Getting Ready For The 2015 Changes To CPR, ACLS, PALS and Beyond Means Getting Ready For Change In General.
Having had the opportunity to attend the last AHA Guidelines roll-out in Chicago in October of 2010 I wound up reading everything I could on the guidelines in the research behind them so that when I showed up to represent my state I didn’t look like some kind of dope. It wasn’t easy digging through all those papers, but when I was finished I noticed something profound in both the recommendations and the research and say how and why we were going to have to make changes to the way we introduced change itself .
- The overall scientific strength of the guidelines (not every recommendation, but the guidelines taken as a whole).
- The specificity of what works, what doesn’t, and what needs further evaluation was very clear.
- The difference in success rates between comparable EMS systems (rural to rural, urban to urban, etc.) throughout North America. Read as “room to improve”.
- Tremendous potential for the continuation of obsolete practices and thought processes, even for those attending regular BLS, ACLS and PALS recertification programs.
These four items led to me picturing an equation of (Local implementation of new and improved guidelines) + (Time) = (Real Lives Saved)
This is what motivated me as an EMS Coordinator and educator in a small regional system to see what changes I could begin in my own service and then, hopefully, propagate throughout the rest of our Region.
We put together a program that addressed the five areas of a systemic approach to improving resuscitation.
- Early CPR and Defib
- True high quality CPR
- Uninterrupted CPR
- Meaningful Medications
- Post ROSC Care
Unfortunately the project would be restricted not only by time and money, but could also deviate only minimally from our current Regional Paramedic Protocols.
So in January of 2011, with more focus on the process than the actual name of the project we began the Initiative for Best Practices in ALS (IBP ALS). With the support of our department’s Chief and our local Medical Director we placed our community-based ALS service as the hub of a program with five spokes.
- Early access to CPR and defibrillation was improved by providing community stakeholders with educational resources and grant materials as well as updating the training for ALL dispatchers and first responders in proper BLS.
- The quality and consistency of CPR was improved through education programs that emphasized the WHY (affective) of BLS as much as the HOW (psychomotor) in order to eliminate low quality and outdated BLS practices. We also stressed the importance of continuous EtCO2 as a tool to monitor effectiveness of CPR, airway management, and achievement of ROSC.
- In addition, our service worked to minimize interruptions of CPR through the use of mechanical CPR devices, automatic ventilators and a modified airway protocol.
- While we couldn’t move completely away from general administration of algorithm based medications during resuscitation, we did implement a drastic change (for us) to using Vasopressin and Amiodarone as “One-and-Done” meds rather than the “rinse and repeat” of epi-lido-epi-lido-epi-lido. We also emphasized medics evaluating and addressing the patient’s underlying problem through history and assessment, as opposed to primarily following an algorithm until arrival at ED was achieved.
- We put protocols and education in place for immediate-post ROSC BP maintenance, 12 lead acquisition and transmission and eventually, hypothermia.
Now three years in to the program I’ve learned some important lessons about rolling out new initiatives. I plan on carrying these with me as we get ready for the 2015 changes.
- Trials and special programs give focus: Many participants in our IBP ALS program were invigorated just by the fact that our service was a part of something special.
- Direct Follow up: I believe that face-to-face follow up after each call helps to improve the quality of care not just in the types of calls addressed in the project (for us, resuscitation) but positively affects all aspects of EMS care in the system. The mechanics of our current QA system don’t allow me to do this as much as I’d like, but I recognize the importance of this follow-up and we’re working on making it happen more often.
- Rise of the machines: While CPR machines haven’t proved to be the be-all, end-all of resuscitation, I can tell you for certain that in our system they have dramatically improved our ability to provide continuous, high-quality CPR. Period.
- Save lives with your MIND, rather than your HANDS: If I had to choose the central concept of the IBP ALS program, this is it right here. Do I believe that we’ll save more lives because Vasopressin is such a great drug? Nope. But I DO believe that paramedics will save more lives when they’re focusing on evaluating and addressing correctable problems, rather than just watching the clock for the next “rinse and repeat” med administration.
- Change attracts attention: Our program required a change in the ambulance load-out. I (very subjectively) believe that this stimulated better rig-checks as the crews took the opportunity to review the new equipment.
- And more change: We took the opportunity to attach other small changes to the program not directly related to resuscitation. As you say, some change lends itself to improve in ways you might not have previously considered.
- Teamwork: While I encountered initial resistance to Pit-Crew CPR concepts (“We get everything done that needs doing! Why change?”), I emphasized that the idea here is, as when you work with a great partner, with Pit-Crew CPR’s pre-assignments, things don’t just “get done”, they get done automagically. Less effort+improved CPR=happy crews.
And this isn’t just for EMS
As we introduce new information to our firefighters about the NIST studies and a new understanding of fire behavior we’re meeting many of the same challenges. There is no doubt that the only constant is that there will always be change and a good leader in the Fire Service, EMS or some combination thereof needs to be ready to lead the charge for change.
It Isn’t Just Us
We’re doing what we can to follow the lead of some pretty progressive departments, and you can too. Take a look at what Wake County North Carolina has done and continues to do to send more people home from the hospital alive and well after a cardiac arrest.
So if you have the opportunity to participate in a research or pilot program, by all means do so. Even if you don’t get that chance, watch closely the people who do. The earlier that you know about what is going on in research and what is coming down the road for your service, the more time you have to prepare your system and your staff for the changes that are heading their way one way or the other.
Sure, they say…
the fire service is 200 years of tradition unimpeded by progress
but they also say…