CPR Report Cards: What’s Your Grade?

Nicole KupchikMN, RN, CCNS, CCRN, PCCN-CMC, CSC

Our Moderator

Kimberly Kelly, BSN,RN,CCRN-CSC• Staff Nurse at Legacy Emanuel

Medical Center, Portland, OR§ Lead Responder: Code Blue/RRT§ Cardiovascular Intensive Care Unit§ AACN Critical Care Fall Symposium

Committee Member

Our Speaker

Nicole Kupchik MN, RN, CCNS, CCRN, PCCN-CMC§ Clinical Nurse Specialist§ Former Code Blue Committee Chair§ Currently consultant

National Resuscitation Presentations:§ American Heart Association (AHA)§ Emergency Cardiovascular Care Updates (ECCU)§ Society of Critical Care Medicine (SCCM)§ National Teaching Institute (NTI)§ Emergency Nurses Association (ENA)

Disclosures

Speaker’s Bureau: § Physio-Control, now part of Stryker § La Jolla Pharmaceuticals§ Cheetah Medical

Consultant: § Physio-Control, now part of Stryker § Baxter Healthcare

§ This educational activity is approved for 1 contact hour. .§ A link to obtain CE credits will be available at the conclusion of the webinarAccreditation Statements§ Saxe Healthcare Communications is accredited as a provider for continuing

education by the American Nurses’ Credentialing Center’s Commission on Accreditation. Provider approved by California Board of Nursing. Provider #14477 and the Florida Board of Nursing Provider # 50-17032

§ This program has been approved for 1.0 contact hours Continuing Respiratory Care Education (CRCE) credit by the American Association of Respiratory Care, 9425 N. MacArthur Blvd. Suite 100, Irving, TX 75063

§ Support for this educational activity provided by Physio-Control, now part of Stryker

Continuing Education for Nurses and Respiratory Therapists

CPR Report Cards: What’s Your Grade?

Nicole KupchikMN, RN, CCNS, CCRN, PCCN-CMC, CSC

Learning Objectives

§ Discuss the importance of high quality CPR during cardiac arrest

§ Describe the importance of post event feedback using CPR reports

§ Discuss common issues with CPR in resuscitation events

Poll # 1

Is your hospital measuring CPR quality and giving feedback to teams?1. Yes2. No3. Sometimes

Solutions to Optimize CPR Performance

§ Metronomes§ Real time feedback

devices§ Capnography§ CPR Coach§ Post Event Review

Ideal – Fix issues as they happen!

AHA Consensus Recommendation

2013 Consensus Recommendation

“…resuscitation data from the defibrillator or any other device or source documentation that captures data at the scene should be used for feedback to the team.”

Circulation, 2013

Post Event Review & Debriefing

§ Data automatically downloads from the defibrillator

§ Evaluate CPR quality§ Rate§ Depth§ Chest Compression

Fraction§ Time to defibrillation§ Peri-shock pauses§ Capnography trends§ Assisted ventilation rate

So, how does this work?

Wireless transmission

Software / Database

Feedback/Report Card to Code Blue teams

CPR Report Card

So, how does this work?

Impedance signal & waveformfrom defibrillation pads

What does a CPR

report card tell you?

Breakdown of the CPR Report Card

% of time on the chest giving compressions

Average CC Rate

Average ventilation rate

Initial Rhythm

Breakdown of the CPR Report Card

Capnography trends during entire event

Total compression count# Pauses over 10 seconds

Longest compression pause

Breakdown of the CPR Report Card

Minute by minute events:Each red dash = single chest compression

Each blue inverted triangle = ventilation

Poll # 2

What do you think is your biggest challenge in codes?1. Chest compression rates are too fast &/or depth is too

shallow2. Pauses in compressions or around defibrillation events3. Over-ventilation4. Forgetting to connect Capnography5. We don’t have issues with any of these! (Yay!)

Does debriefing post-event improve outcomes?

Pediatric patients 8 years or older119 cardiac arrest events:

60 Control; 59 InterventionProspective quality improvement interventional trialDebriefing: **Safe environment**§ Patient history§ Pre-arrest studies (radiographs, CT scans, labs)§ Quantitative resuscitation data§ Patient Outcome and SummaryWolfe et al. (2014) Critical Care Medicine. 42(7)

Four Targets: “Excellent CPR”

§ Depth ≥ 38 mm§ Rate ≥ 100/min§ CPR Fraction > 90%§ Leaning < 10%

Wolfe et al. (2014).Critical Care Medicine. 42(7)

P = 0.054 P = 0.036

Issues with the Chest Compression Rate

Rapid CC Rate!

ROSC

Same case – ROSC, then re-arrest

Intra-Arrest Review

Compression fraction

Goal: at least 80%!

2 months after giving feedback to teams

§ ED patient with STEMI

§ PEA arrest§ Compression

fraction?§ What do you

think about the rate?

Poll # 3

What grade would you give on the 2-month changes?1. A+2. B+3. C+4. Detention

Issues with Chest Compression Depth

CC Rate 141

Minute by minute breakdown

Issues with Chest Compression Pauses

Case #1 Pre-shock Pause Issues

38 second pre-shock pause

Case #2 2 months later…

8 second pulse check

Case #3 Minimized pre & post shock pauses

Poll # 4

What grade would you give on the 6-month changes? 1. A+2. B+3. C+4. Detention!

Mechanical CPR with a Shock - #1

Pre-Shock Pause with Mechanical CPR - #2

Report Card - #3

Mechanical CPR – Don’t forget to shock!

Shock #1Minimal pause

Shock #231 sec pause

Shock #329 sec pause,

then shock

Too much timein between

pauses

Capnography Without & With Pulse

Pulseless – Capno 20 mm Hg with CPR

Conversion to an organized rhythm – Capno over 50 mm Hg

STEMI – Vfib ArrestChest Compressions: 1 of 3

Patient goes into Ventricular Fibrillation

20 seconds until CC started

Chest Compressions – Shock 200J,Organized Rhythm – then Vfib: 2 of 3

Vfib – Defib 300J – 8 CCBack into Vfib: 3 of 3

60-Minute Case… Minutes 1 - 26

Minutes 27 - 53

Patient remains in VF at minute 34, 43 & 46 – no shock

Minutes 54 - 59

How many shocks should have been delivered for a 60

min VF case?

AT LEAST 30!

Vfib – Compressions? Shock?

Poll # 5

What grade would you give this Vfib arrest case? 1. A+2. B+3. C+4. Detention!

Poll # 6

What grade would you give this 41 minute Vfib arrest case? 1. A+2. B+3. C+4. Detention

Issues with Over-Ventilation

Over-Ventilation is Common

In conclusion

§ Improvements in CPR quality and performance can be improved with feedback

§ Post event review can assist in targeting system issues to focus training

You won’t improve what you don’t measure!

Our Moderator

Kimberly Kelly

§ This activity has approved this program for 1.0 contact hour of CRCE and CNE by the AARC and California Board of Nursing and the Florida Board of Nursing

§ Go to http://www.saxetesting.com/sl§ You will need to register on the test site. Complete the evaluation form.§ Upon successful submission, you will be able to print your certificate of

completion.Accreditation Statements § American Association for Respiratory Care, 9425 N. MacArthur Blvd., Suite

100, Irving, TX 75063.§ Provider (Saxe Communications) is approved by the California Board of

Registered Nursing. Provider # 14477 and Florida Board of Nursing. Provider # 50-17032

§ Support for this educational activity provided by Physio-Control, now part of Stryker

Continuing Education for Nurses and Respiratory Therapists

Archive Version

§ An archive/on-demand version will be available on www.savinglivesnow.org

§ An email will be sent to all registrants when it is available

§ The on-demand version will be accredited for nurses and respiratory therapists

Next Webinar in Resuscitation Series

June 6th§ Mechanical CPR: Innovations in Cardiac Arrest

Questions

Kimberly Kelly Nicole Kupchik

Thank you for attending this webinar

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presented with an online Survey. Please keep your web browser open. We appreciate your feedback

CE Certificate of Completion§ In 1 hour following the conclusion of this webinar, you will receive

an email with instructions and this link to obtain your CE credits: saxetesting.com/sl

On-Demand Version§ In a few days, an email will be sent to all registrants when the On-

demand recording of this webinar is available

Thank You