Team-Focused CPR: Bringing Pre-hospital Success to the ED

2017-09-07T21:23:14+00:00

High-quality chest compressions and early defibrillation are the cornerstones of effective cardiac arrest care.1 When implemented correctly these two interventions enhance patient outcomes and improve overall survival.2 However, despite simplified advanced cardiac life support (ACLS) algorithms and extensive training of providers, cardiac arrest scenarios in the emergency department (ED) are still high-stress and mortality rates remain high.3,4 

In addition, ED providers often prioritize other therapies and procedures that have not shown similar survival benefit. What if we could simplify our approach while simultaneously improving patient outcomes?

Team Focused CPR

Team Focused Cardio-Pulmonary Resuscitation (TFCPR) is a choreographed approach to cardiac arrest resuscitation where providers know and practice their specific, individualized roles in order to optimize CPR performance, quality, and outcomes.5  De-emphasis is placed on endotracheal intubation (ETI), intravenous (IV) drug administration, and any other intervention that could potentially distract from effective, high-quality CPR.

How Does TFCPR Work

Figure 1. Schematic for provider positioning during TFCPR used at Carolinas Medical Center. RT = respiratory therapist, RN = registered nurse, MD = emergency medicine physician. MD1 and MD2 are typically residents. POCUS = point-of-care ultrasound; SAD = supraglottic airway device.

  • Chest compressions are performed in cycles of 200 at a rate of 100-120/min, changing out compressors at the start of each new cycle.67 The compressor counts out loud at each 20th compression (i.e. 20-40-60-80-etc.) to keep the team on pace.
  • Ventilated breaths are administered with each 20th compression to avoid hyperventilation and gastric overinflation.
  • After the 180th compression, the defibrillator is pre-charged [prior ALiEM post on precharging the defibrillator].8 A team member’s finger is also placed on the femoral pulse, allowing confirmation of mechanical pulsations with chest compressions and facilitating detection of ROSC after compressions are stopped.
  • After the 200th compression, cardiac rhythm analysis occurs simultaneously with pulse check. If appropriate, shock can be delivered immediately and the next cycle of compressions resumed without delay. Important: The goal time without compressions is less than 10 seconds.9,10

In TFCPR, the use of bag-valve-mask (BVM) or blind-insertion supraglottic airway device (SAD) is encouraged over ETI to avoid any unnecessary pauses.11 If IV attempts are not immediately successful, then intraosseous (IO) lines are placed without hesitation.12,13 Epinephrine administration is automatically timed with every other cycle of 200 compressions, streamlining its delivery.

When point-of-care ultrasound (POCUS) is utilized, it is performed during pulse checks and should never delay resumption of the next compression cycle.14 Central venous and arterial lines are not inserted intra-arrest due to high distraction potential and minimal added benefit.15 Finally, end-tidal CO2 monitoring is universally encouraged, as well as audiovisual CPR feedback tools with code leader observation and coaching to ensure chest compressions are optimal.16–18 

Prehospital Success

Widespread incorporation of TFCPR by North Carolina EMS agencies began in 2011 with a statewide protocol launching in 2012. A retrospective cohort analysis of 14,129 out-of-hospital cardiac arrest (OHCA) patients in North Carolina from 2010-14 was recently published in Resuscitation.19 Survival with good neurological outcome was significantly higher in the TFCPR cohort (8.3%) vs. standard CPR cohort (4.8%) for all patients suffering any type of OHCA. Neurologically-intact survival for witnessed OHCA with initial shockable rhythm was also significantly higher with TFCPR (28.9%) vs. standard CPR (16.8%). Statistically significant increases in overall survival to hospital admission and overall survival to hospital discharge were also seen between the two cohorts.19

Table 1. Outcomes of TFCPR vs. standard CPR for out of hospital cardiac arrest (OHCA) in North Carolina from 2010-14 based on 14,129 total patients (10,104 patients in TFCPR cohort, 4,025 patients in standard CPR cohort) 19

TFCPR In The ED

Individual departments may need to assign different roles or responsibilities to different providers, but the strength of TFCPR is in its simplicity and adaptability to almost any clinical setting by focusing on a few key principles:

  • Structured framework of chest compression cycles
  • Rehearsed and pre-assigned roles/responsibilities to reduce chaos and confusion
  • Streamlined peri-shock pause with pre-charging of the defibrillator
  • SAD and IO usage to decrease chest compression interference
  • Minimization of advanced interventions to limit distraction (also decrease resource utilization)

As an example, the emergency medicine residency at Carolinas Medical Center (Charlotte, NC) recently incorporated TFCPR as the departmental standard for cardiac arrest. Initial provider training was simple and consisted of 2 phases:

  1. 10-minute online training module
  2. 15-minute hands-on simulation with manikin and full code team

Final Thoughts

TFCPR is an established cardiac arrest protocol with proven results in the prehospital setting. Required resources are minimal, and potential benefit substantial. Consider incorporating these principles into your emergency departmental standards for cardiac arrest resuscitation.

Anand Swaminathan, MD MPH Expanded Review

Comment 1: For instance, intubation makes sense but I would not put pericardiocentesis or thoracostomy here. While it is true that we don\'t have data showing that these things are beneficial, they clearly are in select populations.

Comment 2: There are some important caveats to this study. As a retrospective chart review, there are significant bias issues that arise. Why were certain patients given TFCPR as opposed to the standard approach? Was the overall skill level of providers delivering TFCPR higher than that of prehospital resuscitation in non-TFCPR arrests. The fact that ~72% of patients had TFCPR suggests that those teams not supplying it were laggards. While a before and after implementation study could have been interesting here, it would have major issues as well (other interval improvements in care would improve the post-TFCPR training cohort for instance). There likely is not a \"better\" study design from a pragmatic standpoint, but it is important to note limitations.

Comment 3: It is important to note that the odds ratio (OR) for TFCPR was just 1.5 - a weak association. The OR was more robust for witnessed arrest, shockable rhythm and in-hospital hypothermia.

Comment 4: The protocols of individual departments, as well as the resources available, may drastically change this approach and should be taken into account. If your department has an active eCPR program, the placement of arterial and central venous lines may be important. If your institution performs intra-arrest cardiac catheterization, placement of a mechanical CPR device may be integral. These are things to consider in implementation and adaptation.

Final Opinion: TFCPR is an interesting strategy to codify an often chaotic process. While adaptations to this approach in the ED and at specific sites based on resources is important, TFCPR provides a solid base upon which to build resuscitation teams for cardiac arrest care. Further research of the impact of TFCPR on ED arrest care is needed.

Anand Swaminathan, MD MPH
Assistant Professor Emergency Medicine Bellevue/NYU Emergency Department

Robert Nelson, MD Expanded Review

ACLS was first introduced in 1979. Even after multiple revisions and widespread training and adoption of ACLS algorithms, overall survival has not significantly improved. In 2015 the Institute of Medicine published a statement citing overall out-of-hospital cardiac arrest survival of 6% and in-hospital-cardiac arrest survival of 24% in the US.

Despite widespread training and adoption of ACLS algorithms, overall cardiac arrest survival has not significantly increased in 38 years. However, many locations in the U.S. have demonstrated dramatic increases in cardiac arrest survival by approaching from a systems perspective.

Comment 1: This schematic is a wonderful representation of a organized team approach to cardiac arrest. Everyone present should have a specific task to accomplish. Team members should have specific tasks to perform and be involved in continual training on those tasks.

Comment 2: A team focused approach to cardiac arrest leads to decreased chaos and confusion which historically has accompanied resuscitation efforts. And because roles, responsibilities, and tasks are now preassigned this leads to a greater capacity to bring the family to the bedside to witness the resuscitation. An organized approach decreases chaos and confusion and is associated with improved survival. This improved organization facilitates having the family witness the resuscitation. Remember you are really resuscitating both the victim and the survivor(s).

Robert Nelson, MD
Assistant Professor of Emergency Medicine, Director of EMS and Disaster Fellowships, Director of Davie and Stokes County EMS, Wake Forest Baptist Health

Blake Johnson, MD

Blake Johnson, MD

Resident
Department of Emergency Medicine
Carolinas Medical Center
David Pearson, MD

David Pearson, MD

Associate Professor
​Associate Residency Director
​Director of Cardiac Arrest Resuscitation​​
Department of Emergency Medicine
Carolinas Medical Center
  • Blake Johnson

    Drs. Nelson and Swaminathan make excellent points! Their expertise is invaluable, and their willingness to review our post much appreciated. A couple additional comments:

    Having resuscitated patients with providers trained in TFCPR, as well as with providers trained only in ACLS (no TFCPR), the true beauty of TFCPR lies in its organization. When every provider has a pre-assigned role and all providers in the room know what eachother’s roles are, a very chaotic event becomes more controlled and more effective. Counting out loud every 20th compression serves as the metronome keeping everyone informed without unnecessary chatter.

    The frequency in which pericardiocentesis and thoracostomy are indicated for atraumatic arrest is quite low (although not zero); however, deviations from TFCPR are clearly indicated in select patients. A more common example may be cardiac arrest from GI bleeding. In this patient, central IV access and emergent blood transfusion is likely what will save them. In general, I would argue default best practice remains avoidance of additional interventions that make a chaotic event more chaotic and have potential to distract from effective CPR.

    Finally, although the study referenced here (Pearson, et al. Resuscitation 2016) is far from a double-blinded RCT, large trials of this caliber are scarce in cardiac arrest research. It’s important to remember TFCPR does not implement any new resuscitation principles. Instead, TFCPR summarizes the best available data and creates an organized approach optimizing everything already recommended in current ACLS guidelines.

    Does anyone else have thoughts, questions, or suggestions that may help improve resuscitation in these critically ill patients?

    Blake Johnson, MD