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Creating a High-Performance Resuscitation System Paris Hotel and Casino  Las Vegas, Nevada Joseph P. Ornato, MD, FACP, FACC, FACEP Professor & Chairman,

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Presentation on theme: "Creating a High-Performance Resuscitation System Paris Hotel and Casino  Las Vegas, Nevada Joseph P. Ornato, MD, FACP, FACC, FACEP Professor & Chairman,"— Presentation transcript:

1 Creating a High-Performance Resuscitation System Paris Hotel and Casino  Las Vegas, Nevada Joseph P. Ornato, MD, FACP, FACC, FACEP Professor & Chairman, Dept. of Emergency Medicine Professor, Internal Medicine (Cardiology) Virginia Commonwealth University Health System Operational Medical Director Richmond Ambulance Authority Richmond Fire & EMS Henrico County Division of Fire Richmond, VA

2 Disclosure Information Joseph P. Ornato, MD, FACP, FACC, FACEP  Creating a High-Performance Resuscitation System FINANCIAL DISCLOSURE:  Cardiac Co-Chair & Consultant: NIH Resuscitation Outcomes Consortium (ROC)  American Editor, Resuscitation  Advisory Board, Key Technologies, Inc. (Transnasal Cooling Device) UNLABELED/UNAPPROVED USES DISCLOSURE:  Wriskwatch™, Emergency Medical Technologies

3 Creating a High-Performance Resuscitation System  Accurate data  Prevention  Implementing effective community systems of care  Changing research funding priorities  Breakthrough approaches  Detecting unwitnessed OOH cardiac arrest  Effective therapy for pulseless electrical activity (PEA)  Adapting principles & practices from high performance industries

4 Accurate Data

5 Cardiac arrest data  No national U.S.registry  Data sources  NIH Resuscitation Outcomes Consortium (ROC)  8 U.S., 3 Canadian sites  Research sites  Epistry  CDC Cardiac Arrest Registry to Enhance Survival (CARES)  46 communities in 31 states & DC  Voluntary sites ROC CARES

6 Public Health Burden of Cardiac Arrest Heart Disease and Stroke Statistics Go et al. Circulation. 2013;127:e6-e x more deaths/year from OOH-CA than MI Out-of-hospital Cardiac Arrest Acute Myocardial Infarction  720,000 cases per year in the USA  21% 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/year Out-of-hospital deaths/year  359,400 out-of-hospital cardiac arrest cases per year in the USA  23% have an initial documented CA rhythm of VF  Out-of-hospital mortality rate= 90.5% MI Cardiac Arrest

7 Prevention

8 Challenges in SCD Prevention Myerburg et al. JACC 2009; 54: MADIT I, MUSTT AVID, CIDS, CASH MADIT 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:

11 ROC all-site survival over time (Unadjusted) Witnessed VT/VF VT/VF EMS treated PEA Asystole

12  Patient centered care  High quality care that is safe, effective, and timely  Stakeholder consensus on systems infrastructure  Increased operational efficiencies  Measurable patient outcomes  Evaluation mechanism to ensure that quality of care measures reflect changes in evidence-based research  A role for local community hospitals so as to avoid a negative impact that could eliminate critical access to local healthcare  Reduction in disparities of healthcare delivery Guiding Principles for Regionalization of Post-Arrest Care

13 AHA Mission Lifeline Ideal System

14 Richmond EMS System  Enhanced 911 system  Scripted pre-arrival instructions  Advanced system status management  GPS automated vehicle locators on all units with dynamic GPS navigation  Fire AED first response <5 min  ALS on-scene  Median 5-6 min  93-96% in ≤8 min  12-lead ECGs, capnography, pulse oximetry, AutoPulse™ Traffic Impedance Monitor MARVLIS

15 Resuscitation strategy approach  Optimize blood flow/oxygen delivery  Vasopressor support  Autopulse™ CPR with continuous chest compression  No interruptions of CPR for defibrillation  Shorten the time to airway & drug therapy  King LTS™  EZ-IO™  Protect the brain & heart  Pre-hospital therapeutic hypothermia during & post-arrest  Regionalized post-resuscitation center care

16  ARCTIC Alert from field  VCU never on diversion for ARCTIC pts  ARCTIC Team  ED physician and nurse  ARCTIC attending (only 5)  CCU / interventional fellow  CCU NP  RN Coordinator  Inclusion criteria for ARCTIC  Comatose or unable to follow verbal commands  Initial rhythm VF, or  Initial rhythm witnessed PEA or ASYS  Exclusion criteria  DNAR, terminal illness  Shock unresponsive to vasopressors  Uncontrolled bleeding

17 VCU’s ARCTIC Regionalized System of Care for OHCA “Induction Center Concept”  EM focuses on stabilizing patient  Initiates early goal directed therapy  CICU/cath team places cooling catheter and continues standardized post-arrest care  Endovascular cooling strategy with 5 dedicated machines  Continuous EEGs with aggressive seizure Rx  In-hospital ECMO 24/7  Patients admitted to only one ICU (CICU) with specially trained, dedicated ARCTIC nurse staffing  Electronic order sets & personal checklists  72-hour pathway for goal directed therapy  Full time RN ARCTIC coordinator  CICU NP  Clinical consistency  Multidisciplinary ongoing education process  EMS and satellite hospital feedback on all cases  Continuous quality review of data and ongoing evidence based system changes

18  Repeatable Battery for the Assessment of Neuropsychological Status (RBANS)  Immediate memory  List learning  Store memory  Visuospatial / constructional orientation  Complex figure copy / trail making  Line orientation  Language  Picture naming  Semantic fluency  Attention  Digit spanning  Coding  Delayed memory  Recall of above  Beck Depression Scale  Brain injury rehabilitation  3 and 6 month neuro-cognitive testing Detailed neuro-cognitive testing & brain injury rehabilitation program

19  CPC is not accurate in assessing true neurocognitive function  Short term memory deficit  Profound  Transient  Variable resolution  “Reverse PTSD”  “Flock back behavior”  Question ability to return to work  Family stress and re-integration Neuro-cognitive issues

20 Changing Research Funding Priorities

21 Reasons for the paucity of SCD funding and research  Misperception that SCD is largely an untreatable problem  Most of the existing therapies are generic, patent unprotected drugs or devices  Few novel, patented-protected pharmaceuticals are in the pipeline  Funding circle paradox Investigator perception of little NIH interest in topic Few grant applications NIH perception of little investigator interest in topic

22 Need for Cardiac Arrest Research Ornato JP, Becker LB, Weisfeldt ML, Wright BA. Circulation 2010:1876-9

23 NIH Resuscitation Outcomes Consortium (ROC)  First 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 injury  Focus is on very early delivery of interventions by EMS providers, when there is optimal potential for benefit ROC

24 NameTypeDesignNStatus 1Cardiac Arrest EpistryCardiacObservational179,310Ongoing 2Trauma Epistry/PROPHETTraumaObservational21,656Completed 3PRIMED ITDCardiacRCT11,892Completed 4PRIMED AEvALCardiacRCT13,126Completed 5CPR feedbackCardiacAncillary RCT1,586Completed 6Hypertonic ShockTraumaRCT895Completed 7Hypertonic TBITraumaRCT1,331Completed 8Dallas RESCUE TBITraumaRCT pilot50Completed 9Dallas RESCUE ShockTraumaRCT pilot50Completed 10BLAST ground cohortTraumaCase series389Completed 11Hypo Resus – shockTraumaRCT pilot192Completed 12ALPS for VFCardiacRCT3,000Ongoing 13CCC vs 30:2 in OHCACardiacRCT23,600Ongoing 14BLAST air cohort - shockTraumaCase series218Completed 15PROPPR massive transfusionsTraumaRCT680Completed Total257,957 ROC clinical trials ( )

25 Publications  54 abstracts at national meetings  AHA, ReSS, NAEMSP, SAEM  58 peer-reviewed publications ROC accomplishments ( ) Change in medical practice  AHA/ILCOR Resuscitation Guidelines (GL)  15 GL worksheets  31 chapters in CPR GLs  7 additional publications  41 consensus panel statements  ROC is the key data source for OHCA New hypotheses & funding  490 additional resuscitation & trauma publications by ROC PI’s and its leadership ( )  Additional grants - 10 NIH, 9 DOD, 1 CDC, 31 other JournalImpact factor N Engl J Med (2)53.3 JAMA30.0 Circulation14.7 J Amer Coll Cardiol14.2 Brit Med J14.1 Ann Surg7.3 Crit Care Med6.3 J Amer College Surg4.5 Ann Emerg Med4.1 Am J Public Health3.9 Resuscitation3.6 J Trauma2.5

26 Breakthrough Approaches: Unwitnessed Cardiac Arrest

27 The challenge of unwitnessed OOH-CA Ambient Intelligence

28 Detection of the unwitnessed OOH-CA  Wriskwatch™  Emergency Medical Technologies, N Miami Beach, Florida  medtech.com

29 Breakthrough Approaches: Pulseless Electrical Activity (PEA)

30 Pulseless electrical activity Paradis NA et al. Resuscitation 2012; 83:  8 domestic Yorkshire swine  PEA induced by ventilation with a hypoxic mixture  Autopulse™ synchronized compressions applied

31 Breakthrough Approaches: Adapting Principles & Practices from High Performance Industries

32 Aviation vs. resuscitation Ornato JP, Peberdy MA. Resuscitation 2014; 85:173-6 AviationResuscitation Preflight checksCode cart/equipment checks Preflight crew briefDelegation of tasks Take-off/climbInitiate CPR/DF/airway/IV CruiseContinue CPR/DF/drugs Descent/landingROSC or cease resuscitation Post-flight checksStabilization, post-resusc care Crew debriefingTeam debriefing Phases of FlightPhases of Resuscitation

33 Aviation & resuscitation are team efforts Ornato JP, Peberdy MA. Resuscitation 2014; 85:173-6 AviationResuscitation Person in chargePilot in CommandTeam Leader Lives at stakeUp to hundreds1 Multiple phasesYes Didactic trainingFlight SchoolBCLS, ACLS, PALS Scenario-based trainingFlight SimulatorCode Simulation Standard setting organizationFAAAHA Standardized approachChecklistsAlgorithms Consistent standardizationAbsolutelyNo

34 What’s different about aviation? Ornato JP, Peberdy MA. Resuscitation 2014; 85:173-6  Pilots understand that flying is a privilege  Aviation functions in a rigorous culture of safety  Skills & procedures are standardized  Teamwork is the daily routine  Pilots anticipate, train, plan & brief for emergencies  Pilots lives are on the line every flight

35 Aviation toolbox Ornato JP, Peberdy MA. Resuscitation 2014; 85:173-6  Communication  Sterile cockpit rule  Procedures  Crosschecks  Mandatory read backs  Mandatory checklist use  Instrument guided flight

36 Summary  Accurate data  Prevention  Implementing effective community systems of care  Changing research funding priorities  Breakthrough approaches  Detecting unwitnessed OOH cardiac arrest  Effective therapy for pulseless electrical activity (PEA)  Adapting principles & practices from high performance industries


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