When UC San Diego asked Dr. Daniel Davis to train staff on the American Heart Association’s updated Advanced Cardiac Life Support (ACLS) guidelines back in 2005, he didn’t intend to revolutionize the practice. But that was exactly what happened.
Dr. Davis, who has participated in creating the ACLS guidelines, is a recognized Emergency Medicine physician and author of more than 200 published articles. He created Advanced Resuscitation Training (ART), a comprehensive program that integrates resuscitation training, performance improvement, critical procedures, and in-hospital patient safety initiatives.
Since its first year, the ART program has generated impressive results. The program improved UCSD’s patient survival rate following in-hospital cardiac arrest from 20% to 47%, well above the US survival rate of 17%. At UCSD alone, the ART program was found to produce:
- 50% decrease in the rate of in-hospital cardiac arrest incidents
- 75% decrease in arrest-related deaths
- 20% decrease overall hospital mortality.
Not surprisingly, the Joint Commission soon took notice of the ART program, designating it with ‘Best Practice Model.’ Since then, ART has been advocated by the Society of Hospital Medicine and National Association of Public Hospitals. In addition, the American Heart Association has recognized ART as an example of a successful performance-improvement-driven program that has improved clinical outcomes. But what makes ART unique, at least in part, is its focus on prevention as well as resuscitation.
“The most important part of ART’s charter wasn’t just chest compressions and resuscitation, but that it was broadened to include ‘how do you prevent cardiac arrest?’ That was starting to become a hot topic in hospitals because they were beginning to see financial incentives for reducing mortality in certain patient types, such as sepsis, and target populations to prevent catastrophic situations such as cardiac arrest. So two-thirds of an ART class might be spent talking about how to prevent cardiac arrest, and then the rest focused on the traditional how to do chest compressions, etc.”
WHY HAS ART BEEN SUCCESSFUL?
Since its inception, the ART program has had consistently impressive results, regardless of where it is implemented. The program employs a broad definition of “resuscitation” to include patient surveillance/monitoring, critical care, intra-arrest, and post-resuscitative care. Also, ART empowers healthcare providers of all disciplines by creating a “culture of resuscitation” that enhances patient safety. This culture encourages staff to recognize when patients are deteriorating and improves implementation measures for performance improvement. The training adapts to the unique needs of individual institutions and various providers.
“We found that the prevention was very different depending on which part of the hospital you were in. For example, in a cardiac unit the focus is on rhythms and myocardial infarctions, while surgical unit training emphasizes postoperative infections and bleeding. Each unit has a different focus, so ART was adaptive in that we were steering the curriculum toward the individuals who were in the class. It was complicated to create the courses, but the individuals who are attending the classes felt they were getting exactly what they needed. That was dramatically different from traditional life support training in which each class was intended to be exactly the same as a means of quality control, whether you’re a physician, a nurse or paramedic and whether you’re taking it in Michigan, California or Saudi Arabia.”
The ART program addresses failure to rescue and the poor survival rate following in-hospital cardiac arrest. In the United States, the survival rate following an in-hospital cardiac arrest is less than 20%. Research suggests that one-third of inpatient deaths may be prevented by improved practice such as better recognition of deteriorating patients and optimal resuscitation strategies.
WHAT MAKES ART DIFFERENT?
In addition to the focus on preventing cardiac arrest, the ART program includes data collection and analysis to determine where improvements and training can be made. This process allowed UCSD to determine if they were improving and where. So, do hospitals that measure preventable harm improve more readily than those who do not measure?
“That’s the million dollar question. Data collection is a key piece, but is it the most important piece? Our experience suggests that outcomes will improve even after the very first training exposure before data can be collated and analyzed.”
With the ART program, hospitals have seen remarkable improvements in performance, regardless of what element of the program the hospital decides to focus on: chest compressions, improved recognition of deteriorating patients, effective integration of technology, etc.
“Too often people think that ART is successful because we’re using a certain algorithm. ‘Are you using deeper chest compressions? Are you using more or less epinephrine?’ The focus is on the protocols, which I try to deflect. It’s not what we’re asking them to do that is dramatically different. What is different is that they are better equipped to accomplish the key resuscitation objectives.”
Davis adds, “The irony is that people who have taken an ART class are more likely to accomplish the objectives of the AHA/ACLS guidelines than someone who has taken an actual ACLS class.”
So what is the most important piece of the ART program or any resuscitation program? Dr. Davis gives us four takeaways:
- A Culture of Resuscitation: Your training should create a ‘Culture of Resuscitation’ using cognitive psychology to help providers focus on the importance of chest compressions and CPR. Recognize that the traditional approach has not been effective in accomplishing this.
- Create a System of Care: The ideal program is a system of care that includes the collection and use of data on both a case-by-case basis as well as summary data to help guide training. That implies that you need to have some mechanism to conduct training beyond sending people to a class every two years in which you don’t have control of the curriculum. This requires a mechanism to collect data as well and to respond to it. Get feedback and then modify the training: That defines a system of care and characterizes the ART program.
- Technology & Training: Technology has been elevated to a more important role than ever before. It’s critically important to select which technology to use, to understand how it should be used to resuscitate and then to train people on how to use it effectively.
- Prevention: Your biggest opportunity, especially in the hospital, is to prevent an arrest. As your focus on prevention becomes more robust, the opportunity to save people through resuscitation goes down because you have fewer cardiac arrests – which is a win-win!