Out-of-hospital cardiac arrest (OHCA) is a common and lethal public health problem. The North American incidence of emergency medical services (EMS)-treated cardiac arrest is estimated to be 52.1 per 100,000 people per year [1]. Despite advances in the immediate management of sudden cardiac arrest over the past six decades, mortality for patients admitted to hospital is still greater than 50 % [1].
Several international position statements have defined best practices for patients with post-cardiac arrest syndrome, including the rapid induction of targeted temperature management, selective use of percutaneous coronary intervention, assessment for an implantable cardioverter-defibrillator, and appropriately delayed neuroprognostication [1, 2]. Numerous potential barriers to the delivery of optimal post-cardiac arrest care have also been identified in the literature [3–5]. For example, lack of familiarity and experience with post-cardiac arrest patients due to relatively low annual volumes of this type of patient at any given institution has been consistently cited [5]. A lack of interdisciplinary collaboration between emergency department (ED) and intensive care unit (ICU) staff and lack of access to advanced technology and specialized human resources are commonly identified as organizational barriers.
Previous research has demonstrated improved survival with the implementation of standardized bundled care plans for the post-cardiac arrest patient [6–8]. Improved outcomes have also been demonstrated for patients suffering from other types of complex, acute illnesses such as severe trauma and ST-elevation myocardial infarction with the implementation of specialized interdisciplinary teams and evidence-based systems of care [2, 9–13]. With this in mind, the intervention was designed to directly address barriers to optimal care for post-cardiac arrest patients by implementing a specialized Post Arrest Consult Team (PACT) at two urban academic centers. The primary analysis of this intervention, which is published elsewhere [14], involved a quantitative comparison of process and clinical outcomes with concurrent and historical controls from several other hospitals that did not have PACT implementation within the same geographical region.
This paper represents the results of an integrated qualitative evaluation designed to study the PACT implementation process in detail and identify potential mediating factors perceived by frontline clinical staff in the PACT institutions. To date, there is little research on how health organizations take up, support, and embed complex innovations [15], such as the PACT, to inform implementation of other similar interventions. Research on the impact of quality implementation of programs and services has shown that without a focus on implementation best practices, outcomes may not be achieved as expected, and in some cases a poorly implemented program may produce harmful results [16]. As the intervention study was being planned, it was recognized that understanding this piece of the project would be essential to comprehensively evaluate the effectiveness of this novel approach and expand our understanding of the quantitative study outcomes.
The PACT intervention (as designed)
The focus of the intervention was to provide an institution-wide, standardization of post-cardiac arrest care and collaboration across clinical specialties by creating a new "post-arrest consult team” —the PACT. The PACT was designed to improve the consistency of care delivery through a standardized approach, collaboration between the consultation team and the primary services caring for the patient and education to ensure that all patients receive optimal care based on best evidence and current guidelines. Evidence-based clinical pathways, which prescribed evaluation and management strategy guidance to the PACT, were developed through a consensus by a group of investigators comprised of a physician and nursing specialists in emergency medicine, cardiology, and intensive care. These clinical pathways were derived from the 2010 American Heart Association Emergency Cardiovascular Care and Cardiopulmonary Resuscitation Guidelines [17].
The PACT was operationalized through an on-call team including a physician and nurse available for consultation 24 h a day. The PACT physician was asked to be available for urgent (within 30 min) bedside consultations during business hours (9 am to 5 pm, Monday to Friday) and available for phone consultations during off hours (after 5 pm, weekends and holidays) with the option to come to the hospital for bedside assessment when required. The team’s main objective was to provide timely expertise and collaborative hands-on assistance to the treating physicians and nurses who maintained primary responsibility for the patient while they were in hospital.
The immediate emphasis of PACT involvement was on ensuring the rapid induction of targeted temperature management, avoidance of hyperoxia and hypocarbia, and assessment for urgent coronary angiography. These best practices were to be addressed during initial consultation by the PACT, usually in the ED. Ongoing follow-up by PACT with the patient on a daily basis was planned for the first 72 to 96 h after arrest so that the electrophysiology and delayed neuroprognostication pathways could be addressed and supported. During these consultations, PACT members were encouraged to leave a standardized note in the patient chart and discuss items of recommendation directly with the primary service as necessary.
Similar to other consult teams in the hospital, PACT members were to carry pagers when they were on-call. The team could be activated via one of two mechanisms: (a) by the ED team through the hospital switchboard in a fashion similar to activating a CODE BLUE cardiac arrest response or (b) via an automatic email alert facilitated by the local emergency medical services when a post-cardiac arrest patient was delivered to one of the PACT hospitals. When the email alert was received, the PACT was to call down to the ED and confirm that the patient had arrived alive. If the patient was alive, the PACT was to head down to the ED to assist with post-resuscitation care.
The components of the initial PACT assessment are outlined in Fig. 1. Upon receiving a request for consultation, on-call PACT members were asked to assess the patient as soon as possible. If the physician was out-of-hospital, the PACT nurse completed the initial bedside assessment, with physician consultation by phone. In a similar fashion to many other clinical consult services available in most hospitals, the PACT worked in a collaborative way with the most responsible care providers in both the EDs and ICUs. When the PACT was called to assist with a patient, the requesting physician remained in the role of the most responsible physician (MRP). The MRP is the emergency physician assigned to the patient or the physician under whose care the patient has been admitted to hospital. The MRP continued to direct components of ongoing resuscitation and general critical care, and the PACT provided support, expert guidance, and “hands-on” human resources during the management of these complex patients.
Subsequent bedside assessments were made on a regular 24-h basis and additionally as required by the clinical scenario. Each visit included a review of the PACT clinical pathways, a note in the patient chart by the PACT clinician, and verbal communication with assigned clinical team members.
The primary initial task for the PACT nurse was to facilitate the rapid induction of targeted temperature management for eligible patients by providing guidance and assistance to the primary nurses. The PACT nurse would then collaborate with the PACT physician on all other aspects of post-arrest care. This nursing role was designed to be similar to other specialized nursing consultants such as the clinical nurse specialist component of many stroke or trauma teams. The PACT nurse also screened daily hospital admissions for missed cardiac arrests, which may be appropriate for follow-up from the PACT.
PACT physicians and nurses were also intended to provide interprofessional education to the ICU, ED, and cardiac care unit (CCU) personnel through presentations at educational rounds and orientation sessions, as well as informal knowledge translation at the bedside.
The principal investigator and study team intended to facilitate ongoing education and quality assurance by using data on care processes and clinical outcomes as a feedback tool. There were to be monthly rounds scheduled for all PACT and steering committee members in order to exchange feedback on team operations. Reviews of PACT cases were employed to fine-tune the activities of the team for maximal impact.