𝐂𝐏𝐑 𝐌𝐚𝐬𝐭𝐞𝐫𝐲 𝐢𝐧 𝐭𝐡𝐞 𝐀𝐝𝐮𝐥𝐭 𝐄𝐦𝐞𝐫𝐠𝐞𝐧𝐜𝐲 𝐃𝐞𝐩𝐚𝐫𝐭𝐦𝐞𝐧𝐭

All right. Hello everyone and welcome. Thank you so much for joining us on today's webinar. We're excited to dive deep into an incredibly informative session focused on best practices for measuring and improving high performance ER resuscitation programs, ultimately driving better outcomes and creating more survivors. We're especially honored to welcome our guest speakers, Dr. Gerrik Mach and Dr. Victoria Myers, who will bring a wealth of expertise and real world insight that that we know will be valuable for everyone. Let's get started with our amazing host, Dr. Peter Antebbi.

All right, Dan, thank you so much. Welcome everybody. As many of you know, we have been really working hard on both the pre hospital side and the hospital side, realizing that that combination of both teams really results in a great outcome. And I was very fortunate to have met in person Dr. Garak machine. I've never met Dr. Myers in person, but I'm really looking forward to her presentation with Garrick. When I first saw this presentation, I was blown away because this is the first time I actually saw folks in the adult ED actually measuring their CPR metrics. And so I just have a few slides to start off with. And I'm sure many people on this call that are watching the pit and it's a great show and it probably gives you a lot of stress, just like it were if you were sitting at work. But the one tagline that I wanted to start off with, because you're going to hear about it today, and this goes across whether you're an ems, whether you're in the hospital, whether you're in business, then if you're not measuring it, then you're not managing it. And today's presentation is going to hit that point right on the head. But before I pass it over.

I did want to mention that today we're talking about in hospital, adult cardiac arrest. As many of you who know me know, I feel it's all the same, right? Adult cardiac arrest, pediatric cardiac arrest, I think are exactly the same. How things are run pre hospital and how they're run in hospital are different, but the metrics are exactly the same. This comes right from cares calendar year 2024. And what I want you to see here, and just in case it's too small for you to read, I put in here in very large numbers what the CPC 1 and 2 survival is for these hospitals. Look at that discrepancy. If these numbers were transparent, which they're not, if they were transparent, hospital A would recognize that they have a lot of work to do. Unfortunately, most Hospitals, because we go to all of them locally here, they have no idea these numbers even exist. We're making a big push forward to do that. But I hope that what you're going to hear today is going to really change your mind on measurement and then starting to put things into play that'll actually make a difference. I'm very privileged to introduce today Dr. Victoria Myers and Dr. Garrick Mok. Both are from St. Michael's in Toronto and they are doing something very special. They're doing something that I hope all of you leave here today, say I'm going to copy that. But I think some of the metrics and some of the data that they're going to present to you today, they really are going to blow you away. So without any further ado, Dr. Myers, Dr. Mok, if you want to share your screen and welcome to the program.

Thanks so much everyone for having us here. My name is Dr. Gerrik Mok and I'm one of the emergency physicians at St. Michael's Hospital, which is in Toronto, Ontario. I'll let Victoria introduce herself and then we'll go into this a little bit.

Hi, nice to meet you. I'm Dr. Victoria Myers. I'm an emergency physician and trauma team leader at St. Michael's as well. Garrick and I actually went to medical school some time ago together. So it's a pleasure to be here with you today to talk about our program in the emergency department. And I'm from Windsor and my dad's from Detroit, so I actually put that I was from Michigan when I was registering for the talk.

Oh, there we go. Okay, so St. Michael's Hospital is a tertiary care center in the heart of downtown Toronto. If you don't know much about Toronto, I swear it's not always snowing, even though it randomly started snowing yesterday, even though it's the middle of April. But we see a whole bunch of various pathologies. It ranges from trauma to strokes to stem. We get a lot of hypothermic arrests. We get a lot of different types of pathologies at our emergency department. And what that means is that we see the sickest of all patients. We also are inner city hospital, so we, we deal with a lot of patients who are suffering from those socioeconomic status that comes along with it. A lot of social issues that make it difficult to manage as well.

We're also part of the first 60 resist group, which is a pre hospital trauma resuscitation science group within Toronto itself. And then I will give disclosure that I have Given talks for ZO before, so I've been a consultant for them in the past.

So in Canada we get around 60,000 out of hospital cardiac arrests per year. And what we know with those cardiac arrests is that the survival rates are quite variable, somewhere between 3 to 35%. Now there's a lot of discussion about what is the best thing to do for these patients, what's their appropriate dose of epi, how many shocks should you be giving? All those really complicated questions that we don't really know the answer to sometimes. But what we do know is that the basics is what's really important for these patients. And what that really means is that doing high quality CPR and having an aed, those are really your best bang for your buck. We can think a lot about, you know, should I give this bolus of bicarb, should I not? But really it's doing the basics that's the most important thing that we can do.

And the AHA really shows this for us. They have pretty clear guidelines for what they would recommend. They recommend giving your CPR at a rate of 100 to 120 compressions per minute, a depth of 5 to 6 centimeters, which we use in Canada, but in the States it would be 2 to 2.4 inches. A compression fraction of at least 60%. And high performance teams aim for 80 to 90% is a compression fraction. And then maintaining their pauses under 10 seconds. They also recommend that we have a CPR data collection program. And that's really what I want to talk to everyone here about today.

The reason for this and why it's so important is because there's often a clinical difference between what we think is high quality CPR and what's actually measured. There's definitely a disconnect between the two groups. Abela et al looked at this and what they saw was that in hospital cardiac arrest it was very rare that we actually backed the targets and the metrics set up by the aha.

Paplo et al also saw the same thing where people were only meeting their recommended rate and depth for CPR in less than 10% of their cases. And that's really improved with some training. The CPR care study also saw something similar, which is in their simulation studies they saw that it was really rare that they're actually meeting their targets with CPR that the AHA set up. And Crow et al took this to the next kind of step where they started actually measuring their CPR quality within their edge. And then they implemented various ideas to try to help improve that CPR quality and they really could see a big difference. And what these four studies really show is that there's often a disrcape, which is our Canadian association of Emergency Physicians. They asked how are you actually measuring your CPR quality? What they saw was that only 12% of respondents actually utilize any kind of CPR feedback whatsoever. And when they actually asked them how they measure their cpr, how they look at their cpr, the majority of them actually said they either just look at the patient themselves and see, I think that looks good, I think you're going deep enough, I think you're going fast enough. And just pure observation, which I think we've all done many times as well, 29.7% of them actually said they measured it through palpation of the femoral pulse or the carotid pulse. Actually, both of these are actually not recommended in European guidelines. There's definitely a disconnect between what we should be doing and what we're actually doing it. Now, ILOR recently published this. I think it's either last year or the year before. And they really looked at what are the 10 steps that you can use to improve your in hospital cardic rest, quality of care and outcomes. And they really looked at four main pillars. Now we can't really touch base on preventing cardiac arrest, both in the ED as well as in the pre hospital world. Patients are going to come in when they come in, no matter what in the emergency department. But they talk about preventing, performing principles and culture and planning and preparing. And these four steps really kind of add upon themselves and build upon themselves. And I'm going to focus more on the left side of the screen today. So in terms of planning preparing, what they recommend is you have to build and support a governance and infrastructure. What that means is that you have to have some kind of program in order to actually do this. You need to do it together as a group. And you need to make sure that this is both within your ED, but also outside of your ed. And I'll talk about why that's so important afterwards. When you have this program, you have to collect data and in order to do that, and the reason you need to do that is because you need to be able to measure where you're at and measure if you're actually improving or not. And then lastly, for planning, preparing, you have to implement effective education and training depending on where you find those deficiencies.

In your ED or in your inhospital environment. In terms of principles and culture, this is also very important and probably the hardest thing to change in all of medicine is you have to implement a culture of excellence in care. And I'll talk a little bit about how we did that in our program, but also some of the other benefits that you can get from this program afterwards. You also need to ensure the well being of your healthcare professionals. You want to try to make sure that when you're improving this within your group, that you're making sure that you take a look at the emotional well being for your team as well.

And this all, you know, this all kind of comes down to two quotes, which is you can't manage what you don't measure. And the other quote would then be, without data, you're just another person with an opinion. And these two really resonate with me because in the ED we can tell you all we want about how long someone's waiting for their laceration repair, how long someone's waiting for chest pain for, but I can tell you nothing about the quality of CPR that we're providing. I would argue that most of us go into acute care medicine because of cardiac arrest cases and cases like this that are really exciting for us. I actually think about this similar to I just did a big renovation to our house and there was all this black mold in the basement. And you don't really think about the black mold until you take away the walls. And then once you take down the walls and you see it all, you now have no choice. I bet you all of us have some mold in our basement that we don't really think about. But once you take down the walls, you're like, okay, I can't not, you know, I can't not fix it. I can't ignore this. And that's really what we're trying to do here as well. We want to try to identify what our issues are and then show it to our group. Because we as a department need to do better and our patients deserve better. So we broke this down into four different phases. The first phase was just very simply, can we consistently collect CPR quality data? Now, collecting data isn't novel. It's something that's done really well in the pre hospital world. We have Canrock in Canada that has various EMS services that collect their CPR quality data. It's done in the in hospital cardiac arrest environment as well within our, within our hospital. But it's really a paucity in, in the emergency department. And why is that? What's the reason? It's not actually done consistently. That's one of the barriers we tried to break down. Now, after we collected our CPR quality data, we then need to make sure that we can identify what our baseline was and our deficiencies. And the reason that's important is because we're not perfect. And you're going to see very shortly why it's important. The data that we're going to be showing you shows you where we're at before and where we're trained towards, but not where we want to be at the end of the day. So there's still lots of work incoming. We then wanted to implement some changes such as post event debriefing as well as various improvement initiatives, such as a CPR coach that I'll show you guys in a video later on.

And in order to do this, we really broke it down to these kind of big pillars. We utilize quality improvement methodology, which is really following the model for improvement.

Right.

And Victoria, if you can show the next slide, it'll show the thing. Yeah. So the model for improvement, you're really asking yourself these three questions. First, what are we trying to accomplish? Well, in our first phase, what we're really trying to accomplish is just adequate data collection in a way where we're actually getting the data uploaded and seen for us. Then you want to ask yourself, how will we know that a change is an improvement? So how are you actually tracking your data so that if you're implementing a change, it's actually making some kind of improvement that you're intended? And then lastly, what change can we make that will result in an improvement? And then you're going to continually iterate that through plan, do, study, act cycles. It's also really important that you get stakeholder engagement. So our team itself was quite large and we'll break that down in the next slide.

Third, we spend a lot of time on diagnostics. That's when we, we're very fortunate. We have a really great simulation team, but we spend a lot of time on diagnostics trying to really figure out what our current state is. The mistake people make a lot of times when they try to make some kind of quality improvement change is that they just try to enact right away. They want to make all these changes right away without really understanding what their current state is and doing every cost analysis. And then lastly, like I mentioned, we did PDSA cycles as we were kind of iterative with this process.

So the team is big and there's a reason it's big. Right. We have. Cardiac arrest is a big team sport. And that's not just within your ed that's outside your ED as well. If you want to make changes to the culture of quality improvement and the culture of cardiac arrest care within your department, you really have to branch out and have a lot of people involved. So we had our ED leadership. Very fortunate to have a very supportive chief that allowed for this. We had four different emergency physicians part of this team, and each one had their own various specialty and expertise within cardiac arrest. And they were also different in the stages of their career, which is really helpful in trying to someday change ideas in a big group. We had our nurse educators, so we have two nurse educators that are there in our department that help educate over 100 nurses through various monthly simulations. We had quality improvement specialists such as myself and one of my colleagues. We had simulation specialists to have the simulation team available and helpful for diagnostics, but also for implementing change ideas. And then lastly, we had members from the in hospital cardiac arrest committee. And this is what I was talking about before, where it's really important to branch outside of your own department if you want to make changes. The in hospital Cardiac arrest committee had been collecting data for years. They had the infrastructure, they had the devices available to do this. They helped us and taught us a lot about the pros and cons of how they did it. And we learned a lot from them. In order to actually implement this within our own ED itself.

The first thing we did as a group was we did something called the Fishbone diagram or an Ishikawa diagram. Basically, you're going to put your problem at the head, which is basically CPR data not being captured, and then you have various different pillars that you think are the main themes as to why it's not being captured. And it's really just a big brainstorming session between all members of the team. And we found various themes within this that we wanted to address.

The first one, Victoria, would be a lack of awareness. People just weren't aware that this was something that was doable. Again, we saw in the surveys from our emergency physicians across Canada that really.

There were very few groups that were actually utilizing any kind of CPR feedback devices. And when we looked around, there were actually no emergency departments in the country that were formally collecting their their CPR quality to actually make improvement and changes.

Next, we found that another concern people had was will this reflect on their individual performance? And we spent a lot of time trying to debunk this. A lot of people were worried that if they saw that the CPR quality was poor, is that going to reflect and show that this is you Know this person that was doing cpr, will it reflect on that? And we spent a lot of time trying to debunk this from the culture perspective. And I think that's the most important thing to really debunk as well. Then lastly, we wanted to make sure that if we were collecting CPR quality data, we didn't want to have any delays in our cpr. We didn't think that it would be appropriate to stop CPR for long periods of time in order to put on special devices that would be required in order to actually capture data.

Blame culture. I think this is what we spent the most time doing. We always want things to happen really quickly in emergency medicine. We always want these changes to happen really quickly. But the reality is that it takes a long time. And we spent months trying to debunk the concerns that people had about individual performance. And the best way we found to do this is really to just go to the frontline staff. We did quality improvement huddles every day leading up to the implementation of this program. Really addressing people's concerns and making sure that we approached every single person to let them know that this was not going to be utilized for any individual performance. I spent a lot of time curating my emails, making sure that the colors were appropriate, not having too much bold or underlined or red. Little things like that in your emails that you don't think are important, but are really, really important when other people are reading it. Just to make sure that we can frame things in a positive light rather than a negative light.

Now, we utilize simulation a lot for diagnostics. You might recognize the guy in the middle, Sheldon Cheskes. He's the principal author for Dual sequential defibrillation. And I know Dr. Tebbe knows him very, very well through many other endeavors. But we utilize this simulation really to understand our current state process and really to understand how do we actually collect data. What we know is that our EMS colleagues in Toronto will utilize the ZOL X series and we have the R series in red. And what we realized when we did this was that the X series and the R series could connect for you to defibrillate and to pace, but it didn't actually send any CPR quality data or provide any feedback for us.

The simulation was really helpful in actually trying to understand how that worked and understanding how the puck even works. A lot of people had no idea that the feedback was even possible, didn't know that we need the puck to be on the chest in order for us to actually collect the data. So that was all really helpful for actually understanding what the current state was.

So, like I mentioned, the. It says X series here, but it's a typo. Should say R series. The EMS providers will have an X series and that will connect to our Zollr series through the mechanism I can see in that photo there. And it works. It allows us to pace, defibrillate and do the necessary interventions, but it doesn't give us any CPR quality feedback. And that's both in real time as well as for uploading onto case review. Once we found out that that was the case, we were able to reach out to one of the ZOLL reps who taught us about this adapter that we could place. Like I mentioned before, what we didn't want to do is we didn't want to cause a delay in CPR or delay in care for these patients by having a quality monitoring device. We figured that with this adapter, that means that we don't have to take the stickers and the puck off the patient that they already have. We can just switch it over to our Zoll with his adapter already attached and then continue as is.

We introduced adapter, we tested it out in some simulations, and then we went around and did a daily quality improvement huddle to let people know about this adapter. Now, it sounds simple to just implement an adapter, but it was actually pretty complicated because the adapter itself, it can get lost. It's tied with this tiny little string that can be taken off at any point in time. We actually found. I put a towel on these adapters, and then one day I found that I got this message that my device was not there anymore and it had moved to Tim Hortons and then eventually moved to booster juice. And it must have just been attached to some patient who walked out with it. At some point in time. We ended up having to drill some keyholes in it and really just teaching our staff about when we would use the adapters and when we wouldn't use the adapters.

Our nurse educators were instrumental to this because this is really a nursing workflow in terms of actually putting this on and knowing the situations in which we actually want to use an adapter or when we don't. And they create a tip sheet that we attach to a cardiac arrest card as well.

Okay, and I'm going to talk to you about now that we have this process in place, how we're collecting our data, looking at our data, and some of the changes in our department because of the data. So for each CPR case that we. For each cardiac arrest case that we have in our emergency department, we gather our data from two places. The first is our medical electronic record. We recently ported over to epic, so we are getting used to epic. But the advantages of EPIC is that it provides us a lot of data around our cardiac arrests. We collect CPR data from this, and we also then collect our CPR quality data from the Zoll case review. So for every CPR case we have live, the CPR metrics are uploaded onto a cloud that we then collect our metrics from. Afterwards, we combine our chart review and the data with our metrics and put it into a CPR database. So over the last 18 months, we have built a CPR database of all of the cardiac arrests that happen in our emergency department. There's some evolving data collection with this. As we get more familiar with our EMR and the case review series, we're collecting more and more around our cardiac arrest to answer more nuanced questions.

So as Garrick talked about, the first question really is, can we capture our CPR data? We want to capture data on every single cardiac arrest that is coming through our doors. And this is a graph showing kind of our progress with that. So if you look at month one through seven, we're collecting roughly 50% of our cases of data. And that might be because the adapter wasn't attached or there was not there was a problem with the software or. And then via implementing the adapter and also education of our staff, you can see our data collection rise quite nicely, well above the 80% target that we set for ourselves here. You can see that around month 16, we dropped down around 50% again. And when we looked into this, because we were tracking it, we found that there was an upload issue between our defibrillators and the cloud software, which allowed us to address it and fix it. And we're back up above 80 again. So tracking this was really useful just to verify that we were really actually collecting all of our cardiac arrest data.

And with the data, which I'm going to show you kind of near the end of the presentation, but first I'll talk to you a little bit about some of the strategies that we implemented now that we have this great data. So the first is post event debriefing. So after we have a cardiac arrest, we bring the frontline team that was involved in that arrest to a huddle and we show them the data of the case that just occurred. And that allows us to debrief things like pause times or what happened and get a real sense of the quality of CPR that we all just provided as a team. And let me show you some cases.

So just to orient you, the top is the CPR event summary. Yellow is while CPR was going on. Green is pauses. And the little lightning bolt is when a shock was delivered. On the next bar, you have depth. On the next bar, you have rate. The third bar is a combination of depth and rate. When you are in target for both, it will tell you and then the last is release velocity. So how fast you're coming off chest. Now, if you take a careful look at this case, for the first bit of the case, you can see that the depth is way beyond target, up down into the 9 centimeter range. Probably 9 centimeters is more than the depth of the actual patient themselves. And the question is, why was that happening? Well, in the debrief, we discovered there was no backboard for the first part of the case, which is why the patient is being pushed into the mattress of the bed and why the depth appears to be so deep. Probably not providing effective cpr. Not as effective as we'd like. When the backboard was placed, you can see the depth as well as the release velocity comes much more nicely into the target range. And we're able to discuss that and the importance of the backboard and really show our team the importance of the backboard. Right after the event.

Let's look at another case. So in this case, in the post event debrief, we talked about the pauses. We had one pause for 114 seconds. You can see it here and then you can see it there. What was happening during this pause? The post event debrief allowed us to identify that this was an intubation attempt. We have a second pause. It was 60 seconds long. The debrief helped us to identify that this was the placement of an arterial line and why we might have placed it or why maybe that pause was too long for that point of the case. It allows some reflection for the team. And finally, we have a pause of 35 seconds that we talked about. And that during that pause, ultrasound was being used. Not that this justifies the pauses, but it does give us a sense of how long our pauses are and what's happening in during them. And that allows us to change our practice whether we do never stop compressions for the intubation or whether there was a reason why we had to stop compressions for this intubation and why it was so important. But it really provides context for the team.

Let's go through another case. So in this case we were often a bit too deep. We were only 8% in target for the depth, which is 5 to 6 centimeters. Our rate was a little bit fast near the beginning. And you can see as the case goes on, we get closer into our target range of 100 to 120. There was only 2% of time when we were hitting both the rate and the depth in target. And our release velocity was well, kind of above into the blue here. Our chest compression fraction was 87.6%, which is above the target of 80 and closer to that very high performing target of 90.

And when you look at the pauses, our longest pause here was 19.6 seconds. Well, in our debrief, what we learned is that that 19.6 seconds was a placement of a second set of pads. Because this was a dual sequential defibrillation case. It helped us understand why it was so long and also that it would be helpful to choreograph the placement of that second set of pads to try and decrease that pause time under 10 seconds. So really extra education and understanding and then some practice of applying the second set of pads for dual sequential cases. We had also previously discussed with the team before this case about peri shock pauses and trying to pre charge before we shock. And it's evident in this case and we're able to show the team in the debrief that the pre shock pause was 1.48 seconds at the shortest. And that's because the machine was pretty pre charged prior to the pause check.

Another intervention that we initialize, which I'm excited to share with you and we're going to watch a video after this slide is the EDCPR coach. So what the coach does is their only role is to monitor the quality of the cpr. They introduce themselves as the CPR coach. They're responsible for attaching the puck, they track the pauses, and if they're doing a dual sequential case, they place the second set of pads. They also place the CPR adapter which allows us to monitor the data collection. This allows the team lead and the other allied health in the room to take on their roles and offload the cognitive effort of keeping track of the CPR quality. It creates a team of the CPR coach and the compressor to try and deliver the best quality CPR possible. The CPR coach also keeps track of pauses and will make sure that the person is back on the chest at approximately 10 seconds. I'm going to just exit away from my slides right now and I'm going to pull up my share my screen in a different way and we're going to watch kind of a four minute video describing the CPR coach and then a simulation where we trialed the CPR coach.

All right team, we've just received a call from paramedics. We have a few 50 year old male found vsa witness collapsed about 10 minutes ago, was given one shock v fib in the field, has been intubated, no epis have been given and has one iv. So I just want to make sure that we have the room set up and that we have everybody that we need for the team. So we have Pharaoh who's going to be our CPR coach. We have Sarah who's going to be IV and meds. Brandon, we're going to be here for our rt. Selena is going to be our documenting nurse. And then we have Carl and Stan for chest compressions. Can we just make sure we have everything else set up in the room? So we have our defibrillator with all the crash cart meds, we have a backboard, we have our airway equipment and all the medications that we would need. Farah, do you mind us quickly outlining what we do for CPR coach?

So I'm just going to grab my card that's going to be on my soul here. So again I'm Farah, I'm going to be the CPR coach with this resuscitation. So the first thing is, Sarah, if you don't mind, when the patient comes in, attaching the adapter to the EMS pad so we can get CPR feedback. We'll also just make sure that the CPR feedback device and the pack is securely on the patient so we get good CPR translation to our defib. Brandon, if you don't mind connecting the end title from the Zoll as well as the GE monitor so it's visualized in the room. And then Carl and Stan, our goal for high quality CPR and end title is going to be anything over 10. I will be referencing you to the dashboard here and providing you real time coaching. Please let me know if you're tired. So remember, our goal is to be at a rate of 100 to 120 with a depth of 2 to 2.4 inches. And again, if you're tired or fatigued, let me know. We want to keep our elbows nice and straight over the lower half of the breastbone in between the nipple lines. Celine, you'll be documenting. So I will be doing the timing for our pulse and Rhythm checks. I will be counting down at the five seconds as well as a 15 second warning. And I will be pre charging Amit. If it is a shockable rhythm, upon your instruction, I will administer the shock. And Celine, if you don't mind, timing for EPI every three to five minutes.

Great.

Perfect.

And then when the patient arrives, if you can just have 1 milligram of epidron before the patient gets in, we'll have the pads on. And if it's a shock algorithm, we will do a quick pulse check, shock and go with cpr. Sound like a plan?

Spring Robux.

Spring Roblox.

She clearly doesn't have YouTube.

All right, team, can we transfer the patient over?

Connect the equipment and we'll do a.

Quick pulse and rhythm check.

Carl, I'll get you to start compression. Sarah, can you connect the adapter right away?

Yeah.

And turn the defib on, please.

One, two, three.

Good.

Continue chest compressions. Let's get the stretcher out.

Okay, team, in a second we're going to stop for a pulse and rhythm check. Can we please pre charge the machine?

Pre charging. Carl, if a shock is advised, I'm going to shock and I want you to get immediately back on the chest.

Okay, let's stop.

It looks like V. Can we shock the patient, please?

Everyone clear. Shock delivered. Back on the chest, please.

Good.

And can we give 1 milligram of epi now, please?

1 milligram of epi chocolate delivered. 200 Jew.

So, Stan, this is your CPR dashboard. I want you to look at these numbers. You want to be between 2 to 2.5.

Okay, team, in a second we're going to stop for a point and rhythm check. Can we please pre charge the machine?

Pre charging. Carl, if a shock is advised, I'm gonna shock and I want you to get immediately back on the chest.

Okay, let's stop.

One milligram of EPI given.

Thank you. Brandon, can we get a quick airway assessment, please?

Yeah. Patient came intubated by EMS with a number 8 ET secured at 24 ellipse. We have positive end title on our zole and on the Asian monitor.

Her as well.

Thank you.

Bilateral air entry.

Okay, Stan, you want to push a little bit harder. Your goal is to be between 2 to 2.4 inches and you are going a little bit too fast, so 100 to 120. Okay, you'll see your end title here. Right. We're hovering at about 8, so our goal is to be at 10. Okay, let me know if you're tired and keep your Elbows nice and straight. Good compression, excellent job. All right, team, we're approaching.

Okay, so that's a nice depiction of our CPR coach in simulation. That was far one of our nurse educators acting as the CPR coach. And the beauty of the CPR coach is it allows many different members of the team to be the CPR coach. Depending on who you have in the room. This person can be a medical student, it could be a junior resident, it could be one of our nurses. So there's many people that can take on this role, which also improves our team work and culture of the team that this is kind of a multi professional, interprofessional role that can be taken on. So let's look at a few more cases. These are cases that used a CPR coach. This case shows that we were 50% in target for depth. If anything, we were actually not quite deep enough for this patient. 86% we were in the target rate. So pretty nicely here in the 100 to 120 beats per minute with maybe slightly a little bit too fast near the end. And 50% of our target compressions were both in the depth and rate at the exact same time. Our release velocity is shown here at the bottom, kind of a little bit medium, kind of drifting down a little bit slow near the end. And we had a 92.94% compression fraction for this case. And two thirds of our pauses were less than 10 seconds, probably largely in part to the CPR coach keeping track of the pauses so closely. This is a case with even better metrics. 91% of the case we were in target depth, 88% in target rate, and 80% of our compressions were both in depth and rate. And our release velocity was kind of right between the medium and fast down here. Our compression fraction was 89.8% and 100% of the pauses were less than 10 seconds. Both of these cases included a CPR coach. And we have seen with the implementation and utilization of a CPR coach, improvement in all domains of our CPR quality. It's really improved communication amongst our team and a decrease in cognitive load for the team lead who can start thinking about other things, other interventions, other nuances to the cardiac arrest case, because they're not thinking about the quality of CPR because they know that someone else is taking care of it. And that brings me quite nicely into our non data impacts that we've seen seen from this program. We can't measure this, but we've seen and have been given feedback broadly across our department that the staff are very motivated and very into the CPR quality program. They want to know how good the CPR they're delivering is. They have questions about why the metrics are the way they are, how we can improve things, what we can do better. And they're much more likely to give each other feedback around the CPR quality as the case is going. Even if there's not an active CPR CPR coach in the case, it's really improved our knowledge translation, explaining why we do things when we do them, and created a great foundation for QI for this program, but also for other initiatives in our department, building a culture of team high performance within our team.

So let's look at our data. This is data that in graphs that I created about a week ago. And so right now we've been using target rate and depth, really trying to target being in both the rate and the depth metrics during the case. And this is the percent of the case that we're in those metrics. You can see that at the beginning we're like well below 5% here. And with some improved feedback and CPR coach, we have risen slowly. We're still kind of hanging out around the 20% mark. And this is an area of question for us. Why are we struggling to be in the target rate and target depth? Part of this is that it's a two part metric. We have to be in both the rate and the depth. So then we've broken it down. This is our average compression rate for our cases in the department. You can see that we started out having some cases where our average rate was too quick. And we've quite nicely, as time has gone on and we've gathered more data, done more debriefs, implemented a CPR coach drifted into where most of our cases now are well within the 100 to 120. From an average compression rate standpoint, where we're still struggling a bit is our depth. We're often compressing too deep in our cases. So this is an area of focus that we can use going forward. It's also an area of discussion. Should we be compressing 5-6cm on every single patient? Someone who is 40 kilos versus someone who is 100 kilos may require a different depth of compression. Just logically, this is not guidelines, but it's just implemented a bit of discussion in our department about the usefulness of and how important this metric is to watch for. These are our percentage of pauses less than 10 seconds, which you can see since we've implemented the program remain to be a little bit all over the map and are an area of focus for us moving forward. With our ability with EPIC to track our pauses so closely and track when we're doing procedures, when we're using ultrasound, when we're intubating. Exactly. We can link those up with our longer pauses to try and determine exactly for every case, what's causing the long pauses and how we can prevent them. This is our compression fraction case by case. We are always aiming for over 80 and we're kind of sitting around 86%. So we're trying to maintain this, but always sort of shooting for that over 90% that very high performance teams are shooting for.

And this is where we're going in the future. So we're looking to collaborate with other centers to share what works and what doesn't work in terms of data collection as well as interventions to improve improve CPR quality. We're specifically going to focus on our pause times and the interventions associated. One of our staff said to me yesterday, actually at work, he said, you know, we ran a really amazing case the other day and I was really proud of how short our pauses were. But when I pulled up the CPR data, it showed me that a lot of our pauses were 12 seconds, which is over that 10 second goal. Of course, 10 seconds is arbitrary, but it was over the 10 second goal. So in a way, the way we're at least documenting and showing you our stats, it hurts our metrics. And the reason for that is because the CPR coach was counting 10 seconds and then they were saying, please resume compressions. And the person was resuming compressions at 11 seconds and 12 seconds, which was most of the pause length times. This might lead us to change our CPR coach to tell someone to get back on the chest at 8 seconds. So they're really keeping their pause under 10 seconds because it takes a few seconds for that connection communication to transfer and the person to start compressing again. We're doing a study with some of the listeners on the call actually have given us this great idea to look at our EMS and ED handover. So when our paramedics come in with a cardiac arrest case, we're looking at whether quality dips around the time that the EMS team is handing over to the ED team compared to the baselines of both teams. And then we, as Garrick said, are an inner city center. We have had many cases of hypothermic cardiac arrests, often in our homeless population. And because of that, we've started using more mechanical CPR in those cases. And we're going to take a look at how we can measure this and use metrics to sort of get a sense of these cases as well, using mechanical cpr.

These are our emails on the screen as well as our Twitter handles. But we're happy to take any discussion, any questions, and share in any discussion. Thank you for having us.

Excellent. Thank you so much. Victoria and Garrick. We've had a lot of chat going on. Let me just remove the spotlight so we can all be in one room here. Okay, so we've had a lot of chat and discussion, and I'm hoping that what people have seen today is very eye opening. I'm going to start off by asking the question that.

Listen, I've been to all 50 states and I've been to a lot of hospitals, and I hate to say it embarrassingly so even in my own neck of the woods here, this does not exist. People have tried. You go to hospitals and you'll see that they've tried to tape the floor. Person one, person two, person three. And many people are commenting in the chat that when you go in there and you look at the basics of are they using, which monitor are they using? They prefer the one on top of the bed, which is worthless. Right. Because it doesn't really have any of the feedback metrics. They often don't even have end tidal CO2. Like when you, when you say the word end tidal CO2 in hospitals, they literally look at you like you're talking a different language. So my question for you is, now that you've been through this process and you guys have done amazing things, you're looking at the data, what is your overall view as to why this is not happening? Why aren't people looking at this when the data is there and available?

Yeah, it's a really good question, Peter. I think that was a question I asked when I started this whole thing was why are other hospitals not doing this in general? I think that people don't realize the importance of it. I think everyone thinks that they're doing such a great job. And the example I always give them is, how's your time to blood transfusion, how's your time to antibiotics for sepsis patients? And a lot of places don't actually capture it. And then when they start capturing that important information, they realize, oh, wait, we're not great at giving antibiotics quickly to these patients who are. Who are in sepsis. Right. How do we actually improve that? And I use that as the same example for this. What's been nice is that now that we actually have this data there's been a lot more buy in from other hospitals because they realize that it's doable. There's quite a few hospitals within our kind of area within Toronto, all of which are now interested in doing this together. So we're trying to create more of a collaborative within the various hospitals within Toronto. I think there's three or four that we've spoken to thus far to really just collate all of our data so that we can speak about this in general and be like what's actually working for your site and what's not working? What are the barriers that you're experiencing? And I think the other really important thing is that you hit the nail in the coffin when you say it's a hospital problem. Right. It's not just the emergency department. So that's when you have to really expand outside your own group and involve various other people because you realize if you want end title, it's not something that we as the emerge docs place on these patients. It's a respiratory therapist that we have in our department. So if you're part of the cardiac arrest group and there's a respiratory therapist lead that's there, that's when you bring in that kind of question and ask them how to do it. So I think it's really just making sure that you frame the problem as something that's really important and then once you have that framed problem, you explain to people what you can actually do to make this better and then everyone's going to jump on because they all really realize it's the same problem that they have as well.

So I'm going to follow up and Victoria, I'll bring you in here. Last month we had Jen Hayes who's doing exactly what you're doing but on the pediatric side. And she fought like hell to get to hospital to even recognize the importance of her role. And then she realized she had to hire other people. How hard was it for you to actually convince your hospital administration that this was important and how did you do that? Right. That's a question for you.

Yeah, it's hard, right? Like at the end of the day there's only so many dollars within a hospital that they're able to allocate. Right. And that's just the reality. I can't say that we have been given any fte funding to do all this. We just have a group of really interested people that are that want to make changes within our department.

I'm not sure Victoria, if you have anything else to add from that, all.

I'd say is that there are other people, not just emergency physicians in our hospital who are tracking and measuring CPR data going on in the entire hospital. Our code blues are all being tracked with this software as well. So I think having not just emergency physicians, but intensive care physicians, internal medicine physicians, being interested in wanting to utilize this software to measure CPR really helps harness an argument for the hospital that this crosses specialties, this cross crosses just the ground floor and that it can make a difference. And the only thing I was going to say about trying to make get this off the ground is you have to convince, we've had to convince our frontline providers, our emergency room nurses, RTs, clinical assistants, physicians that this matters. We have had to get them to buy in and to care care enough to put the adapter on, to put the puck on, to attend the post arrest debriefs. They have to feel like this is making a difference for patients. And that I think has been one of the biggest keys. And once you have buy in, it really snowballs because then people want to see where this is, for lack of a better terminology. There's like a bit of gamifying going on of how good can our team get at running a cardiac arrest case, but all within the patient's best interest.

Okay, so I'm going to play devil's advocate for a minute. So let's say that in five years from now, Victoria, you're working in Hawaii and Garrick is on a beach somewhere enjoying whatever and all of a sudden the two main principles are not there anymore, the drivers.

So my question for you is, and again, this is something that's being worked on here in the state of Florida and I know other places, should this be mandatory? Should it be in legislation where you must or you shall, number one. Number two is should there be more data transparency such that we are able to see hospital A versus hospital B versus we meaning the lay public, we meaning ems. And you know, there are hospitals who, who are in my area who have such a low outcome rate, CPC 1 and 2 outcome rate that perhaps we, we should not bring anyone there. And why I'm bringing that up is because we're now moving to a concept of resuscitation centers of excellence where we've created a one, the state has created a one page document saying hospitals must do these things. And then we as EMS medical directors go to the hospital and say, will you do these things? And if you don't, we're not coming. But I'm a very big proponent of data transparency, that if all these metrics were at some point put up, and maybe not on a billboard on the highway, but perhaps then the hospital would be forced to, and not just because they have amazing doctors and nurses and so forth like you guys are, but I just have this sense that if it's not required, they're not going to do it. What are your thoughts on that?

I mean, so I think we have to acknowledge in this moment, Garak and I are privileged at working at a reasonably well funded academic center who has funding and resources and a full set of nursing staff and RTs to help us run this program, which in our current province is not the state of most emergency departments. So while, yes, I think it would be an excellent accreditation criteria to have a CPR quality program, and I think if you're going to have a program, I think data transparency is always good. I do think it's important that we acknowledge how well resourced we are to have a CPR coach, to have the Zoll software, which we pay for and to be able to run this program, that it's really not the reality, particularly for our remote and rural colleagues who are keeping the lights on in many emergency departments around the country.

I think it's an interesting question though, Peter, in terms of there are, you know, you have to report this mandatory reporting of ECG times, right? Someone with chest pain, they need to get their ECG within 10 minutes. That's something that is reported to.

You know, the province. I think it's an interesting question. And I think that would be, you know, in 10, 15 years, considering how slow things like to be in healthcare would be a perfect world where this is something that is taken very seriously. And I think that what we need to start with is really just getting more and more places interested in doing this. So that becomes the norm, at least within the bigger centers that can afford to not just have the software, but really the personnel that can actually help with a lot of this. I think that's the hardest part. But I think start, you know, start slow, start small, and then expand from there.

And I think if you make it a mandatory part of accreditation, you can help lobby the government for more funding of our hospitals too. We're coming from a public system, so we don't have outside funding.

Yeah, agree, agree. So now let's get tactical and I want to bring in some of the questions and if there are people in the crowd who want to actually ask your question on your own, which I'd love for you to do that. Just put your hand up and I'll call on you. This is a question that comes up every time. Jennifer Carey asked this question, which is you have the puck, you have, you have a Zol device, but then you have a Lucas. Right. So many, many pre hospital systems and hospital systems have a Lucas. And the question is, has this protocol ever been used with Lucas?

So the case review doesn't actually work if you end up having the Lucas on it because the depth ends up being deeper than what's recommended. And I, I can't get into the details about like, you know, Lucas versus Autopulse in terms of the reasons for the depth. But it, you would still get the, you would still get some information, but you wouldn't get the same amount of stuff. And you might be able to get things like pause times because you can see winds turned on and off. But things like CPR rate and depth would not be as helpful. But it is a, you know, mechanical CPR is something that we think there are other things that you can look at. If it's not just rate and depth, that would be helpful.

Awesome. And I'm going to bring Lewis to bring you in in just a second. My other question, which I think a lot of people, whenever we travel around the country, I was just in Indianapolis all of last week and when I asked people how many people here have case review, which is the Zoll product that you showed, which is great, or codestat and my agencies use that. Use both. And they're, and they're both very good and they're both very valuable and very few hands ever get raised. And so my question for you is.

It'S more of a statement that unfortunately those products cost money. So can you confirm that you're using the Zollr, Right. The hospital version, but the case reviewed, there is an additional cost for you to get that data, send it to the cloud. Just wanted everyone to.

Okay, you're agreeing we pay for the current case review software, which is actually not the most current. I've learned recently that we're like way behind terms of our, the version we have, which we'll continue to have, but we pay for that to be able to analyze the data and take a look at the data. This has not come with the series, with the ER series.

Right, but would you agree with me that there's no way in the world that you'll know anything about anything without, without these metrics? You would agree, right?

Yeah. I can't imagine how we would collect metrics without it.

Right. So for everyone on the call who doesn't have it, go fight for it and get it, get it done. EMS hospital. Okay, Louis, go ahead. Good to see you.

Good to see you, sir. It's been a hot minute. I'm so happy that I was able to jump on the call and participate to add something on to what Victoria was talking about a minute ago. Of resources.

In my experience, I have worked in Florida, in Miami ers, now I work in for Myers. In my experience, usually the amount of resources isn't the issue in the in hospital cardiac arrest.

It's the overabundance of resources but not defined roles that hinders the ability to do very well. Those arrests, you have two RTs, four or five nurses, two, three EMTs, paramedics, a doctor. Everybody is in there and everybody was talking and there's a lot of distractions, but not a lot is getting done. I'm not saying that's everywhere. That's just a lot of what I see now in my current agency running 911 from very close to the hospital to 45 minutes away from the hospital, we have very defined roles to where we run a full cardiac arrest on scene for 25 to 45 minutes with anywhere between five people to seven people at most. And usually it's one or two paramedics and the paramedic, those IV IO access, the medications, intubation, the post cardiac arrest care, ventilator, ultrasound, intubation, everything that there is. But we have very different roles. We do the PIC crew cpr. Usually when we end up arriving at the hospital, if we do transport, everything just goes berserk is between the transfer and then the continuity of care, it just is completely cut off. And it's just a screen match of who's right, who's not. And that CPR quality goes completely out the window.

So Victoria and Garrick know these two gentlemen and they're on the line today. I know at least I saw Adam. I'm not sure if Mike is on, but that's exactly what we're going to be talking about next month, so make sure that you join. I just put the link in the, in the chat. You can scan the code to register, but these two gentlemen have taken that to a whole other level.

And again, it all comes because they were getting people back in ems, right. And when you see their slides, they're just as impressive as what you saw today. You see a bunch of people coming back to life and then for some odd reason, which I'll explain next month. Those people then proceed to die again. And so that post rosc ed hand up for kids and adults are very important. So please join us for that next month. Does anybody else want to come up and ask our guests questions?

Lou Steinberg, you want to come up and ask and give your comment on that tactical issue that we spoke about? You said to me privately, oh, just.

One thing with the Lucas, one of the advantages is the suction cup that creates some negative pressure by drawing the chest back up. So if you were to put a puck or something in there, you would lose that additional advantage.

Okay.

Also, Peter, just one additional thing and not to put a plug, but at the capnography webcast next month, apparently capnography is not as widely used across the country or elsewhere as it is locally. So that's something that we need to get out there. More about the benefits of using it, cardiac arrest and others.

Right? 100%. I completely agree. And maybe I'll bring in Chief Anil Mehra. Chief, I'm not sure if you're still on the call, but what we've been doing locally is taking our EMS system coming into the hospital and working together, training together. We have an entire program now we've created that was initiated at the fire department level. And so Chief, are you there? Because I would like to hear Victoria and Garrick to see are you, are you all doing the same thing up in Toronto where you're bringing in both groups of people saying, hey, we're going to work together and learn from each other.

Yeah, Doc, I'm still here. Correct. So you know Chief Dan Moran, who works for you now, obviously with you as well. We do get together with hospital staff and have that, you know, what you call, what you've kind of coined is that warm handoff where both the pre hospital providers and the hospital providers work together so that there's not that hard transition where we're dropping the patient off, rapid transfer of care and they're pulling the curtain with the mentality of we got it from here. So definitely seen improvement in that aspect. There was some initial hesitation from the hospital staff. Right. I think that, you know, we all have the same goal, but when you have somebody trying to, to coach and guide you, even with the best of intent, there was a little bit of resistance there by some, but it's now being welcomed. I think it is becoming more and more of an expectation or a norm, thankfully. So, yeah, so we're just trying to get more and more of our hospital partners on board and expose Them not only to the concept, but that continual training. Because to do it here and there is one thing, but we really need to work on, you know, that continual training which presents itself challenges between, you know, staffing turnovers and different shifts and what kind of volume that ED is seeing at that particular time. But definitely steps in the right direction for sure.

And we are happy to share any of our PowerPoints. This hospital handoff thing, we'll give it to you. You can put your name on it and you can go do it yourself. So. But Victoria and Garrick, any comments on that concept?

So we're actually working right now on. We measure our EMS service measures all of their CPR quality as well. Well, kind of led by, led by Dr. Cheskes. And so we're in the process of measuring whether around handover the quality dips, which I imagine it will based on anecdotal experience. We're hoping to back with some data. Our paramedics do a handover. They often stick around and participate in CPR and assistance until the case is completely handed over. And we have enough resources. If we're really short in resources that day, say there's two codes going on at one time, which happens rarely, but does happen. They will stay longer and help us with the code. So we do a little bit of this, but I would say it's not quite as blended as was just described. But we're hoping this study will jump start an increased relationship with our EMS services and how we sort of blend our care together seamlessly. They often participate in debriefs of our challenging cases, sometimes even days later. So that's a really nice kind of feature of our, our EMS system with our hospital.

I would, I would love, I would love to hear as you guys go through the process, because my, my thought process is that EMS should stick around for at least 10 minutes. They should be the ones pushing on the chest and they should be be the ones managing the monitor that was left on. So we, because hospitals around here are not as savvy as what you're doing.

Many of them don't use their monitored defibrillator that's sitting there and they'll often pull off hours. Now you have a really big gap in time where things aren't being measured, things are being looked at and the CPR goes down the tubes. Like Louis just mentioned, I'm trying to convince all the hospitals to do a warm handoff.

CPR is being done by us. We're managing the monitor and.