Amanda:It is now my pleasure to turn the program over to Liz Olson. Liz go ahead.
Liz:Thank you so much Amanda. On behalf of the American Heart Association, I would like to welcome you to today's webinar, Get With The Guidelines-Resuscitation: 2016 Program Update. My name is Liz Olson and I'm the National Program Manager for Get With The Guidelines-Resuscitation. On today's webinar, we'll have the opportunity to from Dr. Vinay Nadkarni, MD, Chair Elect of the Get With The Guidelines-Resuscitation Clinical Work Group as he shares with us important highlights from the IOM report and the 2015 ECC guidelines as they relate to the resuscitation module. We invite you to submit questions throughout today's presentation by using the Q&A button in the lower corner of your screen and at the end of today's presentation, we'll go through our Q&A and allow time for questions. A recording of today's webinar will be available next week on the American Heart Association website, heart.org/quality.
It's my pleasure to now introduce our speaker for today. Dr. Nadkarni is the Chair Elect of the Get With The Guidelines-Resuscitation Clinical Work Group, is Endowed Chair of Critical Care Medicine, Director of the Center for Simulation, Advanced Education and Innovation of the Children's Hospital of Philadelphia, an Associate Director of the Center for Resuscitation Science at the University of Pennsylvania Perelman School of Medicine. He's an internationally recognized Physician-Scientist with a long-standing commitment to the discovery, translation and implementation of shock, trauma and resuscitation science. He was Chairman of the National AHA Emergency Cardiovascular Committee from 2006 to 2010. With national colleagues, he formed a scientific advisory board which he founded and obtained funding for an AHA national registry of CPR to collect, analyze and publish national trends in the process and outcomes of in-hospital cardiac arrest. Dr. Nadkarni has authored more than 250 peer-reviewed manuscripts and 30 book chapters related to the practice of critical care and resuscitation science.
It is now my pleasure to turn the presentation over to Dr. Nadkarni. Doctor, the floor is yours.
Dr. Nadkarni:Well, thank you very much and happy new year to everybody. It's really, I think, a good time to talk about Get With The Guidelines-Resuscitation and discuss a little update on the AHA's emergency cardiovascular care metrics and the impact of the new 2015 American Heart Association guidelines and how we might be thinking about in-hospital resuscitation in a little different light. As you know, you can really get to all of the definitions and the output of Get With The Guidelines by clicking on heart.org/quality and that we both are going to talk a little bit about research but also talk about some of the work you do and how it's contributing to the guidelines and how those guidelines are changing. I would be remiss if I didn't mention the Institute of Medicine's [inaudible 00:03:02] report on Strategies to Improve Cardiac Arrest Survival, A Time to Act.
This report from the Institute of Medicine that was supported by a wide variety of organizations including the American Heart Association, the American Red Cross, the National Institute of Health and others, really brought together individuals to try to think about where we are. What is the state of the art now and where do we need to be and how to get there. This Institute of Medicine report is of the impact of the previous report that they put out on hospital safety and quality, "To err is human." We're hoping that this will be real impetus to bring people together, to collaborate, to measure what we do and to share that in ways that will really change the landscape of resuscitation science. The Institute of Medicine is convening a face to face meeting of the key players that will further develop strategies to implement the recommendation, the 8 major recommendations that were put forth by the Institute of Medicine in this report.
I do want to just take a moment to sort of ... You know, it's a new year, that sort of where are we? There are more than 850,000 entries into the Get With The Guidelines registry. As you know, about 338,000 of those are cardio-pulmonary arrest. If we look at just one year's worth of data, the last year of clean data is 2014, cleared all the hoops and we now have more than 279 adult hospitals, more than 80 pediatric hospitals and 77 newborn/neonate hospitals that are reporting newborn and neonatal data. Facilities with greater than 200 beds and the reason I mention this is it's 1 of the AHA-ECC's goal to improve reporting, we now have about more than 200 facilities in the adult category, 70 in pediatric and 69 in newborns. That results about each year in more than 20,000 entries.
They give us data that can be used for results and those results are things like survival of the index event. The adults are now surviving 65.8% of time in the registry, almost 80% in the pediatric numbers in the year 2014 and 75%, so really pretty good, getting much better at return of spontaneous circulation after the index event. Surviving to discharge, we still have a ways to go. It's 25% of the adults, almost 50% of the children and infants. You can see that we still have some issues in 20i4 with a number of in-hopsital cardiac arrest events occurring outside of critical care areas such as the ICU, OR, PACU or emergency department. You can see that 10,000 of them, almost 48% of the events in 2014 for adults were coming outside of the ICU environment and only about 11% of children were occurring outside, doing a little better there.
If we look at the MET numbers, we can see that there are almost 60,000 adults MET events that are being reported in the year 2014, so annually. We're getting a good number of events that are enabling evidence-based practice. Now, [inaudible 00:06:50] has previously gone over on previous webinars how we had set-up the Get With The Guidelines registry to move towards performance improvement. The 5 key metrics based on the data of what matters, increased survival to discharge, our ultimate goal with good neurologic outcome, decreased unmonitored or unwitnessed arrests, decreased time to compressions and time to defribillitation and excellent confirmation of endotracheal tube placement.
Over the next 30 minutes or so, I'm going to try to review with you some of the new additions that are likely to surface based on the new guidelines. I'll review the guidelines and what's coming but just before I do that, I wanted to mention a few of the pertinent American Heart Association cardiovascular care metrics that the AHA-ECC committees, the national committee has set that are relevant to in-hospital cardiac arrest providers. The AHA's goal is to train more than 20 million people per year by the year 2020. We're currently at about 17.9 million per year and you'll see that some of the goals that we've set, we have good metrics for and others, we don't. Now, there is a metric very pertinent to Get With The Guidelines and that's that in-hospital cardiac arrest registry reporting should be increased in hospitals with at least 200 beds by 50% by 2020 and currently, we have about 14.6% of hospitals across the US that a greater than 200 beds that are reporting adult data. There are 1388 total hospitals in the US according to this survey.
We have a ways to go so tell your friends. We'll start moving in that direction. Now, ECC had another goal of continuous training and this is going to link in with the guidelines quite nicely. The number of people actively enrolled in continuous training such as the resuscitation quality improvement program that the AHA has, rolling refreshers if you will, with the goal of training 1 million by 2020. We're starting slow. We only have about 30,000 persons enrolled in the RQI program currently. This is more continuous training, more frequent, sort of [inaudible 00:09:21] those high frequency training. You'll see that the new guidelines suggest that this is a better way to train and retain information than the old once-every-2-year training.
How about CPR feedback in training? The number of people trained per year with real-time CPR quality feedback devices with the goal of 5 million by 2020. We currently really don't have any good data on how many people are trained with real-time CPR quality feedback. We will start to track that and try to reach the goal 5 million by 2020. Here's a number that you just saw. The goal is to decrease the cardiac arrest rate per 1000 bed days in non-critical care, non-procedural inpatient areas by 20% by 2020. We really don't have a good handle on this across the board because we don't have data per 1000 bed days. We have much more data on just the events that are happening. From the best available data from Get With The Guidelines right now, we know that on the adult general floor, about 31.9% overall arrest on the floor in a non-clinical care, non-procedural inpatient area. In pediatric, it's a little better, only 6.5% are arresting out on the floor instead of in the critical care areas.
We have some audacious goals but we can get there if we really work on it and there will be likely a survey or database emerging that will query your rates per 1000 bed days. In addition, the ECC goals to double the proportion of cardiac arrest with attempted resuscitation in which objective CPR performance data is monitored. From the in-hospital cardiac arrest Get With The Guidelines registries, we know that documentation of CPR performance data being monitored is only about 14%, 13% in adults and about 36% in the pediatric registry. Again, we have a long way to go and you'll see that in the guidelines. One of the key things is that there's no magic bullet, there's no brand new magic intervention, new rate that's going to save a lot of lives. It's really going to be the quality monitoring and the performance monitoring that is most likely to move the needle for cardiac arrest in the next 5 years.
Now, as a measure of how sure we are of what these new guidelines will bring us, we looked at the number of class 1 level of evidence A recommendations in the AHA/ECC guidelines with the goal of doubling it by 2020. If you look at the current, the new current 2015 guidelines, there are 78 class 1 recommendations and only 3 level of evidence A. That's the best level of evidence recommendations. Now in 2010, there were a lot more class 1 and level of evidence A recommendations but the format of the guidelines has changed and the rigor of the analysis as sort of upped the ante. We can't do a direct comparison but we know what we're starting in 2015 and we've got 5 years to get there with continuous review process.
Now, this complicated slide is simply to remind you that with the new guidelines being released, we have a new class of recommendation, class 3 no benefit. This class of recommendation means that the benefit equals the risk. We had class 1, strong recommendation, class 2A and 2B which are moderate and weak. We have class 3 which is sort of moderate, sort of no benefit but has some cause. The we have the class 3 that we think of which is strongly against with greatly exceeding benefits. On the right side of this slide, you see the level A and then you see the level B and C levels of evidence going down in quality as it goes down the scale here and we'll see how these plays up. The way the guidelines were evaluated this time by [Ilkhorn 00:13:49] by the American Heart Association was taking specific controversial questions or questions where there was new data and subjecting it to the PICO question, population, the intervention, the comparator and the outcome. The outcomes that were really being prioritized were neurologically in [inaudible 00:14:12] survival, survival to discharge in return of spontaneous circulation for most of the questions and for the education implementation and team's task force, they were looking at educational outcomes and performance as their main outcomes.
Now, what this slide shows us is that in blue, we have the 2010 guidelines and in sort of the orangish with the 2015 guidelines and you can see that there were simply a lot fewer questions that were addressed, almost less than half of the number of questions that were addressed in 2015 because they were selected as the most controversial, the hottest with the ones that had data. You can see though that the level 1 2A recommendation were approximately the same proportion in 2010, 2015. These were a little bit higher in 2015. There's this new category, no benefit and harm which sort of combined would be compared to the 9% of the class 3 are harmful recommendations, harmful intervention in 2010.
Let's look for a moment at what's new, what's happening, what we've done is in red, added on 2 or 3 really key elements that we think will add onto the 5 key metrics. We're still looking at increased survival to discharge and decreasing unmonitored and unwitnessed arrests and decreasing the time to chest compression but paying much more attention to measuring and reporting the quality of chest compressions that are being delivered. We want to decrease the time to defribillitation. Now, new evidence from the Get With The Guidelines registry published in [inaudible 00:16:16] suggested that time to first epinephrine is very important. Less than 5 minutes for the first epinephrine, better survival outcome and for each incremental minute, went down to 2 minutes improved survival outcomes both in adults and in children. In addition to confirming the endotracheal tube placement, we're going to place more emphasis on improving the post resuscitation care, PCARC or post-cardiac arrest resuscitation care.
Specifically, speaking about the indications for going to coronary interventions, percutaneous coronary interventions, [inaudible 00:16:55] STEMI paying attention to hypotension to avoid hypotension, implementing targeted temperature management although the range of temperatures ranging between 32 and 37.5 but selecting the targeted temperature management scheme and sticking to it. Then paying attention to oxygen to avoid hypoxia and also to avoid hyperoxia so titrating down the oxygen. We'll come back to some of these in a moment.
What are some of the key new and updated recommendations? Well, the American Heart Association has really spent time to recognize that the patient's point of entry, the victim, the cardiac arrest victim's point of entry really exposes them to a very different set off circumstances and providers. When the cardiac arrest happens in the community, the out-of-hospital setting within the witness of the EMS or in the hospital. For that reason, the whole chain of survival, the whole system of care has been rethought in 2015 so that there's a separate in-hospital chain of survival that's different from the out-of-hospital chain of survival. The patients and the process of care is kind of the same but the way it happens, the number of participants who you call and even the sequence of when you call for help is altered. For instance, in the in-hospital cardiac arrest setting, this prevention, this detection, this early warning score kind of approach seems to be quite successful.
Implementing, if you will, a surveillance system to detect and prepare for the cardiac arrest victim becomes very important, much more so than in the out-of-hospital cardiac arrest where that's not really possible. Then calling or summoning help by the code blue system or whatever system you have in your hospital but that summons generally a large number of capable providers in most circumstances. The early initiation of good quality CPR and early effective defribillitation when appropriate by either AEDs or manual defibrillators with the arrival of the code team and then consideration of transfer to the cath lab for STEMI or to a critical care area for advanced support, including perhaps ECMO support. I think a key thing is not so much the elements that are within these rings, within these chain links in the chain of survival but more or less the sequence of activation and the recognition that the process is very different for in-hospital and out-of-hospital providers. You've known that all along.
The formula for survival doesn't really change because it's that combination of what we know medical science multiplied by the educational efficiency. How we train, how we perform, how we do and local implementation. Not just what we do in the sim lab, not just what we do during courses but how much of that actually gets translated to the bedside and implemented to the patient in a timely manner, what all about what's Get With The Guidelines does and that sort of formula for survival results in improved survival and in fact, some of you, some hospitals are now reporting up to 40% to 60% good survival outcomes by being able to multiply what we know with how we train with what we do and bringing it to a head by orchestrating teams that can improve survival. We can do it.
What do the new guidelines say? Well, they say push hard, continue to push hard but now, instead of just at least 2 inches, they say 2 to 2.4 inches. There's now sort of an upper limit to shoot for as well when we're measuring depth because there are several studies that suggest that the outcome was best when depth was between 2 and 2.4 inches or 5 to 6 centimeters in European [inaudible 00:21:45] but that when we exceeded 2.4 inches or 6 centimeters, that there was more injury. More broken ribs, more broken sternums et cetera. There wasn't really worse survival outcome but the suggestion was that there was an equivalent survival with less harm and so the new guidelines suggest 2 to 2.4 inches. How about the rate? Push fast but not too fast. Instead of at least 100 per minute, it's now push 100 to 120 per minute. Some studies from the resuscitation outcomes consortium suggested that survival outcomes were optimized when the compression rates were between 100 and 120 per minute. Not too slow, not too fast, sort of like Goldilocks, just in the middle.