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Improving CPR success rate Improvement Project (FOCUS-PDCA)
This document describes a quality improvement project at Al-Iman General Hospital to reduce variability in cardio-pulmonary resuscitation (CPR) success rates. Data showed failure rates ranging from 60-80% monthly, above the benchmark of below 60% set by the Ministry of Health. A team analyzed causes of variation using a fishbone diagram and identified outdated CPR policies, lack of ACLS training, and lack of defibrillator maintenance as key issues. The team selected remedies including updating CPR policies, establishing maintenance schedules, and providing additional training. A pilot implemented the solutions and saw improved availability of supplies and a reduction in failure rates and missing team members. Ongoing monitoring is planned to sustain gains.
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Improving CPR success rate Improvement Project (FOCUS-PDCA)
- 1. Improving Cardio- PulmonaryResuscitation Success Rate Quality Improvement Project using “FOCUS PDCA” Methodology. Al-Iman General Hospital
- 2. The data obtainedover the past year showed great variation in the success rates of CPR in Al-Iman hospital with failure rates ranging between 60 to 80 percent monthly. Find the problem.
- 3. Impact of theproblem: ◦ The hospital was notified being a member of the comparative data base of ministry of health that its rates are suspiciously high and far from the benchmark the MOH is recommending (Steady rate below 60%). ◦ Patient safety was in jeopardy & Joint Commission International compliance was not achieved. ◦ Physician & hospital top management dissatisfaction from high failure rate. Find The Problem.
- 4. 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. Find The Problem.
- 5. Total Vs. WitnessedFailure Rate of CPR From 1/1434 : 12/1434; El-Iman Hospital 70.5% 64.5% 63.20% 57.5% 81% 69% 82.6% 55.2% 64.2% u= 65.86 ---------- u= 61.56 60.3% 58.8% 63.5% 64% 62% 62% 55% 72% 63% 77% 49% 63% 59% 54% 59% 85% 80% 75% 70% 65% 60% 55% 50% 45% Percentage Month Total Failure Rate Witnessed Failure Rate
- 6. The project mission. ◦ Is to reduce the variation in the process & reach failure rates below 60% (as to the benchmark provided by MOH). Find The Problem
- 7. The team charterincluded: ◦ 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. Organize The Team
- 8.
- 9. 1 Clarify CurrentProcess
- 10. Shortage of staff(Anesthesia) Improper scheduling (Anesthesia) ++ CPR Failure Rates Place Lack of Training (ACLS) Dead On Arrival included In the measurement Crash Carts Mal-distribution Pharmacist Shortage Crash carts Policy Not Followed (Open all The time). Lack of PPM of Defibrillators Lack of regular checks On supplies Equipement Patient Policies Personnel Incorrect Policy Poor compliance to the policy (Not all the team attend the CPR Incident) Understand The Variation Lack of Bleeps Missing Crash Carts Nurse Shortage Materials Lack of Medications No Numerical Locks
- 11. Percentage of DefibrilatorAvailability and Functioning 69% Al-Iman Hospital; 12/1434. 15% 15% 80% 70% 60% 50% 40% 30% 20% 10% 0% Available Working Available Not Working Not Available Percentage Status
- 12. Essential Supplies Availabilityin Crash Carts Al-Iman Hospital; 12/1434. 96% 46% 120% 100% 80% 60% 40% 20% 0% N=520 N=26 Epinephrine Ampoles Airways Percentage Supplies
- 13. In order toverify the causes generated by the fishbone diagram (by brainstorming) the team decided to review the failure cases of CPR over the last three months (Shawal, Dhulqeda and Dhulhaj) (8-10/1434). Each case was checked against the generated causes to verify the most common causes for CPR failure. 112 cases were reviewed by the team. Understand The Variation
- 14. Percentage of CPRDone Without Full Team Attendance 37% Al-Iman Hospital; 8-10/1434. 48% 34% 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% N=42 N=35 N=35 8/1434 9/1434 10/1434 Percentage Month
- 15. Percentage of MissingSpecialty In Failed CPR Cases Al-Iman Hospital; 8-10/1434. N= 81 45% 36% 27% 27% 11% 0% 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Percentage Missing Team Member 56
- 16. 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
- 18. According to Paretorule the following causes represented 80% impact of the problem (Vital Few): ◦ Outdated CPR Policy. ◦ Lack of ACLS Training. ◦ Lack of PPM of Defibrillators. Understand The Variation
- 19. The team suggestedthe 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 Crash carts 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 is done 2 Anesthesia Doctor will attend in each shift) Select Remedy
- 20. ◦ Adding Paramedicsto the CPR Team to enhance Chest Compression quality. ◦ Activate the DNR policy & provide training to staff. ◦ Provide Bleeps to all Code Blue Team. Select Remedy
- 21. Selection Matrix SolutionFeasibility Cost (Inverse Scoring) Impact Score Update CPR policy 5 5 5 15 Train & Educate the staff on 3 4 5 12 CPR Policy. PPM for Defibrillators 3 5 4 12 Recruitment of more 1 1 5 7 anesthesia staff Anesthesia Schedule Modifications 3 3 3 9 Purchase New & Redistribute crash carts 4 1 5 10 Item 1 5 Feasibility Hardest Easiest Cost Most Expensive Most Cheap Impact Lowest Highest
- 22. Selection Matrix SolutionFeasibility Cost (Inverse Scoring) Impact Score 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 Item 1 5 Feasibility Hardest Easiest Cost Most Expensive Most Cheap Impact Lowest Highest
- 23. The Selected Remediesin 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). Select Remedy
- 24. 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
- 25. Plan ACTION PLAN Task Responsible Due Date Provide Pagers. Purchasing Dep. 1 month ACLS Training Schedule CME Dep. 4 months DNR Policy Training Quality Team & Anesthesia Director. 1 month Pharmacy Regular checks schedule. Pharmacy 1 week
- 26. A pilot tobe done for the period of 2 months and data will be monitored to detect the effectiveness of the proposed remedies. Do
- 27.
- 28. The following modificationswere made to the policy: ◦ All code blue team (Except Ward Nurse) to be ACLS certified. ◦ For outpatient department cases of arrest, the Anesthesiologist & Internal medicine physician present in the clinics will be the first responders till the team arrives from the hospital main building. ◦ In the crash cart medication policy, in case of code blue the nurse in charge will contact the pharmacy after the end of the code to replenish the cart within 30 minutes of the ward/unit call. CPR Policy Updates.
- 29. Percentage of Availabilityof 5 Sizes of Airway in the Al Iman General Hospital, 12/1434 to 2/1435 46% Crash Cart 81% 73% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 1 2 3 Percentage 12/1434 1/1435 2/1435 Month N=26
- 30. Total Vs. WitnessedFailure Rate of From 12/1434 : 3/1435; El-Iman Hospital 64% 58% 56% 59% 56% 53% 65% 60% 55% 50% 45% 40% 35% 30% CPR 12/1434 1/1435 2/1435 Percentage Month Total Failure Rate Witnessed Failure Rate
- 31. Percentage of CPRDone Without Full Al-Iman Hospital; 8-10/1434. 33% Team Attendance 29% 25% 34% 32% 30% 28% 26% 24% 22% 20% 12/1434 1/1435 2/1435 Percentage Month
- 32. Percentage of MissingSpecialty In Al-Iman Hospital; 12/1434 -2/1435. 27% Failed CPR Cases 45% 11% 27% 25% 30% 0% 0% 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Medical Specialist Anesthesia ICU Nurse Ward Nurse Percentage Team Member Before After
- 33. Recruitment of moreAnesthesia staff couldn’t be achieved during the pilot time. Adding the paramedics to the Code Blue team to enhance quality of chest compressions could not be achieved due to their busy schedule and limited number. DNR was not approved from the directorate to apply. Restrictions
- 34. All the solutionsimplemented during the pilot are sustained. The team will keep continuous monitoring over the process to maintain the gains and ensure compliance to the modified process changes. Act.
- 35. Control Variable How Measured Where Measured Standard Who Analysis Who Acts What Done 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
- 36. Further Improvement Opportunities Team Decided to Start a second phase for the project addressing “Code Rapid” process which will lead to better CPR outcomes. Acting on early warning signs detection & Rapid intervention will definitely improve CPR success rates.