Abstract 241: Abstract QCOR 2017

AHA QCOR 2017 Abstract submission Category: Cardiac Arrest/CPR “How well can you run a code?” Assessing resident comfort and competence with in-hospital cardiac arrest Background: Despite their frequent role in caring for patients with in-hospital cardiac arrest (IHCA), earlier data suggest residents often feel uncomfortable during resuscitations. We sought to characterize the experiences of residents at our academic institution with IHCA, delineate reasons for discomfort (if any) with their roles, and then assess what educational interventions were considered most valuable. Methods: We performed a 9-question survey that was electronically distributed to all internal medicine and medicine-pediatrics residents at the University of Michigan Health System. This survey asked residents about: 1) the number of IHCAs that residents had attended or led, 2) their comfort with their roles including leading an IHCA, 3) possible reasons for any discomfort in their roles, and 4) educational interventions that would be considered favorable. We report simple unadjusted statistics. Results: We received 100 responses from 155 residents, a 64.5% yield. Most PGY-1s and 2s reported being to few or no IHCAs (n=47/69, 68%) and that some PGY-3s and 4s had never run a resuscitation effort (n=4/31, 13%). Regardless of level of training, few residents rated their ability to run a resuscitation effort as very good or excellent (n=8, 8%). Most residents were unsatisfied with the formal education currently in place for IHCAs (ACLS training, code refresher sessions for residents on general medicine or cardiology) (n=62, 62%). The majority of residents had rarely or never given (n=72, 72%)/received feedback (n=68, 68%). Of the possible educational interventions presented as options, the most popular that were perceived among residents were debriefing with the attending physician and other residents (n=66, 66%), and debriefing in a multidisciplinary setting (n=59, 59%). Conclusion: We characterized the experience of internal medicine and medicine-pediatrics residents with leading IHCAs at our academic institution. We found few residents perceived their own comfort and competence as adequate. These findings provide a foundation for future efforts to potentially elevate resident performance in IHCA.

Abstract 222: Optimizing the Application of a Mechanical Chest Compression Device Within a High-Performance CPR Approach to Out-of-Hospital Cardiac Arrest Resuscitation

Background: Minimizing the chest compression pause associated with application of a mechanical CPR (mCPR) device is a key component of optimal integration of mCPR into the overall resuscitation process. As part of a multi-agency implementation project, Anchorage Fire Department deployed LUCAS mCPR devices on BLS and ALS vehicles for initiation early in resuscitation efforts. A 2012 report from that project identified the pause interval for mCPR device application as a key opportunity for quality improvement (QI). In early 2013 we began a QI initiative to reduce device application time and optimize the overall CPR process, which included education on the importance of minimizing pauses, training on techniques for efficient device application, and a requirement for two manual CPR cycles prior to initiation of mCPR. To assess QI initiative effectiveness, we compared key CPR process metrics from before to during and after its implementation. Methods: We included all cases of EMS-treated out-of-hospital cardiac arrest during 2012 and 2013 in which mCPR was used and the defibrillator electronic record was available. Continuous ECG and impedance data were analyzed to measure chest compression fraction, duration of the pause from last manual to first mechanical compression, and duration of the longest overall pause in the resuscitation effort. Results: Compared to cases from 2012 (n=61), median (25th, 75th percentile) duration of the pause prior to first mCPR compression for cases from 2013 (n=71) decreased from 21 (15, 31) to 7 (4, 12) seconds (p<0.001), while median chest compression fraction increased from 0.90 (0.88, 0.93) to 0.95 (0.93, 0.96) (p<0.001). Median duration of the longest pause decreased from 25 (20, 35) to 13 (10, 20) seconds (p<0.001), while the proportion of cases where the longest pause was for mCPR device application decreased from 74% to 32% (p<0.001). Conclusions: Our QI initiative substantially reduced the duration of the pause prior to first mCPR compression. Combined with the simultaneous significant increase in compression fraction and significant decrease in duration of the longest pause, this finding strongly suggests a large improvement in mCPR device application efficiency within an overall high-performance CPR process.

Environmental Emergencies

Environmental emergencies comprise acute exposure of human beings to extremes of temperature, electrical, and radiation injuries, drowning and diving, and high-altitude sickness. Of these, hypothermia, electrical injuries, and drowning are slightly more commonly encountered. However, there are some parts of the UK where scuba diving incidents are more frequent. The story of a physician surviving a temperature of 13.7°C after a 9h resuscitation effort, or various war tragedies in which thousands of soldiers died during cold exposure, etc., are well known. Hypothermia occurs when the core body temperature drops below 35°C, and the compensatory mechanism in a healthy individual is overwhelmed by the extreme exposure. This may be sometimes hastened by various types of medications affecting the thermoregulation. The management in the ED starts with basics (ABCDE). While the ABC and D are taken care of, an accurate measurement of temperature is essential, and most EDs do so by measuring an oesophageal, rectal, or bladder temperature, while the patient is being warmed. The common rhythm in a cardiac arrest associated with hypothermia is asystole. But if the patient is in VF, defibrillation is usually unsuccessful until the core temperature is well above 28–30°C. Therefore, rewarming continues alongside resuscitation and as the core temperature rises, defibrillation attempts should continue according to the UK resuscitation guidelines. The approximate death rate from drowning in the UK is 0.72/100 000 population per year. In 2005, of 435 deaths from drowning, 39 cases were between the ages of 0 and 14 years. Alcohol consumption in the vicinity of water is a major risk factor for morbidity or death by drowning. During the initial assessment, important details surrounding the incident should be obtained rapidly. The outcome of patients in cardiac arrest, who are often hypothermic as well, largely depends on how quickly CPR is initiated. The duration of CPR remains controversial in the hypothermic drowned patient—a safe approach is to continue until the core temperature reaches 35°C. This chapter includes questions on hypothermia, drowning, and some other environmental emergencies to give the reader an insight into the latest management of these situations.