • Stakeholder consensus on systems infrastructure • Increased operational efficiencies • Measurable patient outcomes • Evaluation mechanism to ensure that quality of care measures reflect changes in evidence-based research • A role for local community hospitals so as to avoid a negative impact that could eliminate critical access to local healthcare • Reduction in disparities of healthcare delivery

  13. AHA Mission Lifeline Ideal System

  14. Enhanced 911 system Scripted pre-arrival instructions Advanced system status management GPS automated vehicle locators on all units with dynamic GPS navigation Fire AED first response <5 min ALS on-scene Median 5-6 min 93-96% in ≤8 min 12-lead ECGs, capnography,pulse oximetry, AutoPulse™ Richmond EMS System MARVLIS TrafficImpedance Monitor

  15. Resuscitation strategy approach Optimize blood flow/oxygen delivery Vasopressor support Autopulse™ CPR with continuous chest compression No interruptions of CPR for defibrillation Shorten the time to airway & drug therapy King LTS™ EZ-IO™ Protect the brain & heart Pre-hospital therapeutic hypothermia during & post-arrest Regionalized post-resuscitation center care

  16. Advanced ResuscitationCooling Therapeutics Intensive Care • ARCTIC Alert from field • VCU never on diversion for ARCTIC pts • ARCTIC Team • ED physician and nurse • ARCTIC attending (only 5) • CCU / interventional fellow • CCU NP • RN Coordinator • Inclusion criteria for ARCTIC • Comatose or unable to follow verbal commands • Initial rhythm VF, or • Initial rhythm witnessed PEA or ASYS • Exclusion criteria • DNAR, terminal illness • Shock unresponsive to vasopressors • Uncontrolled bleeding

  17. VCU’s ARCTIC Regionalized System of Care for OHCA Advanced ResuscitationCooling Therapeutics Intensive Care “Induction Center Concept” • EM focuses on stabilizing patient • Initiates early goal directed therapy • CICU/cathteam places cooling catheter and continues standardized post-arrest care • Endovascular cooling strategy with 5 dedicated machines • Continuous EEGs with aggressive seizure Rx • In-hospital ECMO 24/7 • Patients admitted to only one ICU (CICU) with specially trained, dedicated ARCTIC nurse staffing • Electronic order sets & personal checklists • 72-hour pathway for goal directed therapy • Full time RN ARCTIC coordinator • CICU NP • Clinical consistency • Multidisciplinary ongoing education process • EMS and satellite hospital feedback on all cases • Continuous quality review of data and ongoing evidence based system changes

  18. Detailed neuro-cognitive testing & brain injury rehabilitation program • Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) • Immediate memory • List learning • Store memory • Visuospatial / constructional orientation • Complex figure copy / trail making • Line orientation • Language • Picture naming • Semantic fluency • Attention • Digit spanning • Coding • Delayed memory • Recall of above • Beck Depression Scale • Brain injury rehabilitation • 3 and 6 month neuro-cognitive testing

  19. Neuro-cognitive issues • CPC is not accurate in assessing true neurocognitive function • Short term memory deficit • Profound • Transient • Variable resolution • “Reverse PTSD” • “Flock back behavior” • Question ability to return to work • Family stress and re-integration

  20. Changing Research Funding Priorities

  21. Reasons for the paucity of SCD funding and research • Misperception that SCD is largely an untreatable problem • Most of the existing therapies are generic, patent unprotected drugs or devices • Few novel, patented-protected pharmaceuticals are in the pipeline • Funding circle paradox Investigator perception of little NIH interest in topic NIH perception of little investigator interest in topic Few grant applications

  22. Need for Cardiac Arrest ResearchOrnato JP, Becker LB, Weisfeldt ML, Wright BA. Circulation 2010:1876-9

  23. NIH Resuscitation Outcomes Consortium (ROC) 2005-15 ROC • First large-scale, governmentally-sponsored, North American effort to conduct definitive pre-hospital, randomized clinical trials in out-of-hospital cardiac arrest (OHCA) and severe traumatic injury • Focus is on very early delivery of interventions by EMS providers, when there is optimal potential for benefit

  24. ROC clinical trials (2003-14)

  25. ROC accomplishments (2003-14) • Publications • 54 abstracts at national meetings • AHA, ReSS, NAEMSP, SAEM • 58 peer-reviewed publications • Change in medical practice • AHA/ILCOR Resuscitation Guidelines (GL) • 15 GL worksheets • 31 chapters in CPR GLs • 7 additional publications • 41 consensus panel statements • ROC is the key data source for OHCA • New hypotheses & funding • 490 additional resuscitation & trauma publications by ROC PI’s and its leadership (2003-12) • Additional grants - 10 NIH, 9 DOD, 1 CDC, 31 other

  26. Breakthrough Approaches:Unwitnessed Cardiac Arrest

  27. The challenge of unwitnessed OOH-CA Ambient Intelligence

  28. Detection of the unwitnessed OOH-CA • Wriskwatch™ • Emergency Medical Technologies, N Miami Beach, Florida • http://www.emergencymedtech.com

  29. Breakthrough Approaches:Pulseless Electrical Activity (PEA)

  30. Pulseless electrical activityParadis NA et al. Resuscitation 2012; 83:1287-91 • 8 domestic Yorkshire swine • PEA induced by ventilation with a hypoxic mixture • Autopulse™ synchronized compressions applied

  31. Breakthrough Approaches:Adapting Principles & Practices from High Performance Industries

  32. Aviation vs. resuscitationOrnato JP, Peberdy MA. Resuscitation 2014; 85:173-6 Phases of Flight Phases of Resuscitation

  33. Aviation & resuscitation are team effortsOrnato JP, Peberdy MA. Resuscitation 2014; 85:173-6

  34. What’s different about aviation?Ornato JP, Peberdy MA. Resuscitation 2014; 85:173-6 • Pilots understand that flying is a privilege • Aviation functions in a rigorous culture of safety • Skills & procedures are standardized • Teamwork is the daily routine • Pilots anticipate, train, plan & brief for emergencies • Pilots lives are on the line every flight

  35. Aviation toolboxOrnato JP, Peberdy MA. Resuscitation 2014; 85:173-6 • Communication • Sterile cockpit rule • Procedures • Crosschecks • Mandatory read backs • Mandatory checklist use • Instrument guided flight

  36. Summary • Accurate data • Prevention • Implementing effective community systems of care • Changing research funding priorities • Breakthrough approaches • Detecting unwitnessed OOH cardiac arrest • Effective therapy for pulseless electrical activity (PEA) • Adapting principles & practices from high performance industries

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