Approach out-of-hospital cardiac arrest like a NASCAR pit crew approaches a race car. CanStockPhoto/corepics
Hopkins CL, Burk C, Moser S, et al. Implementation of pit crew approach and cardiopulmonary resuscitation metrics for out-of-hospital cardiac arrest improves patient survival and neurological outcome. J Am Heart Assoc. 2016;5(1).
This is a retrospective review of the impact of multiple changes to how Salt Lake City Fire Department EMS cared for cardiac arrest victims. Researchers examined the typical Utstein measures in two periods: from Sept. 1, 2008, to Sept. 1, 2011, and from Oct. 1, 2011, to Dec. 31, 2014.
In September 2011, the agency was trained in the delivery of high-quality CPR, which included the following:
- Clearly assigned roles for each rescuer;
- Minimal compression interruptions;
- Use of the ZOLL E-series monitor/defibrillator to provide audio and visual feedback to improve CPR quality;
- Passive oxygenation of witnessed cardiac arrest patients during the initial 6-8 minutes of CPR;
- Asynchronous ventilations with both bag-valve mask and advanced airway at rate of 10 per minute in all unwitnessed, pediatric and suspected respiratory arrests;
- Use of the ZOLL E-series' See-Thru CPR function, which filters out CPR artifacts created by chest compressions so that the rhythm may be interpreted while CPR is being performed vs. pausing CPR as the machine interprets the rhythm;
- No pulse checks until the appearance of a rhythm with a rate > 40 beats/minute and end-tidal carbon dioxide (EtCO2) > 20 mmHg;
- Pre-charging of the defibrillator while chest compressions continue and counting down until shock delivery, at which point the compressor "hovers" over the chest and then immediately resumes compressions after the shock;
- Use of blind insertion supraglottic airway instead of traditional intubation (use of video laryngoscopy without compression interruption was allowed later);
- Implementation of the ResQPOD impedance threshold device in July 2013;
- Required use of EZ-IO intraosseous vascular access system as the first line technique;
- Induced hypothermia with the infusion of chilled saline during the arrest;
- On-scene resuscitation for at least 30 minutes before deciding to transport, since they hadn't implemented any form of mechanical CPR device;
- Delivery of all patients to a hospital with cath lab capability;
- Post-incident review of all arrests by the medical director, resulting in feedback to all rescuers on CPR quality (including average rate, depth, congestive cardiac failure, pre-shock and post-shock pauses, and proportion of all compressions within guidelines for both rate and depth), ventilation frequency, analysis of rhythm interpretation and treatment decisions, and suggestions for improvement.
Of the 407 cardiac arrests in the post-implementation phase there were 65 (16%) survivors with good neurological outcomes compared to only 25 of 330 (8%) in the pre-implementation phase. Of the patients who survived to hospital admission, 71 of 141 (50%) of post-implementation vs. 36 of 98 (37%) of pre-implementation patients survived to hospital discharge.
Doc Wesley Comments
Although this isn't a rigorously conducted study, it's extremely valuable information because it reflects a real-world experience. We can only draw so many conclusions from randomly controlled double-blind studies of the effects of various CPR techniques and drugs on pigs.
The authors are honest when they state they don't know which components in this implementation are the most important. But again, this is real life. We can't simply make one change to our protocols and then collect data for four years hoping things will improve. How many lives could have been saved if we'd included the techniques we believed could make a difference? The components this program implemented are based either on research or are considered best practice by professional organizations such as the American Heart Association.
I'm convinced there's no single right approach to cardiac arrest resuscitation. However, what I also know is that there's far too much variation from code to code even within a given service. Don't play it by ear by performing intermittent CPR, addressing the airway whenever you get to it, or administering medications whenever you remember. Standardization is the first step in any improvement process. After that, the medical director can add or subtract individual components and measure change.
Medic Wesley Comments
As a NASCAR fan, I'm fascinated by the pit crew approach to CPR. The idea that rescuers would have individual assignments but still work as a team shouldn't be new to EMS. Like Doc said, "there's no single right approach to cardiac arrest resuscitation."
This quote from Hot Rod Magazine really sums up what's necessary to make the pit crew CPR concept a reality: "If you do pit stops, you had better be in shape. Training regimens tailored to your specific duties will help, and it can't hurt to have high endurance levels. Don't get wedded to the idea that the pit stop is always going to happen the way you have it planned. Sometimes the pit stop happens the way it wants to happen, and you have to adapt quickly to whatever conditions present themselves."1
Pit crews are physically fit. They train every day and each members trains for all positions. They train hours a day on simulated pit stops. They train how they'll work, and work how they train. They record and critique the simulation so they can improve on race day.
How often do we train on mega codes, and how realistic is our training? What do we do to make sure we are ready for "race day"? I think the answer is topractice, practice, practice.
Providers should make out-of-hospital cardiac arrest survival rates part of their professional goal, not just a mandate from the education coordinator or the quality assurance guru. Make it competitive by challenging other crews for best accuracy.
I look forward to seeing our cardiac arrest "pit stops" having shorter times with the ultimate goal of a win for our patients. Checkered flag, my friends, is where it's at.
1. Lemasters R Jr. (Sept. 1, 2002.) Building a better crew. Hot Rod Network. Retrieved June 20, 2016, from www.hotrod.com/how-to/additional-how-to/pit-crew-training-regimen/.