Improving Cardio-Pulmonary Resuscitation
Success Rate
Quality Improvement Project using “FOCUS PDCA” Methodology.
Al-Iman General Hospital
Find the problem.
The data obtained over the past year showed greatvariation in the success rates of CPR in Al-Imanhospital with failure rates ranging between 60 to 80percent monthly.
Find The Problem.
Impact of the problem:◦ The hospital was notified being a member of the
comparative data base of ministry of health that its ratesare suspiciously high and far from the benchmark the MOHis recommending (Steady rate below 60%).
◦ Patient safety was in jeopardy & Joint CommissionInternational compliance was not achieved.
◦ Physician & hospital top management dissatisfaction fromhigh failure rate.
Find The Problem.
Successful CPR Definition.◦ Return of spontaneous circulation for more than 20
minutes.
Witnessed CPR Definition.◦ One is seen or heard by another person or an arrest that is
monitored.
Return Of Spontaneous Circulation.Includes breathing (more than an occasional gasp),coughing, movement or a palpable pulse.
These are the definitions adopted by the MOH and used in the comparative data base of the ministry.
70.5%
64.5%63.20%
57.5%
81%
69%
82.6%
55.2%
64.2%
60.3%58.8%
63.5%64%
62% 62%
55%
72%
63%
77%
49%
63%
59%
54%
59%
45%
50%
55%
60%
65%
70%
75%
80%
85%
Perc
enta
ge
Month
Total Vs. Witnessed Failure Rate of CPR
From 1/1434 : 12/1434; El-Iman Hospital
Total Failure Rate Witnessed Failure Rate
u= 65.86
----------u= 61.56
Find The Problem
The project mission.◦ Is to reduce the variation in the process & reach failure
rates below 60% (as to the benchmark provided by MOH).
Organize The Team
The team charter included:◦ Champion: Medical Director◦ Team Leader: Anesthesia Director.◦ Facilitator: Quality Director.◦ Members:
Deputy medical director.Nursing director.Anesthesia specialist.ICU specialist.Cardiology Consultant.Medical Specialist.CPR/Nurse Coordinator.
Understand The Variation
++ CPR Failure
Rates
Place
Patient
Personnel
PoliciesEquipement
Lack of Training (ACLS)
Shortage of staff (Anesthesia)
Improper scheduling (Anesthesia)
Incorrect Policy
Poor compliance to the policy (Not
all the team attend the CPR Incident)
Dead On Arrival included
In the measurement
Crash Carts
Mal-distribution
Crash carts Policy
Not Followed (Open all
The time).
Lack of PPM of
Defibrillators
Lack of regular checks
On supplies
Lack of Bleeps
Missing Crash Carts
Nurse Shortage
Pharmacist
Shortage
Materials
Lack of Medications
No Numerical Locks
69%
15% 15%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Available Working Available Not Working Not Available
Pe
rce
nta
ge
Status
Percentage of Defibrilator Availability and FunctioningAl-Iman Hospital; 12/1434.
96%
46%
0%
20%
40%
60%
80%
100%
120%
Epinephrine Ampoles Airways
Perc
enta
ge
Supplies
Essential Supplies Availability in Crash CartsAl-Iman Hospital; 12/1434.
N=520 N=26
Understand The Variation
In order to verify the causes generated by thefishbone diagram (by brainstorming) the teamdecided to review the failure cases of CPR over thelast three months (Shawal, Dhulqeda and Dhulhaj)(8-10/1434).
Each case was checked against the generated causesto verify the most common causes for CPR failure.
112 cases were reviewed by the team.
37%
48%
34%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
8/1434 9/1434 10/1434
Pe
rce
nta
ge
Month
Percentage of CPR Done Without Full Team AttendanceAl-Iman Hospital; 8-10/1434.
N=35 N=35
N=42
N= 8145%
36%
27% 27%
11%
0%0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Pe
rce
nta
ge
Missing Team Member
Percentage of Missing Specialty In Failed CPR CasesAl-Iman Hospital; 8-10/1434.
N=56
Causes Frequency
• CPR policy outdated 112
• Lack of ACLS Training. 112
• Not all Team Attending. 45
• Lack of PPM of Defib. 112
• Missing Defib. 2
• Missing supplies 2
• Patient was DOA 15
• Crash cart Mal distribution (Area of incident does not have a Crash Cart in near vicinity).
2
Understand The Variation
According to Pareto rule the following causesrepresented 80% impact of the problem (Vital Few):
◦ Outdated CPR Policy.
◦ Lack of ACLS Training.
◦ Lack of PPM of Defibrillators.
Select Remedy
The team suggested the following solutions:◦ Update CPR policy in compliance to the JCI requirements.
◦ Train & Educate the staff about the policy update.
◦ All Code Blue Team to have ACLS Certificates & Training.
◦ Establish preventive regular maintenance checks for Crashcarts Defibrillators.
◦ Redistribute the crash carts to cover all care areas.
◦ Continuous auditing on CPR service by CPR committee &Quality department.
◦ Recruitment of more anesthesia staff (until recruitment isdone 2 Anesthesia Doctor will attend in each shift)
Select Remedy
◦ Adding Paramedics to the CPR Team to enhance ChestCompression quality.
◦ Activate the DNR policy & provide training to staff.
◦ Provide Bleeps to all Code Blue Team.
Solution Feasibility Cost(Inverse Scoring)
Impact Score
Update CPR policy 5 5 5 15
Train & Educate the staff on CPR Policy.
3 4 5 12
PPM for Defibrillators 3 5 4 12
Recruitment of more anesthesia staff
1 1 5 7
Anesthesia Schedule Modifications
3 3 3 9
Purchase New & Redistribute crash carts
4 1 5 10
Selection Matrix
Item 1 5
Feasibility Hardest Easiest
Cost Most Expensive Most Cheap
Impact Lowest Highest
Provide Bleeps 3 3 4 10
ACLS Training Schedule 3 2 5 10
DNR Policy Training 2 5 3 10
Pharmacy Regular checks schedule.
5 5 3 13
Solution FeasibilityCost(InverseScoring)
Impact Score
Item 1 5
Feasibility Hardest Easiest
Cost Most Expensive Most Cheap
Impact Lowest Highest
Selection Matrix
Select Remedy
The Selected Remedies in order:1. Update CPR Policy (15).2. Pharmacy Regular checks schedule (13).3. Train & Educate the staff on CPR Policy (12). 4. PPM for Defibrillators (12).5. Purchase new & Redistribute the crash carts (10).6. DNR Policy Training (10).7. ACLS Training Schedule (10).8. Provide Bleeps (10).9. Anesthesia Schedule Modifications (9).10. Recruitment of more anesthesia staff (7).
Plan
ACTION PLAN
Task Responsible Due Date
Update CPR policy. Quality Team & Anesthesia Director.
1 week
Train & Educate Staff on CPR policy.
Quality Team & Medical Director.
Ongoing
PPM for Defibrillator Biomedical Dep. Ongoing
Anesthesia Schedule Modifications Anesthesia Director. Ongoing
Recruitment of Anesthesia staff. Top Management. 6 months
Redistribute the crash carts to different vicinities
Quality Team & Pharmacy.
1 month
Purchase New Crash Carts Top Management. 2 months
Plan
ACTION PLAN
Task Responsible Due Date
Provide Pagers. Purchasing Dep. 1 month
ACLS Training Schedule CME Dep. 4 months
DNR Policy TrainingQuality Team & Anesthesia Director.
1 month
Pharmacy Regular checks schedule.
Pharmacy 1 week
Do
A pilot to be done for the period of 2 months anddata will be monitored to detect the effectiveness ofthe proposed remedies.
CPR Policy Updates.
The following modifications were made to thepolicy:◦ All code blue team (Except Ward Nurse) to be ACLS
certified.
◦ For outpatient department cases of arrest, theAnesthesiologist & Internal medicine physician present inthe clinics will be the first responders till the team arrivesfrom the hospital main building.
◦ In the crash cart medication policy, in case of code blue thenurse in charge will contact the pharmacy after the end ofthe code to replenish the cart within 30 minutes of theward/unit call.
46%
81%
73%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
1 2 3
Percen
tag
e
Month
Percentage of Availability of 5 Sizes of Airway in the Crash Cart
Al Iman General Hospital, 12/1434 to 2/1435
2/14351/143512/1434 2/14351/143512/1434
N=26
64%
58%56%
59%56%
53%
30%
35%
40%
45%
50%
55%
60%
65%
12/1434 1/1435 2/1435
Perc
enta
ge
Month
Total Vs. Witnessed Failure Rate of
CPRFrom 12/1434 : 3/1435; El-Iman Hospital
Total Failure Rate Witnessed Failure Rate
33%
29%
25%
20%
22%
24%
26%
28%
30%
32%
34%
12/1434 1/1435 2/1435
Perc
enta
ge
Month
Percentage of CPR Done Without Full
Team AttendanceAl-Iman Hospital; 8-10/1434.
27%
45%
11%
27%25%
30%
0% 0%0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Medical Specialist Anesthesia ICU Nurse Ward Nurse
Perc
enta
ge
Team Member
Percentage of Missing Specialty In
Failed CPR CasesAl-Iman Hospital; 12/1434 -2/1435.
Before After
Restrictions
Recruitment of more Anesthesia staff couldn’t beachieved during the pilot time.
Adding the paramedics to the Code Blue team toenhance quality of chest compressions could not beachieved due to their busy schedule and limitednumber.
DNR was not approved from the directorate to apply.
Act.
All the solutions implemented during the pilot aresustained.
The team will keep continuous monitoring over theprocess to maintain the gains and ensurecompliance to the modified process changes.
Control Variable
How Measured
Where Measured
Standard Who Analysis
WhoActs
WhatDone
Total
CPR
Failure
Rate.
Retrospect
ive
Document
Review of
CPR
Sheets.
In
Clinical
Audit.
Below
60%Quality
Dep.
CPR
Commit
tee.
Further
Analysis To
Determine
Causes for
Relapse.
Witnesse
d CPR
Failure
Rate.
Retrospect
ive
Document
Review of
CPR
Sheets.
In
Clinical
Audit.
Below
60%Quality
Dep.
CPR
Commit
tee.
Further
Analysis To
Determine
Causes for
Relapse.
Availabil
ity of
Essential
Supplies
in Crash
Carts.
Direct
Observatio
n.
All
Hospital
Units.
100% Quality
Dep.
CPR
Commit
tee.
Nurses
should
check
supplies
per shift.
Defab.
Availabil
ity &
Function
ing.
Direct
Observatio
n.
All
Hospital
Units.
100% Quality
Dep.
CPR
Commit
tee.
Regular
PPM.
Defab.
Testing/shif
t