Operator:It is now my pleasure to turn today's program over to Liz Olson with the American Heart Association. The floor is yours.

Liz Olson:Thank you, Ginneen. Welcome, everyone. On behalf of the American Heart Association and Get With The Guidelines-Resuscitation, I would like to welcome all of you to the second of three events on our Fall Quality Improvement Series: Start Measuring, Start Improving. Today’s webinar is Techniques and Devices for Measuring Chest Compressions with our presenter Dr. Benjamin Abella. My name is Liz Olson, and I am the national program manager for Get With The Guidelines-Resuscitation. On today's webinar, we will hear from Dr. Benjamin Abella. Dr. Abella will highlight the importance of measuring chest compression quality during a resuscitation event, it’s impact on patient outcomes and the current techniques and devices hospitals can be using to measure the quality of chest compressions during CPR. This session is designed to offer an opportunity for Q&A with our speaker and we encourage your feedback and participation in this event. We invite you to submit questions throughout today’s presentation by using the “Q&A” button in the lower corner of the screen. A recording of today’s webinar will be made available on the American Heart Association website, heart.org/quality.

It is my pleasure to now introduce our speaker for today. Dr. Benjamin Abella studies sudden cardiac arrest, a leading cause of death that claims over 200,000 lives each year in the United States. Specifically projects within his clinical research team include evaluation of CPR and resuscitation performance, testing new methods to teach CPR in the community, prognostication of neurological outcomes after cardiac arrest, and methods to improve the application of therapeutic hypothermia. Dr. Abella is also the developer and medical director of a novel training course for therapeutic hypothermia use in the hospital setting. Dr. Abella has published scholarly work in numerous professional journals, including JAMA in circulation and has authored review, monograph, and textbook chapters on cardiac arrest and resuscitation. He serves on the American Heart Association Research Task Force and the Emergency Cardiovascular Care Task Force and has participated in developing international CPR guidelines. He has won a number of honors for his research, clinical care in the emergency department and his teaching of residents and medical students, and has lectured widely on the topics of cardiac arrest and post-arrest hypothermia treatment. It is now my pleasure to turn today’s webinar over to our speaker, Dr. Benjamin Abella. Dr. Abella, the floor is yours.

Dr. Benjamin Abella:Well, hello, everyone. It's great to be here with you all for this webinar. And I see there's many of you from wide geography and many hospitals, so it is great to see the diverse group. I followed the Get With The Guidelines story for a number of years; it’s really a tremendous success story, on behalf of you and AHA, to put this together and we’re really saving lives so keep up the good work, everyone. I am hoping today to share with you some of my insights into ways we can improve care for patients and in

particular the title of my talk today will focus on CPR, CPR quality, what it is, why it matters and practical techniques to use it. So we all generally understand that CPR is important, that CPR can save lives. And many of you are aware that the CPR quality metrics that we think about are important, that is to say, chest compression rate and depth and hand position, all of these things can make a difference. So my overarching goal today is to share with you what we mean when we say CPR quality, what we mean about these different metrics, and what are the clinical data supporting their importance. Many of you manage quality programs around resuscitation for your hospitals, and you will be faced with questions of, oh, well, why do we care about chest compression rate and depth? Hopefully today I will provide you with tools to help address those questions, and hopefully give you ideas on where we can move forward to improve CPR quality. Most of the work I'll be sharing with you are human studies. There are several animal studies mixed in, but we will avoid any extensive discussions of laboratory science. So have no fears, we will not be delving deep into the mechanics of laboratory work, but mostly staying focused on real clinical work, real clinical experience, so it can be as practical as possible for you moving forward. Okay, so that's a little bit of my introduction.

First, to get us all on the same page, I think it's important that we all have the same definitions and understanding of cardiac arrest. So hopefully you can see the animations here. Let us know if you cannot. The concept of cardiac arrest is quite simply when the heart stops beating, or said with a little more sophistication, it’s when a normally beating heart goes into an abnormal rhythm such that it cannot produce meaningful blood flow. So I show you here a conversion from a normal sinus rhythm to ventricular fibrillation and in v-fib, as you all know, it's a chaotic rhythm and there’s no functional cardiac output. And so in cardiac arrest it is abrupt, it’s a total loss of output, and it’s uniformly fatal unless CPR or other measures are taken. So it’s one of the few diseases in all of medicine that has an instant 100% mortality rate unless something is done. So that is an important thing to keep in mind.

So I wanted to next give you an overview of cardiac arrest mortality, when do people actually die from cardiac arrest. When you start off with a population of people who go into cardiac arrest, most of them do not survive, and you have seen this certainly in the hospital. Despite defibrillation, despite CPR, many patients succumb to cardiac arrest and are not able to be resuscitated. However, we certainly get some people back, and when you look at the Get With The Guidelines numbers, it’s, you know, not a small number. We get raw score return of spontaneous circulation depending on how you define things and anywhere between 25-40% of people, depending on what your denominator is. So an appreciable minority of people in the hospital setting get their pulse back. But as you know, that's only part of the battle. And after you get the pulse back, survival to discharge is a real problem because many, many things happen between getting your pulse back and leaving the hospital. And this is the realm of post-arrest care, a very important topic that I think is certainly worthy of another webinar in the future for this community. We're not going to focus on that today, but as you look at this slide, you see there’s sort of two drop offs. Two time points where survival is impacted. The first drop off is during resuscitation itself, and the second drop off is after

resuscitation. We're going to focus on this first drop off here. What we can do upstream to improve outcomes.

Okay, so first I thought it would be good to have a little bit of a history of CPR for you. And I think it's got a colorful history and we’ll spend a few minutes on this because it's fun and I think also helps put everything in context. So CPR was arguably invented in 1960 clinically after a lot of work in the ‘50s to develop the concept of chest compressions. And these three guys here, Doctors Knickerbocker, Kouwenhoven, and Jude -- try to say that 10 times quickly -- these guys developed chest compressions in the lab at Johns Hopkins and realized that you really could move blood by pushing on the chest. Well, they combined their work with the work of this guy, Peter Safar, who developed mouth-to-mouth ventilations in some modern form. For quite some time, people had thought you could breathe into peoples' lungs, but the really modern version of using a coordinated approach for this was developed by Peter Safar. So his mouth to mouth was put together with the Hopkins team’s chest compressions, and CPR was born. And so in the ‘60s -- in 1960 was the first paper describing it, it spread like wildfire and courses and conferences sprung up all around the world. This is one of the earliest ones I could find from 1961 in Norway talking about this new technique of rescue breathing and closed chest cardiac massage. So the take home point here is it's not as old as people think. People sort of think that CPR has been around forever, but it’s really only since 1960, and I daresay many of us on the call were around at that point and remember perhaps when it first rolled out the wider audience. .

Now, the way we think about CPR is in the context of a chain of survival. And you all are familiar with this term “chain of survival.” It was first proposed in 1991, so it's actually a fairly recent innovation. And the basic idea of the” chain of survival,” at least in its modern form in 2015, is that you recognize first that there's a cardiac arrest. I am going to try to be fancy here and see if this works – you first recognize -- hopefully you can all see me circling things. You can recognize a cardiac arrest, in the hospital that would be recognizing a patient is in trouble and then calling for help, followed by CPR, followed by prompt defibrillation, when possible, and then of course the “chain of survival” really speaks to out of hospital arrest, ambulance response, and then and post-arrest care. I suppose in the hospital setting, the analogy would be if the staff on floor recognize an arrest and start CPR and gets the AED in there. The medical team then arrives that are on the floor from elsewhere and that is sort of the ambulance link in the chain for the in-hospital side. But regardless, you can all see that CPR is right up close and center. It is the second link and it’s firmly in place there. So prompt CPR is important. An over the next set of slides I'm going to hopefully convince you it that's not just prompt CPR but the quality of CPR, the way we deliver CPR makes a lot of difference. And I am sure you know this to some degree, but I want to arm you with some clinical data to make this point very explicit.

So first, on this slide I’m going to share with you this study, and the next set of slides I will be sharing with you a sampler as it were, a sampler platter of studies. There are many I could choose, but just as examples of the sort of work that shows that the way we deliver CPR makes a very, very big difference. So in this study, this was a large out-

of-hospital study done in three sites. They looked at different modes of CPR delivery, different forms of CPR delivered in out-of-hospital setting. Not in-hospital, but again, this is just to drive home some points. Now, this was a dispatch CPR study, and I have to take 30 seconds and explain what that means. In many cities, in the out-of-hospital setting, if you find someone in cardiac arrest and you have no idea how to do CPR, when you call 911, the dispatcher will talk you through the steps of CPR. They will instruct you how to do CPR. That is a wonderful innovation, but it's wonderful for research as well because you can change the script. So people can be given different sets of instructions and you can see what happens. And in 2010, this is published in New England Journal of Medicine, and patients -- actual patients in cardiac arrest for whom 911 calls were made were randomized to two scripts, two instructional modes from the dispatcher. One standard CPR that is 15 compressions and two breaths. That was the standard back then. We all know now it's 32, but back then basic out of hospital BLS was 15 compressions and two breaths in repeating cycles. The other half of the cohort in the study were randomized to chest compression only. That is to say, only delivering compressions without any breaths whatsoever. You might think, gosh, breaths are important. People need to receive mouth to mouth, but perhaps to some people's surprise, survival was much better in the arm that got no breaths. And the absolute numbers are still relatively modest, but it’s almost a 50% jump in survival by omission of breaths. No new drugs, no new devices, just changing the way we did CPR. It is an example, I think a very striking one, of how a slight change in CPR can make a big difference. And probably most of you are aware that near 2015, hands-only or compression-only CPR is really the first choice in out-of-hospital, untrained provider setting. That is, if a layperson comes across someone on the street and isn't sure what to do, compression-only CPR is probably the best thing for them. Even if they know what to do, it may be the best thing to do, which is good news because nobody likes the notion of mouth to mouth on a stranger. But I digress, because we are not going to focus on implementation on the out-of-hospital setting.

On the next slide, I’m going to show you now an animal study. For a long time, people wanted to get at what matters hemodynamically during CPR and that’s easier to study in the animal lab. What I am going to show you here, and hopefully the animation plays nicely, is an actual animal -- it's supposed to repeat, but oh well, doesn't matter. I will do it one more time for those who may have missed it. This is an actual animal in cardiac arrest that I have taken the figure and sort of cartoonified it. But you’ll have to trust me that these are actual data. And what you can see is when compressions are delivered, and the compressions are the orange vertical lines, when compressions are delivered, you ramp up the blood pressure. Or said another way, compressions are a lousy way of generating blood flow, and it takes a number of compressions in a row to ramp it up. Initially it doesn't work so well. When you do stacked compressions, say a series of 15 or 30 compressions, you actually generate a reasonable pressure. Now notice the gaps, those will be gaps for breaths or gaps for pulse checks or what have you. Every time there's a gap, the blood pressure falls, and it falls quite dramatically and you have to ramp up again. So that's a problem. And commonly this is an explanation for the clinical study I just shared with you in that every time a bystander stops compressing to deliver a breath, you’re hemodynamically, adversely affecting that

patient. Compare it to this one where compressions are delivered and there's no stopping them. You actually reach a steady state pressure. So this is probably the much better option, at least hemodynamically. Now, of course at some point deoxygenation is a problem, we don’t know exactly when, but for the first few minutes of cardiac arrest it seems reasonable that compression only is the way to go for this reason. So now you know where that comes from, from the two studies I shared with you.

Now, there’s other quality metrics that are very important as well. For example, in this slide I am showing you looking at compression fraction. And compression fraction is a way of assessing CPR where you count up the fraction of time that you're actually compressing on the chest. So for example, if during a code, you're compressing from the minute you call, start the code, to the minute you call it, that would be 100% compression fraction. Unrealistic perhaps, but just for sake of argument, if a code is called and no CPR is given from start to finish, that would be zero. And as you all know, the truth is somewhere in between depending on pulse checks and intubation and other actions, you may have 50-70%, 30%, some number in between. Well, this study conducted in the raw consortium, which is a large out-of-hospital -- OHCA on this slide stands for out-of-hospital cardiac arrest. In this out-of-hospital study, they looked at compression fraction, and they found that the higher the compression fraction, the better the survival. So that is we want a high compression fraction. Now, those of you who have your coffee and are paying close attention may see that it dips off between 80-100%. That’s actually a statistical anomaly. There are very few patients that actually received 80-100%, so that drop isn't statistically significant. What we think of, there’s a plateau effect. So if you ever wondered where the 2015 recommendation for having a minimum chest compression fraction of 60% came from, it's this study. This study suggests that you want more compressions. So the more compressions, the better for patients. Again, suggesting that the way we do CPR matters. Not all CPR is created equal.

Now, what about depth? We sort of talked about rate and compression fraction in a sense of rate, it’s numbers of compressions. What about compression depth, which is the other major metric? I turn again to the animal lab. This is a pig study where animals were put into ventricular fibrillation, they were given three minutes of CPR and then the CPP, or coronary profusion pressure, was evaluated. And they did this with a mechanical device where they could set the compression depth. Those of you who have been around a little while, dare I say like myself, know that the old guidelines suggested that compression depth of 1.5 to 2 inches was appropriate or sufficient. Now, that's been changed to now being over 2 inches. If you ever wondered where it came from, it came from studies like the one I am sharing with you right now. In this pig study, they compared 1.5 to 2 inches to say, does it matter? Now, I will tell you, coronary perfusion pressure is really important, and in the animal lab, as a rule of thumb, if you can't get the CPP above 15, forget about it. The animals are unlikely to survive. We don't measure CPP actively in humans during cardiac arrest, it’s a little bit tricky to do, but in animals it’s relatively easy to instrument them before you do the experiment. Now, the top line there is the CPP with 2 inches of compression depth.

The bottom line here is the CPP with 1.5 inches of depth. And this is the survival in the end. So the animals were defibrillated after three minutes and that’s the survival rate. This is actually a very dramatic result. This suggests that a half inch of depth difference in CPR very strongly affects both hemodynamics and strongly suggests -- strongly correlates with survival as well. So both hemodynamics and survival are both affected by half an inch depth. I would ask you all rhetorically, since you can't answer it to me on a webinar, when you’ve done CPR, have you measured the depth? Do you know you're not doing 1.5, do you know you’re not doing 2 inches of depth? Is 2 inches of depth enough even? This study really raises those questions.

So to turn to some clinical evidence on this, this is a study that was published in 2012 that actually measured again in out-of-hospital setting, but there's little reason to suggest that this should be that different for the in-hospital side. This out-of-hospital consortium looked at depth of compressions, and you can see on the left-hand side there's one day survival and the rate of survival to discharge, the deeper you push, the better the survival. So a direct human confirmation of the animal study I just showed you. And notice it does not seem to fall off with really deep compressions. There's no maximum depth or no one has ever been able to find a maximum depth. That may raise a question, again, for those of you who are paying close attention, you may say, well, gee, gosh, doc, the 2015 guidelines suggest that a depth of 2 inches to 2.4 inches. They have a maximum. But if the data doesn't show a maximum, what gives? And I would say that's true, and the reason why that 2.4 was chosen in the guidelines as a maximum was based on some data for injury. That there may be increasing rate of rib fractures or other injuries when you push too, too hard, but we have never seen a survival difference. So I'll be honest with you, I am not completely comfortable with saying 2.4 is the maximum in depth. The AHA consensus group chose that, so that’s sort of the guidelines and I certainly respect the guidelines process, but I can say with certainty we have never seen a decreased survival by pushing too hard. It seems to go up and up and up. So certainly at least two inches depth is very important. We can't have wimpy pushing, so make sure when you’re watching people do CPR that they push hard enough.

Now, we did meta-analysis that looked at a number of studies to try to confirm these findings, and indeed we found with rate, there's a sweet spot. Unlike depth, survival does fall if you get way too fast. And you can imagine that to be the case because if you are going too fast, the heart doesn't have time to fill. So we found the sweet spot to be around 90-95, as shown on this slide, which happened to be quite close to AHA 100 so that makes everybody pretty happy. It is fair to say that other out-of-hospital studies have suggested that 100-120 is the sweet spot, so we don't actually know what the total sweet spot is, but again, the way we do CPR matters, and at the very least if you are doing 100 compressions per minute for everybody, you’re probably doing a god job. When we did our meta-analysis, and I am not going into great detail on this busy slide, we did not see a maximum for depth. The deeper you push, the better off you were.

Now, if you believe what I’ve told you so far, that the quality of CPR matters, that the way we do CPR matters a lot, it becomes very important that we actually measure it.

And now we're going to talk a little bit about measuring CPR. This is the device we use. I am not a Phillips sales guy, I am just showing you what we use in our hospital. This is a defibrillator that records CPR and the way it does it is it has a thing here that we call a puck. And the puck, you push and put this on the center of the chest and you push through the puck and it measures the rate and depth of compressions quantitatively. Now, you can also measure the ventilations based on the defibrillation pads so you get a nice picture of the CPR being delivered. And even better, it shows the user on the screen how you're doing. You see in real-time your rate and depth of compressions. We find it really nice. I have to be honest and fair and balanced to say that a lot of companies make this. So Phillips has a device called the MRX with QCPR, that’s our quality CPR tool, Zoll in their R Series household defibrillators has Real CPR Help, again a method of CPR recording with a puck also. And then Physio Control, many of you have LIFEPAK defibrillators. Physio Control also makes a CPR sensor but they’ve chosen a different approach, theirs is free standing which means you don't have to buy their defibrillator. Even if you have a Zoll or Phillips defibrillator or some other company’s, you can buy their CPR sensor as a free standing device called Tru CPR. These are the various tools that are readily available on the market, FDA certified for measuring and recording and hopefully improving CPR.

So I now want to show you an actual recording of an actual cardiac arrest using the Phillips MRX device. This is an actual code from some time ago. On the top strip is ventilations, in the middle is ECG, and the bottom compressions. I'm going to roll the tape. Now, mind you, this is not normal paper speed so if the ECG looks a little funny to you, I have compressed it just for easy viewing. So compressions are stopped to look at the rhythm, and you will perhaps recognize ventricular fibrillation, again, the paper speed is not normal so you can take my word for it. So they quickly move to a defibrillation and you see here a shock being delivered -- that’s those funny lines on the top of the ventilation strip showing an event is taking place -- and the rhythm is changed. And the team quickly goes back to doing compressions, perhaps not too quickly by current guidelines but this is an old cardiac arrest from some time ago, and they start compressions because they recognize pulseless ventricular tachycardia. So you can imagine that there’s a really rich data source that you would love to get your hands on if you’re a QA manager for codes because you can see when there are pauses, you can see when their compressions are too shallow or too deep or too fast, etc., etc. I liken it to a flight data recorder on an aircraft. When airplanes crash, you get this wealth of data from the flight data recorder. This is the in-hospital code equivalent of that. After code, you can download these and really see what went right and what went wrong.

Now, some time ago we asked a very simple question using these defibrillators. In a mode where users did not get feedback on their CPR, so they are secretly being recorded essentially, we asked the question, how did people do? This was a three hospital study and this is in in-hospital cardiac arrest, mind you, so the kind of stuff you guys deal with. So these are ACLS or BLS trained providers in the hospital. And what we found when we looked at compression rate was it wasn't so great. The mean rate that we want is near 100. Sure, a lot of people were compressing near 100, but look at

how widely divergent it was. A lot of times too fast, a lot of times too slow, in essence, it was all over the place. And I'll tell you, in the PIG lab if compressions are done at less than 80, which 1/3 of time they were in our study, survival was almost none. That is to say, people did not survive if compressions are done too slow for an entire code. This was very worrisome in 2005, and I am proud to say it really sort of helped spur this whole concept of CPR quality in the hospitals. I am glad to have been part of that. We also looked at survival, and it turns out that the group that survived hat a much higher chest compression rate than the group that did not, again pointing out that CPR quality probably matters quite a bit and can influence outcomes.

Now, why do people do a bad job? I mean, what is going on here? And we're all well-meaning, we all want to do the right thing. So why is it that CPR quality is such a tricky thing? Well, I suggest one hypothesis is the way we train. And thank goodness this is changing. We're involving SIM centers more, many hospitals are starting to play with mock codes, a very tough thing to do in the hospital, but still, the standard mode around the world and around the U.S. in many hospitals is this. What I show you here is a picture of a class, a CPR training class where you go every few years for your recertification, everyone has had Starbucks coffee, it’s sort of a chill environment, and everybody gets a little bit of time to practice on a mannequin and then an instructor subjectively says, “Yeah, that was good. You passed.” Well, I would suggest that this is not the ideal way to train for CPR because we’re not imposing the same environment of performance on the environment for training. Or said another way, a year later after your CPR certification class when all of a sudden at 2:00 in the morning in the CT scanner there’s a code, it's not so easy to remember how you learned it because you learned in a non-stressful environment. And contrast that with what a real code looks like, here’s a real code in our trauma bay. Or what people feel like in a code when you talk to people after a code, it feels like this. The team leader feels like there's a million people going a million directions and they're panicking.

So is there a solution? Well, there is. The military understands, for example, that it’s really important to train in the environment that you perform. So they do live fire exercises. They get all suited up, they crawl around in the mud, bullets are flying overhead, so the next time they’re in battle, they go, oh yeah, I remember how this is. I remember what this feels like. Very different from the way we teach CPR, so as much as we can as an in-hospital cardiac arrest community, I encourage us to think of ways to make it real, mock codes, high fidelity simulation training, repeat refresher training. We need to put rigor in the way we train people so that they can perform better. It's unfair to expect them to perform well when they haven't been trained well.

The other thing that the military does that I think we need to do a lot more of is debriefing. Here’s a Navy SEAL team on deck after a diving exercise where they’re debriefing. They’re saying who did what right and who did what wrong. We don't do that enough. I would, again, ask you rhetorically, how many have seen a team after a code stick around for 10 minutes right outside the room or even in the room to discuss what went right and wrong in the code? Usually teams disperse right away because everyone is tired, they’ve just spent 30 minutes of their life doing this code, they’ve got

to get back to other duties so they quickly disperse. If a patient didn't survive, they usually disperse quietly and solemnly feeling like a failure. Well, that is unfortunate because we should capture that moment. Debriefing can be very powerful, even if done for 5 or 10 minutes because it changes the culture. It says we care about this. We care about what we did right or wrong. We're not blaming people. We just want to understand how to improve for next time.

So we did a study on this where we coupled the CPR recording devices to a debriefing program and we showed improvements in CPR quality across the board, ventilation rate, compression rate, compression depth, we were able to affect culture and most importantly, we affected initial survival. Here is ROSC in this study that we did a longitudinal study. This was published in 2008. And we saw a big jump in ROSC, in return of spontaneous circulation, when we emphasized CPR quality by both the devices and by debriefing. The important lesson I would also suggest from this, we didn't see the prominent effect just from the devices alone but when coupled with debriefing we saw the effect. So we can't look to technology to solve all our problems. It needs to be coupled with teaching, with education and debriefing. We need to raise awareness as well as introduce technology.

Now, I am pleased to say that our work was replicated in out-of-hospital setting. This is work from Ben Bobrow and his team, basically doing the same thing. They put CPR quality devices, in the case the Zoll device, at work in EMS and they coupled it with a debriefing program. And they found a big jump in survival. This is a busy slide, but if you look just at what is boxed in the bottom there, you can see that in the pre-period and post-period, the survival percentage almost doubled when they coupled CPR debriefing with quality improvement. So now studies are available on the in-hospital side and out-of-hospital side showing that CPR recording and feedback combined can improve survival, and yet I think many hospitals and EMS agencies are not yet doing this. Hopefully this will spur all of you on to thinking about ways you could implement this in your hospital.

Now, what about ventilation? I’ve focused mostly on compressions, well ventilations are a problem as well. This is out-of-hospital work measuring ventilations in the city of Milwaukee. So these are paramedics delivering ventilations seen here is the little spikey parts with the V on them, this is an objective recording of ventilations delivered by EMS. This is a study published in circulation, and what they found with the mean ventilation rate during actual cardiac arrest by paramedics was 30, and you all know that AHA teaches the ventilation rate should be 8-10 approximately, so 30 is way too fast, triple what it should be. This finding was taken back to the animal lab and it was very bad. Pigs receiving this ventilation rate did not survive. In fact, an editorial published around this work was called “Death by Hyperventilation.” So hyperventilation is a big problem, and I would ask you to pay attention to this the next time you’re in a code. I think it is fair to say that most respiratory therapists bag patients way too fast. 8 to 10 is really slow. And in a code, it probably feels too slow because there is all this adrenaline flowing in the room. But keep an eye on it because there is good animal data showing that hyperventilation is bad. It's actually interesting to note that in the

study they actually did a first group of subjects, found 37 was the mean ventilation rate. They did an active retraining of a large group of paramedics and they got the rate down, so training helps. But notice it's still double what it should be. The question is, why would these good people, who want to do the right thing, improve but not improve to where they should be? I think it's hard. I think in the heat of battle, in a code, with everyone yelling and all sort of craziness going on, and your pulse going fast, it is hard to slow down and do the right thing as you have been trained. So I think it requires good team leadership and QA and that is where we, as the people on this webinar, play our role in helping guide why this matters. Now you have heard a little bit why indeed it does matter for patient survival.

Now, there are other things you can learn when you focus on recording of chest compressions. One of them that is very important, we believe, is pre-shock pause. You may be aware of work from Paul Chan, who spoke on one of these webinars some time ago, Paul Chan has been a big leader in looking at in-hospital quality and friends with him, we’ve shared our work together a lot. One of the things that you know perhaps is that he published on time to defibrillation in the hospital. And this is published in the New England Journal of Medicine a few years ago. He found that hospital time to defibrillation is widely variable. Now, that is measuring it from when the code is called. But I would also suggest it's highly variable from when the last compression is delivered, and what I show you here is a pre-shock pause. Excuse me. You see compressions being delivered on the bottom strip there. There's a pause to look at the rhythm. And perhaps you can tell that this is ventricular fibrillation. 15 seconds later a shock is delivered, so there’s a pre-shock pause of about 15 seconds. Now, you can say that's good, you could say that's bad. Better framed in the form of scientific question is: is this good? In other words, what should the pre-shock pause actually be? Well, we looked at this in a published work, and we found that indeed as the shock time goes up, the chance of a shock being successful goes down. And it goes up fairly rapidly -- or I should say the chance of shock success goes down fairly rapidly. So if a pause is 20 seconds from compression to shock, you lost a lot of your chance of rescuing that patient with your therapy. Or said another way, it really matters and we want shocks to be delivered as quickly as possible after the last compression. What happens a lot of the time and I attend to a lot of codes so I can keep fresh on what actually happens in the real world, and I am sure you have all seen this. What happens during codes often, someone stops compressing, they see the rhythm, maybe they’re not sure about the rhythm, they think it's v-fib, and then they discover a pad has fallen off or a couple of people are touching the patient, and there ensues a 20-second flail to get the pad back on or tell everyone to back away from the patient and you lose 10 or 20 seconds in an instant before you know it. So what I would suggest is if you see v-fib and you’re not ready to go, go back to doing compressions, make sure everything is set to your satisfaction, then come off the chest and deliver your shock. So in other words, you want to do whatever you can to minimize that pause between the last compression and the shock. And this is data driven and supported in the AHA guidelines.

Now, if you want to learn more about CPR quality, I would refer you to this manuscript. I think this paper here, if you're going to read one thing, this is what I recommend you

read. This is published in circulation in 2013. This is a really nice summary of everything we know about CPR quality in one paper. So it’s like one-stop shopping. The lead author, Peter Meaney, is a colleague of mine at the University of Pennsylvania, this was a writing group project sponsored by the American Heart Association to put together a bunch of experts who think about CPR quality all the time, and summarize what we know and what we should do in the realm of CPR quality. So I strongly urge you to have a dog-eared copy of this on your desk at all times if you are a Get With The Guidelines-Resuscitation aficionado. Now, one of the things that is in this paper are a speculative thing that I would like us all to consider. If you look in that paper, we have some figures on CPR report cards. These don't exist, or rather, AHA doesn't make this as a product, although AHA and I encourage my colleagues from AHA to spur this on as we are trying as well from volunteer side. We put this in there to stimulate discussion. Imagine a world in which every code had a report card. The one on the left is a subjective record card and the one on the right is an objective report card. You can imagine a report card having both elements. But imagine if the team leader, or perhaps one of you as a QA officer, after each code did something really simple and recorded a check box. Was the team leader readily identified? Was the room quiet? Was CPR delivered promptly? And could have any scale you want. We choose for our speculative one a simple scale of good, bad, or in between. And you could collect these things from each code, and maybe you could amend some comments from the team at the bottom. That would be great to keep in a binder to track over time. It would also be great for the feedback for the teams, wouldn't it? So there are some studies underway right now using different versions of a report card that may we spurred them on, I don't know, so I would be thrilled. But it is being studied as we speak. And you can think of developing your own report cards. It's an open season on what the right report cards should be, and I welcome any thoughts you have on this and hopefully we’ll learn more from upcoming science.

On the right is an objective report card. What that means is this would be a report card generated by a defibrillator that shows you your actual CPR performance. Wouldn't that be nice? After a code, what was your average rate, what was your average depth? Again, that would be great for QA managers like yourself to know, great for code committees to track, and great to give feedback to teams.

Now, I always like to keep it real in these talks by talking about actual cardiac arrests to a certain degree and talking about what we can learn from those events. Tim Russert died some time ago. Perhaps you remember Tim Russert, he was a famous television correspondent. Now, he's a classic cardiac arrest victim. He was a guy in his 50s, I believe, late 50s, he had coronary disease, but was otherwise okay, was generally in good health. So he was the classic out-of-hospital cardiac arrest victim, certainly not the classic in-hospital victim, but nonetheless, he had cardiac arrest and he did not survive. He had both CPR and defibrillation from an AED. We have no idea what the bi-center CPR was like, he have no idea what the pre-shock pause time was, but we know he was a robust, healthy guy, he had a v-fib arrest, and it was a witness cardiac arrest. So if anybody survived, it should be these guys. And I say that for the hospital, too. A witnessed in-hospital v-fib arrest, boy, we should really be saving most of those

people. If we're going to set ourselves a goal, we should have an over 50% survival from witness to v-fib arrest. Maybe it's unattainable, but if we’re having goals, we have goals and it’s people like this that should hopefully -- we can help survive.

Now, Michael Jackson is shown here, of course, had a different kind of cardiac arrest. He had a respiratory arrest from a drug overdose. Nonetheless, CPR quality was an important issue there because he had CPR performed in his big, soft, comfy bed. And as you know, if you’re pushing down on a chest in a very big, soft bed with a lot of compliance, you may actually not be squeezing the chest much or moving much blood at all. So it is possible the CPR received was quite poor. Now, would it have mattered, who knows? But in enough patients it might make a big difference.

Now, I like to end my storytelling and then we’ll turn to some other topics, but storytelling on a good note. This is Fabrice Muamba, he was a soccer player in England who had a cardiac arrest. If you ever want a good anecdotal story for how CPR can save lives, this is the one. This guy had a 78-minute cardiac arrest, so he was dead for well over an hour, had persistent v-fib, they could not shock him out of it after many, many shocks. This is him receiving CPR on the soccer field, he was in the middle of the game when he collapsed dead of v-fib. And this is him in the hospital on a Skype or a Google Chat or some modality that's lost to me, but he was talking to his fans saying, hey, I'm okay, I'm back, it’s all good. This man, what saved his life was really good CPR with few interruptions for 78 minutes. And he had a full neurologic recovery. So proof of concept that says you can be quite dead and yet be quite alive if you receive excellent CPR. So if you ever need an inspirational story, that’s the one.

Now, there are other things that we need to think about as far as techniques of monitoring CPR, and this is really the cutting edge, not quite ready for primetime, although it is suggested as an option in the guidelines. One of them is end-tidal CO2. So what you see here is a strip of end-tidal CO2 recording. When we say end-tidal CO2, we actually mean the value of ET-CO2 at the end of expirations. You see where that little arrow is? That value right there would be end-tidal CO2 and most people would save 35-40 millimeters of mercury and it represents the exhaled waste products from the lungs, the exhaled carbon dioxide. It can be measured non-invasively. And so it’s an attractive target for looking at physiology during CPR because of another important fact. End-tidal CO2 during CPR tracks with CPR delivery, that is the better the CPR, the better the blood flow, the higher the end-tidal CO2. Now, it’s not perfect by any stretch, but in some cases you can use end-tidal CO2 to guide your therapy, at least we believe that to be the case. And we believe that to be the case because some of the work we and others have done, looking at the correlation of CPR quality and end-tidal. So this is a plot showing you a whole bunch of codes looking at compression depth versus end-tidal and the deeper you push, the higher the end-tidal. That is a good thing and it could help us reinforce messages around quality of care. It's not been well studied on the in-hospital side, so I am not suggesting you all run out and start using end-tidal on all your codes, but keep an eye on the literature. End-tidal is one of several modalities that we’re really actively thinking about to improve our way to monitor cardiac arrests.

Invasive blood pressure monitoring is another way, and there's been work undergoing and work underway at a number of hospitals, looking at using art lines to measure blood flow during CPR. This is some work from my colleagues at CHOP, Children’s Hospital of Philadelphia, Bobby Sutton and others, who showed that this was possible.

Another piece of work, actually from Get With The Guidelines program itself, so many of you may have contributed data to this, showed that hospitals that use physiologic monitoring tend to have higher survival. That doesn't mean the physiologic monitoring made the difference, that just means that it may have correlated with survival as a surrogate marker that hospitals that measure physiology also do a better job. But it raises the possibility that monitoring CPR with arterial lines or with end-tidal CO2 may be useful. I don't know, it's still a work in progress, but I wanted to introduce you to that.

Now, what I have shared with you are manual CPR devices. What about mechanical devices? You have all heard of these, seen these at various trade shows and so forth, LUCAS device, Zoll Autopulse. Do they have a role during in-hospital arrest? We don't know that yet, but what we do know is there is mixed results in the out-of-hospital setting. This is one large out-of-hospital cardiac arrest that using the LUCAS -- sorry , the Zoll Autopulse device that suggested that survival to discharge, that’s DC, discharge, survival to discharge was much higher with Autopulse. That sounds good, right? That sounds promising. But another large, randomized trial of Autopulse, again in an out-of-hospital setting, was stopped early because survival was worse with the Autopulse. A big, complex story, we could do a whole lecture just on Autopulse and LUCAS and out-of-hospital arrests, but suffice it to say, the data are mixed. If any salesperson tells you that you got to use Autopulse or LUCAS in the in-hospital setting, the answer is we don't know that yet. There’s no data supporting that practice. There are reasons why that might be useful but we don't know yet. This is another large out-of-hospital study of mechanical CPR that, again, showed equal results. So in this study, it wasn't worse than manual CPR but wasn't better either. And finally, a LUCAS device with a meta-analysis attached to it. So if anyone is trying to sell you the LUCAS device, currently AHA guidelines do not recommend mechanical CPR. That isn’t to say they think they’re harmful, it’s just that there is no data showing they’re better than manual CPR.

Now, that sounds like I am sort of dumping on mechanical CPR. I am actually not, I think it has a real role and may be useful in some settings. For example, in long transport times in EMS or maybe in ED or ICU codes where they have a lot more codes and a device might be readily available. And then I think one of the most important potential uses for mechanical devices is as a bridge to cath lab. There are places now that will take people during active CPR into the cath lab to open up arteries. Imagine that, pretty heroic and also pretty awesome. Patients in active ventricular fibrillation that you cannot get out of refractory v-fib and you shock, you shock, you shock to no avail, put them on LUCAS, get them to the cath lab and open it up under CPR. Now, I’m not suggesting you do that tomorrow, it's got to be a coordinated approach, you got to get cardiology buy-in, but some hospitals are actually starting to do those. So there may be

a role for mechanical CPR in the hospital. But the current AHA recommendations, just to make sure you are clear on this, is they cannot recommend them. Now, it sounds -- the wording of this I find a little unfortunate, it sounds a little bit more negative than it should, but I think “cannot recommend,” it sounds like they are saying they are bad. They’re not, they’re just saying there is no evidence to recommend them. There is no evidence to dissuade you either. But as of now, there is no proof that they are better than manual CPR. But there are, as I said, some studies looking at bridge to cath and you can imagine cath labs having these and maybe deploy them in cases of refractory v-fib. Because remember, it’s the v-fib patients that are the most savable. So we really feel like it's justified to go the extra mile for those patients.

So in summary, hopefully I have convinced you that the way we do CPR matters a lot, that cardiac arrest is not hopeless, and if we do good CPR we can improve survival. And to do so, we need to slow down on our breathing. We need to compress hard and fast, and we really need to think very hard in our local environment about ways to improve both feedback and debriefing. And with that, I want to acknowledge my colleagues and collaborators at the University of Pennsylvania. This is my team getting out there in the real world doing the CPR training. I firmly believe we need to contribute to society as CPR researchers so here we are training the public through a program that we run at our hospital. And thank you very much. And I guess it is time now for your questions.

Operator: And as reminder, to ask a question via the web, click the “Q&A” button in the lower left-hand corner of your screen, type your question in the open area, and click the “submit” button. And I will turn it back for your Q&A session.

Liz Olson: Thank you so much. Mary, I will turn it over to you now for the moderation of our Q&A.

Speaker: Great, thank you. Thanks, Dr. Abella. We do have a few questions. The first one is: Are there any studies regarding ventilation rates for neonates? This is one area in our hospital that we thought if a neonate, small baby requires a higher ventilation, is this accurate?

Dr. Benjamin Abella:That is a really interesting question. And I have to admit I am no expert -- the first to admit things I don't know as much about. I don't know much about neonatal resuscitation to be perfectly frank. I know that in general, and this I know to be true, in general, pediatric cardiac arrests are much more likely to be respiratory in origin. For example, compression-only CPR is for adults, not for kids. Of course, there's some gray area there, what’s a kid, what’s an adult. So a 15-year-old, I probably would do compression-only CPR in the field, but certainly a three-year-old I would ventilate because most babies and certainly neonates have respiratory origins of cardiac arrest, so at least a decent proportion. Now, there have been some recent work that’s been

presented in both abstract form and in publication form, looking at the Get With The Guidelines and ventilations, but it’s not around neonates. So to my knowledge, there has not been a study looking at ventilation rate in neonatal cardiac arrests, unfortunately. It could exist, but I just don't know of it. I do know that in general we’re beginning to realize that even in pediatric cardiac arrest, compressions are more important than we thought. So yes, more pediatric arrests are respiratory in origin, that is true, but we’re learning that delaying compressions to intubate and to ventilate kids may not be as important as starting compressions right away. So I would venture to suggest that probably neonates we do want to start compressions right away, we definitely want to ventilate, but whether ventilating too fast or too low or what the targets are I think has not been adequately studied, at least not to my knowledge.

Speaker:Great. We have a few questions around the ET-CO2 for all codes. How many hospitals do you know or is there any data on the percent of hospitals that are using it on a consistent basis during code?

Dr. Benjamin Abella:That is a great question. We don't really have great data because, after all, the only thing we actually really have is that paper I showed you from Bobby Sutton looking at the Get With The Guidelines population. And that’s just if they checked a box saying they did any physiologic monitoring. We don't know what that means. Is that in all cases, some cases? So it's tricky. Now, it's fair to say that in that case, in that population, so I will tell you a bit more about that study. They had 803 cardiac arrests that had end-tidal CO2 monitoring out of 3,000. We didn't go into the hospitals per se, so I should tell you it was at the patient level. At least among the 3,000 patients looked at in this study, the minority had end-tidal CO2 recording. I think it's fair to say that very few hospitals on a regular basis use end-tidal CO2 during CPR, and that isn’t to say they’re doing the wrong thing, it’s to say we don't really know the best use yet and the algorithms for using it are not there. I actually applied some time ago for a large grant to study this and it got shot down because the reviewer said, “Well, we don't know how to use it.” I said, “That is the point of this grant is to study it.” So we’re sort of caught in this gray zone that we don’t think it's useful, but we don't really know how to use it and no one has developed an algorithm for using it. I don't blame hospitals for not using it. Really I was sharing it with you as food for thought because I know you are an intellectual group and you like to think about where we’re going, but we need more studies to understand how best to use end-tidal CO2 during codes. And in many cardiac arrests, it’s useless because you can't get a good signal or the lungs are full of fluid or whatever, but if you’re getting a good end-tidal CO2 recording and you believe your waveform and it’s saying 20 during CPR, that means that is a viable patient. You are doing good CPR, you’re moving good blood, and that means that is a patient you want to be aggressive with. That’s sort of a basic lesson I draw from it. Other questions?

Speaker:

Yes, we’ll close with one more question, we have a lot around kind of closing the loop on the codes and providing feedback. So who does the analysis of the CPR device quality? And then how do you get that data back to your code teams?

Dr. Benjamin Abella:Yeah, it’s a great question because that is a question of how to operationalize all this. So unfortunately, the defibrillator companies haven't made this as easy as they could, I think, and I am constantly bugging them to innovate and make this easier. So it is fair to say that all the devices they the record CPR, but you have to get out of the thing. In some of them you can Bluetooth it, in some of them you have to pull out a little memory card and then you have to pop in a laptop with special software for that company to analyze it. And you know, the software is not bad, but there's some training involved, you have to know how to use it. So it's not the most user-friendly thing in the world. You have to go download the data from the actual defibrillator that was used, also a pain in the butt. What I think would be terrific would be if these things could just wirelessly send their data through the hospital IT framework so that you don't have to chase down the individual defibrillator. I am sure that day will come. We're not there yet. Probably the closest is the Zoll devices because I think they can interface with the LIFENET software, but don't quote me on that. We would have to ask the Zoll reps. The bottom line is that there is some training and you’d have to talk to the individual reps about how to get that data and it is a little bit of work, so just be aware. What I dream of, is I dream of the defibrillator spitting out a sheet of paper that could then be picked up or could maybe email a PDF of that report card. We're not there yet. It's only in my dreams. So if someone is committed to this, contact your vendor, they can show you how it's done. It's not terrible but it does require a little bit of learning. And then you can store all of the actual CPR data and look at it and on the computer and some of the programs actually produce report cards in the analysis program. And what you can do is bring those reports to the code committee. I think compiling them and summarizing them would be a very useful exercise, but would require a little bit of time and ambition on your part to pull it off. Next question?

Speaker:Great. Let's do one more. Can you comment on the use of IPR therapy using CardioPump and ResQpod?

Dr. Benjamin Abella:So ResQpod. So ResQpod is an interesting question. Those of you who aren’t familiar with this, the ResQpod is what's called an impedance threshold device or ITD. It is really the only commercially available ITD so the terms are used interchangeably. What the ResQpod is, ResQpod is a commercial name, it’s a little widget, a little plastic doohickey that goes between the ET tube and the bag when you ventilate patients. What it has is a little valve that basically helps improve hemodynamics through an interesting mechanism. So I will explain. You can ventilate just fine through the thing -- when you squeeze the bag, you can breathe just fine. But what it does is it prevents air from rushing into the chest when you release a chest compression. If you think about it, when you push on the chest, you do two things. You move blood and you push air out

of the lungs. When you release your chest compression, hopefully you’re sucking blood back into the chest, but you’re also sucking air back into the lungs and you want to avoid that second thing because you want to move more blood. So in the animal lab, using ResQpod greatly augments blood return during CPR and improves hemodynamics and survival from codes. That all sounds terrific, unfortunately the human data are quite mixed. One study shows that it didn't do anything, another study showed that when combined with active compression/decompression, which is another sort of CPR device, it improve outcome but that is tricky because it is a multiple device study. And a secondary analysis of the larger study that showed it didn't work, when you look at the cases that had good CPR, it actually worked. The cases where you had terrible CPR didn't matter. So that is really interesting because one way to think about the ITD, if you’re not doing good CPR, you can do whatever you want as far as a finesse move, you’re not going to save yourself. On the other hand, if you’re doing good CPR, maybe the ResQpod can improve outcomes. Very interesting theory, we don’t know for sure, the bottom line is the data on the ResQpod are quite mixed. We use it at our hospital, I kind of believe in it, but you shouldn't do what I believe in, you should go with what the data show. The data are mixed and I think the current AHA guidelines certainly does not give it a level one recommendation. So if you don't use it, you’re not committing a major foul. If you use it, that is great, I think, and we'll have to learn more. And there's been no study published on survival from in hospital arrests using the ResQpod. That’s probably a study that needs to take place. Next question?

Speaker: Actually, we're going to wrap up our Q&A for today. So thank you so much, Dr. Abella. This is a fantastic presentation. I appreciate everyone for asking questions. Thank you to our attendees for your participation in today's event. In the next week, a recording of today's webinar and presentation slides will be available on American Heart Association's website: heart.org/quality. However, there is a copy in the handouts which you can download from the files section here in the webinar.

Dr. Benjamin Abella:Liz, can you hear me? May I ask a question? And maybe some of the participants want to know as well, that posting of the recording, is that free and open access? That is to say, if some of the folks on the webinar have friends who want to catch it from their hospital, they can go to that site?

Liz Olson: Yeah, absolutely. You will be able to download the recording and the slides and share that with your colleagues who perhaps missed the webinar today or if you’d like to view it again for training. Thanks, great question. We’ll also email everyone who registered to notify you when the presentation is available so you can go ahead and access that, along with a survey because we like to gather your feedback on the quality of our webinars so we can continue to improve and provide you with high-quality content. So thank you, everyone, thank you, Dr. Abella, and have a great day.

Dr. Benjamin Abella:

Thanks, everyone. Have a good one.

Operator:Thank you, all, for joining us today. We hope you found the presentation informative and this concludes the program. You may now disconnect. Everyone have a good day.