Improving the quality of resuscitation care.

Abstract

Sudden cardiac arrest is one of the leading causes of mortality in the hospital as well as in the community setting. Poor quality cardiopulmonary resuscitation (CPR) is believed to be a significant factor in the observed low survival rates, since multiple studies have documented a several-fold survival benefit of well-performed CPR. A number of studies have shown the importance of starting CPR as soon as possible after the onset of sudden cardiac arrest, given that survival falls 10-15% for every minute in which cardiac arrest care is not initiated. An important approach for immediate CPR education is the use of emergency telephone dispatchers to provide instructions to lay witnesses at the scene of a sudden cardiac arrest. A Japanese investigative group performed a prospective, multicenter, observational study of 4068 adult out-of-hospital cardiac arrests. The group showed that 10.8% of patients received compression-only resuscitation, 17.5% received conventional CPR, and 71.7% received no bystander CPR. Another real-time method to improve resuscitation quality is the provision of audiovisual feedback of any deviations from resuscitation guidelines, either via a freestanding CPR-sensing device or a defibrillator outfitted with CPR-sensing technology. The Inspiratory Impedance Threshold Valve is a small device placed at the end of the endotracheal tube or face mask during CPR delivery. It is used to prevent inflow of respiratory gases during active decompression (when the chest wall recoils) while the patient is not being actively ventilated to augment the negative intrathoracic pressure and, therefore, amplify venous blood return to the right heart. More recent small human trials demonstrated improved systolic blood pressures during a sudden cardiac arrest and improved short-term survival rates. A number of mechanical CPR devices have been developed in an attempt to overcome suboptimal chest compressions and CPR interruptions during manual delivery. One of the newer of these devices is a battery-powered compression band that is applied across the anterior chest wall and affixed via a backboard (Autopulse, Zoll Medical Corporation, Chelmsford, MA). LUCAS is a gas-driven sternal compression device that incorporates a suction cup for active decompression. The report of the first 100 consecutive cases treated with LUCAS during out-ofhospital sudden cardiac arrest documented that the 30-day survival was 25% in the setting of ventricular fibrillation and 5% in asystole if the CPR was started within the first 15 minutes from cardiac arrest [34] - these survival characteristics are similar to when conventional CPR is performed in the study locale. An important area that may yield improvements in CPR quality is that of improvements in human factors and resuscitation skills. In the medical domain, simulation methodology has historically focused on resuscitation, and many different tools are now being employed and developed, ranging from on-line simulation to integrated clinical simulators that use high-fidelity whole body manikins. Various different CPR techniques have received attention over the past few years. For example, one research group recently investigated whether CPR quality could be augmented by providing sustained abdominal pressure using an inflatable contoured cuff device on pigs during CPR after inducing ventricular fibrillation.