1. No category

Paris Hotel and Casino  Las Vegas, Nevada
Creating a High-Performance
Resuscitation System
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
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
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
Accurate Data
Cardiac arrest data
 No national U.S.registry
 Data sources
ROC
 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
CARES
Public Health Burden of Cardiac Arrest
Heart Disease and Stroke Statistics
Go et al. Circulation. 2013;127:e6-e245
Acute Myocardial Infarction
 720,000 cases per year in the USA
 21% of these are “silent”
 73% of MI deaths occur out-ofhospital (i.e., cardiac arrests)
 In-hospital mortality rate= 4.6%
In-hospital deaths/year
Out-of-hospital Cardiac Arrest
 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%
Out-of-hospital deaths/year
400,000
400,000
300,000
300,000
200,000
200,000
100,000
32,959
0
325,25
7
100,000
0
MI
Cardiac Arrest
10 x more deaths/year from OOH-CA than MI
Prevention
Challenges in SCD Prevention
Myerburg et al. JACC 2009; 54:747-63
Arrhythmia risk
markers, post-MI
MADIT I, MUSTT
AVID, CIDS, CASH
Cardiac arrest survivor
EF<30%, HF
MADIT II, SCD-HeFT
Prior coronary event
High risk for CAD; no
clinical events
General population
0%
10%
20%
Individual Patient’s SCD Risk
30%
0
100,000 200,000 300,000
Total # of SCD cases/year in USA
Implementing Community
Systems of Care
Regional variation in OOH-CA survival
Resuscitation Outcomes Consortium (ROC)
Nichol et al. JAMA 2008; 300:1423-31
10%
8.1%
8%
6.7%
6.5%
6.1%
5%
3.3%
3%
0%
2.4%
1.1%
3.3%
3.2%
ROC all-site survival over time
(Unadjusted)
Witnessed
VT/VF
VT/VF
EMS treated
PEA
Asystole
Guiding Principles for Regionalization of
Post-Arrest Care






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
AHA Mission Lifeline
Ideal System
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
MARVLIS
 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
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
dvanced
esuscitation
 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
ooling
herapeutics
ntensive
are
dvanced
esuscitation
ooling
herapeutics
ntensive
are
 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
“Induction Center Concept”
Continuous EEGs with aggressive seizure Rx
In-hospital ECMO 24/7
VCU ARCTIC Patients/Year
 Patients admitted to only one ICU (CICU) with
100
specially trained, dedicated ARCTIC nurse
90
staffing
80
Electronic order sets & personal checklists
70
72-hour pathway for goal directed therapy
60
Full time RN ARCTIC coordinator
50
CICU NP
40
 Clinical consistency
30
 Multidisciplinary ongoing education process
20
10
 EMS and satellite hospital feedback on all
0
cases
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
 Continuous quality review of data and ongoing
evidence based system changes
Detailed neuro-cognitive testing & brain
injury rehabilitation program
 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
Neuro-cognitive issues
 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
Changing Research Funding Priorities
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
NIH perception of
little investigator
interest in topic
Few grant
applications
Need for Cardiac Arrest Research
Ornato JP, Becker LB, Weisfeldt ML, Wright BA. Circulation 2010:1876-9
NIH Resuscitation Outcomes Consortium
(ROC) 2005-15
 First large-scale,
governmentally-sponsored,
North American effort to
conduct definitive pre-hospital,
randomized clinical trials in outof-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
ROC clinical trials (2003-14)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Name
Cardiac Arrest Epistry
Trauma Epistry/PROPHET
PRIMED ITD
PRIMED AEvAL
CPR feedback
Hypertonic Shock
Hypertonic TBI
Dallas RESCUE TBI
Dallas RESCUE Shock
BLAST ground cohort
Hypo Resus – shock
ALPS for VF
CCC vs 30:2 in OHCA
BLAST air cohort - shock
PROPPR massive transfusions
Type
Cardiac
Trauma
Cardiac
Cardiac
Cardiac
Trauma
Trauma
Trauma
Trauma
Trauma
Trauma
Cardiac
Cardiac
Trauma
Trauma
Design
Observational
Observational
RCT
RCT
Ancillary RCT
RCT
RCT
RCT pilot
RCT pilot
Case series
RCT pilot
RCT
RCT
Case series
RCT
Total
N
179,310
21,656
11,892
13,126
1,586
895
1,331
50
50
389
192
3,000
23,600
218
680
257,957
Status
Ongoing
Completed
Completed
Completed
Completed
Completed
Completed
Completed
Completed
Completed
Completed
Ongoing
Ongoing
Completed
Completed
ROC accomplishments (2003-14)
Publications
 54 abstracts at national meetings
 AHA, ReSS, NAEMSP, SAEM
 58 peer-reviewed publications
Journal
Impact factor
N Engl J Med (2)
53.3
JAMA
30.0
Circulation
14.7
J Amer Coll Cardiol
14.2
Brit Med J
14.1
Ann Surg
7.3
Crit Care Med
6.3
J Amer College Surg
4.5
Ann Emerg Med
4.1
Am J Public Health
3.9
Resuscitation
3.6
J Trauma
2.5
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 (2003-12)
 Additional grants - 10 NIH, 9 DOD, 1
CDC, 31 other
Breakthrough Approaches:
Unwitnessed Cardiac Arrest
The challenge of unwitnessed OOH-CA
Ambient Intelligence
Detection of the unwitnessed OOH-CA
Wriskwatch™
Emergency Medical
Technologies, N Miami
Beach, Florida
http://www.emergency
medtech.com
Breakthrough Approaches:
Pulseless Electrical Activity (PEA)
Pulseless electrical activity
Paradis NA et al. Resuscitation 2012; 83:1287-91
 8 domestic
Yorkshire swine
 PEA induced by
ventilation with a
hypoxic mixture
 Autopulse™
synchronized
compressions
applied
Breakthrough Approaches:
Adapting Principles & Practices from High Performance Industries
Aviation vs. resuscitation
Ornato JP, Peberdy MA. Resuscitation 2014; 85:173-6
Phases of Flight
Phases of Resuscitation
Aviation
Resuscitation
Preflight checks
Code cart/equipment checks
Preflight crew brief
Delegation of tasks
Take-off/climb
Initiate CPR/DF/airway/IV
Cruise
Continue CPR/DF/drugs
Descent/landing
ROSC or cease resuscitation
Post-flight checks
Stabilization, post-resusc care
Crew debriefing
Team debriefing
Aviation & resuscitation are team efforts
Ornato JP, Peberdy MA. Resuscitation 2014; 85:173-6
Aviation
Resuscitation
Pilot in Command
Team Leader
Up to hundreds
1
Multiple phases
Yes
Yes
Didactic training
Flight School
BCLS, ACLS, PALS
Flight Simulator
Code Simulation
FAA
AHA
Standardized approach
Checklists
Algorithms
Consistent standardization
Absolutely
No
Person in charge
Lives at stake
Scenario-based training
Standard setting organization
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
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
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