1 Best Practices in Resuscitation Management: Family Presence at Codes and Induced Hypothermia Protocol

2 The Region’s Leader Location: Dayton, Ohio providing comprehensive healthcare services for 17 Counties in Southwestern Ohio Bed Size: MVH-865 beds & MVH South-44 Beds Services: Comprehensive Cardiology, High-risk Maternity and Level III NICU, Level I Emergency and Trauma Center, Regional Adult Burn Center, Regional Dialysis Center and Oncology Services including Blood/Marrow Transplant Services. Hospital Statistics: 1st Magnet Hospital in Dayton; 5th in Ohio! > 2,300 Registered Nurses 50 Advanced Practice Nurses Inpatient Admissions : > 36,000 Surgeries : > 20,000 Births : > 5, 200 Emergency Visits: >120,000 * MVH South and MVH Main *Busiest ETC in Ohio Total Outpatient Visits : >709,000 MVH ranks in size among the nation’s top 100 hospitals Bed Size 847 patients 1st Magnet Facility in Dayton; 5th in OHIO Busiest ETC in OHIO

3 Family Presence During Resuscitation- The Evidence

4 Family Presence During ResuscitationCommittee Chair: Carol Griffith BSN, RN; Heart & Vascular Intensive Care Committee Members: Rachel Bledsoe BSN, RN; Heart & Vascular Intensive Care Kim Hedrick BSN, RN, CCRN: Heart & Vascular Intensive Care Patricia Jenkins MSN, RN; Surgical Intensive Care Unit Tom Kerschner , M. Div; Pastoral Care Cara Koesters BSN, RN,CEN; Emergency Department Rachel Perretta MS, APRN Palliative Care Kelly South BSN, RN; Emergency Department Kim Weisenberger BSN,RN,CCRN; Surgical Intensive Care Leadership Support: Lisa Brennan MS, APRN, CNS; Heart & Vascular Intensive Care Jayne Gmeiner MS, RN, NEA-BC; Center of Nursing Excellence Jeanie Heyd MS, RN; Heart & Vascular Intensive Care Pat O’Malley PhD, RN,CNS; Center of Nursing Excellence Kathy Zink MS, RN, Surgical Intensive Care Physician Champion: Gnan Thakore, MD; Critical Care Medicine & Pulmonary

5 Project Goals Develop evidence based guidelines to facilitate Family Presence during resuscitation Evaluate staff & family satisfaction with Family Presence Educate staff and family members regarding Family Presence

6 Evidence for Family PresenceIt is the right thing to do While it is not always comfortable – it is a professional obligation Evidence suggests that Family Presence offers significant benefits for families and staff

7 Evidence Supporting Family PresenceBaumhover, N., Hughes, L., Spirituality & support for family presence during invasive procedures & resuscitations in adults. AJCC, July 2009, Vol 18, No 4. Clark, A., Aldridge, M., et al. Family presence during cardiopulmonary resuscitation. Critical Care Nursing Clinics of North America, 2005, 17 Doran, M., The Presence of family during brain stem death testing. Intensive and critical care nursing. 2004, 20. Duran, C., Oman, K., Attitudes toward & beliefs about family presence: A survey of healthcare providers, patients’, families, and patients. AJCC, May 2007, Vol 16, No 3. ENA Presenting the Option for Family Presence, Third Edition (2007) Mason, D., Family Presence: Evidence Vs Tradition. AJCC, May 2003, Vol 12, No 3. Maurice, H., Family Presence in emergency department resuscitations: A Proposed guideline for an Australian hospital, Australian Emergency Nursing Journal, Dec. 2002, Vol 5, No 3. Mian, P., Warchal, S. et al. Impact of a multifaceted intervention on nurses’ and physicians’ attitudes and behaviors toward family presence during resuscitation. Critical Care Nurse, Feb 2007, Vol 27, No 1. Mangurten, J., Scott, S., et al. Family Presence: Making room. AJN, May 2005, Vol 105, No 5. Nibert, A., Teaching clinical ethics using a case study family presence during cardiopulmonary resuscitation. Critical Care Nurse, Feb 2005, Vol 25, No 1 Twibell, R., Siela, D., et al. Nurses’ perceptions of their self-confidence and the benefits and risks of family presence during resuscitation. AJCC, March 2008, Vol 17, No 2. Wagner, J., Lived experience of critically ill patients’ family members during cardiopulmonary resuscitation. AJCC, Sept 2004, Vol 13, No 5. York, N., Implementing a family presence protocol option. Dimensions of Critical Care Nursing, Mar 2004, Vol 23, No 2.

8 Project Timeline Phase 1 (2009-2010) Phase 2 (2011)Attended 2009 NTI –AACN Chicago - returned with evidence! Creation of Multidisciplinary Committee for Family Presence Extensive Literature review Physician Champion Evidence Based Guidelines drafted with inclusion of a Family Facilitator Staff evaluation of guidelines Phase 2 (2011) Support obtained from Medical Staff Executive Committee (MSEC) for limited trial of policy Obtained IRB approval for the study. Staff perceptions assessed after Family Presence event Family Presence Guidelines revised based on study results

9 Project Timeline Phase 3 (2011 – 2012) Phase 4 (2012 – Future)Family & Staff perceptions assessed post Family Presence event Final revision of guidelines CPR Committee approval obtained Obtained final Medical Staff approval of guidelines Phase 4 (2012 – Future) House-wide education Ongoing evaluation Revise as needed Prepare a poster for national meeting presentations Prepare a paper for publication

10 Forces FOR: AGAINST: Evidence in literatureSynergy with Relationship Based Care Model Staff receptive to trial Families requests Dedication of committee to implement Family Presence Physician Champions & Medical Director Support AGAINST: Initial staff resistance regarding Family Presence Environmental constraints & changes Staff fears of family member behaviors, requests, +/or loss of focus on resuscitation of the patient Legal concerns Availability of a Family Facilitator

11 Results

12 Results Mean Score

13 Results

14 Additional Outcomes Favorable Not FavorableRevised Guidelines work to assist nursing & medical staffs to prepare and facilitate Family Presence Family Presence is offered based on code events, resources and family assessment Families offered planned presence during a code are not required to attend and are assured that not attending is acceptable Data suggests that Family Presence is healing and makes a difference for families and staff for acceptance & grieving Not Favorable Some resistance remains despite experience, evidence and guidelines Family Presence guidelines require extensive education & practice to be successfully implemented

15 Recommendations Create a multidisciplinary committed group to drive practice change Don’t “reinvent the wheel”- adapt existing guidelines for your environment Plan initial & continuing education for all staff The Family Facilitator is the key role for successful Family Presence Guidelines Limit Family Presence to Critical Care Areas. Do not delay transfer of the patient to critical care to facilitate family visitation during a code

16 Questions? Contact Carol Griffith at

17 THERAPEUTIC HYPOTHERMIA: THE COOL WAY TO GOPresented by: Andie Slivinski, MS, RN, ACNS-BC, CEN Miami Valley Hospital Emergency Department Clinical Nurse Specialist

18 Objectives Review pathophysiology and effects of therapeutic hypothermia on the resuscitated arrest patient Identify inclusion/exclusion criteria for therapeutic hypothermia Review mechanisms for actively cooling patient Discuss potentials side effects of the cooling process Discuss case presentations of resuscitated arrest that have been cooled and subsequent outcomes

19 Resuscitation OverviewEMS treats about 300,000 victims of out-of-hospital cardiac arrest each year in the U.S. < 8% of people who suffer cardiac arrest outside the hospital survive Unless CPR and defibrillation are provided within minutes of collapse, few attempts at resuscitation are successful Most common underlying cause of sudden cardiac arrest is a heart attack that results in V fib or pulseless V Tach Brain damage can start to occur in just 4 to 6 minutes after the heart stops pumping blood About 918 Americans each day arrest 19

20 Discharged Alive….only 8% !!!!20

21 What Happens Next? After the resuscitation phase…Post-cardiac arrest myocardial dysfunction Systemic ischemia/reperfusion response Persistent precipitating pathology Post-cardiac arrest brain injury Myocardial dysfunction “Stunning of the heart” or ACS…leads to dysrthymias, decreased cardiac output, and hypotension Treat by early revascularization if AMI, IV fluids, Inotropes Ischemia/reperfusion injury SIRS, increased coagulation, impaired tissue oxygen delivery and utilization…manifested by multiorgan failure, hypotension, tissue hypoxia Treat with IV fluids, vasopressors Persistent precipitation pathology Cardiovascular disease (AMI/ACS), pulmonary disease (COPD, asthma, stroke, PE, overdose, sepsis, pneumonia, hemorrhage, dehydration Disease specific interventions Brain injury Cause of death in over 65% of out of hospital cardiac arrest Limited tolerance of ischemia Responds differently to being reperfusion injury than other organs of the body Some cerebral edema Impaired autoregulation Neurodegeneration (meaning cells break down and die) THERAPEUTIC HYPOTHERMIA 21

22 Who has heard or actually performed therapeutic hypothermia?GMVEMSC incorporated in protocol starting January 2012 22

23 History of Therapeutic HypothermiaCited in medical literature for over 200 years Concept of using it as a neuroprotective measure in the 1950’s By 1959, induced TH was widely used by neurosurgeons for head and spinal cord injuries as well as during cardiac surgery 1960s s – Ceased use, several research studies done showing neuro benefits 2005 – AHA recommended to incorporate TH in treatment guidelines 2008 – TH became gold standard for post-arrest care Not a new concept, but just gaining popularity 1803, Russian method of resuscitation consisted of covering people with snow 1950’s – animal studies proved that TH reduced the cerebral oxygen consumption, blood flow, and metabolic rate of a normal dog brain Complications noted and so therapy was deemed to be too risky– cardiac irritability, spontaneous vfib and increased infection rates… also no equipment to induce and maintain temp ILCOR and AHA – now incorporated into guidelines Pennsylvania has done large quantities of research and have really lead the county…U of Pennsylvania….GREAT resource! 23

24 Goals of TH Improve patient survival Improve neurologic recoveryImprove quality of life post-cardiac arrest Does not bring them back from the brink, merely improves quality of life 24

25 Why Does It Work? Decreases or interrupts reperfusion injuriesDecreases heart rate and increases systemic vascular resistance Decrease oxygen demand Decreases ongoing cerebral ischemia Suppresses cascade of chemical reactions that appear to be temperature sensitive Remember that the brain is particularly vulnerable to these reperfusion injuries Chemical reactions = inflammatory cascade and enzymatic processes that lead to cell death For every 1 degree temperature drop, pH rises .016 which helps acidosis For every 1 degree temp drop, cardiac output decreases by 7% 25

26 **PEA and asystole may be candidates at discretion of physicianInclusion Criteria Cardiac arrest with identified VFib/VTach by pre-hospital, emergency department, or inpatient providers with return of spontaneous circulation Comatose with brain stem function Coma is defined as not following commands. Brainstem reflexes (i.e. pupillary response, gag and cough, intact vestibulo-ocular reflex, spontaneous respirations) and pathological/posturing movements are permissible. Patients with a Glasgow Coma Score (GCS) of 3 are eligible for hypothermia. **PEA and asystole may be candidates at discretion of physician No real debate about who to include…These are GUIDELINES! Most important piece seems to be neuro reflex Research out there on PEA and asystole that does show some benefit, but most “guidelines” exclude. Most of our successes have been in vfib arrests 26

27 Exclusion Criteria Absolute Relative Major trauma SIRS/SepsisSuspected brain death Patient responds to verbal stimulation after ROSC DNR comfort care code status Comatose due to drug overdose or overt status epilepticus Time from return of spontaneous circulation greater than 6 hours Endotracheal intubation Relative Major trauma SIRS/Sepsis Pregnancy

28 Timeframes Cool patient within 6 hours of ROSCReach target temperature of 32˚-34˚C (89.6˚–93.2˚F) within 3 hours of starting cooling process Maintain patient at goal temp for 12 – 24 hours Slow re-warming process Goal times were chosen from the research that has been done ROSC (return of spontaneous circulation) Almost all of our patients we have cooled for 24 hours, 1 we cooled for 12, one for 48 (both had positive outcomes) Re-warming process is slow due to shift of electrolytes again 28

29 Pre-Hospital QuestionsIs earlier better? Only a handful of studies done ACEP Scientific assembly in 2010…before and after study of addition of TH to EMS protocols Doubled rate of survival What about…? Pulmonary edema Pulmonary Congestion Pleural effusions Earlier better… Some studies within the last decade and the results were not statistically significant Recent study that showed with each hour that passes after arrest, 20% increase in mortality The theory is the faster that we cool, the greater impact we have on decreasing the reperfusion injury …resulting in less brain injury and better neuro outcome Studies that were done…no difference between 29

30 Hospital Equipment Surface Cooling Blanketrol 30

31 Hospital Equipment Artic Sun

32 Hospital Cooling Cont…Intravascular Cooling Cool IV solutions Ice packs Chilled water NG lavage Intravascular – Alsius (Zoll) 32

33 Cooling Phase Initial vasoconstriction and tachycardia followed by bradycardia Widened QRS, ST changes, asystole, V Fib Bronchospasm Intracellular shift of calcium, magnesium, potassium, and phosphorous Cold diuresis Hemoconcentration Low platelets, coagulopathy Shivering Glucose increases Increase infection risk Frequently see bradycardia and PVS Electrolyte shift…almost always have to do replacement therapy Have to control shivering…shivering is body’s response to increase temp so is counterproductive 33

34 Maintenance Phase Frequent vitals and neuro checksMust check skin integrity frequently if using surface cooling Glucose shifts Stable but low HR, Stable BP Assess urine output

35 Re-Warming Phase Increase heart rate Decrease BP and SVRExtra cellular shift of Calcium, Magnesium, Potassium, and Phosphorus Glucose shift Decreased urine output Be ready for shifts in electrolytes with fast warming When re-warming complete, watch for rebound HYPERthermia Everything goes in reverse as electrolytes go from cells back into vasculature. 35

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37 DC’d with Positive Outcome (n=34): Discharge DispositionMVH Data DC’d with Positive Outcome (n=34): Initial Rhythm 21 V fib 2 V Tach 5 PEA 2 Asystole 4 Unknown Discharge Disposition 19 to home 12 to skilled nursing facility 4 to inpatient rehab Average LOS 18 days Longest 75 days Shortest 4 days Diagnosis 13 AMI 12 Cardiac origin 3 Respiratory arrests 4 unknown 1 Hyperkalemia Cooled over 100 patients…a couple of TBI, CVA, and one spinal cord injury (19 cases in 2012 thus far) Data above is just for resuscitated arrest National average of successes sits somewhere between 30-40% in positive outcomes Pre-hospital vs. In-house arrests---literature is not overwhelmingly supportive Shortest stay was the person cooled for 12 hours Cardiac origin – spontaneous lethal arrhythmias, status post open heart, Respiratory arrest- choking, COPD Diagnosis Unknown – sepsis? Rhythm unknown – shocked by AED first 37

38 Success Stories Patient R 64 year old maleV Fib arrest while playing basketball AMI to cath lab Decorticate posturing in ED with gag present After 48 hours, GCS 10T…at 72 hours, GCS 15 DC’d to home after 17 days neurologically intact One of our first cooled cases of the year Stayed and had CABG Short term memory loss seems to be a theme in these patients 38

39 Success Stories Patient M 68 Year old female V Fib arrestAMI that was a pre-call and ECG sent ahead Started cooling process in field with NS Initial temp on arrival 93.7 Flexion withdrawal to pain in ED Patient to Cath lab within 15 minutes After 72 hours, started weaning patient off of sedation – GCS 9T DC’d after 10 days to home neurologically intact Note that patient was nearly to goal temp on arrival Some short term memory loss 39

40 Success Stories Patient C 77 year old maleUnknown initial rhythm because shocked with AED AMI to cath lab No motor response to pain in ED but sedated Only cooled for 12 hours because neuro improved so quickly At 48 hour mark, patient was GCS 15 DC’d to home after 4 days completely neurologically intact 40

41 Other Uses Traumatic Brain Injury Spinal Cord InjuryCerebral vascular accident

42 Lessons Learned Cool as soon as possible after resuscitationReach goal temp within reasonable timeframe and maintain Patient needs to have some sort of brain stem reflex for optimal outcome Control shivering Educate family Cool early to prevent reperfusion injury have had a few cases where we were outside of the window (50/50 on outcomes) Can add icepacks, cooled IV solution, ice water gastric lavage to cool and keep cool Have cooled patients with no brain stem reflexes evident – poor outcome Shivering needs to be controlled – demerol or atracurium Shivering increases temp No one is quite sure what the mechanism is for demerol working for shivering Questions??? 42

43 Questions??

44 References American Heart Association (2010 April). CPR and Sudden Cardiac Arrest Fact Sheet. Retrieved from Bahrt, G. (2009 July). What are the merits of mild therapeutic hypothermia post-cardiac arrest? Nursing Management, 40(7), pp Neumar, R. (2008). Post-cardiac arrest syndrome: Epidemiology, pathophysiology, treatment, and prognostication. Circulation, 118, pp Nichol, G. (2008). Regional variation in out-of-hospital cardiac arrest incidence and outcome. JAMA, 300 (12), PP – Varon, J. & Acosta, P. (2008). Therapeutic hypothermia: Past, present, and future. Chest, 133, pp