Abstract Sa406: Stayin’ Alive: Establishing a Rhythm With Resuscitation Data

An interprofessional care model was implemented in 2020 to improve CPR care outcomes based on AHA’s Get With the Guidelines (GWTG) – Resuscitation program. The program provided measures ensuring high-quality care was delivered during cardiopulmonary arrests (CPA). Compliance required >85% for all four measures, which included: confirmation of airway, time to first shock ≤2 minutes for VF/pulseless VT, time to IV/IO epinephrine ≤5 minutes for asystole/PEA, and percent of pulseless cardiac events monitored. Keck Hospital of USC had lost its GWTG award status several years prior to the establishment of the interprofessional team, which consisted of a Physician Champion, CNS, RN Quality Specialist, LVN Quality Data Abstractors and the director of HIM. The primary goals of the team were to improve the workflow of data collection, standardize documentation, and ultimately increase compliance of the measures. The Lean Six Sigma methodology was applied revealing gaps in data collection. HIM and Quality collaborated in developing a systematic method to improve electronic data availability. To decrease documentation variations, the CNS revised CPA forms and the Physician Champion created a standardized electronic Code Blue summary template. Once collected, data was systematically analyzed by the Quality team members to ensure data accuracy and to highlight areas of opportunities for improvement. Findings were then presented on a quarterly basis during the Critical Care and Resuscitation committees chaired by the CNS and Physician Champion. Additionally, the CNS implemented evidence-based practices which included assigning code roles to ICU personnel, educating ICU staff, performing monthly mock codes, and completing weekly reviews of CPA forms that included communicating documentation discrepancies to clinicians. Since the implementation of the team, sustained efforts have succeeded in improving resuscitation care outcomes. Substantial progression was evident in the time to first shock and confirmation of airway measures. In 2020, the hospital had a 69.2% compliancy rate for time to first shock. By 2022, we were performing at 89.5%. For confirmation of airway, we began at 72.4% in 2020; and within one year was at a 95.5% compliancy rate. This achievement continued into 2022 with a rate of 94.9%. Lastly, we achieved >85% compliancy for all four measures receiving AHA’s Gold Award for outstanding performance for two consecutive years (2022&2023).