Welcome to today's session. My name is Maya DeJuan, and I will be discussing Bundle It Up, using bundles to optimize post-resuscitation care. I have no documented conflicts of interest. My work is supported by an AHRQ K08 and by the NIH Loan Repayment Program. The objective for today is to move past the what of post-resuscitation care to the how. What do I mean by that? I mean that while we don't have all the answers, we have enough knowledge and guidance to build a system to optimize post-resuscitation care. Most of us know what we should be doing, but the ability to effectively and reliably meet the guideline is challenging. What is the problem we really want to address? We know that CPR is performed in 1 in 1,300 hospitalizations, with about 80% of in-hospital cardiac arrest achieving ROSC, but only 45% surviving to hospital discharge. This gap is our critical opportunity to treat post-cardiac arrest syndrome and improve survival, and most importantly, survival with good neurological outcomes. So what is post-cardiac arrest syndrome? It is a syndrome of brain injury, myocardial dysfunction, systemic ischemia, and persistence of precipitating pathology. A targeted and systematic response is recommended by the American Heart Association and supported in the literature to improve outcomes. Here are some of these recommendations, but how do we decide where and how to start? I would recommend a formal framework. We use the Translating Research in Practice, or TRIP, framework. In step one of this approach, you summarize the evidence. Luckily for us, that was already nicely done through the work of others and the guideline provided by the AHA. We focused in on hypotension and hyperthermia as our primary focus, believing the evidence and buy-in to be the strongest for these two components. We identified our interventions and prioritized. Next, we identified our local barriers, which were both knowledge and equipment. We spent time looking at the human factors component and observed staff performing all the tasks and walking through the process. Then, following these, we reviewed the cases and asked for suggestions for improvement. We then picked our measures and established a baseline. Lastly, we set up a robust system for review. Led by one of our former fellows, Steve Pfeiffer, we standardized and tracked our post-cardiac arrest care. From the TRIP framework, we developed this evidence-based guideline, and using QI methodology and an interprofessional team, we implemented and standardized our practice. So how good are we at this, and how do we get better? This table shows the percent of patients who met blood pressure and temperature goals for the entire first 12 hours post-arrest at Cincinnati immediately before and after our intervention. We count even one brief episode of hypotension or fever as not meeting the guidelines. While we improved from both a blood pressure and a temperature standpoint, there clearly remains ongoing opportunity. We purposefully set our goals to adhere to best practice and created a buffer prior to the harm of hypotension and hypothermia. We saw a clear difference in not just any hyperthermia, but also in the duration of time spent hyperthermic. While we saw an improvement in the duration of hypotension, it was not significant. This very much mimics the data seen by our colleagues at CHOP led by Jessica Fowler. With more than 50% of their patients experiencing hypotension and more than 25% experiencing hyperthermia, it was very consistent with what we had seen. So how do we improve? Both at Cincinnati and with the work at CHOP, we were aggressively working to support process ease and measure them. However, we continued to fall short of our goals. It is clear that while we both had formalized evidence-based clinical pathway and electronic health record-based solutions, these were necessary, but clearly not sufficient to achieve our goals. So where do we go from here? First, we go back to that human factors approach. Where was the team when a patient was post-RASC? At our institution, they weren't in the electronic health record. Instead, they were still documenting on paper, placing lines, deciding on ECMO candidacy, et cetera. So how do we make sure that information is available to the right people at the right time? We now have a post-arrest room setup and goal sheet. The temperature control device comes to the room rather than the bedside team having to ask for it. The bedside care plan is completed at initiation of the pathway and hung within the patient room, and it's reviewed daily. Here's our example shown here. Next, we provide real-time feedback to care teams through report cards. The report card is sent to all ICU attendings, fellows, and advanced practice providers. It's sent to our nursing clinical coaches, educators, leadership, and the direct bedside team who cared for this patient. We review trends and missed opportunities at our morbidity and mortality conference, and all identified weaknesses have a plan built and followed up on. Of the last 10 post-cardiac arrest patients that we have had, we have only seen temperature greater than 38 in one of them. However, hypotension still, despite these additional components that we have implemented, remains challenging for us. The next thing I would say is don't go at it alone. We know that knowledge of other institutions working on similar quality metrics helps to drive improvement for all through the learning health network model. Join a collaborative and share resources. Get a buddy at another institution and ask them how they overcame their institutional barriers and organizational constipators who tried to hold back progress. Here's an example of the post-cardiac arrest care checklist from the Pediatric Resuscitation Quality Collaborative and the room chart setup checklist from our manuscript that we use to help get a room ready. Ask others what they're doing, and when you are asked, be sure to share your documents, your ideas as well. So here are my final recommendations. Be sure when you're approaching any type of bundle, not just post-arrest, that you build a system. Pick your interventions and make the approach robust. Provide actionable, just-in-time feedback. Our feedback is provided within one week to find opportunities to improve and to make those changes quickly before the next patient. Improve post-cardiac arrest care with other cardiac arrest QI interventions. Tag them together. Make it part of your simulation, part of your co-team training. Next, tell patient stories. Many of us do not get to see the amazing progress our patients make through rehab and during their transitions to home. Follow up with families and consultants and provide that back to the bedside so they can see that the care they're providing really makes a difference. Lastly, ask for help. Chat with friends, join Twitter and social media, and really harness that all-teach, all-learn environment that's necessary to drive improved outcomes for all of our patients. Thank you, and I'll be happy to take any questions.

bundles

post-resuscitation care

survival

neurological outcomes

cardiac arrest