Training in Cardiac Surgical Resuscitation

I commend Tsiouris et al on their report of improved intensive care unit (ICU) preparation for emergency resternotomy following protocol development and institutional training in the June issue of Critical Care Nurse.1 The authors highlight the problem of maintaining staff competencies for low-volume, high-risk procedures and the impact of focused quality improvements. More than 5000 patients experience arrest after cardiac surgery each year in the United States.2 Of patients who experience a cardiac arrest in the hospital, a reported 26% survive to discharge.2 However, in units where staff members have undergone specialized training in cardiac surgical resuscitation (CSR), the discharge survival rates were 65% to 87% for these patients.3,4The Society of Thoracic Surgeons (STS) Task Force on Resuscitation After Cardiac Surgery published a specialized response protocol in the 2017 STS expert consensus statement for resuscitation after cardiac surgical arrest,5 the universal standard of care following a 2020 endorsement from the American Heart Association.2 Key strategies such as immediate defibrillation or pacing of dysrhythmias before compressions, avoiding epinephrine, and rapid resternotomy in the absence of reversable causes differ from Advanced Cardiac Life Support protocols.5Because of the superior patient outcomes demonstrated after CSR training,3,4 all cardiac surgical units should develop institutional protocols and response training aligned with these evidence-based recommendations. Indeed, this is a regulatory expectation of The Joint Commission, whose standards require hospitals to have resuscitation equipment available, “based on the needs of the population served.”6 In 2021, The Joint Commission added that “the hospital provides education and training to staff involved in the provision of resuscitation services,” recommending topics such as procedures, techniques, equipment, and roles and responsibilities that are aligned with national guidelines.6 Clear expectations are needed for immediate activation of the surgical team, locating and using equipment such as internal defibrillators and “mini” resternotomy sets (a class I recommendation),5 and roles and responsibilities to prepare for and assist with an ICU resternotomy. Yet based on an informal survey of 2023 National Teaching Institute attendees, only 40% reported they had received such training.7 Our patients deserve better.The approach by Tsiouris et al offers important insights for others wishing to improve their response to cardiac surgical emergencies. The training included nurses and advanced practice and respiratory care providers—virtually everyone who responds to a cardiac surgical arrest in the ICU—and was highly recommended for surgical trainees.1 By preparing ICU providers for emergency resternotomy, Tsiouris et al avoided 30 to 40 minutes of transfer time, which would have precluded the STS recommendation for reopening within 5 minutes.5The American Heart Association and STS recommend ongoing interprofessional training, creating opportunities to identify equipment and systems issues, foster open communication among providers, and reduce human factors that lead to error during emergencies.2,5 Tsiouris et al follow this recommendation by providing twice yearly didactic and simulation CSR training for the staff.1 Developing a specialized, evidence-based CSR protocol may seem daunting, but several new resources (free blog and newsletter, educational You-Tube videos, items for purchase) are available.8 We have much to learn from each other, as Tsiouris et al demonstrate.Thanks to Tsiouris and his team, other centers will be encouraged to implement and share similar work. After their interprofessional quality improvement project, staff surveys demonstrated significant improvements in recognition of patients at risk, knowledge of evidence-based practice, and feeling prepared for these uncommon arrests.1 The infrequency of these events was noted by the authors, who were unable to report mortality improvements due to the absence of subsequent emergencies.1I have several questions for the authors. Have they had an opportunity since publication to use their training and, if so, has that provided additional insights? Can they offer any specific details of their protocol or content they felt was critical? Additionally, most US centers do not have 24-hour in-house coverage by a cardiac surgeon; how have they addressed this issue?Thank you for the opportunity to respond to this informative report on a critical and timely topic. The time is now. Thousands of lives are at stake.