Going for Gold: A Bundled Approach to Improve Resuscitation Performance

Background:

The global burden of cardiovascular disease and cardiac arrest is significant. According to data from the World Health Organization (2014), cardiovascular diseases are the leading cause of deaths worldwide from noncommunicable disease. Data from a systematic review found that the global average incidence of arrest of presumed cardiac cause was 55 adults per 100,000 person-years, with a survival rate of 7 percent (Berdowski, 2010).

Patients experience cardiac arrest during hospitalization. In their 2014 update, the American Heart Association reports that 209,000 patients experience an in-hospital cardiac arrest each year, with a 22.7 percent survival rate for adults; 36.8 percent for children (Go, 2014). The goals of resuscitation are to support/restore effective oxygenation, ventilation, and circulation (American Heart Association, 2011). To achieve that goal, hospital systems frequently utilize a systematic approach encompassing clinical expertise, effective communication, teamwork, and structured documentation.

Description:

An opportunity for improvement for performance in resuscitation was identified in an academic medical center in Southeast Texas. The academic medical center participates in the American Heart Association’s Get With The Guidelines®-Resuscitation program (American Heart Association, 2014). Data on all adult and pediatric codes is submitted into a database. Reports available from the database include local data for trending and benchmarked data with other hospitals in the same state and across the nation.

Achievement awards are provided by the American Heart Association to hospitals who achieve at least 85 percent compliance in each of four measures. These targets serve as goals for hospitals to ensure that care is based on best evidence.  These 4 measures include time to first chest compressions less than or equal to one minute, device confirmation of correct endotracheal tube placement, time to first shock less than or equal to 2 minutes, and percent pulseless cardiac events monitored or witnessed. Three levels of awards are available; each level is contingent on the length of time maintaining 85 percent compliance. A bronze level award is one calendar quarter; silver is one calendar year; gold is 2 consecutive calendar years.

Institutional data demonstrated that the hospital did not meet the target of greater than or equal to 85 percent compliance in at least one, or more than one measure from 2007 to 2011. A resuscitation committee composed of multidisciplinary stakeholders supported the implementation of a bundled approach to improve resuscitation performance. The bundle consisted of the following: 1.) formal comprehensive review of all non-ICU codes, 2.) mock codes in medical-surgical areas, 3.) revision of paper and electronic documentation, and 4.) formal and informal feedback to team members. A template was developed for the in-depth review of multiple data on patients who experienced an arrest. These reviews were invaluable for resuscitation committee to note trends for improvement efforts.  Mock codes were instrumental in familiarizing frontline nurses in the operation of the automated external defibrillator (AED), their priorities from the time of arrest until the code team arrives, and the contents of the code cart. The need for significant revisions in both paper and electronic documentation was identified and facilitated in order to capture essential components of resuscitation. Finally, both formal and informal feedback on individual codes was provided to team members.  

Evaluation and Outcomes:

Implementation of the bundle approach resulted in sustained improvement, beginning in 2012. This included improved time to first shock by 14.6% (2007-2012), improved time to chest compressions by 7.6% (2007-2012), and improved percent pulseless events monitored or witnessed by 30.8% (2007-2012). These improvements were sustained for two consecutive calendar years (2012 and 2013). In early 2014, the academic medical center was notified by the American Heart Association that they were the recipient of a GOLD level award, having achieved greater than 85 percent compliance in all 4 measures for two consecutive calendar years. Additionally, they were the first in the state to win a GOLD level award. Most importantly, however, patients requiring resuscitation were the recipients of evidence-based guidelines.

Implications:

Improved outcomes in the performance of resuscitation for cardiac arrest are imperative for population health- local, regional, and global. An improvement plan encompassing multiple strategies may be effective in achieving these outcomes. Nurses working in hospitals, in partnership with multidisciplinary teams, can play an instrumental role in improving resuscitation performance and patient outcomes.