Strategies to Improve Cardiac Arrest Survival A Time to Act (2015) / Chapter Skim
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6 Resuscitation Research and Continuous Quality Improvement
6 Resuscitation Research and Continuous Quality Improvement
Pages 315-362
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translation of this knowledge into evidence-based practice on a wide scale; and (4) care that is provided by competent, well-trained individuals and is subject to formal and continuous quality assessment.
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and have explored strategies to optimize postarrest care. In this chapter, the committee evaluates the current state of resuscitation research and identifies potential areas for improvement.
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The final section talks about the need for increased advocacy to generate sustained and sufficient support for resuscitation research and dissemination of research findings to positively affect clinical practice and patient outcomes. THE STATE OF RESUSCITATION RESEARCH: ENHANCING THE SCIENCE To better understand the physiological, social, and environmental risk factors for cardiac arrest and unfavorable health outcomes associated with cardiac arrest, research and specialized expertise are needed across an array of disciplines.
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. The metabolic phase of cardiac arrest is associated with poor survival rates and neurologic and functional outcomes.
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. In a recent human trial, Australian investigators treated cardiac arrest patients who had an initial cardiac rhythm of ventricular fibrillation (VF)
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. Research involving advanced circulatory systems, such as emergency cardiopulmonary bypass resuscitation, which involves the rapid placement of the arrested patient on a heart-lung machine to provide full blood circulation to the heart and brain (Johnson et al., 2014; Nagao et al., 2000, 2010; Nichol et al., 2006; Wallmuller et al., 2013)
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The urgency of identifying new therapies for cardiac arrest can create incentives for researchers to perform confirmatory or even pragmatic trials before clearly establishing efficacy in more controlled and limited settings. Resuscitation research investigating the efficacy of new treatments should utilize clinical designs and research strategies that have the highest probability of demonstrating benefit after accounting for the heterogeneous nature of cardiac arrest and cardiac arrest patients.
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. Examples of research strategies and clinical trial designs that could increase the efficiency and success rate of resuscitation research include the increased use of small, hypothesis-generating studies; a more robust exploration of dose effects and modifiers of efficacy (i.e., interactions between treatments and patient characteristics)
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. Platform trial A clinical trial designed to simultaneously evaluate multiple treatments or combinations of treatment.
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. Table 6-2 offers a summary of key areas of focus for possible future resuscitation research across the spectrum of translational research.
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. In 2005, the American Heart Association sponsored the 2005 Guidelines Conference and identified categories that included medical emergency teams; recognition of cardiac arrest and its causes; body position; electrical defibrillation; blood flow generation; airway management; ventilation; oxygenation; pharmacological interventions; metabolic, temperature, and post-resuscitation management; physiological monitoring and feedback; ethical issues; education and training; and outcomes (Gazmuri et al., 2007)
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criteria for broad distribution because of the lack of evidence from large-scale clinical trials, the committee recognizes that these state-of-the-art technologies have the potential to significantly improve worldwide survival of cardiac arrest. Innovations in smartphone and mobile applications, social media, home monitoring devices, and wearable technologies could significantly reduce the time interval between collapse and treatment and substantially improve patient survival rates (Scholten et al., 2011)
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Although the private sector plays an integral role in developing technologies to improve cardiac arrest treatment, the public sector can also support progress through a variety of mechanisms. Research to determine the effectiveness of mobile applications, social media, and innovative devices such as wearable alert systems in improving cardiac arrest survival is paramount.
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Although an initial clinical trial demonstrated a 10 percent false-positive rate, such outpatient monitoring can significantly reduce collapse-to-treatment times in cardiac arrest and shows great promise. Bystander Response Assistance There are more than 50 smartphone applications currently on the market that can perform a variety of tasks including providing a plat form that connects cardiac arrest patients with the nearest bystander or trained first responder, and providing CPR instructions and locating the nearest AEDs (Sakai et al., 2011, 2015; Scholten et al., 2011)
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. INFRASTUCTURE AND SUPPORT FOR RESUSCITATION RESEARCH Many barriers within the resuscitation research field limit the impact of much-needed cardiac arrest research.
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provide traditional support for general resuscitation research through various grant mechanisms that fund individual research studies, large-scale data collection, and infrastructure. However, within agencies, resuscitation research grants may be spread across a wide range of institutes or offices and various topics (e.g., basic science, training, and treatment protocols)
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, which could be used for resuscitation research. In addition to support provided by NIH, CDC, and HRSA, a number of other federal agencies and private organizations provide support for cardiac arrest and resuscitation research or whose missions aligns with improving cardiac arrest treatment and care.
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332 STRATEGIES TO IMPROVE CARDIAC ARR S E REST SURVIVAL L NIH Institute # Grants I G Count t NHLB BI 42 NINDDS 23 NICHHD 6 NIDDDK 2 NIDAA 2 NIMH H 2 NHGR RI 1 NIA 1 NIGMMS 1 NCI 1 NIEHHS 1 NCAT TS 1 FIGUR 6-3 Locatio and number of grants rela RE on r ated to cardiac arrest within t the National Institutes of Health in 2013 f 3. SOURC Lathrop, 2014.
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The search terms "cardiac arrest" and "resuscitation science" generally identify grants related to the treatment of cardiac arrest, whereas the term "sudden cardiac death" is categorized as an arrhythmia, which also includes prevention-related research on "arrhythmogenesis, genetic and environmental bases of normal cardiac electrical activity and arrhythmias, and etiology of rare and common arrhythmias" (NIH, 2014)
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Similarly, the grants supporting resuscitation research are distributed across multiple academic institutions throughout the United States, and the current administrative structure of these grants provides very little incentive for cross-institutional collaboration. Some academic institutions have attempted to create translational "centers of excellence" that conduct research from the bench to the bedside.
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The ability to successfully treat cardiac arrest depends on having a workforce that knows how to conduct research and translate that research into practice. In addition to the lack of population health data for cardiac arrest (see Chapter 2)
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For example, the Resuscitation Outcomes Consortium funded five training sites as "core leaders" in resuscitation research training and has trainees attend meetings to learn from mentors as they conduct research (Ornato, 2014)
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Yet, there are no high-level studies, such as randomized clinical trials, that compare compression depth. A recent study by Stiell and colleagues (2012)
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This approach will allow for local-level innovations that account for local needs and resources while contributing to a broader and more authoritative evidence base from which to update guidelines. CONTINUOUS QUALITY IMPROVEMENT Continuous quality improvement (CQI)
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. In a 2013 consensus statement, the American Heart Association noted that, although measuring, reporting, and reacting to resuscitation performance data can positively influence cardiac arrest survival, such activities are not universally employed by health care systems; consequently, outcomes from cardiac arrest remain at unacceptably low and disparate levels (Meaney et al., 2013)
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The examples included in Box 6-4 highlight select communities within the United States that have adopted CQI approaches and local implementation approaches to available guidelines. Proactive leaders within these communities have encouraged and supported the adoption of innovative and adaptive strategies informed by active CQI programs, which use locally available data to improve cardiac arrest survival rates and health outcomes.
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. The principles of implementation science can complement and inform efforts to adopt a meaningful, system-wide CQI program to improve cardiac arrest outcomes.
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. A recent analysis of temporal trends between 2005 and 2012 found that communities enrolled in CARES demonstrated improved risk-adjusted survival rates (from 5.7 to 7.2 percent)
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The Get With The Guidelines–Resuscitation Registry is a quality improvement program designed to promote adherence to treatment guidelines for IHCA, by collecting IHCA patient data and providing hospitals with feedback (AHA, 2014)
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Conversely, those living with conditions such as cancer or AIDS have a more visible and vocal presence in the media and are better able to advocate on behalf of others living with the same condition. The field of resuscitation also suffers from fragmentation and the absence of a single, unified voice to generate the necessary political, private, and public support to advance resuscitation research.
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. Many of the CTSAs are creating long-term partnerships that are in turn leading to successful community programs and interventions that focus on areas such as diabetes, reducing health disparities, substance abuse, increasing clinical trial participation, and training community leader (IOM, 2013b)
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. The Epilepsy Leadership Council also maintains websites that focus on clinical trials and opportunities for participation (HERO, 2015)
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Continuous quality improvement is a relatively simple but essential concept to optimize system performance and contribute evidence related to existing treatments and protocols. As new knowledge emerges, local EMS and health care systems have an important responsibility to translate consensus guidelines into local practice protocols that reflect the resources and needs of a specific community.
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With united leadership from key stakeholders, the resuscitation field can elevate its presence and effectively advocate for needed support to engage local, state, and federal stakeholders in a vision to improve cardiac arrest treatment and outcomes through research, evidence-based practice, innovation, and an unwavering commitment to saving lives in communities across the United States. REFERENCES AHA (American Heart Association)
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2002. The pulse initiative: Scientific priorities and strategic planning for resuscitation research and life saving therapies.
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https://mycares.net/sitepages/latestnews.jsp (accessed June 15, 2015)
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Seattle, WA: Emergency Medical Services Division of the Public Health Department -- Seattle and King County. http://www.kingcounty.gov/healthservices/health/%7e/media/ health/publichealth/documents/ems/2014AnnualReport.ashx (accessed June 8, 2015)
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http://www.epilepsy. com/get-help/sudep-institute/sudep-surveillance-efforts (accessed June 15, 2015)
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2010. Improved out-of-hospital cardiac arrest survival after the sequential implementation of 2005 AHA guidelines for compressions, ventilations, and induced hypothermia: The wake county experience.
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Presentation at the first meeting of the Committee on Treatment of Cardiac Arrest: Current Status and Future Directions, Washington, DC. https://www.iom.edu/~/media/Files/ Activity%20Files/PublicHealth/TreatmentofCardiacArrest/2014-MAR-12/ IOM%20-%20Lathrop.pdf (accessed June 8, 2015)
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improving cardiac resuscitation outcomes both inside and outside the hospital: A consensus statement from the American Heart Association. Circulation 128(4)
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2013. Continuous quality improvement (CQI)
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2010. Post-cardiac arrest syndrome: Epidemiology, pathophysiology, treatment, and prognostication: A scientific statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; and the Council on Stroke (part II)
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2010. Part 9: Post-cardiac arrest care: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.
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2014. The science of continuous quality improvement.
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http://www.sca-aware.org/sca news/nih-and-cdc-announce-grantees-for-the-sudden-death-in-the-young-registry (accessed June 12, 2015)
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2010. Part 4: CPR overview: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.
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Presentation at the third meeting of the IOM's Committee on Treatment of Cardiac Arrest: Current Status and Future Directions. https://www.iom.edu/~/media/Files/Activity %20Files/PublicHealth/TreatmentofCardiacArrest/August%202014/Yannop oulos%20IOM%20presentation%208-25-14.pdf (accessed June 15, 2015)
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