Enhancing CPR During Transition From Prehospital to Emergency Department: A QI Initiative
Authors: Hoehn EF, Cabrera-Thurman MK, Oehler J, et al.
Published in: Pediatrics, 2020 May; 145(5): e20192908
High-quality CPR increases the likelihood of survival from cardiac arrest. However, the best methods and initiatives to improve CPR quality can be system-dependent.
This month we review a manuscript that describes the results of a quality improvement initiative by a multidisciplinary team that included prehospital and pediatric emergency department providers. The authors began with the conclusion of an interprofessional committee that transfer of pediatric OHCA (out-of-hospital cardiac arrest) patients from prehospital to pediatric emergency department care “frequently involved inadequate compressions, prolonged pauses, and challenges with defibrillator pad application.” Their objective was to minimize those pauses in chest compressions during pediatric OHCA patient handoffs.
Team and Roles
The QI project was conducted in the resuscitation area of a high-volume academic pediatric emergency department. Each resuscitation bay was equipped with digital video cameras and microphones that continuously recorded video and audio.
In this system EMS calls ahead for OHCA patients. A care team convenes in a resuscitation bay and includes at least 10 members: two physicians, four nurses, one respiratory therapist, two patient care assistants (PCA), and one paramedic. The PCAs are primarily responsible for chest compressions, and the paramedic for deﬁbrillator pad placement and managing the deﬁbrillator.
Since this was a quality improvement initiative, some of the important first steps were to outline a theory for improvement and design interventions aimed at key drivers. The authors “theorized that standardization of roles during CPR handoffs would lead to improved CPR quality, especially reducing interruptions in chest compressions.” Further, the authors “postulated that engaging frontline, nonphysician providers to develop a standardized approach to CPR handoffs would be associated with improved CPR quality.”
The authors made a wise decision to include a paramedic and a PCA to colead the design and dissemination of the intervention. They cited the principal of “deference to expertise” in recognizing that paramedics and PCAs had “far greater insight into the CPR handoff process and would be effective in designing an intervention.”
To identify key drivers, the authors constructed a driver diagram. According to the Institute for Healthcare Improvement, a driver diagram is a visual display of what “drives,” or contributes to, the achievement of a project aim. Key drivers here included clearly defined roles and responsibilities for pediatric ED team members to take over CPR from EMS; standardized processes for CPR transition and defibrillator pad placement; reduced cognitive load during high-stress, low-frequency events; and empowered frontline providers.
Following interviews with paramedics and ED team members, the authors noted that conflicting priorities during handoffs contributed to increased stress and decreased CPR quality. The authors then developed their main intervention, a detailed description of the responsibilities of all team members involved in pediatric OHCA patient handoffs. They tested it initially through simulations involving only the study team. This intervention was then distributed via study team members who were involved in patient handoffs by modeling and educating colleagues during monthly educational programs and via e-mail. Finally, in situ simulations were performed to test the CPR choreography before it was utilized on real patients.
The specific measure used to evaluate improvement was total duration of chest compression interruptions during the two minutes that started when the EMS stretcher was parallel to the bed. Interruptions were determined by video-based observation. Pauses for ventilations were excluded unless the patient was intubated or had a supraglottic airway placed. The goal for improvement in average duration of interruptions was a reduction from 17 (baseline) to 10 seconds. A secondary goal for improvement was to decrease the length of the longest pause in chest compressions to less than 10 seconds and decrease the time to defibrillator pad placement to less than two minutes.
From March 2018 to July 2019, 33 pediatric OHCA patients were cared for using the study intervention CPR choreography. The number of seconds off the chest during CPR decreased from 17 to 12 seconds. The longest pause in chest compressions decreased from 14 to 7 seconds. Time to defibrillator pad placement did not change.
The authors noted the clinical importance of a five-second decrease in compression interruption is unclear. They also observed a limitation of their study was that it was performed in a single large pediatric center with specialized resources—this may limit generalizability. They also acknowledged the low frequency and poor outcomes of pediatric OHCA are among the factors limiting their ability to assess the clinical importance of their findings.
This study is a great example of providers working within their system to improve care and then telling the world about it. This was not a traditional research project and included a small number of patients. However, it implemented small tests of change and was successful in the main objective of reducing interruptions in chest compressions. It was also nice to see a paramedic involved in this project.
Antonio R. Fernandez, PhD, NRP, FAHA, is a research scientist at ESO and an assistant professor in the department of emergency medicine at the University of North Carolina–Chapel Hill. He is on the board of advisors of the Prehospital Care Research Forum at UCLA.