- Email: [email protected]
CPR team work, interpersonal skills and team efficiency audit
e118
Poster Presentations / Resuscitation 83 (2012) e24–e123
blankets for induction of MTH. Rewarming was done actively in 64% with an average rate of 0.4 ◦ C/h. Events of cardiac arrhythmia, hemodynamic instability and bleeding were the main reasons that caused 21 ICUs (28%) to interrupt cooling. The most common reasons not to cool were a low number of cardiac arrest cases treated at the ICU (57%), high costs of cooling methods (36%) and high technical effort (27%). Conclusions: Implementation of MTH in Austria is at a high level, but could be further improved by education and training. http://dx.doi.org/10.1016/j.resuscitation.2012.08.303 AP245 A novel approach to ensuring availability of Resuscitation equipment – And improving standards Michelle Davies Julie Bradley Heart of England Foundation NHS Trust, Birmingham, UK Background: A number of reports have described failures in the provision of resuscitation equipment and the clinical impact this has. Key points taken from these publications were that an organisation must have systems in place for standardised equipment, stock replenishment and that daily checks must improve. This report identifies particular errors within the provision of resuscitation equipment within our organisation and describes improvements in adherence to standards of provision equipment using a novel system that is easily transferable to other organisations. Method and materials: The contents and the expiry dates of 21 trolleys were audited and staff were timed performing their daily checks. Clinical incident reports related to resuscitation equipment issues were reviewed. Adherence to trolley checking was sub optimal and this was reflected within the number of incidents reported related to equipment. Three trays were then introduced providing basic and advanced airway equipment and IV access and fluids. They were produced and sealed centrally each single item was bar coded and scanned with the data stored in a specially designed database. This would enable ease of tracking items should a recall be necessary. Each sealed tray displayed the nearest expiry date and the contents. Following the implementation of the sealed tray system across the organisation the audit process was repeated. Results: Pre implementation Items to check on a trolley Mean time to check a trolley Audit of trolley contents Local CLINICAL INCIDENTS
126 12 min 71% of trolleys had missing item 7
Post implementation 14 3 min 0% 0
Conclusions: Provision of resuscitation equipment is often sub optimal and can impact patient care. The implementation of a sealed tray system ensures that resuscitation equipment is present, in date and ready for use in clinical emergencies. http://dx.doi.org/10.1016/j.resuscitation.2012.08.304
AP246 innovation, patient safety and costing saving at Croydon University Hospital, Croydon, UK Russell Metcalfe Smith ∗ , Muhammad Khan, Ann Starr Croydon University Hospital NHS Trust, Croydon, UK Introduction: Most adverse incidents involve an element of system error. Cardiac Arrest Trolleys hold key emergency equipment which when needed can be accessed rapidly. Traditional models involved Registered Nurses spending considerable periods of time checking these trolleys daily. Even when checking had taken place equipment was still often missing. Aims: Introduction of a sealed Airway and Vascular Access tray in all ward based Cardiac Arrest Trolleys. The purpose to reduce error by reducing the reliance of staff being required to check equipment. To reduce cost by preventing overstocking, and reducing considerably the amount of time staff take to check this essential equipment. Methods: Evaluation of the cost of Registered Nurses checking Cardiac Arrest Trolleys twice daily was undertaken. Results: Prior to the introduction of sealed resuscitation trays (spring 2011) the average time spent by Registered Nurses checking equipment was 30 min across 50 locations, twice daily at a cost of approximately £320 K. Since the introduction of this new innovation the checking time has reduced by a third to 10 min result in a cost saving of £215 K and an additional 12,000 Nursing Hours being available for patient care. Conclusion: CUH Simulation Centre has introduced a system which has achieved the following: • No recorded episodes of missing equipment in high risk situations • Reduced checking time from 1 h daily to only 10 min resulting in a significant cost saving
Recommendations: Implementing a simple strategy improves patient safety by ensuring equipment is present when required and increases time available for Nursing Staff to care for patients. http://dx.doi.org/10.1016/j.resuscitation.2012.08.305 AP247 CPR team work, interpersonal skills and team efficiency audit Velitchka Schembri Agius ∗ , Tanya Esposito, Marie Eleanor Farrugia Mater Dei Hospital, Msida, Malta Background & goal of study: Our hospital CPR team is composed of one medical registrar, one anaesthetist, two cardiac care unit nurses and one foundation year doctor. The team members change daily and meet only during resuscitation in the wards. The aim of the study was to evaluate the level of team work as an important component of the CPR team. With good communication as a team we can provide a better level of care to our cardiac arrest patients. Method: A questionnaire was used as a tool to gather the opinion of the members forming part of the CPR team. In the questionnaire the efficiency of the CPR team, communication between team members, interpersonal skills and team work were evaluated. The years of experience on the CPR team, knowledge of the new ALS guidelines and ALS certification status were also included. Results: The years of experience on the team ranged between 0.2 months up to 19 years. 46 members of the CPR team took part in this study – 32% nurses, 37% anaesthetists and 31% medical doctor.
Poster Presentations / Resuscitation 83 (2012) e24–e123
91.31% had awareness of the new ALS guidelines. An average of 76% had a current ALS certification. Positive feedback on: • • • •
Efficiency of carrying out CPR was 66.8% Communication between team members 55.1% Interpersonal skill 49.3% Team work 48.5%
Conclusion: The most common problems that the team members encounter during CPR are the lack of communication and teamwork. This study concludes that there is the need to improve the CPR team group dynamics in different aspects of team work including interpersonal skills and communication so as to improve the efficiency of delivery of CPR. Our goal is to improve the situation by regular meetings of the CPR team to improve the communication between members to provide the best care for our patients. http://dx.doi.org/10.1016/j.resuscitation.2012.08.306 AP248 Survival from inpatient cardiac arrest in a specialised referral hospital Philip Cokkinos, Evangelia Papadopoulou, Aggeliki Gkouziouta, Konstantinos Farsalinos ∗ , Androniki Tasouli, Vasillis Voudris, Dennis V. Cokkinos Onassis Cardiac Surgery Center, Athens, Greece Purpose: To estimate survival from inpatient cardiac arrest at the Onassis Cardiac Center, a referral hospital for Cardiology and Cardiac Surgery. Methods: We recorded cardiac arrests over a 48-month period, using the Utstein style for cardiac and surgical patients (pts) distributed on 3 floors. The arrival time of the arrest team (CAT) was calculated from the “code blue” call. All our pts are on telemetry so the initial rhythm is accurately recorded. Our institution’s CAT includes the on call Registrars and SHOs, anaesthesiologist, and nurses, all trained in Advanced or Immediate Life Support (ALS, ILS). Biphasic defibrillators are available on every floor. Results: During the 48-month period, there were 65,565 admissions (52,720 in the Cardiology wards and 12,845 in Cardiothoracic Surgery wards). We recorded 105 inpatient arrests (29 women, mean age 68.6 ± 14 years): 37 (35%) in the cardiology wards (0.06% admissions) and 68 (65%) in surgical wards (0.53% admissions). Of those, 57 presented with asystole, 46 with ventricular fibrillation or pulseless ventricular tachycardia (VF/VT), and 2 in pulseless electrical activity (PEA). In total, 82 pts (78.1%) survived the initial resuscitation attempt (IRA) and 48 (45.7%) survived to discharge (35% of the cardiology pts and 51.5% of the surgical pts). We intubated 70 pts, of whom 73% survived the IRA and 34% to discharge. Survival from the IRA and to hospital discharge was 68% and 25%, respectively, for asystole, and 91% and 72% for VF/VT. Both PEA pts survived to discharge. The CAT arrival time was less than 1 min in 80 (76.2%) of pts. Conclusions: Survival from in-hospital cardiac arrest to discharge in our institution was 45.7%. Factors such as telemetry monitoring, defibrillator presence on all inpatient floors, and the prompt arrival of a properly trained cardiac arrest team to the patient’s bedside contributed to successful resuscitation attempts. http://dx.doi.org/10.1016/j.resuscitation.2012.08.307
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AP249 Implementing therapeutic hypothermia after cardiac arrest in the era of new guidelines: A longitudinal qualitative study of perceived barriers and facilitators Young-Min Kim 1,∗ , Seung-Joon Lee 1 , Sun-Jin Jo 2 , Kyu-Nam Park 1 1
Department of Emergency Medicine, School of Medicine, The Catholic University of Korea, Seoul, Republic of Korea 2 Department of Preventive Medicine, School of Medicine, The Catholic University of Korea, Seoul, Republic of Korea Purpose: Therapeutic hypothermia (TH) after cardiac arrest was strongly recommended in 2010 guidelines. Understanding of barriers and facilitators is important for development of effective implementation strategies. The aim of this study was to identify the barriers to, and facilitators of implementation of TH for cardiac arrest survivors in a country with limited critical care human resources. Material and methods: Up to two serial individual interviews over one year (i.e. 6 and 12 months) and focus group discussions (for acting and managing champions) were conducted with 21 physicians recruited from a TH training course for hospital champions. Interviews were transcribed and coded by two independent assessors. Contents were analyzed thematically and group interaction was also examined. Results: Two participants changed their hospitals during the study period. The final dataset comprised 40 interviews and two focus group discussions. The identified barriers and facilitators could be classified into 3 major categories: (1) healthcare professionals’ perception of the guidelines and protocols, (2) interdisciplinary and interprofessional collaboration, and (3) organizational resources. Perception of the guidelines and protocols has been improved with accumulation of clinical experiences over the study period. Lack of resources was the most commonly agreed barrier for the acting champions whereas lack of interdisciplinary collaboration was for the managing champions. Educational activities and sharing successfully treated cases were the most frequently identified facilitators. Most of the participants identified and agreed that cooling equipment was not only an important barrier to but also a facilitator of successful TH implementation. Conclusions: Healthcare professionals’ internal barriers to TH implementation may be influenced by guideline changes and can be changed with accumulation of successful clinical experiences. Promoting Interprofessional and interdisciplinary collaboration through educational activities and use of cooling equipment with auto-feedback function could improve adherence to the guidelines in a country with limited critical care human resources. Further reading
[1].Sinuff T, Cook D, Giacomini M, Heyland D, Dodek P. Facilitating clinician adherence to guidelines in the intensive care unit: a multicenter, qualitative study. Crit Care Med 2007;35:2083–9. [2].Brooks SC, Morrison LJ. Implementation of therapeutic hypothermia guidelines for post-cardiac arrest syndrome at a glacial pace: seeking guidance from the knowledge translation literature. Resuscitation 2008;77:286–92. [3].Bigham BL, Dainty KN, Scales DC, Morrison LJ, Brooks SC. Predictors of adopting therapeutic hypothermia for post-cardiac arrest patients among Canadian emergency and critical care physicians. Resuscitation 2010;81:20–4.
http://dx.doi.org/10.1016/j.resuscitation.2012.08.308
Poster Presentations / Resuscitation 83 (2012) e24–e123
blankets for induction of MTH. Rewarming was done actively in 64% with an average rate of 0.4 ◦ C/h. Events of cardiac arrhythmia, hemodynamic instability and bleeding were the main reasons that caused 21 ICUs (28%) to interrupt cooling. The most common reasons not to cool were a low number of cardiac arrest cases treated at the ICU (57%), high costs of cooling methods (36%) and high technical effort (27%). Conclusions: Implementation of MTH in Austria is at a high level, but could be further improved by education and training. http://dx.doi.org/10.1016/j.resuscitation.2012.08.303 AP245 A novel approach to ensuring availability of Resuscitation equipment – And improving standards Michelle Davies Julie Bradley Heart of England Foundation NHS Trust, Birmingham, UK Background: A number of reports have described failures in the provision of resuscitation equipment and the clinical impact this has. Key points taken from these publications were that an organisation must have systems in place for standardised equipment, stock replenishment and that daily checks must improve. This report identifies particular errors within the provision of resuscitation equipment within our organisation and describes improvements in adherence to standards of provision equipment using a novel system that is easily transferable to other organisations. Method and materials: The contents and the expiry dates of 21 trolleys were audited and staff were timed performing their daily checks. Clinical incident reports related to resuscitation equipment issues were reviewed. Adherence to trolley checking was sub optimal and this was reflected within the number of incidents reported related to equipment. Three trays were then introduced providing basic and advanced airway equipment and IV access and fluids. They were produced and sealed centrally each single item was bar coded and scanned with the data stored in a specially designed database. This would enable ease of tracking items should a recall be necessary. Each sealed tray displayed the nearest expiry date and the contents. Following the implementation of the sealed tray system across the organisation the audit process was repeated. Results: Pre implementation Items to check on a trolley Mean time to check a trolley Audit of trolley contents Local CLINICAL INCIDENTS
126 12 min 71% of trolleys had missing item 7
Post implementation 14 3 min 0% 0
Conclusions: Provision of resuscitation equipment is often sub optimal and can impact patient care. The implementation of a sealed tray system ensures that resuscitation equipment is present, in date and ready for use in clinical emergencies. http://dx.doi.org/10.1016/j.resuscitation.2012.08.304
AP246 innovation, patient safety and costing saving at Croydon University Hospital, Croydon, UK Russell Metcalfe Smith ∗ , Muhammad Khan, Ann Starr Croydon University Hospital NHS Trust, Croydon, UK Introduction: Most adverse incidents involve an element of system error. Cardiac Arrest Trolleys hold key emergency equipment which when needed can be accessed rapidly. Traditional models involved Registered Nurses spending considerable periods of time checking these trolleys daily. Even when checking had taken place equipment was still often missing. Aims: Introduction of a sealed Airway and Vascular Access tray in all ward based Cardiac Arrest Trolleys. The purpose to reduce error by reducing the reliance of staff being required to check equipment. To reduce cost by preventing overstocking, and reducing considerably the amount of time staff take to check this essential equipment. Methods: Evaluation of the cost of Registered Nurses checking Cardiac Arrest Trolleys twice daily was undertaken. Results: Prior to the introduction of sealed resuscitation trays (spring 2011) the average time spent by Registered Nurses checking equipment was 30 min across 50 locations, twice daily at a cost of approximately £320 K. Since the introduction of this new innovation the checking time has reduced by a third to 10 min result in a cost saving of £215 K and an additional 12,000 Nursing Hours being available for patient care. Conclusion: CUH Simulation Centre has introduced a system which has achieved the following: • No recorded episodes of missing equipment in high risk situations • Reduced checking time from 1 h daily to only 10 min resulting in a significant cost saving
Recommendations: Implementing a simple strategy improves patient safety by ensuring equipment is present when required and increases time available for Nursing Staff to care for patients. http://dx.doi.org/10.1016/j.resuscitation.2012.08.305 AP247 CPR team work, interpersonal skills and team efficiency audit Velitchka Schembri Agius ∗ , Tanya Esposito, Marie Eleanor Farrugia Mater Dei Hospital, Msida, Malta Background & goal of study: Our hospital CPR team is composed of one medical registrar, one anaesthetist, two cardiac care unit nurses and one foundation year doctor. The team members change daily and meet only during resuscitation in the wards. The aim of the study was to evaluate the level of team work as an important component of the CPR team. With good communication as a team we can provide a better level of care to our cardiac arrest patients. Method: A questionnaire was used as a tool to gather the opinion of the members forming part of the CPR team. In the questionnaire the efficiency of the CPR team, communication between team members, interpersonal skills and team work were evaluated. The years of experience on the CPR team, knowledge of the new ALS guidelines and ALS certification status were also included. Results: The years of experience on the team ranged between 0.2 months up to 19 years. 46 members of the CPR team took part in this study – 32% nurses, 37% anaesthetists and 31% medical doctor.
Poster Presentations / Resuscitation 83 (2012) e24–e123
91.31% had awareness of the new ALS guidelines. An average of 76% had a current ALS certification. Positive feedback on: • • • •
Efficiency of carrying out CPR was 66.8% Communication between team members 55.1% Interpersonal skill 49.3% Team work 48.5%
Conclusion: The most common problems that the team members encounter during CPR are the lack of communication and teamwork. This study concludes that there is the need to improve the CPR team group dynamics in different aspects of team work including interpersonal skills and communication so as to improve the efficiency of delivery of CPR. Our goal is to improve the situation by regular meetings of the CPR team to improve the communication between members to provide the best care for our patients. http://dx.doi.org/10.1016/j.resuscitation.2012.08.306 AP248 Survival from inpatient cardiac arrest in a specialised referral hospital Philip Cokkinos, Evangelia Papadopoulou, Aggeliki Gkouziouta, Konstantinos Farsalinos ∗ , Androniki Tasouli, Vasillis Voudris, Dennis V. Cokkinos Onassis Cardiac Surgery Center, Athens, Greece Purpose: To estimate survival from inpatient cardiac arrest at the Onassis Cardiac Center, a referral hospital for Cardiology and Cardiac Surgery. Methods: We recorded cardiac arrests over a 48-month period, using the Utstein style for cardiac and surgical patients (pts) distributed on 3 floors. The arrival time of the arrest team (CAT) was calculated from the “code blue” call. All our pts are on telemetry so the initial rhythm is accurately recorded. Our institution’s CAT includes the on call Registrars and SHOs, anaesthesiologist, and nurses, all trained in Advanced or Immediate Life Support (ALS, ILS). Biphasic defibrillators are available on every floor. Results: During the 48-month period, there were 65,565 admissions (52,720 in the Cardiology wards and 12,845 in Cardiothoracic Surgery wards). We recorded 105 inpatient arrests (29 women, mean age 68.6 ± 14 years): 37 (35%) in the cardiology wards (0.06% admissions) and 68 (65%) in surgical wards (0.53% admissions). Of those, 57 presented with asystole, 46 with ventricular fibrillation or pulseless ventricular tachycardia (VF/VT), and 2 in pulseless electrical activity (PEA). In total, 82 pts (78.1%) survived the initial resuscitation attempt (IRA) and 48 (45.7%) survived to discharge (35% of the cardiology pts and 51.5% of the surgical pts). We intubated 70 pts, of whom 73% survived the IRA and 34% to discharge. Survival from the IRA and to hospital discharge was 68% and 25%, respectively, for asystole, and 91% and 72% for VF/VT. Both PEA pts survived to discharge. The CAT arrival time was less than 1 min in 80 (76.2%) of pts. Conclusions: Survival from in-hospital cardiac arrest to discharge in our institution was 45.7%. Factors such as telemetry monitoring, defibrillator presence on all inpatient floors, and the prompt arrival of a properly trained cardiac arrest team to the patient’s bedside contributed to successful resuscitation attempts. http://dx.doi.org/10.1016/j.resuscitation.2012.08.307
e119
AP249 Implementing therapeutic hypothermia after cardiac arrest in the era of new guidelines: A longitudinal qualitative study of perceived barriers and facilitators Young-Min Kim 1,∗ , Seung-Joon Lee 1 , Sun-Jin Jo 2 , Kyu-Nam Park 1 1
Department of Emergency Medicine, School of Medicine, The Catholic University of Korea, Seoul, Republic of Korea 2 Department of Preventive Medicine, School of Medicine, The Catholic University of Korea, Seoul, Republic of Korea Purpose: Therapeutic hypothermia (TH) after cardiac arrest was strongly recommended in 2010 guidelines. Understanding of barriers and facilitators is important for development of effective implementation strategies. The aim of this study was to identify the barriers to, and facilitators of implementation of TH for cardiac arrest survivors in a country with limited critical care human resources. Material and methods: Up to two serial individual interviews over one year (i.e. 6 and 12 months) and focus group discussions (for acting and managing champions) were conducted with 21 physicians recruited from a TH training course for hospital champions. Interviews were transcribed and coded by two independent assessors. Contents were analyzed thematically and group interaction was also examined. Results: Two participants changed their hospitals during the study period. The final dataset comprised 40 interviews and two focus group discussions. The identified barriers and facilitators could be classified into 3 major categories: (1) healthcare professionals’ perception of the guidelines and protocols, (2) interdisciplinary and interprofessional collaboration, and (3) organizational resources. Perception of the guidelines and protocols has been improved with accumulation of clinical experiences over the study period. Lack of resources was the most commonly agreed barrier for the acting champions whereas lack of interdisciplinary collaboration was for the managing champions. Educational activities and sharing successfully treated cases were the most frequently identified facilitators. Most of the participants identified and agreed that cooling equipment was not only an important barrier to but also a facilitator of successful TH implementation. Conclusions: Healthcare professionals’ internal barriers to TH implementation may be influenced by guideline changes and can be changed with accumulation of successful clinical experiences. Promoting Interprofessional and interdisciplinary collaboration through educational activities and use of cooling equipment with auto-feedback function could improve adherence to the guidelines in a country with limited critical care human resources. Further reading
[1].Sinuff T, Cook D, Giacomini M, Heyland D, Dodek P. Facilitating clinician adherence to guidelines in the intensive care unit: a multicenter, qualitative study. Crit Care Med 2007;35:2083–9. [2].Brooks SC, Morrison LJ. Implementation of therapeutic hypothermia guidelines for post-cardiac arrest syndrome at a glacial pace: seeking guidance from the knowledge translation literature. Resuscitation 2008;77:286–92. [3].Bigham BL, Dainty KN, Scales DC, Morrison LJ, Brooks SC. Predictors of adopting therapeutic hypothermia for post-cardiac arrest patients among Canadian emergency and critical care physicians. Resuscitation 2010;81:20–4.
http://dx.doi.org/10.1016/j.resuscitation.2012.08.308