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Post Arrest Consult TeamPACT

“Resuscitation is just the beginning…”

Steven Brooks MD MHSc FRCPC, Principal InvestigatorLaurie Morrison MD MSc FRCPC, Co-Principal Investigator

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FundingFunding

Sunnybrook Health Sciences Center

AFP Innovation Fund

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Rationale for Rationale for PACTPACT• High mortality after OHCA resuscitation

• Post Cardiac Arrest Syndrome

• Hospital survival rates vary • E.g. 25%-30% locally vs. 50-60% in US and

Europe

• Local data shows care is not standardized

• Studies from elsewhere show improved survival with champions and a standardized, multi-faceted approach

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BarriersBarriers

• Process concerns due to low volume of OHCA

• Lack of a standardized approach

• Difficulty gaining experience

• The disjointed patient journey

• Access to specialized services – (ICU, PCI, EP)

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Post Arrest Consult Team Post Arrest Consult Team (PACT)(PACT)

• Building on other Centres of Excellence models– Trauma, stroke, STEMI etc

• Building on the CCRT model– Dedicated consult service of RN/RT/MD to

assist MRPs and primary nurses with complex/high risk patients

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Post Arrest Consult Team Post Arrest Consult Team (PACT)(PACT)

• Guidelines inspired• Evidence based• Standardized clinical pathways

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PACT Process

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PACT ActivationPACT Activation

• Single page PACT activation through locating• Automated pre-hospital alert to PACT RN text

pager from upload of electronic ambulance call report from Toronto EMS

• MDs will have cell phone/pager registered with communications with call schedule

• RNs will have a PACT text pager which is passed on to the PACT RN on call

• We will be tracking activation rates and missed cases

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Goal directed gas exchange and Goal directed gas exchange and hemodynamicshemodynamics

• Hyperoxia is bad– minimize FiO2 for oxygen saturation ≥ 94%

• Hypocarbia is bad– ventilate to ETC02 of 35-40 mmHG or PaCO2

levels of 40-45 mmHG

• Hypotension is bad– MAP goal specified in pre-printed order set

• Best evidence suggests these are urgent issues

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Therapeutic hypothermiaTherapeutic hypothermiaWhere PACT can have an IMPACTWhere PACT can have an IMPACT

• Cooling more eligible patients• Appropriate core temperature monitoring• Facilitating rapid decline in temperature

through the “danger zone” (quickly to 33.5)– Proper placement/replacement of ice bags – RAPID infusion of cold saline – Shivering prevention/treatment

• Encouraging aggressive sedation, analgesia and paralytic (PRN) as per hospital protocol

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Therapeutic hypothermiaTherapeutic hypothermiaWhere PACT can have an IMPACTWhere PACT can have an IMPACT

• Use of the trouble-shooting checklist when cooling rates are too slow

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Be aware of potential complications Be aware of potential complications during induction of hypothermiaduring induction of hypothermia

• Shivering– Will slow cooling– Increase in metabolic rate and oxygen demand

• Volume depletion• Electrolyte abnormalities

– Hypokalemia, Hypomagnesemia, Hypophospatemia

• Glucose resistance

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PACT MD PACT MD Roles and ResponsibilitiesRoles and Responsibilities

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• 24-hour availability. • In house M-F 9-5 with callback ASAP and

bedside assessment ASAP with a target of within 15 minutes of consult.

• Home call for telephone consult after-hours with discretionary bedside assessment

• For the ICU physicians call schedule synchronized with ICU call

PACT MDPACT MD

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PACT MDPACT MD

• Interaction with the PACT RN modeled after the CCRT– PACT RN will discuss case details, clinical

assessment and plan with the PACT MD after initial contact with the patient is made

– A collaborative plan with the PACT RN will be determined

– Similar to a resident to staff exchange• PACT MD will provide “suggest” orders as needed and

discuss them immediately with the MRP or their delegate at the time of assessment

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• Initial involvement directed towards items in the PACT clinical pathways that are urgent

– Gas exchange and hemodynamic goals

– Trouble-shooting therapeutic hypothermia to ensure goal temperature reached

– Need for urgent coronary reperfusion?

– Making appropriate sub-specialty consultations

– Encouraging delayed neuroprognostication

PACT MDPACT MD

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• Subsequent bedside follow-up daily during acute phase of care

– Support maintenance of hypothermia– Support safe, controlled re-warming at 24 hours– Support neuroprognostication pathway– EP involvement as per protocol– Consider etiology in collaboration with primary

team

PACT MDPACT MD

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• Clinical note expected for each consult• Detail clinical assessment and management

plan, highlighting the important features related to the PACT clinical pathways

• Hand-over PACT patient consult list to on-coming PACT MD for continuity of follow-ups

• Sign-off from patients when acute post arrest issues are resolved (~72 hours?)

PACT MDPACT MD

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• Dr. Steven Brooks• Dr. Andre Amaral• Dr. Martin Chapman• Dr. Brian Cuthbertson• Dr. Robert Fowler• Dr. Gordon Rubenfeld• Dr. Damon Scales• Dr. Paul Hawkins

PACT MDPACT MD

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PACT RN PACT RN Roles and ResponsibilitiesRoles and Responsibilities

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PACT RNPACT RN

• 24 hour in-hospital presence for PACT• Goal: Respond to page for consultation and attend

patient bedside as soon as possible to assist the primary care team in the implementation of best practices for the post-arrest patient

• PACT will only consult on out-of-hospital arrest patients; requests for in-hospital post cardiac arrest patients will be politely refused

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An advocate for the patient and an ambassador for the PACT

• Communication with primary MD, ED RN’s and PACT MD and the RT’s

• WILL NOT take over primary nursing responsibilities Review PACT eligibility

• OHCA• Comatose (not responding to verbal commands)• ROSC

PACT RNPACT RN

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The PACT RN as a ChampionThe PACT RN as a Champion

• The PACT RN is expected to have the greatest impact related to optimizing the induction of therapeutic hypothermia

accurate temp measurement

surface cooling

sedation & analgesia

cold fluids-FAST

NMBA’s

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Therapeutic HypothermiaTherapeutic Hypothermia

• SHSC Pre-printed Therapeutic Hypothermia orders

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TH Potential ConcernsTH Potential Concerns

PACT TH Trouble Shooting Checklist

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Cooling EquipmentCooling Equipment

• Pre-printed orders and quick reference

• Ice (freezer)• Cold fluids – saline • zip lock bags • Esophageal probe

– Guide for esophageal probe placement

– Paper measuring tape

• Note ED does not have a cooling blanket

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The PACT RN will also play a major role in assessing the patient with respect to the other clinical pathways • Goal directed gas exchange/

Hemodynamics• 12-lead ECG-urgent PCI • EPS• Neuroprognostication

The PACT RN as a ChampionThe PACT RN as a Champion

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Hemodynamic Optimization Hemodynamic Optimization and Gas Exchangeand Gas Exchange

RT collaboration to help facilitate the gas exchange targets

Minimize FiO2 to maintain O2 saturation of 94-96%

Ventilate ETCO2 to levels of 35 – 40 mmHg OR

Maintain PaCO2 levels of 40 – 45 mmHg

Maintain MAP goal specified in pre-printed order set

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Coronary Angiography Coronary Angiography Assessment Assessment

• Check to see if 12-lead ECG completed by the attending team– If not done, work with ED RN to

complete• Review the ECG with the MRP in the

ED and/or PACT MD to determine possible STEMI

• If possible STEMI, discuss activation of Code STEMI protocol

• Follow up with primary care team after patient returns from Cath Lab

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Electrophysiologist Electrophysiologist AssessmentAssessment

• Collaborate with PACT MD / MRP to call for Electrophysiologist consult

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PACT RN CoveragePACT RN Coverage

PACT RN will be the on call 24/7.

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PACT RN Communication ToolsPACT RN Communication Tools

Pager

Two pagers with the same number have been set up with locating for PACT

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PACT RN Hand OverPACT RN Hand OverAfter the PACT RN shift has ended

Contact the next on call PACT RN

Transfer pager

Provide a debrief of any PACT patient that may have been admitted for 12 hour follow up

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A A PACTPACT Case Case

• 52 yr old male• Acute onset chest pain followed by collapse

outside home– Witnessed – Bystander CPR initiated

• 911 call @ 20:32

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EMS TreatmentEMS Treatment

• Toronto Fire– First on scene– Confirmed VSA, continued CPR– AED applied – 1st shock

Analysis: started

Prompt: don't touch patient, analyzing

20:37:43 20:37:44 20:37:45 20:37:46 20:37:47 20:37:48 20:37:49Defib mode: Auto defib

Grid size is 0.20 s x 0.50 mV at Gain x1ECG

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EMS TreatmentEMS Treatment

• Toronto EMS– Bradycardic PEA, continued CPR– Course V-fib – 2nd shock– ROSC– Intubation

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SMH Emergency DepartmentSMH Emergency Department• Patient brought into a resuscitation bay• Assessment by emergency RNs, ER residents

and MD– BP 80/50, HR 110 Sinus Tachy, BVM ventilations

(apneic), O2 100% on FiO2 100%, Temp 36

• Tube position confirmed with colorimetric ETCO2, RT paged, cxray ordered, blood drawn, additional IVs established

• 12-lead ECG ordered• Order for dopamine give for a BP 80/40• ER puts in right femoral central line

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SMH Emergency DepartmentSMH Emergency Department

• Pre-printed post arrest therapeutic hypothermia orders signed by emergency staff MD

• Several ice bags placed around patient• Critical Care paged through locating• PACT team activated

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A A PACTPACT Case Case

• After hours paging protocol – PACT RN

• PACT RN – Calls back to emergency– Attends ASAP– Determines eligibility– Undertakes a focused assessment of the

patient

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A PACT Case• PACT-focused problem based approach

using the checklist and pathways– Pt is comatose (not responding to voice or

painful stimuli)– Intubated on vent. RT at bedside.– On emergency cardioresp monitor– BP 80/50, HR 110 Sinus Tachy, Vented O2

100% on FiO2 100%, Temp 36 (tympanic)– Ice bags at neck and groin

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PACT RN ActionsPACT RN Actions• Discussed gas exchange goals with RT and obtained

orders from MRP or PACT MD– Requested end-tidal CO2 monitor from RT

• Identified hypotension as an issue and advocated for fluids/pressors/central line by primary team– Pre-printed orders support this

• Ensured 12-lead ECG was done and assessed by MRP– Draw attention to PCI pathway if indicated

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PACT RN Actions• Helped bedside nurses place an esophageal

temp probe• Assisted bedside nurses with proper ice bag

placement and reminded about hourly replacement

• Started 2L cold saline bolus as per pre-printed orders with pressure bags

• Encouraged sedation/analgesia and paralytic PRN as per pre-printed orders

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PACT RN ActionsPACT RN Actions• At completion of initial assessment and

management, contacted the PACT MD through locating to discuss the case– Focus on:

• Hx and focused physical assessment• Review eligibility• Review interventions/investigations prior to PACT• Review any PACT interventions• Discussion with RN/MD around issues requiring attention by

PACT MD

• After MD contact, the PACT RN completed the eCRF on iPAD

• Brief PACT RN note in chart

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PACT MD actionsPACT MD actions• Reviewed case with the PACT RN over

the phone• Provided verbal “PACT Suggest” orders

for ventilation parameters• After review with PACT RN, contacts

MRP to discuss the suggest orders and discuss the ECG/PCI pathway

• Assessment for PCI• Assessment for EP involvement acutely

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PACT RN ActionsPACT RN Actions• One hour later – PACT RN follows up

with emerg– BP 120/70 on 10 mcg/kg/min– HR Sinus at 95

– Ventilated FiO2 40% O2 sats 95% ETCO2

40– Temp (esophageal) 36 degrees

• Action?

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THANK YOU