265: Can Feedback by Using Audible Sound Improve Performance of Cardiopulmonary Resuscitation in Simulated Cardiac Arrest?

Research Forum Abstracts Study Protocol: Participants consented and answered 16, written, closed questions. Statistical Analysis: Continuous data presented as means⫹/⫺standard deviations; analyzed by t-tests. All test two-tailed; alpha ⫽ 0.05. Categorical data presented as frequency of occurrence; analyzed by chi-square. Results: 686/686 (100%) of eligible workers completed the survey; 170 (25%) were CPR trained. Prior to orientation, 37% had seen an AED prior to in-service, 16% had performed CPR in real-life, and 4% had used an AED in real-life. Within the cohort, 72% were willing to start CPR on a stranger if mouth-to-mouth breathing was required vs. 88% who were willing to start CPR if chest compressions only were required (p ⬍ 0.0001). With respect to those who were CPR trained vs. no training, the groups were similar in mean age (47⫹/⫺15 years vs. 50⫹/⫺15 years; p⫽ NS) and % female respondents (42% vs. 41%; p⫽NS). Those with CPR training were significantly more likely than untrained workers to start CPR if mouth-mouth breathing was required (83% vs. 64% p ⬍ 0.0001) and also if it wasn’t required (95% vs. 83% p⫽ 0.0001). Both groups reported a similar belief that mouth-mouth breathing is necessary for survival from cardiac arrest (49% vs. 48%; p⫽NS). Conclusion: Many within our cohort of workers at a mass gathering venue appeared unfamiliar with new AHA guidelines that deemphasize the importance of ventilation in resuscitation efforts. This was the case even for workers with prior CPR training suggesting that recertification would be beneficial.

263

Pre-resuscitation Predictors of Event Mortality in 49,130 In-Hospital Cardiac Arrests: A Report from the National Registry for Cardiopulmonary Resuscitation

Larkin GL, Copes WS, Nathanson BH, Kaye W/Yale University, New Haven, CT; Tri-Analytics, Inc., Bel Air, MD; OptiStatim, LLC, Longmeadow, MA; Brown University School of Medicine, Providence, RI

Background: Validated cardiac arrest mortality models based on pre-resuscitation variables could improve advance-care planning and facilitate resuscitation program comparisons. Currently, no such model exists. Study Objective: To develop and validate a model for predicting event mortality for adults experiencing in-hospital cardiopulmonary arrest using pre-resuscitation variables. Methods: A development/validation cohort of 49,130 hospitalized adults from 366 US hospitals who experienced pulseless cardiopulmonary arrest came from the National Registry for Cardio-Pulmonary Resuscitation (NRCPR). Imputation was used to maximize the number of analyzable records. Univariate analysis, bootstrapping and logistic regression were used for screening and multivariate modeling. Model performance was assessed by Hosmer-Lemeshow (H-L) statistics and area under the receiver operator characteristic (ROC) curve. Event mortality, defined as no return of spontaneous circulation for ⬎20 minutes after attempted cardiopulmonary resuscitation was the main outcome. Results: Screening identified 69 statistically significant candidate predictors for possible entrance into logistic regression models; 33 were ultimately retained. Increasing patient age, male gender, black race, pre-existing malignancy, and prior residence other than home increased the likelihood of resuscitation failure. Events occurring in the ED or general inpatient area were associated with poorer outcomes. Some pre-arrest interventions had protective effects (e.g. cardiac monitoring outside the ICU) while others negatively effected survival (e.g., vasopressors). Witnessed events and initial pulseless rhythms other than asystole improved the chance of survival. On the validation set, the model’s area under ROC curve (.65) revealed only fair performance. Conclusions: While many pre-resuscitation variables are associated with cardiac arrest mortality, multivariate models using them have only limited clinical utility.

264

Preliminary Cost Estimation of Goal-Directed Protocol Treatment of Sepsis: What is the Role of the ED in Generating Costs Relative to Total Hospital Costs?

Venkatesh AK, Schmidt MJ, Carney M, Bhayani R, Courtney DM/Northwestern University, Feinberg School of Medicine, Chicago, IL

Study Objective: The use of early goal-directed therapy has been shown to reduce overall mortality in patients with severe sepsis and septic shock. To date there is virtually no publication in the United States of emergency department costs of early

Volume , .  : September 

goal-directed therapy. Furthermore, the emergency department decision to initiate a sepsis protocol may create cost implications for downstream hospital care. The objective of this study was to quantify the cost of care for patients enrolled in a sepsis protocol. Methods: We conducted a prospective, observational, case-series in a 70,000 patient/year urban ED over a ten month period between February and November 2005. The sequential sample included all ED patients that entered an established protocol based on the bundle of measures recommended as part of the Institute for Healthcare Improvement’s Surviving Sepsis Campaign. All patients met the definition of severe sepsis and septic shock based on definitions developed by the American College of Chest Physicians and Society of Critical Care Medicine. Cost data was derived from a hospital-wide activity based cost system that utilized actual costs. Results: A total of 70 consecutive patients entered the sepsis protocol after meeting nationally recognized criteria for early goal directed therapy. Of these, 30 (42.9%) of patients were female and 40 (57.1%) were male. The patients had an average age of 60.9 years (range 17-89). Patients had a median total length of stay of 7 days (range: 1-51), of which the median intensive care unit stay was 2 days (range: 0-44). The median total cost of care was $19,156 (range: $3232-$259,122). The median cost for the intensive care unit (ICU) care was $4536 (range: ($0-$115,100), and the median cost of emergency department care was $975 (range: $376-$6083). Based on all median costs, 3.6% were derived from emergency department care, 32.0% from ICU care and 64.4% from inpatient care. Based on total mean costs, 5.1% were derived from emergency department care, 23.7% care from ICU care and 71.2% from inpatient care. There was no statistically significant difference in emergency department, ICU, or total costs based on age or gender. Conclusions: Our findings show that ED costs represent less than 5% of total costs for these patients; however, decisions to initiate the sepsis protocol has important downstream cost implications. Future investigation into the implications of emergency department and total health care costs associated with early goaldirected therapy will be necessary to gain long-term commitment to improvements in sepsis care.

265

Can Feedback by Using Audible Sound Improve Performance of Cardiopulmonary Resuscitation in Simulated Cardiac Arrest?

Oh J, Kim S, Lee S, Kim C, Lee K/Chung-Ang University Hospital, Seoul, Republic of Korea; Chung-Ang University Yongsan Hospital, Seoul, Republic of Korea

Study Objectives: The American Heart Association has suggested guidelines for cardiopulmonary resuscitation (CPR) since 2000. However, it appears that the performance of actual CPR has been lowered. Many devices have been developed so far in order to enhance rescuers’ performance but they are not being used widely due to various reasons including high cost and complexity in application not to mention lack of evidence. Thus, the present study proposed to examine if the performance of CPR can be enhanced through feedback using simple beep sounds as a preliminary study before developing a simple electronic metronome for improving the performance of CPR. Methods: This research was conducted as a prospective randomized study, and the subjects were fourth year students at a medical school who had received CPR education within the last one year according to the 2005 guidelines. In order to test compression and ventilation at the same time, we made a simulated arrest model with advanced airway by modifying the airway part of Skillreporter ResusciAnne®(Laerdal, Stavanger, Norway). Audible feedback used a metronome program for windows, and compressions were guided by making beep sound 100 times per minute, and a ventilation at every six seconds was guided by making high-pitch beep sound once at every 10 beeps. Each test took 2 minutes, and rescuers who performed compression were requested to do external chest compressions at a rate of 100 times per minute without break and those who performed ventilation were requested to do ventilation at a rate of 8-10 times per minute. Two students made a team, and all the teams had the first test of two minutes, and after 30 minutes they were divided at random into a feedback group and a control group and had the second test. The role of compression and ventilation was not changed between the two tests. The tests measured three indicators as average rate (numbers/min) and average depth (mm) as compression data and average count per minute as ventilation data and calculated their means, and Mann-Whitney U test and Kruskal-Wallis test were performed. Results: Twenty four students were assigned at random to the feedback group (n⫽6) and the control group (n⫽6). In the results of the first test, the two groups did not show any statistically significant difference in the three indicators. In the results of

Annals of Emergency Medicine S83

Research Forum Abstracts the second test, the feedback group’s average compression rate was 99.8 times per minute (range 99-100) and the average ventilation count per minute was 10 (range 10-10), consistent with the audible feedback. However, because the number of participants was small, only the average compression rate before and after audible feedback showed a statistically significant difference (p⫽0.031). Conclusion: The results of this study show that the compression rate and the ventilation count can be guided accurately through audible feedback using simple beep sound.

266

Rapid Response Team Intervention for Unstable Patients in a Community Hospital System

Morton MJ, Williams JM, Piper JJ, Jones JA, McManus Jr. JG/University of Pennsylvania School of Medicine, Philadelphia, PA; Methodist Health Care System, San Antonio, TX; US Army Institute of Surgical Research, San Antonio, TX

Study Objectives: Some hospitalized patients who experience a cardiac arrest often display abnormal signs and symptoms several hours prior to the code event. Previous studies have shown a patient’s survival declines approximately 10% for each additional minute of delay in defibrillation. In order to optimize resuscitation outcomes through education, planning, equipment, standardization, and research, the Methodist Health Care System (MHCS) developed a Rapid Response Team (RRT) system of early intervention for unstable patients. The goal was to improve survival from code events, and also to encourage intervention before patients deteriorated to code status. The purpose of this study was to test the hypothesis that the RRT would result in an increased survival rate at the time of the code and at hospital discharge. Methods: From 1999 to 2005, a retrospective chart review was conducted to obtain the overall number of codes in the five community hospitals in the MHCS. Beginning in October 2005 these community hospitals initiated the RRT system. Anyone in the hospital (family members, clerks, nurses) with concern for an acutely ill patient was permitted to initiate the RRT process. Responders were to be present at bedside within 2 minutes. Each RRT was composed of an ICU nurse and a respiratory therapist. Data on RRT activations, actual National Registry of Cardiopulmonary Resuscitation (NRCPR)-classified codes, survival of the code, and survival to hospital discharge were collected. Data from before and after 2005 were compared. Correlations were also calculated between the rate of RRT response and code survival rates for the data collected from October 2005 to September 2006. Results: According to the NRCPR the 5 year code survival rate (return of spontaneous circulation) in the MHS was 15% and the survival rate to hospital discharge was 8% from 1999 - 2005. A total of 549 codes occurred between October 2005 and September 2006 (12 months) with 296 patients [53.9% (p ⬍ 0.0001)] surviving the initial event. Of the survivors 158 patients [28.8% (p ⬍ 0.0001)] survived until hospital discharge. There was a modest positive correlation between the rate of RRT activation and survival to discharge after 2005, (r2 ⫽ 0.59), which was statistically significant (p ⫽ 0.05). There was also a modest positive correlation between the rate of RRT activation and code survival after 2005, (r2 ⫽ 0.42), but this was not statistically significant for dependence (p ⫽ 0.18). Conclusion: The RRT had a profoundly positive impact on both the rate of patient survival from codes, and on the rate of survival to hospital discharge. An increased rate of activation of the RRT was associated with increases in the number of code patients who survived to hospital discharge. There was a modest correlation between increased rate of activation of the RRT and code survival. Use of lower threshold to initiate the code process and having a dedicated ICU nurse and respiratory therapist on the RRT, are highly recommended policies for code mitigation and response in the community hospital setting.

267

Emergency Health Care Providers’ Adaptation to a Hospital-Wide Guideline for the Mechanically Ventilated Patient

Arbelaez C, Gilboy N, Szumita P, Munz K, Keenan H/Brigham and Women’s Hospital, Boston, MA; Harvard Medical School, Boston, MA

Study Objectives: An increase of patients boarding in the ED due to crowding, increased lengths of stay, higher acuity, and scarcity of ICU beds has led to the care of critically ill intubated patients in the ED. National guidelines exists in the ICU setting but not in the emergency department. We developed and implemented a comprehensive hospital-wide guideline for the management of the mechanically ventilated patients including a provider education and training program, a computerized physician order entry template, and a critical care nursing flow sheet.

S84 Annals of Emergency Medicine

The objective of this study was to evaluate the adaptation of a comprehensive guideline into clinical practice by emergency care providers and see its effects on objective patient outcomes. Methods: A multi-phase retrospective chart review study of all admitted mechanically ventilated patients from the emergency department was done a month after each of the phases were introduced into clinical practice. Data were collected along the following domains: aherence to the guideline recommendations, use of the physician order entry, ED LOS, hospital LOS, adverse events, and mortality. The chi-square test was used for categorical data, the wilcoxon rank sum test for continuous variables, and ANOVA was used for three-way comparison of continuous variables. Results: A total of 171 patients charts were reviewed (46 baseline, 42 at month 1, 42 at month 2, and 41 at month 3). Patient demographics were consistent across all timepoints. Overall results of guideline compliance showed more patients received an analgesia bolus (60%, p⬍0.01) and a sedation bolus (63%, p⬍0.01) then did not. There was protocol adaptation with propofol (82%, p⬍0.01), RASS (4%, p⬍0.01), and lack of paralytic agents(12%, p⬍0.01). However, there were no significant trends across the four month in the use of analgesia or sedation bolus (p⫽0.14 and p⫽0.58, respectively). Despite the implemenation of the protocol, ED LOS (p⫽0.14), hospital LOS (p⫽0.75), self-extubation (p⫽0.17), and mortality (p⫽0.57) did not have any signifcant changes except for the neuro-ICU patients who were more likely to receive propofol 28% (p⫽0.04) and be discharged alive (59%, p⫽0.02). Patients who lived were more likely to have received analgesia and sedation boluses (82% p⫽⬍0.01, 83% p⬍0.01). The other outcomes measures showed ED average LOS was 4.2⫾2.8 hours, average hospital LOS was 12.0⫾12.8, self extubation (99%, p⬍0.01), and condition upon discharge was 72% alive versus 28% dead (p⬍0.01). Conclusions: The implementation of guidelines for the treatment of mechanically ventilated patients originating in the ED at a major urban Boston teaching hospital showed mixed results. There was a significant association with the implementation of this protocol and the use of analgesia, sedation, and propofol, and RASS which demonstrates a fractional acceptance of the new protocol. There was also a signifcant decrease in the use of paralytic agent. However, changes in hospital LOS, mortality at discharge, and self-extubation did not vary across the time points of the study. This experience shows that protocols need sustained efforts in order to be adpated in clinical practice.

268

Innovative Methods of Dispatcher-Assisted Cardiopulmonary Resuscitation, Mobile Movie Assisted: A Preliminary Study

Seol S/Ajou University School of Medicine, Suwon, Republic of Korea

Study Objective: According to developing information technology, mobile phones are very popular and improved and can transfer multimedia such as pictures, sounds and show any types of movies. We studied effectiveness of mobile movieassisted compression-only cardiopulmonary resuscitation (CPR) and compared to dispatcher-assisted CPR to untrained persons using a training manikin (Resusci Anne, Laerdal co.) Methods: This randomized controlled trial used a manikin model of cardiac arrest to compare skill performance in untrained persons to do either dispatcherassisted compression-only CPR (Dispatcher group (DG) n⫽18) or mobile movieassisted compression-only CPR (Movie group (MG) n⫽20) of a 10-minute scenario. A training manikin with skill-reporting system attached to a computer and manikin was placed in isolated room with the mobile phone and two video cameras viewing of right (90 degree) angles. Emergency physicians were watching on the monitor and recorded CPR performance in the other room. Another emergency physician evaluated the performance of CPR, who was not a member of our study. Results: Total 38 college-student persons (DG 18, MG 18 and man 20) were enrolled to our study. Average depth and rate of compression, DG vs. MG is 31.78mm vs. 34.13mm and 84.28/min vs. 117.46/min. respectively. The correct hand position between nipple and midline of sternum during compressions, DG vs. MG are 13(68.4%) vs. 16(80%) and global performance of MG is superior to DG. And injurious point, abdomen or below the sternum during compressions were observed in two cases of DG. Conclusion: Mobile movie-assisted CPR is effective to CPR in untrained persons. In emergency medical service activation system, mobile movie transfer will be important role of CPR of out-of-hospital arrest without further delay.

Volume , .  : September 