Pediatric Hospital Readiness: How Teamwork & CPR Metrics Drive Better Outcomes

Well, good afternoon, everyone. Welcome to our second Hospital Readiness Webinar. My name is Daniel Moran. I have the honor of being the vice president of Education for Hent Heavy. We're thrilled to have you here and we know today is going to be an amazing webinar for you. I promise it'll be an unforgettable presentation that includes a story of cardiac arrest, survival. And hundreds more are actively being saved because of the presenters we have on today. Before we begin, a couple of very quick housekeeping items. Please keep your mics on mute to minimize background noise. We encourage questions, put them into the chat. We'll try to respond real time. And we're hoping at the end of the presentation to have a little bit of time for Q and A. We will be recording today's presentation and we do plan on sharing it afterwards.

We're especially excited about today's webinar because we have an incredible guest joining us. You're going to hear one of the most powerful stories we've ever come across about survival and the work that's being done to save countless children's lives. I'd like to introduce Jen Hayes. Jen is a PICU critical care nurse and an educator who has dedicated her career to improving every link in the chain of survival. She is responsible for leading efforts to ensure that when a child's life is on the line, the right people, the right processes and the right training are in place to give them the best chance for survival. And of course, we're honored to have Dr. Peter Entebbe with us today as well. Many of you know Dr. Antevi is a leader in pediatric emergency medicine and resuscitation. Today he's going to dive deep into why pediatric readiness matters and how hospitals can elevate their approach to pediatric emergencies. With that, let's jump in. Dr. Antevi, I'll turn it over to you.

All right, Dan, thanks so much. And Jen, welcome. Welcome to the webinar. Just a quick story. I was very honored to meet Jen several years ago, and I told her this the other day. But I remember leaving that room after she gave her talk, and I said, this woman is a unicorn. She's such a special human being. And I remember leaving, saying, how come there aren't any other people like her in this world? Really, when you hear what she's doing, what I think everybody should be doing, you'll, I think all agree. And as Dan mentioned, her story is very special, very emotional, and you'll understand quickly why before I do turn it over to Jen, for the people on this call, I know we have nurses, we have physicians on the call, we have paramedics on the call. And you for sure have heard about pediatric readiness. I'm going to start by just going over a few slides on why this is important and then Jen's going to take it to a whole nother level and you'll see exactly what I'm talking about in a minute. But before we get to Jen, let me just fess up a little bit. And for people who don't know, as a pediatric ER doc, I made a tenfold medication error very early in my career. I gave 10 times more epi than I was supposed to to a little 4 year old girl who was in anaphylaxis. She ended up in the ICU that night because of my error. I, I was ashamed. I was embarrassed. And that wasn't the first mistake I had ever made, by the way. And that started my mission to say, how do we fix what's going on here in this world? And quite frankly, I don't think many people thought that was really a problem. However, and really I put these up here because these are the hospitals I trained at and this wasn't supposed to happen to me. I was supposed to be the smartest guy in the room. I mean, I was the dumbest guy in the room, it turned out. But it turns out that I wasn't alone.

And recently, many of you may have read these articles, but it's now in the media. The media now understands how rampant errors are in the emergency department. We know how errors are rampant in ems. But let me just take you through a quick couple of slides to make you very aware that there's 34 million ER visits every year. What most of the population doesn't recognize is that 80% of those children are not seen in Children's Hospital of Orange County. Joe DiMaggio, Children's Hospital, Boston Children's Hospital no, they're seen at the local immunity hospital.

When you start to look at how ready these other hospitals are, you start to recognize that there's a lot of work that needs to be done. The Wall street journal in October 2023 published this very powerful article. The two children you see on the screen are no longer with us. These children died because of medication errors and other errors, such as diagnostic errors in the emergency department. Through the data that I'm about to show you, they found that only 14% of ERs are certified as ready to treat kids. That should be striking to each and every one of us. Children are four times as likely to die in less prepared emergency departments. Four times 400%.

And in the five year period, over 1400 children died because of errors in emergency departments in the United States of America. So we now know that all ERs are not created equal. But the question is, how do we change that? And again here the New York Times article, this is November 2024 folks. This is just a couple of months ago. So the, the lay public now wants answers, our politicians now want answers. People are going to have to now start to really ramp up their readiness and really that's why we've started this pediatric readiness series and we're bringing in experts like Jen Hayes to really help everyone understand what the work that needs to be done. So I have a couple of cases up on the screen. I, I don't want to get anyone nervous or anxious, but these are all cases that came in when I was working in the er. Not all the same day thankfully. But just imagine you had a kid in septic shock, rollover MVA. I had a 5 year old shot in the chest by his father on accident, 8 month old actively seizing.

Another screw up. I did norepi drip and a 7 year old. I knew I needed it, didn't know how to mix it, didn't know how to run it at a children's hospital. A chest tube for a five year old just go down the list. What about if you had to Transcutaneously pace a 10 year old, which I had to do at 2 o' clock in the morning on a Sunday. I'll never forget that day. Right. So you can understand, but just by looking at this screen here that you could be in pediatric emergency medicine and still get nervous by this, but then you could be working at the community hospital where you see mainly adults and it gets even more anxiety provoking. And that's, that's really why we exist and that's why we're putting on webinars like this and that's why we're bringing people like Jen Hayes here. What I did back in 2005, I just started something called the Code Committee. We just every, you know, every month we just started doing this. Obviously Jen takes it to a whole other level, which you'll see in a minute. However, the question comes up, what if someone developed a pediatric ready scoring system? We have this person to thank, Marianne Gachethi Hill. She's had a very storied career out in California and she came up with this national Pediatric readiness project. If you work in ems, there's an EMS readiness project. If you work in the hospital, there's a pediatric readiness project for hospitals. Here's what it does. Again, busy screen. But there's over 175 items that you need to check off to say, yes, I'm ready and actually get these done. But by the way, very few of these items relate to CPR quality, CPR metrics. So it says, yeah, you ought to know how to run an arrest, but it's nothing like what you're about to hear. So my point here is that pediatric readiness is important. It's kind of step one and then we want you to go to a whole nother level with respect to CPR metrics. And after Jen speaks, I'm going to bring in Dan Moran, who was my EMS chief at Davey Fire Rescue until he retired and we stole him away. But he's going to show you what he did on the EMS side to show you how you can bridge the gap using metrics, using data specifically around cardiac arrest in kids. That's what we're really focusing on today. Some of the questions in that survey, they're pretty basic things. These are not cardiac arrest items. One of them that we care about is they ask you, do you have a process in place for pre calculated dosing in all children? We care about that. But overall they grade you, you take the survey, you get a grade. I like the Amazon star system. You either get a one star, which means you get a failing score, you get a two star, three star. If you get a four star, you're considered pediatric ready. Right? But unfortunately only 14% of hospitals around the country achieve that goal. And if you can see here, here's some odd ratio plots with respect to medical patients, respiratory patients, neurologic patients, they all do better with respect to mortality at a four star hospital. What about injured patients? You know, this is all trauma patients. Only the four star hospitals make a difference. So now what is the world seeing? What is your community seeing? What are your politicians seeing? They say we want everybody to be a four star hospital. Make it happen. That's what they're going to tell you to do. So and the final slide, which is the important one, this is like the money shot that the mortality at a four star hospital is 3.4%, at a one star hospital is 11%. That's where you get that fourfold difference in mortality based on how ready you are. So all of us, no matter, you're at a children's hospital, you're at a community hospital, you need to focus on Getting Pediatric ready, it takes time, it takes people, it takes doing it right. That's phase one. Now you want to get to the next step, and you want to be like Jen Hayes.

This is where we're going to exist now for the next step. 30 or 40 minutes. And that says here emergency department, because this is kind of my home. It's where I love to work, and it's where I work my entire career. But Jenna is going to talk to you about cardiac arrest anywhere in the hospital. And what I love about this photo is, is that, tell me who the doctor is, tell me who the nurses are, who's medication nurse, who's documenting, who are the students, who's respiratory, who's focusing on the CPR that's being done. And then when you leave the room and everything's on the floor and blood everywhere and people are, you know, upset and so forth, who comes after you to say whether or not the job that you did was good. Introducing Jen Hayes. So Jen is that person. She is what I call the unicorn in a very good way, obviously, Jen. And so what I want to do now is welcome Jen to do the. To the webinar and she'll go ahead and share her slides. And what you're going to hear is really a story of perseverance, of wicked smartness, and something that we should all hope to achieve in the future. So, Jen, take it away.

Well, thank you so much, Peter and Dan, for having me and everyone for, for taking the hour to be here for this webinar. This is something that is so incredibly near and dear to my heart. And pediatric resuscitation has really been something I've been incredibly, incredibly passionate about since I was in nursing school. And that's what really drove me to become a nurse in the pediatric ICU. And then in 2017, the Children's Hospital of Orange county created a role that was dedicated to resuscitation. So I'm now the supervisor of our resuscitation program. And in that I basically oversee every single link in the chain of survival, the quality improvement, the research, the education processes for the entire institution. So that includes our emergency department. I partner very closely with them. And so today we're really going to dive into, like Peter said, the, the pediatric resuscitation, the cardiac arrest piece of it. And let's see some disclosures. So I do speak for Zoll Medical. I do receive compensation and travel reimbursement. This is not a supported talk by Zol. And then I am on the Aha Pals. Writing group. The piece that's in italics here is very, very, very important. The views and opinions that I'm expressing today are completely my own and they do not reflect and are not endorsed by the American Heart Association. So please do not take anything that comes out of my mouth as an official position of the AHA because we will be talking about some things that may be a little controversial. And I just want to make that very clear. And then of course, always follow your agency or organization standards of care. So, objectives Today we're really going to dive into quality improvement, continuous learning, and how we can make actually like significant improvements in CPR quality. We're going to really examine the role of data in improving our pediatric resuscitation and then with a focus on both prevention and CPR quality, really discuss student steps that we can take to improve our outcomes. The bulk of our time is going to be spent on, like I said, CPR quality. But please remember that the entire link, you know, every link in the chain of survival has very important pieces that need to be addressed to really create this, this strong chain that ultimately improves our outcomes. So I come to you from Chalk Children's Hospital in Southern California. We are a freestanding Children's Hospital.

Level 1 Trauma Center. We have 356 beds with 66 critical care beds, 104 NICU beds, and 36 ED beds. I share that with you because that's where pretty much all of our cardiac arrests take place. And on average we have between 70 to 80 cardiac arrest events each year. So this is a very busy slide and not intended for you to be able to read, but I think that it really highlights like a key driver diagram that if we want to increase and improve survival from in hospital cardiac arrest, there are so many things that we can do. And the question always is, you know, where in the world do I start? Because it can be very overwhelming to look at this. And I wish that I could give you a step one, step two, step three, you know, step by step direction. I'm going to do the best I can for you on that. But the reality is that improving resuscitation quality, especially in the pediatric world, but a lot of what we're talking about today can really be taken throughout your organizations, throughout your EMS agencies, regardless of age. But it really looks more like this, that you kind of hit forks in the road and you don't really know what direction you're going, kind of have to turn around based off of the data that you're seeing. So really our goal today is to really help you be able to strive for a culture of resuscitation excellence in your agency or at your institution. And the big piece of this is really getting to the place where people believe that they can actually make a difference. I mean, how many of us have responded to, you know, numerous cardiac arrest events? And I know in my, you know, bedside days, there were certainly moments that I was like, oh my gosh, here we go again. Like we're going to do CPR again and the kid's not going to survive. And you know, we, we tend to potentially get a little jaded because we don't always see the positive side of cardiac arrest. And so we really need to shift the focus to help our staff see that small changes can lead to huge improvements in outcome. So when I started this, many of you may be in the same exact boat. I really, truly believe that there was absolutely nothing that I could do on the in hospital side to improve CPR quality, resuscitation quality or outcomes. I very much kind of fell into the camp of we're amazing, I'm a pick you nurse, we're always there, we do amazing cpr. Like it's Peter and his people that need to fix this, right? Kidding, Peter. But you know, really I, I really didn't think that there was much improvement that could be made. And you know, when we look at the in hospital chain of survival for pediatrics, the this is really where pediatric resuscitation readiness starts. And I'm using in hospital. I know many of you are treating patients who have out of hospital cardiac arrest, whether you're an EMS or you're receiving children who have had an out of hospital cardiac arrest.

The chains are pretty similar. And the reason why I'm focusing on the in hospital piece is because if somebody, if a child has a cardiac arrest in front of us, even though it's not necessarily in the doors of the, of the emergency room, or maybe it is in the doors of your emergency department. There are things in that first link with recognition and prevention that are really key for us as healthcare providers to pick up on and intervene on. And that's why I'm really using the in hospital link or chain of survival. What we know is that besides prevention, high quality CPR is absolutely the foundation of each one of these links. If you do not do high quality cpr, all of your advanced resuscitation post cardiac arrest care, it doesn't matter as much. It's not going to be as powerful if you are not perfusing the heart and brain. So we all know the components of high quality cpr, right? Right. Depth release, minimizing interruptions, avoiding hyperventilation. And we know that the American Heart association tells us that high quality CPR is the primary component that influences survival, and yet we know that it does not translate into practice. These are just pediatric specific. Actually, I'm lying to you. There are a couple adult articles in here, but the majority of these are pediatric specific.

Articles looking at healthcare professional CPR quality. And we know that we do a horrible job at hitting correct rate, correct depth, full release, pause times, pre and post shock, pause times, pulse rhythm check, pause times. They. We know we do a very poor job. And if you are anything like me, I can read this and say, yeah, that's really nice. There's no way that chalk is that bad. There's no way that my agency is that bad. Like, we are amazing. And so we really find ourselves in this predicament where there's a lot of data that says there's opportunities to improve, and yet we don't believe it because we don't trust that that's actually how we're performing in our institution. What we know, though, is regardless of how well you think you're doing, survival requires perfusion and perfusion requires high quality cpr. And if that's the case, I would encourage each of you to focus on high quality cpr, because without it, what are we perfusing? And the reality is we truly only have one chance to get this right. There's no do overs. This is not like an IV start that you're like, shucks, I missed it. Let's try again. We've got one chance. And I always like to think about this as if, if this was my loved one, if this was my loved one who was receiving cpr, would I be willing to sit there and be okay with them getting subpar resuscitation quality? And I think all of us would agree that the answer is no. And I really, really, truly believed this. And then in 2017, I actually then found myself on the other side. So in 2017, I had just taken my resuscitation role and my husband Kyle and I had just celebrated 11 years of marriage and we're really enjoying time with our son Matthew, who was three and a half at the time. We found out that year that I was pregnant and we were going to have our second son in 2018. And I have to tell you, I loved being pregnant. It was a very smooth, very, very comfortable pregnancy. November 9th started in 2017 started as a completely normal day for me. Went to work, gave a resuscitation report, and then came home. And that evening, my husband and I went out to dinner with Matthew. And as we got home, I took Matthew upstairs to bed as usual. Shortly after entering Matthew's room and placing him in bed, I collapsed. And in that moment, my personal and professional lives collided. Just four short months after taking over Choc's resuscitation program, when at 30 weeks pregnant, I suffered an out of hospital cardiac arrest. So my husband and neighbor did CPR with guidance from the dispatcher. And five minutes after the 911 call was made, the first responders arrived. In their hand was a device that offered CPR feedback. And they were very. A very data driven agency. So they placed the feedback pads, took over compressions, identified that I was in V fib. That is really my rhythm. Sometimes I have to remind myself that that does say my name. And they took over compressions. One shock was delivered, and then they continued the ACLS algorithm. I got the entire algorithm. I was shocked twice. I got 15 minutes of CPR, an IO was placed, I was intubated, and then I was airlifted to a tertiary high risk OB center near home, where they did very quick and extensive testing and decided that the likely cause of my cardiac arrest was eclampsia. So the. The cure was to deliver our son. So in the early mornings of November 10th, our son Micah was born. And he was born limp, gray, not breathing, 1600 grams. And following my C section, as you saw on that last slide, they did targeted temperature management. So I was in the hospital for eight days total. Four days later, after my arrest, I met Micah for the first time. Matthew came to visit him. And then as I was discharged, Micah was transferred to choc, which really became our home away from home. And really not knowing how the cardiac arrest had affected him, we really celebrated all of his achievements and milestones. And after 71 days, Micah came home and made her. Made her home complete, I have to say. And you know, I always like to give this little view because, you know, with how much I've done with cardiac arrest, I really, truly always thought like, we just saved your life, Go live it. And I very quickly came to realize that being a cardiac arrest survivor is not that easy. And, and the emotional toll of it is just overwhelming. I couldn't go in Matthew's room alone. I had significant panic attacks, postpartum depression, severe anxiety, and really had this fear that each and every day was going to be the Day that I was going to have another cardiac arrest and this time maybe not be so lucky. So as we went through all of this, we continued to celebrate Micah's achievements. I did wear an external defibrillator for seven and a half months at home. Micah really continued to just grow and thrive. And I was off work for, for 10 months. And when I returned to chalk, I really had this reinvigorated passion to really look at what is our CPR quality look like and how do we ensure that every single one of our patients are given the same exact chance that Micah and I were given on the night of my cardiac arrest. And so we really started this huge quality improvement project looking at our CPR quality. And my computer, I apologize, my computer's being silly. This is a quote that I kind of live by when it comes to resuscitation quality because like I said, I really thought that we were amazing, right? And I didn't have any data to support that. So really, without data, you're just a plus person with a hopefully really great opinion. But until you have the data to support that opinion, it's. You can't say it's accurate. And we were absolutely in this camp. My physicians that I worked with, my nurses, respiratory therapists, my multidisciplinary teams, really felt we were doing very, very well. And data really is what tells your story, right? And so at this point, I felt like I was way down here, like not even at basecamp, and really felt like I don't even have data. And that in my mind was worse than having data that showed we were doing a terrible job because at least I wasn't living in this, like, fog of, of thinking that there was nothing that we could improve. And so many of you may feel like this right now. By the end of this presentation, you may feel like this. And I'm going to tell you, like, do not lose hope. Do not give up. We're going to talk through some first initial steps towards the end that can help you take that first step. For us, we didn't have feedback pads. The defibrillator was never brought to the bedside because we were like, we only use this twice a year to defibrillate our peds patients. That just collects dust, right? And so we had a ton of work to do. And really we know that data is what tells our story. So I'm going to ask each of you to really think about what data do you currently have and what story is it telling when you think about your pre arrest identification and prevention Whether it be in the back of an ambulance or in your emergency department, or if you're, you know, outside of those two areas and you work in a different unit in that unit. Are you, are you identifying pediatric decompensation? Because it looks very different than adult decompensation, the cause and etiology of the arrest, and pediatric patients are going to be so different than adults. And so, you know, are we identifying that early? Are we trying to prevent the arrest? The highest quality of CPR is no CPR at all. That's my motto. Right. And then if we can't prevent it, we're going to make sure you get the best quality of CPR possible. Do you know all about your arrest? You know, the out of hospital, the kids that come in and then arrest in your emergency department, or you, you get into the back of your rig and then they arrest? Do you know about all of those and are they being reviewed? What about your quality of resuscitation? You don't have to have a fancy machine to look at quality of resuscitation. Yes, it certainly can help with components of it, but it's not the end all, be all. So, you know, if you have a machine that's giving you some CPR data, you know, where are you at with rate, depth, time to defibrillation, pause times during your cpr? What about EMS to ED handoff? How much are we pausing when, when we're doing that handoff? What about your epidoses intervals? Are you following PALS guidelines? Especially if you're in a community center where you may not see very many pediatric cardiac arrests each year? This is not something that is your bread and butter. And so how do we then look at this and say, this is what our data's showing. Here's where we can improve, here's where we're doing really well. And then outcomes, Ross grades, survival rates. So I'm going to, I'm going to air our dirty laundry here. In 2017, we had gone through a series of steps to start collecting our actual CPR quality data off of actual real life events. And here's the first six events we got. It was, you know, quite humbling. Our whole, we are amazing. You know, that was clearly just an opinion because our data was really showing otherwise. And remember, these are all pediatric patients. And each one of these events happened in our pediatric ICU. Not a single one hit 10% in total. We basically found that only 4% of our compressions were being delivered within the American Heart association guidelines. So that's like any of us going to an ECMO surgeon and saying, hey, that ECMO pump, It's only working 4% of the time. So not sure what you're going to do. You got to go ahead and figure out that other 96% because all we've got for you is four. Right? So this was so incredibly sobering. Our compressions were too fast 71% of the time and our survival to hospital discharge was 26%. Which for you that work in the adult world primarily, you probably feel like that's amazing. And in the pediatric world that's terrible.

We see survival rates in the, in hospital setting upwards of the 40s. So this was pretty telling to us. And what this data really started to do was tell us our story. It started to tell us the opportunities that we had. So we needed to get CPR feedback onto each and every one of our patients every single time. And that was a huge, huge, huge culture shift. And really start changing the staff's view of the defibrillator because everybody saw it as we just pull that to the bedside if we're going to defibrillate. And really what we needed them to say and see it as is that's a device that comes to the bedside for every single resuscitation because it's going to help us do high quality cpr, minimize pause times and hey, it also happens to defibrillate should we need it. And so we really started this campaign around that to start getting staff buy in. Like I said at the beginning, staff need to see why you want them to do this and understand the then downstream effects of the outcomes that you can improve. So this was kind of our first initial steps. And I will say, you know, we don't have a ton of time on this webinar. I could spend a whole webinar just talking about each like little step that we did and really diving into that. So I'm really giving you a very high level view of the approaches that we took and my emails at the end and I'm happy to answer any additional questions via email or at the end of the webinar. So just know I'm not diving in to all the nitty gritty like our CPR challenge and things like that. One of the things we really started doing was closing the loop with our staff and really creating some significant data transparency. And so what we do is we create the CPR report cards after all of our events and we actually, you know, give them their CPR quality. And then at the bottom we Actually give them very specific indicators as to, you know, the green section shows that you are doing great rate, great depth, you know, great release. This section here, we're leaning a little bit more. Our rate is a little bit higher. And so one of the most common questions I get about this is how do you go about doing this? When you have that ER team, like Peter said, who is just devastated at the loss of a child that's come in, they feel like they've done a really good job and now I pull the CPR quality and it's zero percent, right? And so this really comes down to that, the human factors, right? And really like meeting them where they're at. Never would I walk into one of those events and say, wow, you guys did a terrible job. Right? Because the reality is in so many, especially in these traumatic cardiac arrests that come into the ED or back of the ambulance, there's a lot that you can't control. And so what we really want to focus on then are what are the things we can control? Maybe we can't control the 30 second pause while we're putting in bilateral chest tubes and trying to get, you know, an airway in. But what we can control is to make those as short as humanly possible with high quality communication. And when we get on the chest, making sure that we're doing the highest quality of compressions. And so we give people very, very real, tangible steps that they can take the very next time. So on this, for instance, kind of the, the last bullet point is, you know, you had two pauses greater than 10 seconds. Here's some tricks to try next time to really help minimize those pauses. So we're not just saying to them, wow, you didn't do very well. We said, here's where we identified some opportunities, here's exactly what you can do as a team next time to help fix that. And it really started to get some significant buy in. So over the course of 2017 through 2021, we saw a tenfold increase, increase in our CPR quality. So we went from 4% to 4.3%. But we had to ask ourselves, you know, what continues to lead to poor quality CPR? Because 43% is still not going to be sufficient for my ECMO surgeon for the amount of time that the ECMO pump is working. And so we started to take this very deep dive with our clinical staff to really say, what is it that is leading to this? Because nobody wants to go to the bedside and do poor quality resuscitation. That's not in Our, you know, DNA as healthcare providers. And so what we did is we, oh, my thing did not show up. So we actually process mapped our entire from code call all the way through the debrief. And we really started pulling out what are the key things that are making it challenging for you as a team to achieve high quality cpr. And we found that our CPR feedback device didn't always have a consistent place. We didn't have consistent roles, we didn't have high quality communication. Kind of like Peter said with that picture, right? It's kind of who's doing what. There's a lot of people, and we're not really sure what everyone is doing. And so we took all of the staff feedback, we looked at data, and I still deal shamelessly, you know, 95 of what I'm presenting today is because somebody else came before me and did it and showed that it worked. And I said, why reinvent the wheel, right? And I would encourage all of you to do the same. Like, if you like any of this, don't reinvent the wheel. Just reach out to me and I'll happily share things with you. And so what we did is we really took from Betsy Hunt's code asis paper this idea of choreography. And so we do use Zol. I'm not, you know, this is not about Zol. You can do this with any particular device that gives you feedback. But we developed this cart that gives them all the things that they felt they needed right there at the bedside. We didn't have step stools readily available. We couldn't switch pads super easily. And so we really wanted everything right there. And it goes right, right under the monitor. So they have in like line of sight for physiologic indicators in the ed I recognize you will not have arterial lines, but you may have end title. And if it's hooked up to the bedside monitor versus the defibrillator device, that gives you that ability as the team leader or a part of the team to kind of have that direct line of sight of all of those key metrics. And then we built the choreography around the CPR feedback. Because what we found is oftentimes a CPR feedback device doesn't even get invited to the kids table at holidays, let alone the adult table. And we really felt like this needed to be, like, at the center of that adult table.

Really being the centralized part that allows us to do this high quality CPR and hopefully improve outcomes. The other thing that we found was that we were not following feedback. We really took A step back, we looked at adult data, we looked at pediatric data, which there isn't a ton of pediatric data on release velocity. But we really took this step back and said, gosh, does everybody actually understand the physiology of each part, part of the compression that they're providing? Because so often we say push hard and push fast. And I think we sometimes forget about the physiology that happens with the release and the depth. With the release needing to be rapid, complete to create that negative pressure, fill the heart, mimic diastole and perfuse the coronaries. So if we're not releasing, we're not filling the heart. And I always say to staff, if you want this heart to restart, you probably want to get oxygen to its coronaries.

We really started focusing on this release component. We said, if you quickly release and allow that full recoil, you're perfusing the heart, then you're primed and ready to then achieve correct depth to perfuse the brain. And that rate of 100 to 120 really allows you to achieve those two things. So we, we shifted our focus off of you must only compress 100 to 120. Although that was a, that is obviously a part that we talked through. But we really focused on the release and found that things kind of fell into place. So we started teaching CPR like this, that your downward stroke is perfusing your brain, your upward stroke is perfusing your heart. So each piece of your compression is equally important. And it was amazing the light bulbs that started going on with our staff, like, because I had my own aha moment as I started realizing this, right? Because we're not taught the physiological things that are happening in each cell segment of cpr, I think to the level that give us the why? Why is it important that I fully and rapidly release? Why is it important that I achieve correct depth? Well, this is why, because we're perfusing the heart and the brain. And if you don't allow that full release, you now don't have a full heart to now perfuse the brain. So now you're not perfusing anything. And we really started on our way with this modified CPR technique. And this is where we know, of course, I give my caveat again, this is not endorsed by the aha.

We also saw that we were having significant pause times. This is a 27 second pulse rhythm check pause time, 9 second pre shock pause, which in our book was far too long. And so we really allowed, like, we really used all of this data, as you can see. That we were getting from our CPR quality and there's so much other data that we collect. I'm just focusing on CPR quality right now to really say where are the gaps that we're consistently seeing trends and what first step, second step, third step can we take to really start improving that? And so with our pauses, we really started talking about processes that they could do to really minimize that pause time. My favorite is finding the pulse while you're doing CPR before you pause compressions.

Really the communication among the team, if you're the person charging the defibrillator, making sure you're saying, keep doing compressions, keep doing compressions. Otherwise that compressor is not sure that you see them and that you're going to clear them. But if they, if you're saying keep doing compressions, they know that you are very cognizant that they are there and you will, you will clear them. So they keep doing high quality compressions. And then all of us have seen the Hollywood clear, right? Clear. And we step 10ft away from the patient. I'm clear. And so we really started teaching the hover technique of, you know, there's nothing different besides you're not taking 10 steps back, you're still clear from the patient. And then that action linked phrase that really Betsy Hunt really coined with her CPR coach work and her codices work is really, you know, okay, shock is delivered, resume compressions. So really identifying not only the role, so we know who was who, the choreography of where is everyone standing? And then how do we communicate to each other to ensure that this is high quality resuscitation.

So following some of our work with our pause times, this is some events that happened shortly after. So this is a 5 second pulse rhythm check and a 3 second peri. Shock pause time. I will say the first time the three second pause time happened, we were like, that might be a fluke. The second time it happened was in a different unit. And we said, all right, now we know it's possible. So I'm going to, you know, challenge all of you to go to your agencies, whether it be adult or pediatric cardiac arrest. And this is your goal, a three second per shock pause time. It's about a one and a half pre, one and a half second post shock pause. And so as we come to an end, really, you know, I have just flown through seven years of work, so, you know, this is not an overnight thing by any means, but really to kind of give you a glimpse into what difference it's made and really My hope today is to give you a glimpse into what is possible by using data to drive change. So first and foremost, when we talk about the prevention piece, it's been 371 days since we have done CPR in our acute care areas. So that's outside of our icu, ED and surgical service area. So any of our floor medical surgical units, we've not done chest compressions. I purposely put it on wood because I knock on wood every time I say it. But we, you know, our team is doing a remarkable job with the prevention piece, identifying and that could be a whole nother talk, prevention of cardiac arrest and kind of the what the literature shows in, in best practice. This is our overall CPR quality in our picu. So this is where we initially started our efforts. It helped. I had come from that unit. This is the unit that has the most of our cardiac arrest within our institution. And so it just made sense to start here.

And so, you know, now we're looking at median. Before I was looking at averages kind of just average, but statistically it's more accurate, I'm told, to look at the median. So here we are. So they started fiscal year 17 with 2% CPR quality. And basically over the course of these seven years we have done a lot of this QI. So all the stuff that I flew through and is kind of year by year things that we have focused on. Fiscal year 21 is actually when we rolled out the Zolcart and started our modified CPR technique and really started pushing for patient driven CPR using physiologic indicators to drive quality. And so that huge jump does take into account when they're using physiologic indicators and achieving the goals that we have set. And you can see as of the end of our last fiscal year, they were at 77% and they are, they are holding steady for this fiscal year as well. Our ED data I don't have in here.

Because we started in the PICU first. Our ED just rolled out the Zollcarts and started a very targeted education campaign around the modified technique about a year and a half ago. And you see this same, same exact, like huge spike in their CPR quality. They're able to use end title because we're getting that device to the bedside much easier. And so they're, they started at about 2% as well and they're up into like the high 50% range. And I have no doubt that they will continue to, to improve that quality. So overall they're, they're doing a remarkable job. And it's, it's really been because we've used data to really drive change and give them that. Why? So I'm just going to go through a quick case study that we had.