Transcript Video Quality of Care for Cardiac Arrest < Back to Summit23 Brain Injury Management Quality of Care for Cardiac Arrest Presented by Professor Christian Hassager So we are back on uh on the stage to continue this session. And our next speaker has been already introduced yesterday is Christian Haeger from Copenhagen. He's involved at every and each level, from local to university to a country and to Europe. So Christian, please have the stage for quality and ca and of care for cardiac arrest patients. Thank you so much, Samantha. I uh I think my presentation today will not be as itchy as it was yesterday. Um But I'll try to go through some quality of care discussion that we have had in a European society where I have just been president for, for two years. Now, I'm past president and uh these are my conflicts of interest and I would like to highlight the lower line there that my presentation really builds upon a consensus document that we did in A CV C. That's association for cardiovascular care, acute cardiovascular care in ec that's the doctors and nurses that take care of acute cardiac patients around Europe. And we uh we chaired a consensus document that I will try to show you the, the details from and this the possibility to write this paper was actually sponsored by uh by BD. In form of an educational grant. BD. Had nothing to do what we wrote. But they gave our society some uh money to do the process. Before I start, I'd like to highlight why I think we need, we need some, some accreditation. We need some quality control. And the thing is that we, we, we, we saw this yesterday and uh is this mouth working? I'm not sure how it works anyway. It can, I can't see, it doesn't matter if you look at the lower graph, you can see survival in Denmark over the last uh the first decade of this uh millennium increased uh from about 45 6% to more than 20 the survival to hospital. And you can see also that in the same time period, bystander CPR increased whether there's a link there or not, we don't know of course. But, but, but there is an indication and in the same time, this is all of Denmark from the registry, we saw that survival increased both in VTV F but also in non shocks. So and, and we have discussed a lot about bystander CPR. So I put in this graph because we have registered how many of our patients with cardiac arrest actually have a bystander CPR. And as you see in the beginning of the millennium, it was only 20%. Now it's about 80%. And for the last six years, the curve is flattened out, so we cannot get above 80%. And I think that's fair, you cannot have 100%. It's not feasible at all. And I think this is the most important thing that we can do to improve the outcome of categorized patients that is to live in a society where we help each other if something goes wrong. And I think that all industrialized, wealthy countries should implement a curve like this. And I would like to highlight too that if this curve comes a little above 50% then it's only natural that the time to CPR has a median of one minute because then if people see somebody falling down, they start to give massage immediately and you can only have zero minute, one minute, two minutes, four minutes and so forth. So the median in this population will be one because more than half of the population will receive immediate bystander CPR. So excluding patients from discussions about hypothermia just because the time to CPR so basic CPR is so short. I think it's wrong. Then there's a problem with your country. You should aim for this looking at the last six years where we have had a sort of a, a level off of I standards. We've had other things. We have bystander who are members of a network, an app on your phone and it rings if there's a cardiac arrest close to you and then you go, then you can see on the map where to go. Actually, the first real publication in New England came from, from his group in Stockholm. And you can see here that we have improved that from from 14,000 to 150,000. The total number today is 161,000. So it's improving. And in the same time, we have plastered the country over with AED. So we have really tried to improve the pre hospitals part this is basically the same curves. You can see resuscitated patients, patients that comes into the hospital with risk and you can see 30 day survival over the last 20 years in my country. No court in s final eye goes to 100 here. So the curves are a little flatter. But what is really irritating is that once we are at the hospital, this ratio is 50% 50% survives of the patient that comes in. So there is some indication I know of course it might be we we receive more fragile patients now and so forth. There is some indication that we have not really improved within the hospitals. And that's why that we would like to say that we, we need some sort of quality indicators that you're performing well. Another point is that uh we have led in the Acute Cardiovascular Care Association. We have led a collaboration between the ourselves, the European Society of Cardiology, the European Resuscitation Council to take care of the patient. Immediately, the European Society for Emergency Medicine, the next phase and intensive European Society of Intensive Care Medicine. We've all together. First, we made this publication where we saw how much it's very much like Dr Levi showed from France. I'll show here a very few data from all over Europe. And as you see, we don't really agree in Europe. This is just, it's just because I'm a cardiologist, I pick these numbers anyway. We don't agree exactly with blood pressure we aim for, but the majority go for more than 65 in, in. And the type of mechanical support that can be added is also depending on the institution. So, so we have not really improved. There's some indication for that and we do things differently regarding TTM. This is all over Europe, not just France, all over Europe. You can see it's still 20% 21% who goes for the old lower level. And between 34 and 36 is the majority and only a small fraction have actually converted to fever prevention. You can also see the duration varies. So we have four different societies that has to agree on what we should do. And this agreement is of course, sort of just like when the eu passes a law, it's, it's not always very sharp, but it has to be agreement upon all companies. So these four societies sat together and and did this quality indicate post resuscitation care work. And this is the thing I'll try to go through. I should say that I have just been sharing the process from the beginning and then I gave it over to 22 very, very good people, Johannes K from my own institution and Pablo Perez from, from Spain, who's going to give the next talk. And they should actually be accredited for this paper because they did all the work again, four different uh major societies. So scientific societies agreeing on what to do. The process of this collaboration was a literature which was done fairly easy because we already had the guidelines that are so detailed from er C and EIM that, that it was just add on to that. And then based on consensus obtained through meetings of the task force, they decided to have eight domains of care, eight areas where we should monitor if care is OK. And having these meetings uh which was at the tail of the COVID period. So it was uh zoom meetings. They decided on 39 candidate quality indicators from these eight domains. And then the process is what you call a modified Delphi technique which means that you make some conducting some structured anonymous surveys. What do you think? And you answer that anonymous and then you have meetings where you reach consensus and for each domain, for each of these eight domain, you have one primary quality indicator. This is the most important one. And then you always have doctors saying somewhere but I also need to monitor this and this and this. So there are some secondary ones. The primary one that uh that are most important. The domains are the pre hospital organization. It's also about card arrest centers. We heard a little bit about that yesterday. The initial examination of the cause of the arrest when the patient comes in the intensive care, hemodynamic management and neurologic prognostication, we have something on follow up and then some composite end points trying to say, can we put all this together? I'll come into details for that. I'll just show you how it looks. And then we go into it. There is two big tables in the paper that shows the domains and the indicator. And this, if you just this is table two from that paper, this is all you need. Actually, this is summing up the definition target population and how it should be reported. But I'll try to go briefly through these. The first domain is in the pre hospital uh setting. Um How is it organized? And then it says that the center should be part of a network organization with written protocols. And did you notice in, in Levi's brilliant presentation here, less than 50% in France, 49% actually had a written protocol at the hospital for what they were doing, think we could do better there. So written protocols for how they should do in this. And then there's one of the secondary ones where, where there should be somebody who can interpret the pre hospital ecg diagnose so forth. We don't need to go into details is the number one that is most important. Then the patient comes in to the hospital. And one of the primary domains there is the primary angiography defined as less than 90 minutes from risk. You should have already put the wire in the patient with a semi and you can see then it's written in details that the denominator here is all patients that have risk comes into the hospital with an ECG showing semi. Then you have to put a wire in no more than 90 minutes after the the the the uh arrest. We also have a secondary marker there that it's it should be within the first two hours. You need to do an echo that's on all patients. You can see the denominator there is patient with risk. After out of hospital cardiac arrest that are admitted to the hospital, we need to see if we can get a quick diagnosis of the heart. I think these are, these are very reasonable. Then domain three is what happens at the ICU the temperature control. Now, the denominator for temperature control is all patients who are in coma regardless of the initial rhythm. And there are some secondary ones which I'll just briefly mention here, intubation, arterial blood gas is needed within two hours and the evaluation of organ donation for brain death patient is also something that needs to be written in a protocol. So just to show you how detailed it is, I'll show you this single one in details temperature control. That's domain number three under the ICU. That's the most important thing in the ICU. We have decided the target population is those that remain comatose. The measurement period is the time of all the way until hospital discharge. The nominator is giving there those that receive temperature control and the denominator is just those that remain comatose. And then it's also noted for each of these, whether there's some exclusion criteria, some patients you can take out before you're doing your marker. And that is uh for instance, patients who might have an admission temperature below 30 or pregnant or intracranial bleeding, other other things. So it's mentioned briefly go through the the other domains, hemodynamic manner management. It's not that people should have a, a ECMO. If they have a low blood pressure, it's that they should be evaluated. It should be noted that you have thought about whether this patient needs something for this persistent shock or not. And there's a secondary one, whether you use space oppressors, neurologic prognostication. Remember this is something that all the scientific societies in Europe that take care of these things mean together. So it's important to use a biomarker. It doesn't say whether you should use NSE or NFL neurofilament lighting or whatever you should do, but you should use brain biomarker, you should use some sort of neurological imaging. It doesn't say that you have to use Mr but you can also do CT electrophysiology is also mentioned more broadly. Of course, mainly we need, we need an EEEG there and then there's a neurological examination and then it has to be a multi modal prognostication. You need to collect all this information and you have to wait until 72 hours and then do a decision on the prognosis decision can be considered to stop treatment or go on for or just wait a few days and reconsider of course. So there are some secondary parts which I don't think we should go into. But the main thing about prognostication is that we need to document that we after three days collect these things and, and do a prognostication. Then the next domain is when the patient is discharged and follow up, we think that there should be a functional assessment of physical and non-physical impairment. Before the discharge from hospital, they need to have a written assessment of how are they doing physically and how is the brain, uh the the capacity and secondary. There should be some sort of systematic follow up of this because I think the the status of the patient when they leave the hospital may be somewhat better than the state, somewhat worse than the status uh three months out. So we need to find out and we need to also to get them there to see if they still have cognitive problems and try to help them if you go into detail with this, then many of our patients still have some minor problems. And then there are these last domains where we try to find a sort of all 11 number that, that gives it all there is uh one sort of outcome quality indicator alive and a good functional status. That means simply that he can walk and he can, he or she can uh can, can, can, can survive without any can, can, can do their own, can take care of themselves without help from others. Three months after the arrest and finally, to make this composite, if you just need one month, 11 number, then there's actually uh if you can do OK. On these three, these were decided to be the most important one that you really get this echo. Now it's four hours just to make a consensus that you really get this echo done that you have temperature control and that you follow up your patient that you don't just skip them and say take care of yourself. And then there's another one that we also proposed that you could use that is that you assign one point for each of the eight ones that has fulfilled. So that's more quantitative way of doing it. So in summary, we do have a consensus in Europe among different scientific societies took a couple of years to obtain it. It's mainly due to Pablo and Johannes. And uh so we have this consensus. Now, the next phase is how do we implement this? And uh Pablo is going to tell you about the Spanish experiments where they uh where they had a very good uptake and they had accreditation institutions that take that controls, that this is the case. I don't think that is possible. If we wait for that, we will lose the train. If we are going to cover all over Europe, it would be too expensive, too difficult. What we have done in cardiology is actually having accreditations where the institution itself fill out that where they feel that what they do, then they send it in and then they pay for, pay a fee and then they get a document they can put on the wall and then random checkups are done. I think perhaps this is the way to do it. Um But this is the phase we are now discussing among the societies, how to handle this. So I think I'll finish here and thank you very much for your attention and thank you very much for inviting me to this wonderful meeting. Created by
