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THE GAPS BETWEEN THE CPR TRAINING AND IN HOSPITAL IMPLEMENTATION ARE WE PRACTICING GOOD CPR? Dr. Abdul Majeed Khan The chairman, National CPR Committee Miss. Cherry Ofelio The quality officer Heraa General Hospital

Background •

• •

Despite substantial efforts to make cardiopulmonary resuscitation (CPR) algorithms known to healthcare workers, the outcome of CPR has remained poor during the past decades. Resuscitation teams often deviate from algorithms of CPR. in addition to technical skills of individual rescuers, human factors such as teamwork and leadership affect adherence to algorithms and hence the outcome of CPR.

Background • The study performed in HERAA hospital (Jun- Dec

2012) • It is a phase one of the study. • First clinical study national wise to analyze the gaps

between CPR training and in hospital implementation of CPR guidelines.

Aims • Improve performance (qualified CPR at any time) • Educational session (debriefing) • Refreshment of knowledge • Preparation to seasonal emergency and disaster • Implementation of CPR Drill Policy • JCI requirements

Methodology • CPR Event form : Criteria for Complete Documentation and Compliance to Guidelines

• CPR Event Review Checklist • Event forms are distributed to reviewers for review using the • • • • •

CPR Event Review Checklist Report Verification – Patient’s medical records are retrieved and reviewed. Event Review Checklists - Tabulated, Validated, Trended, Analyzed, Action Plan. Aggregated data are trended monthly and reported quarterly together with the analysis, recommendation and action plan. Discussed during CPR Committee meeting. Interesting cases are recommended for in depth review by selected members of the committee. • Education issues – Education Sub-committee. • Resuscitation equipment – Crash Cart Sub Committee.



Results Muharram


I Rabia

No. of Patients




No. of CPR’s




II Rabia

I Jumada

II Jumada

No. of Patients




No. of CPR’s







No. of Patients




No. of CPR’s







No. of Patients




No. of CPR’s




Recommendation ďƒź Reeducation of the responders to the

adopted SHA Algorithm

Activate the CODE BLUE DRILL

Process…. • Cardiopulmonary Resuscitation policy revised • Code Blue Drill Policy developed

• Purpose: Evaluate the competency of the code responders

• Schedule. • Code Blue Drill Review Checklist • Conducted hospital wide orientation. • Code Blue Drill Activated. • Use of Simulator. • Debriefing with the reviewers/observers. • Post Code Evaluation

Simulation: is a technique, not a technology, to replace or amplify real experiences with guided experiences, often immersive in nature, that evoke or replicate substantial aspects of the real world in a fully interactive fashion.‖ (Gaba, 2004). • Sophisticated mannequins, • interactive software programs and • simulated actors

Findings • Mismanagement due to wrong / misinterpretation of the

rhythm displayed • Ineffective, shallow and improper chest compression • Un-familiarization in the use of the defibrillator • Un-familiarization with the contents of the crash cart • Crash cart incomplete; equipment's malfunctioned • Algorithm not properly followed

Findings • Responders are unfamiliar with the simulator • Lack of communication between members • Overlapping of roles and responsibilities • Lacks Teamwork • Lose in the chain of command • Difficulty to work effectively in high stress situation

Action Plan Phase 1: • Recognizing and managing the technical flow of the

execution and management of the event. • Effective communication between the members. • Acknowledgement and Respect to the chain of command. • Strategies to work in high stress situation. • Stabilization of the Teamwork.

How? • Orientation in the use of the Simulator • Conduct general orientation to all clinical staff,

social workers, muraquib and security personnel. Emphasized strict observance on their roles and responsibilities. Encourage verbalization of their limitation in performing efficiently performing their roles and responsibilities. • Closer intervals of the drills.

Action Plan Phase 2: • Managing the skills, knowledge and training of the clinical staff’s compliance to SHA Algorithm. • Competency of the staff in performing CPR

in accordance with the Algorithm

How? • CPR Education Sub-Committee activated • Conduct a day-long lecture and workshop: • Training on the use of the simulator. • Use of the Code Blue Drill Evaluation Form. • Reeducation on the CPR policy. • Video Model of actual resuscitation and its proper management. • Crash cart related educational needs such as use proper use

equipment (defibrillator, emergency and drugs). • Distribution of SHA Algorithm booklet

How? • Coordinates with the Post Graduate Education

Department for Life Support Certification among physicians, nurses, technicians and other staff. • Continuous monitoring of the staff competency

thru drills and time and motion and post code evaluations


Discussion More than 75 studies were reviewed. Most of them either observational or retrospective studies.

Discussion There is some evidence from the human literature that the use of cognitive aids, standardized didactic, and hands-on training with high-fidelity simulators, team and leadership training, and post-cardiac arrest debriefing improve adherence to cardiopulmonary resuscitation guidelines and, in some cases, patient outcomes..... RECOVER evidence and knowledge gap analysis on veterinary CPR. Part 2: Preparedness and prevention McMichael M; Herring J; Fletcher DJ; Boller M; J Vet Emerg Crit Care (San Antonio); 2012 Jun; 22 Suppl 1():S13-25. PubMed ID: 22676282

Discussion There are gaps in the knowledge and implementation of resuscitation protocols and the recommended modifications for pregnancy among residents. Teaching can improve performance during management of maternal cardiac arrest. Electronic learning and didactic teaching offer similar benefits. Management of simulated maternal cardiac arrest by residents: didactic teaching versus electronic learning. Hards A; Davies S; Salman A; Erik-Soussi M; Balki M Can J Anaesth; 2012 Sep; 59(9):852-60. PubMed ID: 22777579

Discussion Research has shown that a prolonged process of team building and poor leadership behavior are associated with significant shortcomings in CPR. Teamwork and leadership in cardiopulmonary resuscitation. Hunziker S; Johansson AC; Tschan F; Semmer NK; Rock L; Howell MD; Marsch S J Am Coll Cardiol; 2011 Jun; 57(24):2381-8. PubMed ID: 21658557

Discussion Brief bedside booster CPR training improves CPR skill retention. Low-dose, high-frequency CPR training improves skill retention of in-hospital pediatric providers. Sutton RM; Niles D; Meaney PA; Aplenc R; French B; Abella BS; Lengetti EL; Berg RA; Helfaer MA; Nadkarni V Pediatrics; 2011 Jul; 128(1):e145-51. PubMed ID: 21646262

Discussion Delivering high-quality CPR in-hospital requires a multifaceted approach. Collecting data during arrests and feeding back in real time and postevent during debriefings can be used to improve delivery of high-quality CPR. Delivering high-quality cardiopulmonary resuscitation in-hospital. Soar J; Edelson DP; Perkins GD Curr Opin Crit Care; 2011 Jun; 17(3):225-30. PubMed ID: 21478746

Discussion Use of a simulation-based educational program enabled us to achieve and maintain high levels of resident performance in simulated ACLS events. Given the limitations of traditional methods to train, assess and maintain competence, simulation technology can be a useful adjunct in high-quality ACLS education. A longitudinal study of internal medicine residents' retention of advanced cardiac life support skills. Wayne DB; Siddall VJ; Butter J; Fudala MJ; Wade LD; Feinglass J; McGaghie WC Acad Med; 2006 Oct; 81(10 Suppl):S9-S12. PubMed ID: 17001145

Discussion Chest compression training showed weakness for four out of five variables. Only the end results for compression depth were satisfactory. The deficits observed in the training on chest compression were relevant and must be remedied. Strengths and weaknesses of chest compression training: a preliminary retrospective study. Osterwalder JJ; Braun D Swiss Med Wkly; 2011; 141():w13221. PubMed ID: 21720970

Conclusion / recommendations Efforts should concentrate in improvement of the adherence of the CPR team to the guidelines during inhospital resuscitation. HOW????. On going teaching of the team leaders and members inside the hospitals improve the overall performance of CPR.

Conclusion / recommendations Team building and leadership.WHAT TO DO IN ACLS COURSES?. post CPR feedback and debriefing improve the delivery of high quality CPR. Improve the BLS skills in particular the chest compression.

Conclusion / recommendations The use of simulated- education inside the hospital improve the performance of the CPR team. This necessitate the presence of education committee under the hospital CPR committee.