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A New Resuscitative Protocol

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For many years, the standard model for resuscitation training has revolved around the American Heart Association (AHA) guidelines, which are based on expert consensus and updated every five years. After release of the guidelines, modifications are made to advanced cardiac life support (ACLS) and BLS courses.

The ACLS and BLS philosophies have focused on standardization to ensure consistency across training centers and between hospitals and EMS agencies. However, in many EMS systems, the static and generic curriculum, divorced from institution- or agency-specific performance improvement data and ongoing scientific updates, has resulted in ACLS and BLS devolving into “merit badge” requirements. Rather than considering the biennial course as an opportunity to learn new information or practice critical resuscitation skills, some providers take a “tell me what I need to do to get my card” approach, with little personal investment in the training.

Seeking Change
Multiple changes in the climate of resuscitation are forcing a re-evaluation of our traditional model. Resuscitation science is undergoing a renaissance, with an explosion of new information and rapid progression in our understanding of the basic mechanisms of ischemia-reperfusion. Not only does this force more frequent updates, but it has also led to a more complex understanding of cardiopulmonary arrest. This means the prospect of a single algorithm or training platform to address different patient populations, provider types, crew configurations and equipment may be unrealistic at best—and potentially harmful at worst.

For example, dramatic improvements in neurologically intact survival have been observed in areas adopting cardiocerebral resuscitation (CCR). This technique emphasizes perfusion over ventilation and appears to work well in patients with bystander-witnessed V-fib arrest. It’s possible, however, that other arrest patients—such as the asphyxial arrest patients—may do poorly with CCR due to a lack of critical oxygen delivery. In addition, medical directors’ interpretation of scientific evidence and how it might apply to their particular institution or agency may have legitimate variability.

Finally, performance improvement capabilities, including the ability to measure and record chest compressions and ventilations, have evolved to allow observation of the most critical components of resuscitation during actual clinical practice. The ability to integrate these data into training and potentially modify treatment protocols to meet the needs of a particular institution or agency should be a primary objective of a resuscitation program going forward.

Creating Customized Programs
These pressures led the University of California, San Diego, (UCSD) Center for Resuscitation Science to create a different resuscitation program that has since spread to other inpatient institutions and prehospital agencies. Advanced resuscitation training (ART) and basic resuscitation training (BART) represent alternatives to ACLS and BLS.

In addition to being alternative courses, ART/BART represents a platform for a resuscitation program that offers flexibility with regard to treatment algorithms, as well as training content and format. In addition, an indelible link to performance improvement data is a critical component of the program.

Implementation of an ART/BART program allows an institution or agency to take a more active role in pursuing improved outcomes from cardiopulmonary arrest, while also maintaining a link to something recognizable that has a predictable structure to address regulatory and liability concerns. You can integrate ART/BART with other resuscitation training, including pediatrics, trauma and airway management, to avoid the artificial separation of these critical skills.

Not all institutions or agencies are ideal for an ART/BART program. A strong desire to improve resuscitation outcomes, a willingness to pursue an alternative pathway and an internal champion are critical to successful implementation of the program.

Selection of an optimal treatment algorithm is an important step in the process. Although the standard AHA guidelines can serve as a starting point, it’s possible that an institution or agency will want to make modifications to create its “ideal” algorithm. Such modifications should be justified based on available evidence or in-depth knowledge of the particular institution or agency’s capabilities.

Monitor changes whenever possible by using performance improvement data. Once the treatment algorithm has been selected, a training curriculum can be developed. The curriculum should be built around the algorithm and can be adapted to the unique educational structure and calendar of each institution or agency.

Consider both initial and ongoing training plans, as well as remediation strategies, for suboptimal performance during training sessions or in actual clinical practice. Finally, performance improvement efforts should be developed to monitor overall clinical outcomes, as well as the individual components of the treatment algorithm, particularly those that deviate from the standard AHA guidelines.

It’s anticipated that the UCSD Center for Resuscitation Science and the network of institutions and agencies implementing ART/BART programs can serve as resources for these efforts. The various components of an ART/BART program should be reviewed on an annual basis.

Introducing ART/BART
The UCSD Medical Center implemented ART/BART in 2007. The key components of our program include: treatment guidelines oriented toward inpatient resuscitation and the capabilities of our ZOLL E series defibrillators, which include universal capnography, high sensitivity pulse oximetry and ECG filtering.

The unique features of our inpatient environment include:

  • A predominance of hypoxemia and hypotension as the cause of arrest (rather than V-fib);
  • Limited arrest experience for most providers;
  • The availability of respiratory therapists and pharmacists; and
  • The presence of monitored beds, allowing documentation of the early indicators of impending deterioration and the opportunity for response prior to arrest.


Our treatment algorithm emphasizes a simple approach to resuscitation that minimizes interruptions in compressions, augments perfusion using pressors and integrates continuous compressions for all patients, with synchronized ventilations (10:1 ratio) in non-V-fib arrests.

An increase in heart rate noted on filtered ECG and quantitative capnometry are used as indicators of return of spontaneous circulation, with capnometry and “next generation” pulse oximetry used to rapidly confirm the presence of perfusion. In addition, aggressive surveillance using a “front-loaded” rapid response team helps prevent arrests.

Conclusion
Since implementing our ART program, the incidence of non-ICU arrests has decreased threefold, while the rate of neurologically intact survival has doubled overall and tripled in non-ICU areas. This success has resulted in recognition by multiple organizations including: The Joint Commission, National Association of Public Hospitals, UC Regents, Council on Accreditation of Air Medical Transport Services, and the University HealthSystem Consortium. In addition, we’ve established a collaborative relationship with the AHA to explore the components of our ART/BART program that make it successful and to help establish a mechanism for other institutions and agencies to pursue a similar path. JEMS

This article originally appeared in July 2010 JEMS as “The ART of Resuscitation: A new protocol for cardiopulmonary arrest calls.”

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