Resuscitation System Paris Hotel and Casino Las Vegas Nevada Joseph P Ornato MD FACP FACC FACEP Professor amp Chairman Dept of Emergency Medicine Professor Internal Medicine Cardiology ID: 1045290
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1. Creating a High-PerformanceResuscitation SystemParis Hotel and Casino Las Vegas, NevadaJoseph P. Ornato, MD, FACP, FACC, FACEPProfessor & Chairman, Dept. of Emergency MedicineProfessor, Internal Medicine (Cardiology)Virginia Commonwealth University Health SystemOperational Medical DirectorRichmond Ambulance AuthorityRichmond Fire & EMSHenrico County Division of FireRichmond, VA
2. Disclosure InformationJoseph P. Ornato, MD, FACP, FACC, FACEPCreating a High-Performance Resuscitation SystemFINANCIAL DISCLOSURE: Cardiac Co-Chair & Consultant: NIH Resuscitation Outcomes Consortium (ROC)American Editor, ResuscitationAdvisory Board, Key Technologies, Inc. (Transnasal Cooling Device)UNLABELED/UNAPPROVED USES DISCLOSURE: Wriskwatch™, Emergency Medical Technologies
3. Creating a High-Performance Resuscitation SystemAccurate dataPreventionImplementing effective community systems of careChanging research funding prioritiesBreakthrough approachesDetecting unwitnessed OOH cardiac arrestEffective therapy for pulseless electrical activity (PEA)Adapting principles & practices from high performance industries
4. Accurate Data
5. Cardiac arrest dataNo national U.S.registryData sourcesNIH Resuscitation Outcomes Consortium (ROC)8 U.S., 3 Canadian sitesResearch sitesEpistryCDC Cardiac Arrest Registry to Enhance Survival (CARES)46 communities in 31 states & DCVoluntary sitesROCCARES
6. Public Health Burden of Cardiac ArrestHeart Disease and Stroke StatisticsGo et al. Circulation. 2013;127:e6-e24510 x more deaths/year from OOH-CA than MIOut-of-hospital Cardiac ArrestAcute Myocardial Infarction720,000 cases per year in the USA21% of these are “silent”73% of MI deaths occur out-of-hospital (i.e., cardiac arrests)In-hospital mortality rate= 4.6%In-hospital deaths/yearOut-of-hospital deaths/year359,400 out-of-hospital cardiac arrest cases per year in the USA23% have an initial documented CA rhythm of VFOut-of-hospital mortality rate= 90.5%MICardiac Arrest
7. Prevention
8. Challenges in SCD PreventionMyerburg et al. JACC 2009; 54:747-63 MADIT I, MUSTTAVID, CIDS, CASHMADIT II, SCD-HeFT
9. Implementing Community Systems of Care
10. Regional variation in OOH-CA survival Resuscitation Outcomes Consortium (ROC)Nichol et al. JAMA 2008; 300:1423-31
11. ROC all-site survival over time(Unadjusted)WitnessedVT/VFVT/VFEMS treatedPEAAsystole
12. Patient centered careHigh quality care that is safe, effective, and timelyStakeholder consensus on systems infrastructureIncreased operational efficienciesMeasurable patient outcomesEvaluation mechanism to ensure that quality of care measures reflect changes in evidence-based researchA role for local community hospitals so as to avoid a negative impact that could eliminate critical access to local healthcareReduction in disparities of healthcare deliveryGuiding Principles for Regionalization of Post-Arrest Care
13. AHA Mission Lifeline Ideal System
14. Richmond EMS SystemEnhanced 911 systemScripted pre-arrival instructionsAdvanced system status managementGPS automated vehicle locators on all units with dynamic GPS navigation Fire AED first response <5 min ALS on-sceneMedian 5-6 min93-96% in ≤8 min 12-lead ECGs, capnography,pulse oximetry, AutoPulse™TrafficImpedance MonitorMARVLIS
15. Resuscitation strategy approachOptimize blood flow/oxygen deliveryVasopressor supportAutopulse™ CPR with continuous chest compressionNo interruptions of CPR for defibrillationShorten the time to airway & drug therapyKing LTS™EZ-IO™Protect the brain & heartPre-hospital therapeutic hypothermia during & post-arrestRegionalized post-resuscitation center care
16. Advanced Resuscitation Cooling Therapeutics Intensive CareARCTIC Alert from fieldVCU never on diversion for ARCTIC ptsARCTIC TeamED physician and nurseARCTIC attending (only 5)CCU / interventional fellowCCU NPRN CoordinatorInclusion criteria for ARCTICComatose or unable to follow verbal commandsInitial rhythm VF, orInitial rhythm witnessed PEA or ASYSExclusion criteriaDNAR, terminal illnessShock unresponsive to vasopressorsUncontrolled bleeding
17. VCU’s ARCTIC Regionalized System of Care for OHCAAdvanced Resuscitation Cooling Therapeutics Intensive Care“Induction Center Concept”EM focuses on stabilizing patientInitiates early goal directed therapyCICU/cath team places cooling catheter and continues standardized post-arrest careEndovascular cooling strategy with 5 dedicated machinesContinuous EEGs with aggressive seizure RxIn-hospital ECMO 24/7Patients admitted to only one ICU (CICU) with specially trained, dedicated ARCTIC nurse staffingElectronic order sets & personal checklists72-hour pathway for goal directed therapyFull time RN ARCTIC coordinatorCICU NP Clinical consistencyMultidisciplinary ongoing education processEMS and satellite hospital feedback on all casesContinuous quality review of data and ongoing evidence based system changes
18. Repeatable Battery for the Assessment of Neuropsychological Status (RBANS)Immediate memoryList learning Store memoryVisuospatial / constructional orientationComplex figure copy / trail makingLine orientationLanguagePicture namingSemantic fluencyAttentionDigit spanningCodingDelayed memoryRecall of aboveBeck Depression ScaleBrain injury rehabilitation3 and 6 month neuro-cognitive testingDetailed neuro-cognitive testing & brain injury rehabilitation program
19. CPC is not accurate in assessing true neurocognitive functionShort term memory deficitProfoundTransientVariable resolution“Reverse PTSD”“Flock back behavior”Question ability to return to workFamily stress and re-integrationNeuro-cognitive issues
20. Changing Research Funding Priorities
21. Reasons for the paucity of SCD funding and researchMisperception that SCD is largely an untreatable problemMost of the existing therapies are generic, patent unprotected drugs or devicesFew novel, patented-protected pharmaceuticals are in the pipelineFunding circle paradoxInvestigator perception of little NIH interest in topicFew grant applicationsNIH perception of little investigator interest in topic
22. Need for Cardiac Arrest ResearchOrnato JP, Becker LB, Weisfeldt ML, Wright BA. Circulation 2010:1876-9
23. NIH Resuscitation Outcomes Consortium (ROC) 2005-15First large-scale, governmentally-sponsored, North American effort to conduct definitive pre-hospital, randomized clinical trials in out-of-hospital cardiac arrest (OHCA) and severe traumatic injuryFocus is on very early delivery of interventions by EMS providers, when there is optimal potential for benefitROC
24. NameTypeDesignNStatus1Cardiac Arrest EpistryCardiacObservational 179,310Ongoing2Trauma Epistry/PROPHETTraumaObservational21,656Completed3PRIMED ITDCardiacRCT11,892Completed4PRIMED AEvALCardiacRCT13,126Completed5CPR feedback CardiacAncillary RCT1,586Completed6Hypertonic ShockTraumaRCT895Completed7Hypertonic TBITraumaRCT1,331Completed8Dallas RESCUE TBITraumaRCT pilot50Completed9Dallas RESCUE ShockTraumaRCT pilot50Completed10BLAST ground cohort TraumaCase series389Completed11Hypo Resus – shockTraumaRCT pilot192Completed12ALPS for VFCardiacRCT3,000Ongoing13CCC vs 30:2 in OHCACardiacRCT23,600Ongoing14BLAST air cohort - shockTraumaCase series218Completed15PROPPR massive transfusionsTraumaRCT680CompletedTotal257,957ROC clinical trials (2003-14)
25. Publications54 abstracts at national meetingsAHA, ReSS, NAEMSP, SAEM58 peer-reviewed publications ROC accomplishments (2003-14)Change in medical practiceAHA/ILCOR Resuscitation Guidelines (GL)15 GL worksheets31 chapters in CPR GLs7 additional publications41 consensus panel statementsROC is the key data source for OHCANew hypotheses & funding490 additional resuscitation & trauma publications by ROC PI’s and its leadership (2003-12)Additional grants - 10 NIH, 9 DOD, 1 CDC, 31 otherJournalImpact factorN Engl J Med (2)53.3JAMA30.0Circulation14.7J Amer Coll Cardiol14.2Brit Med J14.1Ann Surg7.3Crit Care Med6.3J Amer College Surg4.5Ann Emerg Med4.1Am J Public Health3.9Resuscitation3.6J Trauma2.5
26. Breakthrough Approaches:Unwitnessed Cardiac Arrest
27. The challenge of unwitnessed OOH-CAAmbient Intelligence
28. Detection of the unwitnessed OOH-CAWriskwatch™Emergency Medical Technologies, N Miami Beach, Floridahttp://www.emergencymedtech.com
29. Breakthrough Approaches:Pulseless Electrical Activity (PEA)
30. Pulseless electrical activityParadis NA et al. Resuscitation 2012; 83:1287-918 domestic Yorkshire swinePEA induced by ventilation with a hypoxic mixtureAutopulse™ synchronized compressions applied
31. Breakthrough Approaches:Adapting Principles & Practices from High Performance Industries
32. Aviation vs. resuscitationOrnato JP, Peberdy MA. Resuscitation 2014; 85:173-6AviationResuscitationPreflight checksCode cart/equipment checksPreflight crew briefDelegation of tasksTake-off/climbInitiate CPR/DF/airway/IVCruiseContinue CPR/DF/drugsDescent/landingROSC or cease resuscitationPost-flight checksStabilization, post-resusc careCrew debriefingTeam debriefingPhases of FlightPhases of Resuscitation
33. Aviation & resuscitation are team effortsOrnato JP, Peberdy MA. Resuscitation 2014; 85:173-6AviationResuscitationPerson in chargePilot in CommandTeam LeaderLives at stakeUp to hundreds1Multiple phasesYesYesDidactic trainingFlight SchoolBCLS, ACLS, PALSScenario-based trainingFlight SimulatorCode SimulationStandard setting organizationFAAAHAStandardized approachChecklistsAlgorithmsConsistent standardizationAbsolutelyNo
34. What’s different about aviation?Ornato JP, Peberdy MA. Resuscitation 2014; 85:173-6Pilots understand that flying is a privilegeAviation functions in a rigorous culture of safetySkills & procedures are standardizedTeamwork is the daily routinePilots anticipate, train, plan & brief for emergenciesPilots lives are on the line every flight
35. Aviation toolboxOrnato JP, Peberdy MA. Resuscitation 2014; 85:173-6CommunicationSterile cockpit ruleProceduresCrosschecksMandatory read backsMandatory checklist useInstrument guided flight
36. SummaryAccurate dataPreventionImplementing effective community systems of careChanging research funding prioritiesBreakthrough approachesDetecting unwitnessed OOH cardiac arrestEffective therapy for pulseless electrical activity (PEA)Adapting principles & practices from high performance industries