Spotlight Case July 2007 Resuscitation Errors: A Shocking Problem

2 Source and Credits This presentation is based on the July 2007 AHRQ WebM&M Spotlight Case –See the full article at –CME credit is available online Commentary by: Benjamin Abella, MD, MPhil, University of Pennsylvania, and Dana Edelson, MD, University of Chicago –Editor, AHRQ WebM&M: Robert Wachter, MD –Spotlight Editor: Tracy Minichiello, MD –Managing Editor: Erin Hartman, MS

3 Objectives At the conclusion of this educational activity, participants should be able to: Appreciate that delays in defibrillation can have negative effects on survival from cardiac arrest List the most common causes of defibrillator failures Appreciate the importance of hands-on, ongoing training on defibrillator devices for users Propose the use of checklist by rescuers at their institution to assess the readiness of the defibrillator and its components

4 Case: Resuscitation Errors A middle-aged man presented to the hospital with chest pain. He was stabilized in the emergency department and admitted to the telemetry ward. He later developed torsades de pointes (an unusual form of ventricular tachycardia, which can be fatal if untreated) while on telemetry, associated with loss of his pulse. A code blue was called.

5 Case: Resuscitation Errors The cardiology resident arrived and confirmed torsades on the monitor. Defibrillation pads were placed on the patient, but when the nurse tried to connect the pads to the defibrillation unit, the cables didn’t connect. In the ensuing confusion, it soon became apparent that the pads and the box were not compatible.

6 Sudden Cardiac Arrest (SCA) SCA is leading cause of death worldwide, claiming more than 300,000 lives each year in the United States alone Requires a complex set of resuscitative actions to be instituted within minutes Thom T, et al. Circulation. 2006:113:e

7 Sudden Cardiac Arrest (SCA) Survival is poor –Out-of-hospital SCA survival to discharge less than 10% –In-hospital SCA survival estimated at 18% See Notes for complete references

8 Defibrillation Ventricular fibrillation (VF) or ventricular tachycardia (VT) has best chance of survival if electrical shock is quickly applied to chest Survival from VF decreases profoundly over course of minutes without defibrillation –Provision of CPR ameliorates this effect Defibrillation failure increases over course of seconds when CPR is halted immediately preceding defibrillation Wik L, et al. JAMA. 2003;289: Edelson DP, et al. Resuscitation. 2006;71:

9 Survival as a Function of Time to Shock Figure adapted with permission from JAMA. Copyright © 2003, American Medical Association. All rights reserved. Wik L, et al. JAMA. 2003;289: Survival from SCA due to VF as a function of time from emergency notification to first shock

10 CPR and Defibrillation CPR parameters and defibrillation are often not compliant with American Heart Association resuscitation guidelines Problems include: –Slow chest compression rates –Shallow chest compression depths –Hyperventilation –Defibrillation delivered for non-shockable rhythms –Long pauses in CPR before shock delivery See Notes for complete references

11 CPR and Defibrillation Variable quality of resuscitation care likely due to: –Infrequent practice of resuscitation skills training among hospital staff –Need for providers to immediately function as a team with others with whom they have not rehearsed See Notes for complete references

12 Defibrillator Failures Majority of failures/delays due to user errors –Holding the defibrillator in a charged state too long Device discharges automatically and requires recharging for actual use –Attempting to shock VF in synchronized mode –Inattention to lead selection Cummins RO, et al. JAMA. 1990;264: Eisenberg MS, et al. N Engl J Med. 2001;344:

13 Defibrillator Failures Other failures due to device-related issues –Failure to properly maintain and check devices Batteries not properly charged Devices kept in circulation far longer than their natural life expectancy of 5-8 years –Mismatch of cables with specific defibrillators –Having different defibrillator models results in device confusion and increased time to defibrillation See Notes for complete references

14 Case: Resuscitation Errors (cont.) The patient remained in torsades until the resident administered magnesium, which resulted in rapid conversion to sinus rhythm. The patient was ultimately stabilized and transferred to the cardiac intensive care unit. He suffered no long-term ill effects.

15 Reducing Defibrillator Errors Use of a checklist by clinical operators Adherence to a maintenance schedule for both device and batteries Uniformity of the make and model of defibrillators All users of the defibrillator receive training in the specific device(s) they are going to use See Notes for complete references

16 Reducing Defibrillator Errors Continued hands-on experience with the device in cardiac arrests or training at least every 3 months to maintain those skills –Increased experience and frequency of device use results in better familiarity and reduced user error –Fewer errors in high-use locations such as Emergency Departments and Critical Care See Notes for complete references

17 Improving Resuscitation Care Introduce mock SCA events into clinical care routines Leadership and group training exercises to improve team function Routine incorporation of SCA event debriefing to identify common errors and serve to exploit “teachable moments” for further skills improvement

18 Improving Resuscitation Care Equipment standardized across an institution or health service provider Daily/per shift equipment checklist should be completed Institute resuscitation leadership, such as the hospital CPR or “code” committee

19 Case: Resuscitation Errors (cont.) This incident prompted a major review of code blue procedures, an inventory of the types of defibrillator machines and pads, and an effort to cross check machine–pad compatibility. The review resulted in the machines and pads being standardized to prevent the possibility of this error in the future at this particular hospital.

20 Take-Home Points Delays in defibrillation can have significant negative effects on survival from cardiac arrest Although most failures to defibrillate are due to user error, they occur in the context of systems problems caused by device confusion and failure to properly maintain defibrillators and their disposable supplies

21 Take-Home Points When possible, defibrillators should be standardized within institutions Rescuers should be trained on the device they will use and should have frequent hands-on experience with the defibrillator, either in clinical practice or simulations Rescuers should use checklists to assess the readiness of the defibrillator and its components on a daily basis