Saving the 3 percent

New protocol at Medical Center of the Rockies’ cardiac ICU is proving successful at saving lives.
July 20, 2016

It’s a small number — 3%— of heart surgery patients who go into cardiac arrest in the days following their procedure. But for those who do, the survival rate is low. Now at Medical Center of the Rockies, new cardiac arrest protocols for cardiac surgery patients has been initiated to help that 3% pull through.

“Although it’s only 3 percent of the [cardiovascular] surgery population that arrest, once they do, survival to discharge is only 33 to 57 percent,” said Jessie Willard, UCHealth’s clinical director of Critical Care Services for northern Colorado. “With this new protocol, evidence shows that survival to discharge can be as high as 80 percent.”

Cardiac arrest protocols for cardiac surgery patients

Editors note: CALS, as referred to in this article, is the adopted name for the protocols in Europe. Since this article was published, the protocols have been adopted in the United State and are referred to as Cardiac Surgery Unit-Advanced Life Support (CSU-ALS).

UCHealth recently initiated the Cardiac Surgery Advanced Life Support (CALS) protocol in its cardiovascular intensive care unit at MCR. If it shows great outcomes, the protocol could expand to UCHealth’s other cardiac ICUs, he said.

“Early data is promising,” Willard added. “We are noticing that these [CALS] early interventions are keeping patients from arresting in the first place.”

Nurses train in cardiac arrest protocols for cardiac surgery patients
Staff in Medical Center of the Rockies’ cardiovascular surgery intensive care unit train in CALS, which includes being able to open the chest immediately when needed after a patient goes into arrest. Photo by Susan Miller, UCHealth.

Susan Miller, cardiovascular surgery nurse practitioner supervisor, and Melanie Roberts, clinical nurse specialist for critical care, both of UCHealth in northern Colorado, explained that the CALS protocol is based on the concept that cardiac arrest in cardiac surgery patients in the ICU is a unique situation that requires different actions.

Traditional life support methods — which usually start with CPR — don’t make sense in an ICU where life-saving interventions are immediately available. These interventions, such as pacemakers and defibrillators, may prevent the need for CPR. Chest compressions can cause injury to the patient, so if other interventions can treat the problem and be initiated immediately they should be done first, both Miller and Roberts reiterated.

ACLS [advanced cardiac life support] guidelines are designed with out-of-hospital arrest in mind,” Willard added. “There are a lot of interventions you can do with CALS while the patient is deteriorating. It has specific protocols to intervene on the patient’s behalf earlier than ACLS would have you do.”

Patients who have undergone complex cardiac surgical procedures, such as open-heart surgery, have unique hemodynamics, Miller and Roberts said. Compressions from CPR can cause serious issues, and ACLS-recommended medication has the potential to cause bleeding in these patients. ACLS guidelines don’t address this specific group, but CALS does.

Miller and Roberts encouraged UCHealth cardiac leadership to consider CALS, developed in Europe in 2009 and then approved by the European Resuscitation Council. Recently, the Society of Thoracic Surgeons in the United States endorsed the guidelines.

The new protocol has unique interventions and calls on a special “cardiac surgery code team.” These interventions include utilizing temporary pacing wires, using already attached defibrillation pads, employing different standards for CPR rhythm and depth, and even training the team in how to open up the chest in the ICU to get to the heart.

Miller and Roberts introduced the protocol to MCR management about two years ago, presenting the research to validate that more than 80 percent of their patients may benefit from CALS protocols. They soon received the support of the cardiothoracic surgeons, quality and code committees and senior leadership. Both nurses attended a CALS conference in 2014, and instructor training in 2015, becoming two of the first health care professionals in the United States certified to train others in CALS.

New protocols prove positive

What a patient chest looks like when following cardiac arrest protocols for cardiac surgery patients
Here you can see where defibrillator pads have been placed on a patient following open-heart surgery and pace wires are hooked into a machine ready to be turned on if a patient shows signs of cardiac arrest, all of which are new protocols under CALS. Photo by Kati Blocker, UCHealth.

Over the past year, Miller and Roberts have trained more than 60 nurses and other members of the ICU cardiac team in CALS, and each month, the unit holds mock training to keep their skills sharp.

Preliminary CALS outcomes are showing that the new protocol — and the early interventions it promotes — are keeping patients from arresting because it allows staff to pace (using a pacemaker) the patient before they go into full arrest, whereas ACLS would have them doing chest compressions.

“We’ve had several patients since initiating this protocol where we’ve done this and got their rhythm back and prevented them from going into a full arrest,” Willard said. “It’s really neat to see this bedside buy-in. We’ve had a lot of administration changes over the years, but this change directly affects patient care, and there is a lot of excitement around that.”

“[CALS] allows the critical care nurse at the bedside caring for the patient to rescue the patient before things get out of hand,” said Dr. Mark Guadagnoli, a UCHealth cardiothoracic surgeon in northern Colorado. “Sometimes patients and their hearts/cardiovascular systems are irritable and labile. This can lead to a rapid deterioration in the patient’s condition that requires a quick recognition and intervention. The algorithms involved in the CALS protocol are designed to facilitate treatment and prevent catastrophic deterioration.

“This will continue to protect our patients when problems are anticipated and should help to ensure our already excellent outcomes.”

About the author

Kati Blocker has always been driven to learn and explore the world around her. And every day, as a writer for UCHealth, Kati meets inspiring people, learns about life-saving technology, and gets to know the amazing people who are saving lives each day. Even better, she gets to share their stories with the world.

As a journalism major at the University of Wyoming, Kati wrote for her college newspaper. She also studied abroad in Swansea, Wales, while simultaneously writing for a Colorado metaphysical newspaper.

After college, Kati was a reporter for the Montrose Daily Press and the Telluride Watch, covering education and health care in rural Colorado, as well as city news and business.

When she's not writing, Kati is creating her own stories with her husband Joel and their two young children.