JAPACVS Vol. 4 No. 1

VOLUME 4 •

NUMBER 1 •

WINTER 2022 •

www.japacvs.org

APACVS J

Journal of The Association of PAs in Cardiothoracic and Vascular Surgery

Official Journal of The Association of Physician Assistants in Cardiothoracic and Vascular Surgery

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

JAPACVS

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

Editor-in-Chief Aaron R. Morton, MMSc, PA-C, ATC, FAPACVS Emory University, Atlanta, GA Associate Editor—International Anitha Chandrasekhar, BS, PA, FAPACVS Medanta the Medicity – Delhi, India

Associate Editor—Writer Development Edward A. Ranzenbach, PA-C, MPAS, CAQ-CVTS, FAPACVS, DFAAPA Forest Ranch, CA

Editor Emeritus Doug Condit, PA-C Montefiore Medical Center – New York, NY

Editorial Board David J. Bunnell, MSHS, PA-C Frostburg, University, Frostburg, MD JoAnn Montecalvo, MPAS, PA-C Winthrop University Hospital, Mineola, NY Mitesh Patel, MSHS, PA-C Baylor Scott and White, Plano, TX David Tecchio, MPAS, MBA, PA-C Vassar Brothers Medical Center, Poughkeepsie, NY

Publisher David E. Lizotte, Jr. MPAS, PA-C, FAPACVS Executive Director APACVS Fenton, MO

EDITORIAL MISSION: The JAPACVS is the official clinical journal of the Association of PAs in Cardiothoracic and Vascular Surgery. The mission of the JAPACVS is to improve Cardiac, Vascular and Thoracic Surgical and CVT Critical Care patient care by publishing the most innovative, timely, practice-proven educational information available for the physician assistant profession. PUBLISHED CONTENT IN THE JAPACVS: Statements and opinions expressed in the articles and communications herein are those of the authors and not necessarily those of the Publisher or the Association of PAS in Cardiothoracic and Vascular Surgery (APACVS). The Publisher and the APACVS disclaim any responsibility or liability for such material, including but not limited to any losses or other damage incurred by readers in reliance on such content. Neither Publisher nor APACVS verify any claims or other information appearing in any of the advertisements contained in the publication and cannot take responsibility for any losses or other damage incurred by readers in reliance on thereon. Neither Publisher nor APACVS guarantees, warrants, or endorses any product or service advertised in this publication, nor do they guaranty any claim made by the manufacturer of such product or service. SALES OFFICE APACVS 1442 Legacy Circle Fenton, MO 63026 Phone (502) 321-6155 admin@apacvs.org JAPACVS/Journal of the Association of PAs in Cardiothoracic and Vascular Surgery is published quarterly (4 issues per volume, one volume per year) by APACVS 1442 Legacy Circle, Fenton, MO 63026. Volume 4, Number 1, Winter 2022. One year subscription rates: $40 in the United States and Possessions. Single copies (prepaid only): $10 in the United States

© 2022 APACVS, INC. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including by photocopy, recording, or information storage and retrieval system, without permission in writing from the publisher. 2

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

Editorial 4 From the Editor’s Desk Aaron R. Morton, MMSc, PA-C, ATC, FAPACVS— Editor -In-Chief Case Report 7 A Case Study of a Complex Single Ventricle Patient and Placement of a Transvenous Transpulmonary Atrial Pacemaker Mary Pickard, MSPAS, PA-C Amy Benson, DMSc, PA-C Peer Reviewed Content 17 Alternative Resuscitation Protocol For Special Population Aaron R. Morton, MMSc, PA-C, ATC, FAPACVS

David Lizotte, MPAS, PA-C, FAPACVS Amanda Murray,MMSC, PA-C, FAPACVS Peer Reviewed Content 27 Successful Organizational Strategies for Clinician Burnout Roberta E. Funck, MHS, PA-C

APACVS is the only association representing Cardiac, Thoracic and Vascular Surgery and CTV Critical Care PAs. By PAs, For PAs!

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Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

_________________________________________________________________________________________________________

From the Editor's Desk

Aaron R. Morton, MMSc, PA-C, ATC, FAPACVS Editor-in-Chief

Welcome to the first JAPACVS issue of 2022. 2021 was an incredible year of adaptation, change, discovery and firsts – some of these better than others. The APACVS had its first virtual meeting, followed by its first stand alone in-person hands-on education meeting in Louisville. At the start of 2021, we saw the first round of vaccine completion for healthcare workers which eventually opened to all adults and many children, followed with booster vaccines and the discovery of multiple Sars Cov-2 strains. We navigated through two Covid-19 surges in 2021 only to find we are ending the year on another. On the practice side of things, we saw the implantation of a new total artificial heart by Carmet, a drastic increase in utilization of adult ECMO, increase in lung transplantation following Covid-19 infections, and we likely all faced enough supply and medication shortages or substitutions to last a lifetime. 2021 was a year full of change as well for the JAPACVS, both from a leadership and structural point of view. This issue is my first issue as Editor-in-Chief. I want to extend my personal gratitude as well as that of the APACVS Board to our founding Editor, Mr. David J. Bunnel, MSHS, PA-C, DFAAPA. Under his leadership, through sheer tenacity, commitment and dedication, we saw the journal grow from an idea to an actual publication. Additionally, this year we have undertaken an immense restructuring effort to situate our journal for growth both in our respective specialties as well as internationally. This was initiated with the appointment of Ms. Anitha Chandrasekhar, PA as our new International Associate Editor. Ms. Chandrasekhar will work to incorporate our international Cardiac Surgical, Thoracic Surgical, Vascular Surgical and Critical Care PA colleagues into the JAPACVS. Additionally, Mr. Edward Ranzenbach, PA-C, MPAS, FAPACVS, DFAAPA has been appointed as the Associate Editor for Writer Development. He will work with interested authors who might not have had the opportunity to write before, to develop a manuscript and work through the writing process. 4

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

Furthermore, we have developed additional structure for the JAPACVS in the form of Section Editors who will support each of our represented specialties: Cardiac Surgery, Thoracic Surgery, Vascular Surgery and Cardiothoracic and Vascular Critical Care. The Section Editors will assist with specialty area peer review, content development and serve as specialty experts for the JAPACVS Editorial Board. If you are interested in serving as a Section Editor, be on the lookout for an invite in the new year. What an incredible year it has been! In this issue, we look at continued care following a complex congenital cardiac repair, examine a protocol for enhanced resuscitation following cardiac surgery and discuss strategies to mitigate clinician burn-out. There has been much in both the lay press as well as the academic world in the last few years regarding burn-out. This well written manuscript helps examine the aspects of burn-out and will be the JAPACVS’s first publication on professional issues. As always, a journal must have submissions to remain viable. If you would like to contribute an article or get involved with the Editorial Board, please feel free to drop me a line. Wishing you and yours health and prosperity in the new year! Be well, -AM Aaron Morton MMSc, PA-C, ATC, FAPACVS JAPACVS Editor-in-Chief editor@japacvs.org

JAPACVS publishes invited commentary and letters to the editor in response to published articles in which the authors are given the opportunity to respond .

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Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

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Case Study A Case Study of a Complex Single Ventricle Patient and Placement of a Transvenous Transpulmonary Atrial Pacemaker Mary Pickard, MSPAS, PA-C Amy Benson, DMSc, PA-C* Presbyterian Hospital, Albuquerque, New Mexico

ABSTRACT The Fontan operation is the final intervention in the palliation of single ventricle pathology. Advances in the operation and post-operative care have dramatically increased life expectancy. However, the complications post operatively and inherent to single ventricles remain a growing area of concern with arrhythmias being the most common complication. The need for pacemakers, particularly endocardial lead placement in adult Fontan patients, are challenging due to complete redirection of venous blood flow to the pulmonary arteries. This case study visits an alternative option to epicardial lead implantation by inserting an endocardial lead via a puncture through the pulmonary artery and highlights the common complications that are seen in the aging Fontan population. KEY WORDS Single ventricle, Fontan, transpulmonary, epicardial lead pacemaker, adult congenital heart disease, endocardial lead placement, arrhythmias

CASE The patient is a 25-year-old male, with complex congenital cardiac history. He was admitted to the hospital secondary o episodes of junctional bradycardia in the 30s, and pauses up to 4.6 seconds, detected on a Holter Monitor. This precipitated symptoms of dizziness, lightheadedness, and near syncope.

Cardiac History The patient has a complex cardiac history including single ventricle disease (double inlet left ventricle with subaortic stenosis and coarctation of the aorta) who had previously undergone surgical palliation with bidirectional Glenn anastomosis, Damus-Kaye-Stansel (DKS)

*Dr. Benson is now employed as a Senior Medical Science Liaison with The Janssen Pharmaceutical Companies of Johnson & Johnson. This position was obtained after involvement in the development of this manuscript.

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Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

procedure due to subaortic stenosis and extracardiac Fontan completion at the age of six (final anatomy seen in Figure 1). Two previous attempts of the Fontan were aborted due to inadvertently entering the heart while performing redo sternotomy. The patient is also noted to have progressive Fontan failure and stenosis with previous stent placement in the Fontan conduit and related liver cirrhosis and evidence of decompensated portal hypertension with varices. Other cardiac history includes paroxysmal atrial flutter and atrial fibrillation, which have been previously cardioverted, and now medically managed with metoprolol and rivaroxaban. Previous attempts to initiate sotalol ended with torsade de pointes and cardiac arrest. Past Medical History The patients past medical history includes: Depression, alcohol abuse and polycythemia, likely due to chronic hypoxemia from right to left shunting through his veno-venous collaterals. Figure 1.

Legend 1. Total Cavo-Pulmonary Connection (TCPC) 2. Extracardiac Fontan Conduit 3. Fenestration 4. Damus-Kaye-Stansel (DKS) Procedure 5. Pulmonary Artery Ligation 6. Atrial Mass with ASD Enlargement 7. Hypoplastic Right Ventricle 8. Double Inlet Left Ventricle 9. Single left ventricle

TCPC with Extracardiac Conduit and DKS Anastomosis for DILV Illustration created June 2021

Illustration taken from http://www.chd-diagrams.com.1

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Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

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Background The Fontan procedure was initially performed in 1968 by Dr. Fontan for tricuspid atresia but is now utilized for any functional or anatomical single ventricle pathology including pulmonary atresia with intact ventricular septum, hypoplastic left heart syndrome, unbalanced atrio ventricular (AV) canal defects, double outlet right ventricle (DORV) and double-inlet left ventricle (DILV).2 The original operation has significantly evolved since it was first introduced and is now the last step in a series of staged interventions for functional single ventricles. Most commonly, the initial procedure, as seen in this patient, starts with a Glenn shunt which connects the superior vena cava (SVC) to the right pulmonary artery. This is followed by an extracardiac total cavopulmonary connection (TCPC) which connects the inferior vena cava (IVC) to the right pulmonary artery via a conduit, also known as a Fontan operation.2 Depending on individual anatomy and patient’s cardio-pulmonary blood flow, several other operations can be seen prior to the Fontan operation. These include atrial septectomy or septostomy, pulmonary artery banding, systemic-pulmonary shunts such as Blalock-Taussig shunt, Norwood operation and Damus-Kaye-Stansel (DKS) procedure.2 In this case study, the patient’s primary underlying cardiac anatomy is a double inlet left ventricle; meaning that both left and right atrium drain into an enlarged left ventricle with a hypoplastic right ventricle.3 Furthermore, this patient was born with subaortic stenosis requiring a DKS procedure prior to Fontan palliation. The DKS procedure is utilized for instances in which the systemic arterial outflow tract is obstructed, such as subaortic stenosis. This procedure includes dividing the main pulmonary artery away from the right and left pulmonary arteries and joining it to the side of the ascending aorta in an end to side anastamosis.4 The DKS is also noted to have several modifications. Under these techniques, systemic venous blood flow is completely redirected to the pulmonary arteries which allows for the single ventricle to be utilized as the systemic arterial pump. Hospital Course The patient was directly admitted to hospital on the cardiac floor and placed on telemetry. His rivaroxaban was discontinued with plans to implant a pacemaker for his sinus node dysfunction. He was initiated on a heparin infusion for continued thromboembolic prophylaxis, given his various atrial arrhythmias. His metoprolol was discontinued due to sinus node dysfunction. On telemetry, he continued to exhibit episodes of paroxysmal 2:1 atrial flutter with rapid rates in addition to junctional bradycardia and sinus pauses, with associated hemodynamic compromise and symptoms of dizziness and presyncope. Given patient’s extensive cardiac history, cardio-thoracic (CT) surgery was consulted to review the option of epicardial lead placement. A chest CT angiogram (CTA) was ordered in anticipation of this consult and surgical plan for reoperation of the chest. Ultimately, after review of imaging and history, CT surgery felt the patient was too high risk for surgical epicardial lead placement. As stated earlier, the patient had repeated attempts at redo sternotomy that had been aborted due to inadvertent entry into the heart and associated hemorrhage. In addition, on the CTA, multiple bilateral pulmonary emboli (PE) were identified as well as advanced liver cirrhosis and extensive paraoesophageal varices and potential thrombus within the Fontan conduit. Since the epicardial lead placement was no longer an option by CT surgery, electrophysiology (EP) service was consulted and started the patient on Dofetilide 500mg twice daily for arrhythmias with consideration future transvenous placement of pacemaker. A transesophageal 10

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

echocardiogram (TEE) was ordered to evaluate the Fontan conduit for possible thrombus and gastroenterology was consulted for esophagogastroduodenoscopy (EGD) to evaluate the paraesophageal varices found by CTA. Given the need for anticoagulation and plans for transesophageal echocardiogram (TEE) to evaluate the potential Fontan thrombus, gastroenterology was consulted for esophagogastroduodenoscopy (EGD) to evaluate for paraesophageal varices found by CTA. The EGD found small esophageal varices, portal hypertensive gastropathy and gastric/duodenal erosions. Gastroenterology felt it was safe to initiate anticoagulation in addition to proton-pump inhibitor (PPI) therapy. After completing two days of Dofetilide, the patient continued to have intermittent junctional bradycardia and second-degree AV block. After review of several options for atrial support pacing, it was deemed the safest option was to attempt at a transvenous pacemaker system via a puncture through the pulmonary artery into the atrial mass. Given the left and right atria are no longer divided by a septum, the atria are considered one and often referred to as an “atrial mass”. The procedure would require a multidisciplinary approach with extensive TEE guidance and cardiopulmonary angiography with pressure assessments. Procedure After informed consent was obtained, the patient was taken to the electrophysiology lab and placed under general endotracheal anesthesia by the pediatric cardiac anesthesia team. The right internal jugular vein was accessed, and a pigtail catheter was positioned into the left pulmonary artery. The TEE probe was inserted to visualize the atrial mass. Multiple angiographic images were taken to assess system and pulmonary pressures and an angiogram was taken for visualization of anatomy (see Figure 2). No thrombus was identified in the Fontan conduit by TEE or angiogram visualization. An incision was made below the left clavicle and the left subclavian vein access was achieved and a Glidewire was placed into the left pulmonary artery. A preface sheath and dilator were advanced and placed into the more distal portion of the pulmonary artery. However, the BRKTM transseptal needle was unable to be advanced past the tight curve from the Glenn anastomosis into the left pulmonary artery (see Figure 3). For this reason, attempts for placement of an atrial lead from left subclavian vein were abandoned. The catheters and needle were removed and the left infraclavicular incision was closed. Next, the right internal jugular sheath was accessed, and a 12 French sheath was advanced over a wire into the left pulmonary artery. The preface sheath was retracted onto the dome of the left atrial mass. The BRKTM transseptal needle was then inserted. Transesophageal echocardiographic imaging was utilized to make certain the preface sheath and needle were positioned correctly over the dome of the left atrial mass. Once confirmed, the BRKTM needle was advanced and entered the left atrial mass and followed by preface sheath and dilator. The dilator and needle were then removed and an Amplatz stiff wire was then inserted through the preface sheath down into the systemic ventricle and up the pulmonary vasculature. Three different delivery sheaths were utilized including multiple deployments of the 3830 lead. Limitations of the procedure included poor thresholds and or poor sensing. Ultimately, a site was identified, lead was deployed and found to have good thresholds and excellent sensing (see Figure 4). Adequate slack was left, and the lead was secured at the neck utilizing a sewing sleeve. A device pocket was created below right clavicle and utilizing a tunneling tool, the atrial lead was accessed from the right internal jugular vein down into the pocket. The neck incision was closed, 11

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

and the lead was secured with a second sewing sleeve within the pocket and secured to the pulse generator. The device pocket was closed with an occlusive silver dressing applied over skin. The patient tolerated the procedure well without any apparent complications such as pericardial effusions, tamponade, or excessive bleeding issues. Figure 2.

Angiogram showing Superior vena cava filling Glenn Anastomosis into pulmonary arteries Left PA Right PA

Atrial Mass

Angiogram taken October 20205

Figure 3.

Left PA

Angiogram showing the acute angle from left subclavian through the SVC, Glenn anastomosis into the left pulmonary artery

Atrial Mass

Angiogram taken October 20205

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Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

Figure 4.

Final placement of lead in atrial mass from right jugular vein

Left PA Atrial Mass Right PA

X-ray taken October 20205

Post Procedure Hospital Course The patient was taken back to his room and a chest radiograph was performed the next morning showing device and lead were well positioned. Interrogation of device showed good function with no change in thresholds and sensing. A transthoracic echocardiogram was performed with no evidence of a pericardial effusion. His Dofetilide was decreased to 250 mcg twice daily and heparin was converted back to rivaroxaban 20mg nightly. He was discharged home post procedure day two. Follow up The patient was enrolled into the device clinic. Three weeks post discharge, he returned to clinic for a device check. The patient was feeling better with improved energy, no further dizziness or syncope. Incisions had healed with some moderate bruising over device pocket without hematoma. His device was functioning normally without any atrial tachycardia/atrial fibrillation events and 44.3% atrial pacing.

DISCUSSION Advances in the Fontan procedure have increased life expectancy significantly with a 30year post surgery life expectancy of greater than 80%.6 A meta-analysis of 5,859 patients who underwent Fontan completion after the year 2000, found the 5, 10, 15-year transplant free survival was 90.7%, 87.2% and 87.5% respectively.7 Despite advances in the Fontan operation and the marked increase in survivability, complications are inevitable. The Fontan procedure is palliative in nature and the innate complications associated with having single ventricle remain present.7,8 The single ventricle pathophysiology is characterized by chronically elevated systemic venous pressures and decreased cardiac output.6 Common complications include 13

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

congestive heart failure, arrhythmias, thromboembolic events, protein-losing enteropathy (PLE), plastic bronchitis, and progressive liver fibrosis and renal dysfunction.6,7 In addition, cognitive and behavioral issues are common.6 The most common complication following a Fontan procedure in both short term and long term follow up are arrhythmias, particularly atrial arrhythmias.7,9 The incident of arrhythmias have been reported as high as 44%, followed by thromboembolic event and protein-losing enteropathy.8,9 A significantly high morbidity is associated with development of atrial tachycardia given the progression to heart failure and creation of thrombosis.6 However, treating these arrhythmias, particularly with antiarrhythmic medications, presents a challenge given the related and progressive hepatic and renal dysfunction. In addition to atrial arrythmias, sinus node dysfunction is present in about 9% of Fontan patients and presents its own set of challenges.10 Pacemaker implantation and revision are the most common late reoperation indication in the post Fontan population at 23%.8,10 Currently in Fontan patients, the standard of care and most pragmatic choice for pacemaker insertion is through redo sternotomy or thoracotomy with epicardial lead placement due to the redirection of venous blood flow into the pulmonary arteries. However, epicardial pacemakers are fraught with issues including rapid battery depletion, frequent lead complications, limited sites for lead implant and limited ability to cause synchronous ventricular systole. Therefore, there is a growing need for alternative options, particularly endocardial lead placements in the adult population.11 Atrial access can be achieved via a puncture in the Fontan conduit which is typically made of a plastic or Gore-Tex tubing. However, this option can be difficult to puncture, increase infection and thrombosis rates. The technique described in this case study via the SVC and puncture through the pulmonary artery has proven both feasible and effective. CONCLUSION Advances in the Fontan operation have led to a substantial increase in life expectancy. Unfortunately, a TCPC Fontan palliation does not alleviate the inherent complications associated with a single ventricle pathology that is marked by chronically elevated systemic venous pressures and decreased cardiac output. Complications in Fontan circulation all present their own unique challenges and treatment of arrhythmias and sinus node dysfunction is no exception. Traditional epicardial lead pacemakers are fraught with issues and alternative options are limited given the complete redirection of venous blood flow directly to the pulmonary arteries. As emphasized in this case study, a transvenous endocardial lead placement via puncture through the pulmonary artery was both safe and effective. However, the path to this decision was marked by difficulties and highlights the complexity of the aging Fontan population and the need for a multispecialty team approach for best patient practice in the congenital cardiac patients.

KEY POINTS 1. Fontan patients are highly complex requiring a multispecialty team approach. 2. Longer life expectancy in Fontan population is leading to an increase in complications to be addressed. 3. Recurrent atrial arrhythmias and need for pacemakers in Fontan circulation are prevalent and marked by challenges. 4. Transpulmonary transvenous pacemaker is a safe and effective way to obtain pacing in 14

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

REFERENCES 1. Figure 1. TCPC with extracardiac conduit with fenestration and DKS anastomosis for DILV. University of Basel. Image created June 20, 2021. Illustration taken from http://www.chddiagrams.com 2. Fredenburg TB, Johnson TR, Cohen MD. The Fontan procedure: Anatomy, complications, and manifestations of failure. Radiographics. 2011;31(2):453-463. Accessed Nov 24, 2020. https://doi.org/10.1148/rg.312105027 3. Double Inlet Left Ventricle DILV. The Royal Children’s Hosptial Melbourne. Accessed November 24, 2020. https://www.rch.org.au/cardiology/heart_defects/ Double_Inlet_Left_Ventricle_DILV/ 4. Yang CK, Jang WS, Choi ES, et al. The clinical outcomes of damus-kaye-stansel procedure according to surgical technique. Korean J Thorac Cardiovasc Surg. 2014;47(4):344-349. https://doi.org/10.5090/kjtcs.2014.47.4.344 5. Love, Jon MD. West, Michael MD. Figure 2-4. Taken October 2020. file:///Users/Mary/ Downloads/figure4pacemaker.JPG 6. Rychik, Jack, Atz Andrew M, Celermajer, David S, et al. Evaluation and management of the child and adult with fontan circulation: A scientific statement from the American Heart Association. Circulation. 2019;140(6):e234-e284. Accessed Nov 24, 2020. https:// doi.org/10.1161/CIR.0000000000000696 7. Schwartz I, McCracken CE, Petit CJ, Sachdeva R. Late outcomes after the Fontan procedure in patients with single ventricle: a meta-analysis. Heart. 2018;104(18):1508-1514. doi:10.1136/heartjnl-2017-312807 8. Kay, Aaron W, Moe, Tabitha, Suter, Blair, et al. Long term consequences of the Fontan procedure and how to manage them. Accessed Nov 24, 2020. https://doi.org/10.1016/ j.pcad.2018.09.005 9. Pundi, Kavitha N, Johnsons, Jonathan N, Dearani, Joseph A, et al. 40-year follow-up after the Fontan operation: Long-term outcomes of 1,052 patients. Journal of the American College of Cardiology. 2015;66(15):1700-1710. Accessed Nov 24, 2020. https:// doi.org/10.1016/j.jacc.2015.07.065 10. Kverneland LS, Kramer P, Ovroutski S. Five decades of the Fontan operation: A systemic review of international reports on outcomes after univentricular palliation. Congenital Heart Disease. 2018;(13)2:181-193. Accessed April 2021. https://doi.org/10.1111/chd.12570 11. DeWitt E, Callahan R, Blume E, Marshall A, Mah D. Trans-fontan baffle placement of an endocardial systemic ventricular pacing lead. HeartRhythm Case Rep. 2017;3(2):129-132. Accessed Nov 24, 2020. https://doi.org/10.1016/j.hrcr.2016.10.002

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Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

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Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

Peer Reviewed Content

Alternative Resuscitation Protocol for Special Population Aaron Morton MMSc, PA-C, ATC, FAPACVS Emory Center for Critical Care / Emory University Hospital Atlanta, Georgia David Lizotte MPAS, PA-C, FAPACVS Cardiac Advanced Resuscitation Education / Fenton, Missouri Amanda Murray MMSc, PA-C, FAPACVS Appleton, Wisconsin

ABSTRACT Purpose: The purpose of this article is to inform readers of the presence and need for alternative resuscitation protocol and review the evidence surrounding post-cardiac surgery patients. Method: A PubMed search was completed reviewing evidence behind specific protocols. Search terms included post-cardiac surgery arrest management, epinephrine in cardiac surgery, emergent resternotomy, and internal cardiac massage. Additionally, MeSH terms were searched including heart arrest, resuscitation, cardiac surgery complications. Results: Significant evidence supporting utilization of alternative protocol and interventions were well supported within the body of published literature. Conclusion: An alternative evidenced-based resuscitation protocol for post-cardiac surgery patients who suffer cardiac arrest is well supported. The protocol which deviates from Advanced Cardiac Life Support (ACLS) with alternation in medication dosing, emphasis on electrical therapy via epicardial pacing, defibrillation and cardioversion, as well as emergent resternotomy reduces the failure to rescue rate. Further adoption of protocol and team-based training will be necessary to provide the best opportunity for survival in this special population. Keywords: post-operative cardiac surgery arrest, resternotomy, cardiac surgery complications. INTRODUCTION Advanced Cardiac Life Support (ACLS) is taught to scores of healthcare providers every year regardless of their role or specialty. Many providers are required to maintain ACLS certification even though it is not the best protocol for their patient population. While standard

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Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

ACLS protocol works well for a large assortment of patients, it fails to consider multiple clinical features of the post cardiac surgery patient.1 Some of these features include the presence of an endotracheal tube, chest tubes, temporary epicardial pacing wires, utilization of peri-operative chronotropic and inotropic medications, as well as the use of intravenous (IV) sedation and analgesic medications.2 The ACLS guideline, as published by the American Heart Association fails to address any of the significant clinical features for the post cardiac surgery patient. Multiple national and international resuscitation and surgical specialty groups have outlined the clinical benefit and appropriateness of an alternative protocol. The European Resuscitation Council (ERC), European Association of Cardiothoracic Surgery (EACTS), The Society of Thoracic Surgery (STS) and the American Heart Association (AHA) have outlined benefits of components of the protocol. Most recently, the ERC, which has for years endorsed an alternative protocol, now highly recommends team-based training in the care of post cardiac surgery arresting patients take place.3 Additionally, Cardiac Advanced Resuscitation Education, which is a specialized educational organization, has formed and developed a specific educational platform to support knowledge of alternative protocols.4 Over the course of the previous decade, the recognition for the need of a specialized alternative protocols has grown widely; the understanding and utilization of these protocols has not. A review of the protocol and the evidence behind it will help increase the understanding and clinical utilization. DISCUSSION In the United States there are approximately 500,000 cardiac surgeries performed in 1,120 cardiac surgery centers each year.5 Post-cardiac surgery cardiac arrest occurs between 0.7% - 8% of all cases.5-12 This represents a substantial annual number of patients who present a clinical quandary for cardiac surgery and cardiothoracic critical care providers who must direct the resuscitation efforts. As much of the evidence used to support the ACLS protocol is based out of prehospital studies and populations, it is not well suited for post-operative cardiac surgery patients. As mentioned above many support devices utilized in post-operative cardiac surgery patients are not addressed in ACLS, nor is the presence of a highly educated, multi-disciplined expert team at the ready to respond to the highly monitored in hospital arrests. A well-researched and specialized alternative protocol is of great benefit to the medical teams who respond to specialized cardiac arrest patients. Comparison In October 2020 the American Heart Association published their Scientific Update on Resuscitation and the updated algorithm for ACLS. The updated algorithm for Ventricular Fibrillation or Pulseless Ventricular Tachycardia in the 2020 ACLS protocol instructs one shock followed by two minutes of Cardiopulmonary Resuscitation (CPR), followed by a rhythm check. If shockable, another shock is administered to the patient as well as Epinephrine 1mg 1:10,000 Intravenous (IV), followed by two minutes of CPR, and another rhythm check. If shockable, a third shock and an additional two minutes of CPR and administration of an IV anti-arrhythmic agent such as Amiodarone or Lidocaine.2 In comparison, the specialized protocol for post-cardiac surgery cardiac arrest patients has a significant difference from the AHA protocol. For Ventricular Fibrillation or Pulseless Ventricular Tachycardia, the alternative protocol instructs

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to first attempt defibrillation or cardioversion with three sequential shocks. If return of spontaneous circulation (ROSC) is not achieved, CPR is initiated, and an Amiodarone bolus is to be given, immediately followed by preparations for emergent resternotomy.5 (see Appendix 1) An obvious and key difference from ACLS is the absence of reflexive epinephrine administration, stacked or sequential shocks and emergent resternotomy. Additionally, the alternative postcardiac surgery protocol permits one minute without CPR to allow for application of electrical therapies via defibrillator or epicardial pacemaker generator.5 For Asystole and Pulseless Electrical Activity (PEA), the 2020 ACLS update instructs administration of 1mg 1:10,000 Epinephrine IV and immediate CPR for two minutes followed by a rhythm and pulse check.2 For the Bradycardia algorithm, administration of Atropine 1mg IV every three to five minutes is recommended.13 For the alternative post-cardiac surgery arrest protocol, asystole and severe bradycardia and PEA are separated into two distinct response actions. For asystole and severe bradycardia, initial rescue involves immediate attempts at epicardial pacing via pacing wires. If pacing is unsuccessful, CPR is initiated as a bridge to emergent resternotomy.5 Transcutaneous pacing may also be attempted. For post-cardiac surgery PEA, it recommends immediate CPR, a quick review of H’s and T’s, and emergent resternotomy. Patients who are paced via epicardial pacing wires at the time of their PEA arrest should be removed from the epicardial generator to ensure the patient is not in fine Ventricular Fibrillation and able to be defibrillated.5 In summary, the alternative protocol seeks to avoid CPR, with preference for electrical attempts at rescue and attention to emergent resternotomy for the benefits of access to the mediastinum which will be discussed. Evidence-based alternative approach. As presented above, there are some significant and striking differences between ACLS and the alternative post-cardiac surgery arrest protocol. It is worth breaking down the key differences with a review of the available evidence. Most apparent is the reduced emphasis on early initiation of CPR in most presenting arrest scenarios. This is counterculture to the well accepted practice of immediate chest compressions in ACLS, however in the post-cardiac surgery patient CPR carries an added risk of increased mortality. Multiple studies have demonstrated significant risk associated with chest compressions in the general population. These risks include rib fractures, sternal fractures, conduction system injuries, airway injuries, hepatic contusions, to name a few. A recent publication reported thoracic injuries in up to 85% of patients who receive CPR.14 An additional meta-analysis surveying 23 publications has reported an incident rate of 9% for retrosternal hematomas and upwards of 10% for all mediastinal bleeding in non-divided sternums.15 This is particularly worrisome as these injuries were found in the non-sternotomy out of hospital arrest (OCHA) population. In the post-cardiac surgery patient, a fresh sternotomy increases the risk of injury following CPR. Multiple publications in the late 1990s and into the 2000s have recognized the inherent risk with recent sternotomy and chest compressions with reports of hemopericardium, Right Ventricle lacerations from posterior sternal recoil during chest compressions, and dehiscence of prosthetic valves.16-18 Deferring immediate CPR in fresh sternotomy patients, allows time to intervene with electrical therapies which are very effective in post-cardiac surgery patients while avoiding the risk of chest compressions.

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While the etiologies of post-operative arrest can vary, many of them are able to be rescued with electrical therapies. The most prevalent arrhythmias leading to arrest include Ventricular Fibrillation, Ventricular Tachycardia and Bradycardia.5,13,19 Rescue efforts for these rhythms are easily preformed in an intensive care unit (ICU) or hospital ward with standard available equipment. The alternative protocol and most recently the AHA recommend utilization of epicardial pacing as a means for restoration of heart rate in bradycardia or asystole patients.5,13 This therapy option is unique and only available to post-cardiac surgery patients who typically have temporary epicardial pacing wires implanted in the operating room. Additional evidence supports the alternative protocol in patients arresting from Ventricular Fibrillation and Pulseless Ventricular Tachycardia. While the AHA continues to recommend one shock followed by two minutes of CPR, the alternative protocol recommends a sequential shock approach without intervening CPR.5 Multiple retrospective studies revealed a higher rate of ROSC and survival to discharge of in-hospital monitored Ventricular Fibrillation and Pulseless Ventricular Tachycardia arrest if patients receive defibrillation within 2 minutes of the arrest and in a sequential 3 stacked shock approach.20,21 Specifically, post-cardiac surgery Ventricular Fibrillation has high rates of ROSC and survival when treated rapidly with electricity.1,3,11,13,19 This data supports the alternative approach of immediate preferential application of electrical energy for post-cardiac surgery patients to avoid the increased risk of chest compressions. Looking at success rate of each sequential defibrillation attempt, it has been well documented that the success rate of additional shocks decreases substantially. Several studies have found success rates for first defibrillation attempts near 80%, this decreases rapidly to less than 10% on the fourth and subsequent defibrillation attempts.22,23 This further supports the alternative approach of immediate application of electrical energy for post-cardiac surgery patients, chest compressions which carry an increased risk in these patients until electrical attempts have clearly failed. Chest compressions are not the only routine element of the ACLS protocol that carry increased risk following cardiac surgery. The use of Epinephrine is also reduced within the alternative protocol. Multiple studies and case reports have demonstrated harm with the administration of Epinephrine. Specifically, in post-cardiac surgery patients, a well-done case report from 2008 demonstrates risk associated with administration of high dose Epinephrine. This case report highlighted a patient who suffered a tension pneumothorax and arrested, received 1mg IV Epinephrine per routine ACLS protocols and then suffered a rupture of his aortotomy suture line and massive hemorrhage leading to emergent resternotomy and repair.24 While this is admittedly a dated report, the very same event could occur today as dosing and intervals for administration of Epinephrine have not changed. Post-operative endogenous catecholamine elevations following cardiac surgery is a well-known occurrence, additional Epinephrine, as demonstrated above, is not without risk.25,26 Furthermore, there is added controversy regarding the actual dosing intervals of Epinephrine. A large meta-analysis reviewing over 140,000 in hospital cardiac arrest (IHCA), found more frequent dosing was associated with high risk of mortality for both shockable and non-shockable rhythms.27 It specifically found patients with the dosing frequency found within the AHA recommendations has lowest level of survival compared to patients with dosing in the five to six minute range and even as long as nine to ten minute range. What is probably most interesting in resuscitation science is the lack of randomized control trials for the utilization of Epinephrine. In fact, there has been only one randomized control trial completed to date over the use of Epinephrine during cardiac arrest. The Paramedic-2 trial with over 8,000 subjects, completed in 20

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the United Kingdom, was the randomized control trial with administration of Epinephrine during a cardiac arrest for out of hospital arrest patients. The trial, carried out by National Health Service paramedics, made a blinded comparison of saline flush to 1mg Epinephrine 1:10,000 IV. It found the patients who received Epinephrine had higher rates of ROSC at 36% compared to only 11% with saline.28 An analysis of 30-day survival was also slightly higher with Epinephrine at 3.2% compared to the saline placebo group at only 2.4%.28 What is most interesting is looking at the study’s secondary outcomes and statistical analysis. Secondary outcomes of interest included neurologic function, survival at 30 days and survival at 3 months following the arrest. Of note, while the subjects that received Epinephrine had higher rates of ROSC, they also experienced much higher rates of severe neurologic impairment at 31% compared to the placebo group which experienced a rate of 17.8%.28 The statistical evaluation of treatment success the authors found with administration of Epinephrine is exceedingly thought provoking. With a number needed to treat (NNT) of 112, the Paramedic-2 Trial demonstrated there is no clinical benefit in the utilization of Epinephrine.28 Given the inconsistent evidence regarding the use of Epinephrine, dosing interval and long-term outcomes of its use, combined with the well understood risk in fresh post-operative patients, high dose reflexive Epinephrine use is not well supported and not present in the alternative protocol. Additional medication changes for the alternative protocol includes the exclusion of Atropine for non-shockable rhythm patients, specifically PEA, Asystole and Bradycardia. Atropine was removed by the AHA in 2010 following inconsistent evidence for its effectiveness and absence of well powered clinical control trials.29 This was further evaluated with a retrospective study in 2018 that compared ROSC rates prior to the 2010 ACLS update and post exclusion of Atropine. It was found there was no statistical difference in survival with exclusion of Atropine from ACLS protocols.30 In the subsect of cardiac surgical patients who have received a heart transplant, utilization of Atropine is ineffective as the heart is denervated. In fact, administration in this subgroup has been shown to cause high grade atrial-ventricle block and sinus arrest.31 Considering the evidence from the AHA and its follow-up study, the potential risk in a subgroup of cardiac surgery patients, as well as the presence of epicardial pacing wires in post cardiac surgery patients, the utilization of Atropine is not recommended in the alternative protocol. Emergent Resternotomy is a core tenet of the alternative protocol, and one which is instructed to be completed if early resuscitation efforts are unsuccessful. A unique opportunity presents itself to enhance resuscitation following arrest after cardiac surgery with performance of a resternotomy. Utilization of emergent resternotomy is well solidified in the cardiothoracic surgical literature with multiple focused publications all greater than a decade in age. Performance of rapid emergent resternotomy has been proven to increase survival. If completed within the first 10 minutes of arrest, survival has been demonstrated to increase by four-fold.32 If completed within 5 minutes of the arrest onset, survival rates increased to almost 50%. 33 This increase in survival is likely multifactorial. Re-sternotomy is a key maneuver in post-operative tamponade, by relieving the increased mediastinal pressure which prevents normal loading and unloading of the heart. Additionally, we know from studies completed in the 1960s to the early 2000s, which have not been updated, that access to the mediastinum and performance of internal cardiac massage is a more effective means of resuscitation.33-37 In fact, in human models, internal massage increases coronary perfusion pressure as well the Cardiac Index with transition to internal cardiac massage having been found to increase the Cardiac Index by as much as 1.3 liters / minute.34,36 Concerns do arise, considering an emergent surgical intervention is not always an easy or safe 21

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

endeavor, however a retrospective study with over 100 subjects who received emergent resternotomy in the ICU found this safe with no increase in mortality, chest tube drainage, blood transfusion, deep and superficial infection or increase in hospital length of stay.38 Additionally, the authors identified 3 patients from the control arm of the study who died waiting for transport to the operating room for urgent resternotomy secondary to mediastinal bleeding.38 As substantiated in the literature, emergent resternotomy not only allows for possible resolution of the etiology of the arrest, but also enhances resuscitation efforts and survival, and is a key component of the alternative protocol. Resuscitation education and training has varied widely in the previous two decades, with a continuous shift from individual to team-based response.39 Team based resuscitation training and clinical utilization has been found to increase overall task performance and efficiency, team communication, protocol knowledge and adherence, higher survival rates and neurologic outcome.39-41 As the alternative protocol addresses inpatient post-cardiac surgery cardiac arrest with a multitude of disciplines ready to respond, team-based resuscitation training and education in the new protocol will enhance team performance and patient outcomes.

CONCLUSION

The 2020 AHA ACLS update fails to meet the unique needs of a post-operative cardiac surgery patient, whereas the STS publication and Cardiac Surgical Unit Advanced Life Support (CSUALS) protocol that outlines succinctly the team response to the arresting cardiac surgery patient does. Additionally, as demonstrated, the historical resuscitation approach of early chest compressions, high dose epinephrine and lack of direction with already highly medically supported patients creates significant risk to post-cardiac surgery patients. Utilization of first line electrical therapy interventions, reduced dose inotropic and vasopressive agents, early resternotomy, internal massage and deployment of frequent team-based training can reduce the failure to rescue rate. Increased awareness of alternative resuscitation protocols like CSU-ALS, as well as their widespread adoption, can have positive impact on patient outcomes.

REFERENCES 1. Society of Thoracic Surgeons Task Force on Resuscitation After Cardiac Surgery. The Society of Thoracic Surgeons expert consensus for the resuscitation of patients who arrest after cardiac surgery. Ann Thorac Surg. 2017;103(3):1005-1020. doi:S0003-4975(16)31482-5 2. Merchant RM, Topjian AA, Panchal AR, et al. Part 1: Executive summary: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2020;142(16_suppl_2):S337-S357. doi:10.1161/CIR.0000000000000918 3. Lott C, Truhlar A, Alfonzo A, et al. European Resuscitation Council guidelines 2021: Cardiac arrest in special circumstances. Resuscitation. 2021;161:152-219. https://www-sciencedirectcom.ezproxy.lynchburg.edu/science/article/pii/S0300957221000642. Accessed May 15, 2021. doi:10.1016/j.resuscitation.2021.02.011

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REFERENCES 4. About cardiac surgical unit advanced life support course. https://www.csu-als.org/. Accessed May 16, 2021 5. Jacobs JP, Shahian DM, D'Agostino RS, et al. The Society of Thoracic Surgeons national database 2018 annual report. Ann Thorac Surg. 2018;106(6):1603-1611. doi:S0003-4975(18) 31477-2 6. LaPar DJ, Ghanta RK, Kern JA, et al. Hospital variation in mortality from cardiac arrest after cardiac surgery: An opportunity for improvement? Ann Thorac Surg. 2014;98(2):534-40. doi:S0003-4975(14)00609-2 7. Reddy HG, Shih T, Englesbe MJ, et al. Analyzing "failure to rescue": Is this an opportunity for outcome improvement in cardiac surgery? Ann Thorac Surg. 2013;95(6):1976-81; discussion 1981. doi:S0003-4975(13)00604-8 8. Mackay JH, Powell SJ, Osgathorp J, Rozario CJ. Six-year prospective audit of chest reopening after cardiac arrest. Eur J Cardiothorac Surg. 2002;22(3):421-425. doi:S1010794002002944 9. Pottle A, Bullock I, Thomas J, Scott L. Survival to discharge following open chest cardiac compression (OCCC). A 4-year retrospective audit in a cardiothoracic specialist centre--Royal Brompton and Harefield NHS trust, United Kingdom. Resuscitation. 2002;52(3):269-272. doi:S0300957201004798 10. Birdi I, Chaudhuri N, Lenthall K, Reddy S, Nashef SA. Emergency reinstitution of cardiopulmonary bypass following cardiac surgery: Outcome justifies the cost. Eur J Cardiothorac Surg. 2000;17(6):743-746. doi:S101079400000453X 11. Anthi A, Tzelepis GE, Alivizatos P, Michalis A, Palatianos GM, Geroulanos S. Unexpected cardiac arrest after cardiac surgery: Incidence, predisposing causes, and outcome of open chest cardiopulmonary resuscitation. Chest. 1998;113(1):15-19. doi:S0012-3692(16)39542-3 12. Wahba A, Götz W, Birnbaum DE. Outcome of cardiopulmonary resuscitation following open heart surgery. Scand Cardiovasc J. 1997;31(3):147-149. doi:10.3109/14017439709058084 13. Panchal AR, Bartos JA, Cabanas JG FADonnino M, et al. Part 3: Adult basic and advanced life support: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2020;142(16_suppl_2):S366-S468. doi:10.1161/ CIR.0000000000000916 14. Dunham GM, Perez-Girbes A, Bolster F, Sheehan K, Linnau KF. Use of whole body CT to detect patterns of CPR-related injuries after sudden cardiac arrest. Eur Radiol. 2018;28 (10):4122-4127. doi:10.1007/s00330-017-5117-0 15. Ram P, Menezes RG, Sirinvaravong N, et al. Breaking your heart-A review on CPR-related injuries. Am J Emerg Med. 2018;36(5):838-842. doi:0735-6757(17)31065-3 16. Miller AC, Rosati SF, Suffredini AF, Schrump DS. A systematic review and pooled analysis of CPR-associated cardiovascular and thoracic injuries. Resuscitation. 2014;85(6):724-731. doi:10.1016/j.resuscitation.2014.01.028 17. Kempen PM, Allgood R. Right ventricular rupture during closed-chest cardiopulmonary resuscitation after pneumonectomy with pericardiotomy: A case report. Crit Care Med. 1999;27(7):1378-1379. doi:10.1097/00003246-199907000-00033

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18. el-Banayosy A, Brehm C, Kizner L, et al. Cardiopulmonary resuscitation after cardiac surgery: A two-year study. J Cardiothorac Vasc Anesth. 1998;12(4):390-392. doi:S1053-0770(98) 90189-6 19. Mir Mohammad Sadeghi P, Mir Mohammad Sadeghi M. Cardiopulmonary arrest after cardiac surgery: A retrospective cohort of 142 patients with nine year follow up. Heart Lung. 2021;50 (3):382-385. doi:S0147-9563(21)00018-2 20. Davis D, Aguilar SA, Sell R, Minokadeh A, Husa R. A focused investigation of expedited, stack of three shocks versus chest compressions first followed by single shocks for monitored ventricular fibrillation/ventricular tachycardia cardiopulmonary arrest in an in-hospital setting. J Hosp Med. 2016;11(4):264-268. doi:10.1002/jhm.2499 21. Bradley SM, Liu W, Chan PS, et al. Defibrillation time intervals and outcomes of cardiac arrest in hospital: Retrospective cohort study from get with the guidelines-resuscitation registry. BMJ. 2016;353:i1653. doi:10.1136/bmj.i1653 22. Nichol G, Sayre MR, Guerra F, Poole J. Defibrillation for ventricular fibrillation: A shocking update. J Am Coll Cardiol. 2017;70(12):1496-1509. doi:S0735-1097(17)39140-4 23. Richardson L, Dissanayake A, Dunning J. What cardioversion protocol for ventricular fibrillation should be followed for patients who arrest shortly post-cardiac surgery? Interact Cardiovasc Thorac Surg. 2007;6(6):799-805. doi:icvts.2007.163899 24. Webb ST. Caution in the administration of adrenaline in cardiac arrest following cardiac surgery. Resuscitation. 2008;78(1):101; author reply 101-2. doi:10.1016/ j.resuscitation.2008.03.001 25. Dunning J, Trevis J. Results of the PARAMEDIC-2 trial and how they relate to resuscitation after cardiac surgery. J Thorac Cardiovasc Surg. 2020;160(6):1519-1522. doi:S0022-5223(20) 30469-4 26. O'Connor E, Fraser JF. The interpretation of perioperative lactate abnormalities in patients undergoing cardiac surgery. Anaesth Intensive Care. 2012;40(4):598-603. doi:20120083

27. Warren SA, Huszti E, Bradley SM, et al. Adrenaline (epinephrine) dosing period and survival after in-hospital cardiac arrest: A retrospective review of prospectively collected data. Resuscitation. 2014;85(3):350-358. doi:S0300-9572(13)00798-3 28. Perkins GD, Ji C, Deakin CD, et al. A randomized trial of epinephrine in out-of-hospital cardiac arrest. N Engl J Med. 2018;379(8):711-721. doi:10.1056/NEJMoa1806842 29. Neumar RW, Otto CW, Link MS, et al. Part 8: Adult advanced cardiovascular life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122(18 Suppl 3):729. doi:10.1161/ CIRCULATIONAHA.110.970988 30. Holmberg MJ, Moskowitz A, Wiberg S, et al. Guideline removal of atropine and survival after adult in-hospital cardiac arrest with a non-shockable rhythm. Resuscitation. 2019;137:69-77. doi:S0300-9572(19)30022-X 31. Wang Ji J, Ye S, Haythe J, Schulze PC, Shimbo D. The risk of adverse events associated with atropine administration during dobutamine stress echocardiography in cardiac transplant patients: A 28-year single-center experience. J Card Fail. 2013;19(11):762-767. doi:S1071-9164 (13)01192-5 24

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32. Mackay JH, Powell SJ, Osgathorp J, Rozario CJ. Six-year prospective audit of chest reopening after cardiac arrest. Eur J Cardiothorac Surg. 2002;22(3):421-425. doi:S1010794002002944 33. Pottle A, Bullock I, Thomas J, Scott L. Survival to discharge following open chest cardiac compression (OCCC). A 4-year retrospective audit in a cardiothoracic specialist centre--Royal Brompton and Harefield NHS trust, United Kingdom. Resuscitation. 2002;52(3):269-272. doi:S0300957201004798 34. Delguercio LR, Feins NR, Cohn JD, Coomaraswamy RP, Wollman SB, State D. Comparison of blood flow during external and internal cardiac massage in man. Circulation. 1965;31:SUPPL 1:171-80. doi:10.1161/01.cir.31.4s1.i-171

35. DeBehnke DJ, Angelos MG, Leasure JE. Comparison of standard external CPR, open-chest CPR, and cardiopulmonary bypass in a canine myocardial infarct model. Ann Emerg Med. 1991;20(7):754-760. doi:S0196-0644(05)80837-6 36. Bartlett RL, Stewart NJ,Jr, Raymond J, Anstadt GL, Martin SD. Comparative study of three methods of resuscitation: Closed-chest, open-chest manual, and direct mechanical ventricular assistance. Ann Emerg Med. 1984;13(9 Pt 2):773-777. doi:10.1016/s0196-0644(84)80433-3 37. 2005 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. part 4: Advanced life support. Resuscitation. 2005;67(2-3). https://pubmed-ncbi-nlm-nihgov.ezproxy.lynchburg.edu/16324990/. Accessed May 27, 2021. doi:10.1016/ j.resuscitation.2005.09.018 38. Dj K, Yc S, Dj K, Js K, C L, Kh P. The safety of resternotomy in the intensive care unit for postcardiotomy bleeding control. Journal of cardiac surgery. 2016;31(11). https://pubmedncbi-nlm-nih-gov.ezproxy.lynchburg.edu/27600712/. Accessed May 27, 2021. doi:10.1111/ jocs.12837 39. Kleinman ME, Brennan EE, Goldberger ZD, et al. Part 5: Adult basic life support and cardio pulmonary resuscitation quality. Circulation. 2015;132(18_suppl_2):S414-S435. https:// www.ahajournals.org/doi/full/10.1161/CIR.0000000000000259. Accessed May 27, 2021. doi:10.1161/CIR.0000000000000259 40. M M, K C, A M. What is the impact of multidisciplinary team simulation training on team performance and efficiency of patient care? an integrative review. Australasian emergency nursing journal : AENJ. 2016;19(1). https://pubmed-ncbi-nlm-nihgov.ezproxy.lynchburg.edu/26614537/. Accessed May 27, 2021. doi:10.1016/ j.aenj.2015.10.001 41. Yang Y, Hu D, Peng D. Team-based resuscitation for out-of-hospital cardiac arrest. The American Journal of Emergency Medicine. 2018;36(5):889-890. https://www-sciencedirectcom.ezproxy.lynchburg.edu/science/article/pii/S0735675717307489. Accessed May 27, 2021. doi:10.1016/j.ajem.2017.09.023 42. Morton A, Lizotte D, Dunning J, Levine A. Cardiac Surgery Advanced Life Support. 4th ed. Simpsonville, KY: Cardiac Advanced Resuscitation Education; 2020

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Peer Reviewed Content

Successful Organizational Strategies for Clinician Burnout Roberta E. Funck, MHS, PA-C Northern Arizona Healthcare, Cottonwood, AZ

ABSTRACT Objective: Clinician burnout is a public health crisis that demands immediate attention and intervention. This article reviews the organizational strategies of two established well-being programs shown to reduce clinician burnout and increase professional engagement. Method: A search of PubMed and the Cochrane Review databases revealed two articles on active clinician well-being programs (Mayo Clinic and Stanford Medicine). Fifteen documents supplied background information and supporting evidence. Results: Little research has been done on active evidence-based well-being programs or cost analyses for starting and supporting a viable clinician well-being program. Conclusion: Despite increasing awareness of the devastating consequences of clinician burnout, most health care systems lack a robust well-being program. Further research is necessary to estimate startup and maintenance costs, and the unique applications of burnout interventions in various health care settings. Keywords: Physician, burnout, well-being, organizational interventions, administration INTRODUCTION Clinician burnout is a public health crisis with devastating consequences.1,2 It is driven by rapid changes in health care and the work environment, and is widespread among clinicians.1 Health care organizations typically seen burnout as the practitioner’s problem; however, evidence shows that it is primarily a system issue.3 The purpose of this paper is to review two premier health care systems with highly developed, evidence-based wellness programs (Mayo Clinic4 and Stanford Medical Center5) and to highlight their successful strategies. METHOD PubMed and Cochrane Reviews databases were searched to capture articles on established organizational well-being programs. The inclusion requirements included articles published in the United States within the last five years, institution-based interventions, active well-being programs, and practicing clinicians. Articles excluded were those on a specific specialty only, medical students and residents, and individual-based interventions. The terms “physician assistant,” “nurse practitioner,” or “advanced practice provider” were not used because their

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inclusion narrowed the search to exclude important physician-based studies. The literature search produced 354 articles. Of the 354 articles, 118 were reviewed and six articles chosen. A review of the references of the six sources produced another nine articles. Two references were from a textbook on organizational behavior (Borkowski et al).

RESULTS There are few research studies on health care systems with established clinician well-being programs. An extensive search of the literature captured two publications on the Mayo Clinic Physician Well-Being4 and the Stanford Medicine WellMD Center5 programs. Fifteen other articles detailed the costs and consequences of burnout. Overall, most burnout studies have been on physicians with very few investigating the impact of burnout on physician assistants and nurse practitioners.

DISCUSSION First described in 1974 by American psychologist, Herbert Freudenberger,6 clinician burnout is now so prevalent that at least 50% of physicians experience it.7 Burnout can negatively impact job satisfaction, patient outcomes, and health care costs.4,7,8 It is a moral-ethical imperative to acknowledge that health care delivery is dependent on talented, dedicated, and committed professionals and address burnout.8 Most organizations erroneously see burnout as a clinician’s problem and have focused on less effective individual-based interventions (mindfulness, stress management, etc.).4 However, systematic reviews and meta-analyses have found organization-based interventions to be more effective in reducing burnout.9,10 There is a lack of awareness of the economic costs of clinician burnout.8 Atrius Health cited the cost to replace a physician at $500,000 to $1,000,000 in their 2017 report.2,8 Most health care organizations assume that burnout interventions are cost-prohibitive; they are not aware that many strategies are relatively inexpensive or cost-neutral, and small investments make a big impact.4 Both Mayo Clinic and Stanford Medicine have evidence-based, comprehensive clinician programs shown to improve well-being. Mayo’s “Nine Strategies to Promote Physician Well-being” (see Table 1) arose from annual physician surveys and research on clinical work units.4 Stanford’s WellMD program is based on three domains (see Table 1): Culture of Wellness, Workplace Efficiency, and Personal Resilience.5 Both programs arose from research, implementation, and reassessment of applied interventions in their respective institutions. Acknowledge and Assess the Problem Mayo’s first intervention is for leadership to “acknowledge” that clinician burnout is a problem that demands immediate attention and “assessment.”4 This is a “necessary first step” in setting up a well-being program.4 Once an organization recognizes the pervasive and destructive effects of burnout, it can intervene and act. A successful program develops through the shared responsibility of clinicians and health administration.4 28

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Leadership Development Mayo’s second step is to “harness the power of leadership.4” Committed leadership is key to implementing interventions and monitoring burnout.4 Mayo selects leaders who can listen, engage, and lead clinicians.4 Behaviors of physician supervisors play a critical role in the well-being of the practitioners they lead.4 At Mayo, physicians evaluate their supervisors annually; those leaders with consistently poor ratings are removed.4 Stanford has a similar strategy – “leadership development” – although it focuses more on physician leadership,5 whereas Mayo focuses on the collaboration of physicians with leaders.4 Stanford’s leader selection is an egalitarian process that supports a combination of transformational and servant leadership.11 Transformative leaders primarily focus on organizational success;5 servant leaders focus on the growth of others and building of community.12 Together, this leadership fusion model seeks to learn their constituents’ aspirations, engage their perspectives, and develop their abilities.5 Mayo and Stanford both support participatory decision-making of clinicians with leadership.4,5 Stanford also advocates for an executive level burnout champion, a Chief Wellness Officer (CWO).5,7,13 The CWO is solely accountable for the clinician well-being of an organization.5,7,13 Their role should be clearly defined,5 with the CWO on par with other executive leaders and reporting directly to the Chief Executive Officer (CEO).13

Cultivate Community and Collegiality A culture of wellness creates a work environment that encourages clinicians to collaborate, communicate, and coordinate patient care.5 Peer support is critical for helping practitioners maneuver clinical challenges.5 Organizations should encourage clinician gatherings and create dedicated spaces with amenities (healthy food and beverages, computer workstations, etc.). 4,5 They should also provide clinicians protected time to gather together during the workday.4,5 Strong social connections can improve engagement, fulfillment, and productivity.14 Open, frank, and collaborative dialogue between clinicians and organizational leaders is another important aspect of a healthy, dynamic community.4 Develop and Implement Targeted Interventions To counter burnout and improve engagement, promising interventions need to be developed at the local level (departments, work units, etc.)4,5 Each work unit is unique with its own burnout and engagement factors.4,5 Mayo’s approach is to first identify local influences that can be quickly changed.4 Then Mayo focuses on “high-opportunity work units” – those units with the highest burnout rates.4 These high-opportunity units are prioritized based on external benchmarks: burnout rates higher than the national average and clinician satisfaction scores below the 50th percentile relative to other US health organizations.4 All work units are annually reassessed for burnout and engagement using the same external benchmarks.4 Mayo’s goal is to have at least 50% of high-opportunity work units improve so they are no longer high-opportunity with twelve months.4 This goal is now part of the CEO’s annual performance 29

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scorecard.4

Workplace Efficiency Stanford specifically addresses the electronic health record (EHR) as a driver for burnout and professional dissatisfaction,5 and other research supports the EHR as a burnout source.13,15 Measures should be taken to improve EHR usability and interoperability.5 A study of physicians in a three-day EHR intensive training program showed improvement in job satisfaction, proficiency, and work-life balance.15

Careful evaluation of any new EHR task needs to be done with the goal of eliminating waste and redundancy.5 Stanford advised the simplification, automation, and sharing of EHR tasks, in addition to allotting adequate time to document.5 Clinicians should be involved in the clinical structure and process design for workplace efficiency and improved quality of care.5 Team-based models should allow every team member to function at the top of their license, and support positive team attributes (clear goals and roles, mutual support, etc.).5 Input for solutions should be explored at all levels: work units, departments, organization, policy, and law.5 Stanford encourages physician involvement in the design of effective team-based models.5

Appreciation, Rewards, and Incentives Appreciating each other and celebrating achievements are effective ways for clinicians to connect while improving satisfaction and motivation.5 Appreciation and celebration can counteract the negative effects of burnout and promote community.5 Compensation should facilitate individual and organizational long-term health.4 Productivitybased pay sometimes forces clinicians to shorten in-person patient time, order more tests and procedures, and work long hours.4 To counter these behaviors, Mayo promotes the incorporation of self-care and well-being dimensions into the productivity-based equation.4 Another option is to switch to salaried compensation.4 Job satisfaction improves when clinicians can spend 80% of their time attending to organizational objectives and the remaining 20% in pursuing professional interests.4

Strengthen Culture/Community and Align Values Inequality, discrimination, and exclusion erodes well-being, and affects medical decisionmaking and patient outcomes.5 It is an organizational imperative to promote a culture of wellness that supports equity, diversity, and inclusion.5 Equity provides fair treatment, opportunity, and advancement for all.16 Inclusion creates environments where anyone feels welcomed, respected, and supported.16 A diverse community is rich with varying people and viewpoints.16 When equity, diversity, and inclusion are supported, all employees can fully participate within the organization.16 Due to health care demands, limited resources, and the need for rapid decision-making, clinicians 30

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are vulnerable to implicit bias.5 Normalizing diversity can reduce subconscious bias.5 Leaders can support an inclusive community by celebrating and recognizing the contributions of women and under-represented minorities.5 Clinicians should feel comfortable about work regardless of their age, gender, race, ethnicity, language, or other characteristics.5 Health care organizations should support a healthy work culture.4,5 Every year, all Mayo staff complete a survey, rating how well Mayo Clinic is living out its values.4 In 2011, the staff perceived an erosion in Mayo’s commitment to them.4 A task force of physicians and leaders collaborated to determine the problems and develop the solutions.4 The task force produced a document of eleven key components that outlined their shared commitment to Mayo’s mission and values.4 This document was reviewed and approved by the staff.4

Promote Flexibility and Work-Life Integration Stanford’s program supports “job-crafting,” which allows individuals to shape their jobs based on their needs, abilities, and preferences.17 Job-crafting can improve well-being and increase overall performance.17 Organizations benefit from policies that allow clinicians occupational flexibility and work-life integration.4 Flexibility in work schedules allows practitioners to meet their personal obligations.4 Decisions for any schedule adjustments should take place within the work unit.4

Promote Resources for Resilience and Self-Care Although health care organizations and systems are the major drivers of burnout and disengagement,3 individual resources are a part of a healthy work environment.4,5 Organizations should provide interventions to improve self-care and resilience.4 These resources can address work-life integration, exercise/fitness, diet, relationships, hobbies, etc.4 Senior clinicians and leaders can inspire others by exhibiting healthy habits.4 Providing accessible, healthy food and beverages, on-site exercise facilities, stand-up desks, and mindfulness training can reduce the impact of burnout and improve engagement.4 Expectations of long work hours should be discouraged; improving clerical burden should be the reality.4,5 Clinicians need to prioritize self-care to preserve and improve cognitive and physical performance.5 Easily accessible counseling resources allow clinicians to manage distress and promote well-being.4 Confidential peer support groups and mental health services should be readily available.5

LIMITATIONS Limitations to this review included the scantness of literature on established clinician well-being programs. Also, most burnout studies focus on physicians with only a few on physician assistants and nurse practitioners. There is little data studying the implementation of burnout inventions by different health care organizations. This author did not find any research on the upfront costs or cost analyses to aid organizations in starting a well-being program. Mayo is already furthering research through its ninth strategy: “facilitate and fund 31

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organizational science.”4 New research studies can gather more information specific to the implementation and maintenance of clinician well-being and engagement programs.

CONCLUSION Clinician burnout is a public health crisis with far-reaching, destructive consequences. It demands attention and requires the shared responsibility of all health care organizations and key stakeholders. Vanguard institutions like Mayo Clinic and Stanford Medicine have created wellbeing programs based on evidence-supported strategies that improve burnout and professional engagement. Other health care systems can adapt these strategies to meet their own local and individual needs.

REFERENCES 1. Jha A, Iliff A, Chaoui A, Defossez S, Bombaugh M, Miller Y. A crisis in health care: a call to action on physician burnout. Massachusetts Medical Society; Massachusetts Health and Hospital Association; Harvard T.H. Chan School of Public Health; Harvard Global Health Institute. Published January 30, 2019. Accessed May 30, 2021 2. https://www.massmed.org/Publications/Research,-Studies,-and-Reports/Physician-BurnoutReport-2018/. Noseworthy J. Madara J, Cosgrove D, et al. Physician burnout is a public health crisis: a message to our fellow health care CEOs. Health Affairs Blog. March 28, 2017. Assessed May 29, 2021. doi:10.1377/hblog20170328.059397 3. Shanafelt T, Swensen S. Leadership and physician burnout: using the annual review to reduce burnout and promote engagement. Am J Med Qual. 2017;32(5):563-565. doi:10.1177/1062860617691605 4. Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017;92(1):129-146. doi:10.1016/j.mayocp.2016.10.004 5. Olson K, Marchalik D, Farley H, et al. Organizational strategies to reduce physician burnout and improve professional fulfillment. Curr Probl Pediatr Adolesc Health Care. 2019;49 (12):100664. doi:10.1016/j.cppeds.2019.100664 6. West CP, Dyrbye LN, Shanafelt TD. Physician burnout: contributors, consequences and solutions. J Intern Med. 2018;283(6):516-529. doi:10.1111/joim.12752 Shanafelt T, Trockel M, Ripp J, Murphy MI, Sanborg C, Bohman B. Building a program on well-being: key design considerations to meet the unique needs of each organization. Acad Med. 2019;94(2):156-161. doi:10.1097/ACM.0000000000002415 7. Shanafelt T, Goh J, Sinsky C. The business case for investing in physician well-being. JAMA Intern Med. 2017;177(12):1826-1832. doi:10.1001/jamainternmed.2017.4340

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7. Shanafelt T, Goh J, Sinsky C. The business case for investing in physician well-being. JAMA Intern Med. 2017;177(12):1826-1832. doi:10.1001/jamainternmed.2017.4340 8. Shanafelt T, Goh J, Sinsky C. The business case for investing in physician well-being. JAMA Intern Med. 2017;177(12):1826-1832. doi:10.1001/jamainternmed.2017.4340 9. West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: as systematic review and meta-analysis. Lancet. 2016;388(10057):2272-2281. doi:10.1016/S0140-6736(16)31279-X 10. Panagioti M, Panagopoulou E, Bower P, et al. Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis. JAMA Intern Med. 2017;177(2):195-205. doi:10.1001/jamaintermed.2016.7674 11. Swensen S, Gorringe G, Caviness J, Peters D. Leadership by design: international organization development of physician leaders. J Manag Dev. 2016;35(4):549-570. doi.org/10.1108/JMD08-2014-0080

12. Borkowski N, Meese KA. Chapter 12: Contemporary leadership theories. Organizational Behavior in Health Care. 4th ed. Jones & Bartlett Learning; 2021:213-214 13. Sinsky C. Creating the organizational foundation for joy in medicine. Published August 7, 2017. Assessed May 29, 2021. https://edhub.ama-assn.org/steps-forward/module/2702510 14. Murthy, V. Connecting at work. Harvard Business Review. October 12, 2017;95(5):1-24. https://hsc.unm.edu/school-of-medicine/education/assets/doc/wellness/murthyloneliness.pdf

15. Robinson KE, Kersey JA. Novel electronic health record (EHR) education intervention in large healthcare organization improves quality, efficiency, time, and impact on burnout. Medicine (Baltimore). 2018;97(38):e12319. doi:10.1097/MD.0000000000012319 16. Borkowski N, Meese KA. Chapter 2: Diversity, equity, and inclusion in healthcare. Organizational Behavior in Health Care. 4th ed. Jones & Bartlett Learning; 2021:13-258 17. Bakker AB. Job crafting among health care professionals: The role of work engagement. J Nurs Manag. 2018;26(3):321-331. doi:10.1111/jonm.12551

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APPENDIX 1: Table 2

Stanford WellMD and Mayo’s Nine Strategies Stanford Domains1

Stanford Strategies1

Culture of Wellness*

Leadership Development

Control and Autonomy

Efficiency of Practice**

Personal Resilience***

1. 2.

Stanford Interventions1 -Select, assess, develop leaders -Egalitarian leadership selection -Physician leaders -Alignment of mission and values -Participatory decision-making -Clinicians “job-craft” for needs, preferences ~20% of clinician worktime allotted for meaningful pursuits

Collegiality and Community

-Protected clinician time to gather, reflect -Clinician lounges

Teamwork

-Teammates function at licensure -Team shares clerical workload -Clear goals/roles, mutual support, etc.

Appreciation

Equity, Diversity, and Inclusion

Mayo Nine Strategies2

Mayo Interventions2

1-Acknowledge/assess the problem 2-Harness power of leadership

-Select the right leaders -Physicians and leaders work together -Equip leaders with core competencies -Assess leaders’ performance -Remove those with poor ratings

4-Cultivate community at work

-Clinicians, leaders collaborate -Dedicated clinician meeting spaces -Formal and informal clinician meetings

-Give/receive appreciation -Celebrate “above and beyond”

5-Use rewards/incentives wisely

-Align climate (beliefs, attitudes) with culture (policies) -Goals/procedures to reduce implicit bias -Normalize diversity -Support parent clinicians (onsite childcare, lactation facilities) -Improve usability, interoperability -Simplify, automate, share tasks -Share EHR work w/non-clinician teammates -Adequate time for documentation -Refrain, evaluate, review, reduce, eliminate when adding new tasks

6-Align values, strengthen culture

-Counteract negative effects of productivitybased pay -Add self-care/well-being into productivity equation -Allow meaningful pursuits -Salaried compensation models -All staff rates organization through annual survey -Work units, divisions, etc., are optimized into healthy environments

Workplace Efficiency

-Engage clinicians in clinical structure, design, improvements -Seek solutions at all levels: work units, departments, policy, law -design effective team-based models

3-Develop/implement targeted interventions

-Determine burnout/engagement of each work unit/division -Target high-opportunity work units -Tailor interventions to specific work unit/ division -Use external benchmarks to monitor burnout, report progress

Support Healthy Lifestyle Behaviors

-Leaders, clinicians are role models for resilient health habits -Healthy choices available: food, beverages, exercise facilities, etc. -Reduce/eliminate expectations for after-hours work

7-Promote flexibility, work-life integration

-Flexibility/work-life integration policies -Flexible schedule for personal responsibilities -Team/work units decide schedules -Burnout drivers periodically assessed -Well-being is a performance metric with other key organizational metrics

Peer Support

-Confidential, proactive peer support programs -Secure confidential mental health services

8-Provide resources for resilience/self-care

-Easy access to individual resources -Clinicians/leaders model healthy habits -Healthy options available: food, beverages, exercise facilities, etc.

9-Facilitate/fund organizational science

-Vanguard institutions develop evidencebased strategies for use

Electronic Health Record (EHR)

Olson K, Marchalik D, Farley H, et al. Organizational strategies to reduce physician burnout and improve professional fulfillment. Curr Probl Pediatr Adolesc Health Care. 2019;49(12):100664. doi:10.1016/ j.cppeds.2019.100664 Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017;92(1):129-146. doi:10.1016/ j.mayocp.2016.10.004

*CULTURE OF WELLNESS: the relationships physicians need to effectively collaborate, communicate, and coordinate patient care. **EFFICIENCY OF PRACTICE: sufficient resources for the clinician and administrative workload to maintain quality, productivity, and work life balance. To promote workplace efficiency. ***PERSONAL RESILIENCE: organizational support for work-life integration and personal resilience allows for self-care and rejuvenation required for peak performance and the ability to manage and bounce back from adversity.

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