PACT St Michael`s Training PowerPoint

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Post Arrest Consult Team
PACT
“Resuscitation is just the beginning…”
Steven Brooks MD MHSc FRCPC, Principal Investigator
Laurie Morrison MD MSc FRCPC, Co-Principal Investigator
Funding
St. Michael’s Hospital
AFP Innovation Fund
2
Rationale for PACT
• High mortality after OHCA resuscitation
• Post Cardiac Arrest Syndrome
• Hospital survival rates vary
• E.g. 25%-30% locally vs. 50-60% in US and
Europe
• Local data shows care is not standardized
• Studies from elsewhere show improved
survival with champions and a
standardized, multi-faceted approach
3
Barriers
• Process concerns due to low volume of
OHCA
• Lack of a standardized approach
• Difficulty gaining experience
• The disjointed patient journey
• Access to specialized services
– (ICU, PCI, EP)
4
Post Arrest Consult Team
(PACT)
• Building on other Centres of Excellence
models
– Trauma, stroke, STEMI etc
• Building on the CCRT model
– Dedicated consult service of RN/RT/MD to
assist MRPs and primary nurses with
complex/high risk patients
5
Post Arrest Consult Team
(PACT)
• Guidelines inspired
• Evidence based
• Standardized clinical pathways
6
PACT Process
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PACT Activation
• Single page PACT activation through locating
• Automated prehospital alert to PACT RN text
pager from upload of electronic ambulance call
report from Toronto EMS
• MDs will have cell phone/pager registered with
communications with call schedule
• RNs will have a PACT text pager which is
passed on to the PACT RN on call
• We will be tracking activation rates and missed
cases
8
Goal directed gas exchange and
hemodynamics
• Hyperoxia is bad
– minimize FiO2 for oxygen saturation ≥ 94%
• Hypocarbia is bad
– ventilate to ETC02 of 35-40 mmHG or PaCO2
levels of 40-45 mmHG
• Hypotension is bad
– MAP goal specified in pre-printed order set
• Best evidence suggests these are urgent
issues
9
Therapeutic hypothermia
Where PACT can have an IMPACT
• Cooling more eligible patients
• Appropriate core temperature monitoring
• Facilitating rapid decline in temperature through
the “danger zone” (quickly to 33.5)
– Proper placement/replacement of ice bags
– RAPID infusion of cold saline
– Shivering prevention/treatment
• Encouraging aggressive sedation, analgesia and paralytic
(PRN) as per hospital protocol
10
Therapeutic hypothermia
Where PACT can have an IMPACT
• Use of the trouble-shooting checklist when
cooling rates are too slow
11
Be aware of potential complications
during induction of hypothermia
• Shivering
– Will slow cooling
– Increase in metabolic rate and oxygen
demand
• Volume depletion
• Electrolyte abnormalities
– Hypokalemia, Hypomagnesemia,
hypophospatemia
• Glucose resistance
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13
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PACT MD
Roles and Responsibilities
PACT MD
• 24-hour availability.
• In house M-F 9-5 with callback ASAP and
bedside assessment ASAP with a target of
within 15 minutes of consult.
• Home call for telephone consult afterhours with discretionary bedside
assessment
• For the ICU physicians call schedule
synchronized with ICU call
17
PACT MD
• Interaction with the PACT RN modeled after the
CCRT
– PACT RN will discuss case details, clinical
assessment and plan with the PACT MD after initial
contact with the patient is made
– A collaborative plan with the PACT RN will be
determined
– Similar to a resident to staff exchange
• PACT MD will provide “suggest” orders as
needed and discuss them immediately with the
MRP or their delegate at the time of assessment
18
PACT MD
• Initial involvement directed towards items in the
PACT clinical pathways that are urgent
– Gas exchange and hemodynamic goals
– Trouble-shooting therapeutic hypothermia to ensure
goal temperature reached
– Need for urgent coronary reperfusion?
– Making appropriate sub-specialty consultations
– Encouraging delayed neuroprognostication
19
PACT MD
• Subsequent bedside follow-up daily during
acute phase of care
– Support maintenance of hypothermia
– Support safe, controlled rewarming at 24
hours
– Support neuroprognostication pathway
– EP involvement as per protocol
– Consider etiology in collaboration with primary
team
20
PACT MD
• Clinical note expected for each consult
• Detail clinical assessment and management
plan, highlighting the important features related
to the PACT clinical pathways
• Hand-over PACT patient consult list to oncoming PACT MD for continuity of follow-ups
• Sign-off from patients when acute post arrest
issues are resolved (~72 hours?)
21
PACT MDs
•
•
•
•
•
•
•
Dr. Andrew Baker
Dr. Chris Hayes
Dr. Jan Friedrich
Dr. Sara Gray
Dr. Paul Dorian
Dr. Neil Fam
Dr. Laurie Morrison
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PACT RN
Roles and Responsibilities
23
PACT RN
• 24 hour in-hospital presence for PACT
• Goal: Respond to page for consultation and attend
patient bedside as soon as possible to assist the
primary care team in the implementation of best
practices for the post-arrest patient
• PACT will only consult on out-of-hospital arrest patients;
requests for in-hospital post cardiac arrest patients will
be politely refused
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PACT RN
 An advocate for the patient and an ambassador for the
PACT
• Communication with primary MD, ED RN’s and PACT
MD and the RT’s
• WILL NOT take over primary nursing responsibilities
 Review PACT eligibility
• OHCA
• Comatose (not responding to verbal commands)
• ROSC
25
The PACT RN as a Champion
• The PACT RN is expected to have the
greatest impact related to optimizing the
induction of therapeutic hypothermia
accurate temp measurement
surface cooling
sedation & analgesia
cold fluids-FAST
NMBA’s
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Therapeutic Hypothermia
• SMH Pre-printed Therapeutic Hypothermia
orders
ED
ICU
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Therapeutic Hypothermia
Pre-Printed Orders TH ED
Pre-Printed Orders TH ICU
•MD administer neuromuscular
blocking agents
•RN administer sedation & analgesia to
target Sedation Agitation Score (SAS) 1
prior to induction of neuromuscular
blockade
•RN to obtain a baseline Train of Four
(TOF) measurement (if available).
Administer neuromuscular blocking
agents (NMBA) as ordered below.
•MD in the ICU would give the first dose
28
TH Potential Concerns
 PACT TH Trouble Shooting Checklist
29
Cooling Equipment
• Pre-printed orders and quick
reference
• Ice packs (freezer)
• Cold fluids – saline
• zip lock bags
• Esophageal probe
– Guide for esophageal probe
placement
– Paper measuring tape
• Note ED does not have a
cooling blanket
30
The PACT RN as a Champion
The PACT RN will also play a major role in
assessing the patient with respect to the
other clinical pathways
•
•
•
•
Goal directed gas exchange/ Hemodynamics
12-lead ECG-urgent PCI
EPS
Neuroprognostication
31
Hemodynamic Optimization and
Gas Exchange
 RT collaboration to help facilitate the gas exchange
targets

Minimize FiO2 to maintain O2 saturation of 94-96%

Ventilate ETCO2 to levels of 35 – 40 mmHg OR

Maintain PaCO2 levels of 40 – 45 mmHg

Maintain MAP goal specified in pre-printed order set
32
Coronary Angiography
Assessment
• Check to see if 12-lead ECG
completed by the attending team
– If not done, work with ED RN to
complete
• Review the ECG with the MRP in the
ED and/or PACT MD to determine
possible STEMI
• If possible STEMI, discuss activation of
Code STEMI protocol
• Follow up with primary care team after
patient returns from Cath Lab
33
Electrophysiologist Assessment
• Collaborate with PACT MD / MRP to call
for Electrophysiologist consult
34
Patient Follow-Up
• If a patient has come in after hours please
provide Karen or Tessa with a patient
debrief, via email of in person.
• Karen Wannamaker and Tessa Diston as
PACT RNs will complete a follow up after
12 hours of ED admission to monitor
cooling.
35
PACT RN Coverage
8:00 to 16:00 hrs Monday to Friday Karen
Wannamaker or Tessa Diston will be the
on call PACT RN.
16:00 hrs to 8:00 Monday to Friday and 24
hours weekend coverage, the CCRT nurse
will be the on call PACT RN.
36
PACT RN Communication Tools
Pager and iPAD
 Two pagers with the same number have been
set up with locating for PACT
 iPAD has the electronic version of the Case
Report Form (eCRF)
37
PACT RN Hand Over
After the PACT RN shift has ended
 Contact the next on call PACT RN
 Transfer pager (only applicable for CCRT
nurses)
 Provide a debrief of any PACT patient that
may have been admitted to Karen and Tessa
for 12 hour follow up
38
Working Together… to COOL!
“You may have the greatest bunch of
stars in the world, but if they don’t play
together, the club won’t be worth a
dime.”
Babe Ruth
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A PACT Case
• 52 yr old male
• Acute onset chest pain followed by collapse
outside home
– Witnessed
– Bystander CPR initiated
• 911 call @ 20:32
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EMS Treatment
• Toronto Fire
– First on scene
– Confirmed VSA, continued CPR
– AED applied – 1st shock
ECG
Grid size is 0.20 s x 0.50 mV at Gain x1
Prompt: don't touch patient, analyzing
Analysis: started
20:37:43
20:37:44
20:37:45
20:37:46
20:37:47
20:37:48
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20:37:49
EMS Treatment
• Toronto EMS
– Bradycardic PEA, continued CPR
– Course V-fib – 2nd shock
– ROSC
– Intubation
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SMH Emergency Department
• Patient brought into a resuscitation bay
• Assessment by emergency RNs, ER residents
and MD
– BP 80/50, HR 110 Sinus Tachy, BVM ventilations
(apneic), O2 100% on FiO2 100%, Temp 36
• Tube position confirmed with colorimetric
ETCO2, RT paged, cxray ordered, blood drawn,
additional IVs established
• 12-lead ECG ordered
• Order for dopamine give for a BP 80/40
• ER puts in right femoral central line
44
SMH Emergency Department
• Pre-printed post arrest therapeutic hypothermia
orders signed by emerg staff MD
• Several ice bags placed around patient
• Critical Care paged through locating
• PACT team activated
45
A PACT Case
• After hours paging protocol – PACT RN
• PACT RN
– Calls back to emergency
– Attends ASAP
– Determines eligibility
– Undertakes a focused assessment of the
patient
46
A PACT Case
• PACT-focused problem based approach
using the checklist and pathways
– Pt is comatose (not responding to voice or
painful stimuli)
– Intubated on vent. RT at bedside.
– On emergency cardioresp monitor
– BP 80/50, HR 110 Sinus Tachy, Vented O2
100% on FiO2 100%, Temp 36 (tympanic)
– Ice bags at neck and groin
47
A PACT Case
• PACT RN actions?
48
PACT RN Actions
• Discussed gas exchange goals with RT and obtained
orders from MRP or PACT MD
– Requested end-tidal CO2 monitor from RT
• Identified hypotension as an issue and advocated for
fluids/pressors/central line by primary team
– Pre-printed orders support this
• Ensured 12-lead ECG was done and assessed by MRP
– Draw attention to PCI pathway if indicated
• Helped bedside nurses place an esophageal temp probe
• Assisted bedside nurses with proper ice bag placement
and reminded about hourly replacement
49
PACT RN Actions
• Started 2L cold saline bolus as per preprinted orders with pressure bags
• Encouraged sedation/analgesia and
paralytic PRN as per pre-printed orders
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PACT RN Actions
• At completion of initial assessment and
management, contacted the PACT MD through
locating to discuss the case
– Focus on:
•
•
•
•
•
Hx and focused physical assessment
Review eligibility
Review interventions/investigations prior to PACT
Review any PACT interventions
Discussion with RN/MD around issues requiring attention by
PACT MD
• After MD contact, the PACT RN completed the
eCRF on iPAD
• Brief PACT RN note in chart
51
PACT MD actions
• Reviewed case with the PACT RN over the
phone
• Provided verbal “PACT Suggest” orders for
ventilation parameters
• After review with PACT RN, contacts MRP
to discuss the suggest orders and discuss
the ECG/PCI pathway
• Assessment for PCI
• Assessment for EP involvement acutely
52
PACT RN Actions
• One hour later – PACT RN follows up with
emerg
– BP 120/70 on 10 mcg/kg/min
– HR Sinus at 95
– Ventilated FiO2 40% O2 sats 95% ETCO2 40
– Temp (esophageal) 36 degrees
• Action?
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THANK YOU
54
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