Improving Cardio-Pulmonary Resuscitation

Success Rate

Quality Improvement Project using “FOCUS PDCA” Methodology.

Al-Iman General Hospital

Find the problem.

The data obtained over the past year showed greatvariation in the success rates of CPR in Al-Imanhospital with failure rates ranging between 60 to 80percent monthly.

Find The Problem.

Impact of the problem:◦ The hospital was notified being a member of the

comparative data base of ministry of health that its ratesare suspiciously high and far from the benchmark the MOHis recommending (Steady rate below 60%).

◦ Patient safety was in jeopardy & Joint CommissionInternational compliance was not achieved.

◦ Physician & hospital top management dissatisfaction fromhigh failure rate.

Find The Problem.

Successful CPR Definition.◦ Return of spontaneous circulation for more than 20

minutes.

Witnessed CPR Definition.◦ One is seen or heard by another person or an arrest that is

monitored.

Return Of Spontaneous Circulation.Includes breathing (more than an occasional gasp),coughing, movement or a palpable pulse.

These are the definitions adopted by the MOH and used in the comparative data base of the ministry.

70.5%

64.5%63.20%

57.5%

81%

69%

82.6%

55.2%

64.2%

60.3%58.8%

63.5%64%

62% 62%

55%

72%

63%

77%

49%

63%

59%

54%

59%

45%

50%

55%

60%

65%

70%

75%

80%

85%

Perc

enta

ge

Month

Total Vs. Witnessed Failure Rate of CPR

From 1/1434 : 12/1434; El-Iman Hospital

Total Failure Rate Witnessed Failure Rate

u= 65.86

----------u= 61.56

Find The Problem

The project mission.◦ Is to reduce the variation in the process & reach failure

rates below 60% (as to the benchmark provided by MOH).

Organize The Team

The team charter included:◦ Champion: Medical Director◦ Team Leader: Anesthesia Director.◦ Facilitator: Quality Director.◦ Members:

Deputy medical director.Nursing director.Anesthesia specialist.ICU specialist.Cardiology Consultant.Medical Specialist.CPR/Nurse Coordinator.

Clarify Current Process

1

1

Clarify Current Process

Understand The Variation

++ CPR Failure

Rates

Place

Patient

Personnel

PoliciesEquipement

Lack of Training (ACLS)

Shortage of staff (Anesthesia)

Improper scheduling (Anesthesia)

Incorrect Policy

Poor compliance to the policy (Not

all the team attend the CPR Incident)

Dead On Arrival included

In the measurement

Crash Carts

Mal-distribution

Crash carts Policy

Not Followed (Open all

The time).

Lack of PPM of

Defibrillators

Lack of regular checks

On supplies

Lack of Bleeps

Missing Crash Carts

Nurse Shortage

Pharmacist

Shortage

Materials

Lack of Medications

No Numerical Locks

69%

15% 15%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Available Working Available Not Working Not Available

Pe

rce

nta

ge

Status

Percentage of Defibrilator Availability and FunctioningAl-Iman Hospital; 12/1434.

96%

46%

0%

20%

40%

60%

80%

100%

120%

Epinephrine Ampoles Airways

Perc

enta

ge

Supplies

Essential Supplies Availability in Crash CartsAl-Iman Hospital; 12/1434.

N=520 N=26

Understand The Variation

In order to verify the causes generated by thefishbone diagram (by brainstorming) the teamdecided to review the failure cases of CPR over thelast three months (Shawal, Dhulqeda and Dhulhaj)(8-10/1434).

Each case was checked against the generated causesto verify the most common causes for CPR failure.

112 cases were reviewed by the team.

37%

48%

34%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

8/1434 9/1434 10/1434

Pe

rce

nta

ge

Month

Percentage of CPR Done Without Full Team AttendanceAl-Iman Hospital; 8-10/1434.

N=35 N=35

N=42

N= 8145%

36%

27% 27%

11%

0%0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Pe

rce

nta

ge

Missing Team Member

Percentage of Missing Specialty In Failed CPR CasesAl-Iman Hospital; 8-10/1434.

N=56

Causes Frequency

• CPR policy outdated 112

• Lack of ACLS Training. 112

• Not all Team Attending. 45

• Lack of PPM of Defib. 112

• Missing Defib. 2

• Missing supplies 2

• Patient was DOA 15

• Crash cart Mal distribution (Area of incident does not have a Crash Cart in near vicinity).

2

Understand The Variation

According to Pareto rule the following causesrepresented 80% impact of the problem (Vital Few):

◦ Outdated CPR Policy.

◦ Lack of ACLS Training.

◦ Lack of PPM of Defibrillators.

Select Remedy

The team suggested the following solutions:◦ Update CPR policy in compliance to the JCI requirements.

◦ Train & Educate the staff about the policy update.

◦ All Code Blue Team to have ACLS Certificates & Training.

◦ Establish preventive regular maintenance checks for Crashcarts Defibrillators.

◦ Redistribute the crash carts to cover all care areas.

◦ Continuous auditing on CPR service by CPR committee &Quality department.

◦ Recruitment of more anesthesia staff (until recruitment isdone 2 Anesthesia Doctor will attend in each shift)

Select Remedy

◦ Adding Paramedics to the CPR Team to enhance ChestCompression quality.

◦ Activate the DNR policy & provide training to staff.

◦ Provide Bleeps to all Code Blue Team.

Solution Feasibility Cost(Inverse Scoring)

Impact Score

Update CPR policy 5 5 5 15

Train & Educate the staff on CPR Policy.

3 4 5 12

PPM for Defibrillators 3 5 4 12

Recruitment of more anesthesia staff

1 1 5 7

Anesthesia Schedule Modifications

3 3 3 9

Purchase New & Redistribute crash carts

4 1 5 10

Selection Matrix

Item 1 5

Feasibility Hardest Easiest

Cost Most Expensive Most Cheap

Impact Lowest Highest

Provide Bleeps 3 3 4 10

ACLS Training Schedule 3 2 5 10

DNR Policy Training 2 5 3 10

Pharmacy Regular checks schedule.

5 5 3 13

Solution FeasibilityCost(InverseScoring)

Impact Score

Item 1 5

Feasibility Hardest Easiest

Cost Most Expensive Most Cheap

Impact Lowest Highest

Selection Matrix

Select Remedy

The Selected Remedies in order:1. Update CPR Policy (15).2. Pharmacy Regular checks schedule (13).3. Train & Educate the staff on CPR Policy (12). 4. PPM for Defibrillators (12).5. Purchase new & Redistribute the crash carts (10).6. DNR Policy Training (10).7. ACLS Training Schedule (10).8. Provide Bleeps (10).9. Anesthesia Schedule Modifications (9).10. Recruitment of more anesthesia staff (7).

Plan

ACTION PLAN

Task Responsible Due Date

Update CPR policy. Quality Team & Anesthesia Director.

1 week

Train & Educate Staff on CPR policy.

Quality Team & Medical Director.

Ongoing

PPM for Defibrillator Biomedical Dep. Ongoing

Anesthesia Schedule Modifications Anesthesia Director. Ongoing

Recruitment of Anesthesia staff. Top Management. 6 months

Redistribute the crash carts to different vicinities

Quality Team & Pharmacy.

1 month

Purchase New Crash Carts Top Management. 2 months

Plan

ACTION PLAN

Task Responsible Due Date

Provide Pagers. Purchasing Dep. 1 month

ACLS Training Schedule CME Dep. 4 months

DNR Policy TrainingQuality Team & Anesthesia Director.

1 month

Pharmacy Regular checks schedule.

Pharmacy 1 week

Do

A pilot to be done for the period of 2 months anddata will be monitored to detect the effectiveness ofthe proposed remedies.

Check The Results

CPR Policy Updates.

The following modifications were made to thepolicy:◦ All code blue team (Except Ward Nurse) to be ACLS

certified.

◦ For outpatient department cases of arrest, theAnesthesiologist & Internal medicine physician present inthe clinics will be the first responders till the team arrivesfrom the hospital main building.

◦ In the crash cart medication policy, in case of code blue thenurse in charge will contact the pharmacy after the end ofthe code to replenish the cart within 30 minutes of theward/unit call.

46%

81%

73%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

1 2 3

Percen

tag

e

Month

Percentage of Availability of 5 Sizes of Airway in the Crash Cart

Al Iman General Hospital, 12/1434 to 2/1435

2/14351/143512/1434 2/14351/143512/1434

N=26

64%

58%56%

59%56%

53%

30%

35%

40%

45%

50%

55%

60%

65%

12/1434 1/1435 2/1435

Perc

enta

ge

Month

Total Vs. Witnessed Failure Rate of

CPRFrom 12/1434 : 3/1435; El-Iman Hospital

Total Failure Rate Witnessed Failure Rate

33%

29%

25%

20%

22%

24%

26%

28%

30%

32%

34%

12/1434 1/1435 2/1435

Perc

enta

ge

Month

Percentage of CPR Done Without Full

Team AttendanceAl-Iman Hospital; 8-10/1434.

27%

45%

11%

27%25%

30%

0% 0%0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Medical Specialist Anesthesia ICU Nurse Ward Nurse

Perc

enta

ge

Team Member

Percentage of Missing Specialty In

Failed CPR CasesAl-Iman Hospital; 12/1434 -2/1435.

Before After

Restrictions

Recruitment of more Anesthesia staff couldn’t beachieved during the pilot time.

Adding the paramedics to the Code Blue team toenhance quality of chest compressions could not beachieved due to their busy schedule and limitednumber.

DNR was not approved from the directorate to apply.

Act.

All the solutions implemented during the pilot aresustained.

The team will keep continuous monitoring over theprocess to maintain the gains and ensurecompliance to the modified process changes.

Control Variable

How Measured

Where Measured

Standard Who Analysis

WhoActs

WhatDone

Total

CPR

Failure

Rate.

Retrospect

ive

Document

Review of

CPR

Sheets.

In

Clinical

Audit.

Below

60%Quality

Dep.

CPR

Commit

tee.

Further

Analysis To

Determine

Causes for

Relapse.

Witnesse

d CPR

Failure

Rate.

Retrospect

ive

Document

Review of

CPR

Sheets.

In

Clinical

Audit.

Below

60%Quality

Dep.

CPR

Commit

tee.

Further

Analysis To

Determine

Causes for

Relapse.

Availabil

ity of

Essential

Supplies

in Crash

Carts.

Direct

Observatio

n.

All

Hospital

Units.

100% Quality

Dep.

CPR

Commit

tee.

Nurses

should

check

supplies

per shift.

Defab.

Availabil

ity &

Function

ing.

Direct

Observatio

n.

All

Hospital

Units.

100% Quality

Dep.

CPR

Commit

tee.

Regular

PPM.

Defab.

Testing/shif

t

Further Improvement Opportunities

Team Decided to Start a second phase for theproject addressing “Code Rapid” process which willlead to better CPR outcomes.

Acting on early warning signs detection & Rapidintervention will definitely improve CPR successrates.