This is a guest post from Rom Duckworth, paramedic and educator that follows-up on this post about my experience in the CIRC trial. If you want to guest post or review on this blog, check out the guidelines here.
CIRC Trial and IBP ALS
Having had the opportunity to attend the ACLS Guidelines roll-out in Chicago in October of 2010 I noticed something profound in both the recommendations and the research (though not the ACLS algorithms or course, but that is another topic). In the process of evaluating the science behind the guidelines four things became apparent to me.
1) The overall scientific strength of the guidelines (not every recommendation, but the guidelines taken as a whole).
2) The specificity of what works, what doesn’t, and what needs further evaluation.
3) The difference in success rates between comparable EMS systems (rural to rural, urban to urban, etc.) throughout North America. Read as “room to improve”.
4) Potential for the continuation of obsolete practices and paradigms among healthcare providers, even those attending regular BLS, ACLS and PALS recertification programs.
These four items led to me picturing an equation of:
(local implementation of guidelines) + (Time) = (Real Lives Saved)
This equation 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.
Initiative for Best Practices in ALS Education Program
I put together an education program that addressed the five areas of a systemic approach to improving resuscitation.
1) Early CPR and Defib
2) True high quality CPR
3) Uninterrupted CPR
4) Meaningful Medications
5) Post ROSC Care
Unfortunately the project would be restricted not only by time and money, but it could also deviate only minimally from our current Regional Paramedic Protocols.
So in January of 2011, with more focus on the process than the 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 Medical Director we placed our community-based ALS service as the hub of a program with five spokes.
1) 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.
2) 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.
3) In addition, our service worked to minimize interruptions of CPR through the use of mechanical CPR devices, automatic ventilators and a modified airway protocol.
4) 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.
5) We put protocols and education in place for immediate-post ROSC BP maintenance, 12 lead acquisition and transmission and eventually, hypothermia.
Lessons Learned
As we wind up our first year of the program I’ve been surprised by some of the lessons learned.
1) 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.
2) Direct Follow up: I too 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.
3) Rise of the machines: While some complain that 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.
4) 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.
5) 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.
6) And more change: We took the opportunity to attach other small changes to the program not directly related to resuscitation. Some change lends itself to improve in ways you might not have previously considered.
7) 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.
So if you have the opportunity to participate in a research or pilot program, by all means do so. Even better, you may want to start one yourself! Yes, it will take a great deal of work, but you’ll be contributing quality data to pre-hospital medicine, and you may find yourself surprised at the return on investment for you and your service.
A passionate emergency responder and recognized speaker and educator on leadership and emergency services living in Connecticut, Rom Duckworth has more than twenty years of experience working in career and volunteer fire departments, public and private emergency medical services and hospital based healthcare systems. Connect at www.romduck.com
or the www.RescueDigest.com blog and podcast.
