Sir Ganga Ram Hospital, New Delhi, India

Quality Improvement Team of the year

Padmashree Dr.(Prof.) D.S. Rana,

Chairman Board of Management & Deptt of Nephrology

Dr Reena Kumar, (MHA AIIMS)

Addl. Director Medical Services, Head Department of Hospital administration and Quality, Principal Assessor NABH

Dr Suruchi Sinha,

Deputy Medical Superintendent

Sir Ganga Ram Hospital is a 675-bedded Tertiary Care, State-of-the-art Hospital in India. The hospital was founded initially in 1921 at Lahore by Sir Ganga Ram (1851-1927), a civil engineer and leading philanthropist of his times. The foundation stone was laid in April 1951 by Late. Prime Minister of India Shri Jawahar Lal Nehru. It provides comprehensive Healthcare services, and has acquired the status of a premier Medical Institution.

It continues to maintain its charitable character in accordance to the wishes of its founder. Funds generated from the hospital services are partially utilised for providing free health care to the poor and needy patients.

The Quality team adapts a holistic approach to long-term success that views continual improvement in all aspects of an organization as a process and not as a short-term goal. It aims to radically transform the organization through progressive changes in the attitude, practice, structure, and system keeping patient first and patient safety as its ultimate objective.

"IT's not about perfect. It's about effort and when you implement that effort into your life….Every single day, that's where transformations happen. That's how change occurs. Keep going remember why you started …..

Jillian Michaels

Cardio Pulmonary Resuscitation Committee Code Orange-Medical Emergency Paediatric *5777
Dr. B.K. Rao, Chairperson Chairperson - Deptt. of Critical Care & Emergency Medicine Paediatric ICU Registrar on Duty
Dr. Reena Kumar A.D.M.S Nursing Supervisor
Dr. Ashwini Mehta Sr. Consultant, Cardiology Nursing Supervisor
Dr. Suresh Gupta Sr. Consultant, Paediatrics DMS on Duty
Dr. Debashish Dhar Sr. Consultant, Paediatrics ECG Technician
Dr. Jyoti DMS & In-charge - Quality Telephone Exchange
Ms. Usha Pandey Chief Nursing Officer  
Code Blue-Cardiopulmonary Arrest *5111 Code Indigo-Medical Emergency Neonatal *5999
ICU Consultant Neonatology ICU Registrar on duty
ICU Registrar Nursing Supervisor
Cardiology Registrar Nursing Supervisor
DMS On duty DMS on duty
Nursing Supervisor ECG Technician
Telephone Exchange Telephone Exchange
Crash Trolly
Standardized List of Crash Cart – Uniform in all locations
BLS Training
BLS Training 2015/2016/2017
Categories of staff 2015 2016 2017 Total
Doctor 200 440 98 738
Nurses 500 800 210 1510
Paramedical Staff 109 150 40 299
Grand Total 811 1396 348 2555
ACLS Training
ACLS Training 2015/2016/2017
Categories of staff 2015 2016 2017 Total
Doctor 102 240 60 402
Nurses 367 605 200 1172
Grand Total 471 851 203 1552
Code Blue Performa
Six Sigma Tools - DMAIC
Code Blue activated vs. Cardio Pulmonary Respiratory Arrest
Code Blue team arrive within 3min
Discharged after ROSC(%)
  Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Average (%)
2015-16 92.86% 100% 88.24% 100% 100% 50% 66.67% 100% 92.86% 82.61% 90.91% 87.50% 87.64%
2016-17 84.60% 81.25% 100% 86.67% 85% 93.75% 80.00% 100% 100% 100% 100% 94% 92.89%
Return of spontaneous circulation (ROSC) after CPR
Discharged after ROSC(%)
  Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Average (%)
2015-16 44.4% 42.9% 30.0% 33.3% 20.0% 0.0% 0.0% 33.3% 57.1% 33.3% 35.7% 54.5% 32.10%
2016-17 45.5% 50.0% 14.3% 41.7% 33.3% 46.7% 46.7% 30.8% 16.7% 36.4% 63.6% 40.0% 38.60%
Discharged after ROSC
Discharged after ROSC(%)
  Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Average (%)
2015-16 0.0% 14.3% 20.0% 16.7% 0.0% 0.0% 50.0% 16.7% 14.3% 19.0% 14.3% 9.1% 14.50%
2016-17 27.3% 28.6% 57.1% 16.7% 22.2% 40.0% 22.0% 15.4% 50.0% 36.4% 18.2% 33.3% 30.60%
Logistic Checklist -Code Blue Performa 2015/2016/2017
13 Was staff able to readily locate/operate the following: Available, and was used Available, but not used on the patient Available, but defective Not Available
  a)Emergency Medicines        
  b)Defibrillator        
  c)Laryngoscope        
  d)Ambu bag        
  e)Oxygen Cylinder (filled or not)        
  f)Suction machine & suction catheter        
  g)Glucometer        
Logistic Checklist Code Blue Performa
Logistic Checklist Code Blue Performa 2015,2016,2017
  Ambu Bag Laryngoscope & intubation Defibrillator ET tube & Airways O2 therapy Emergency Medicines Others(
Non-compliance (%) 0.5 0.3 0.3 0.0 0.5 0.3 2.5
Compliance (%) 99.5 99.7 99.7 100.0 99.5 99.7 97.5
Glossary :

Basic Life Support (BLS): Emergency treatment of a victim of cardiac or respiratory arrest through cardiopulmonary resuscitation and emergency cardiovascular care.

Code Blue: A declaration of or a state of medical emergency and call for medical personnel and equipment to attempt to resuscitate a patient especially when in cardiac arrest or respiratory distress or failure.

CPR: A basic emergency procedure for life support, consisting of mainly manual external cardiac massage and some artificial respiration.

Cardiac arrest: Defined as the cessation of cardiac mechanical activity as confirmed by lapse in circulation, which was determined by the absence of a palpable central pulse.

Continual Quality Improvement: CQI is serial experimentation (the scientific method) applied to everyday work to meet the needs of those we serve and improve the services we offer.

Return of Spontaneous Circulation (ROSC): is resumption of sustained perfusing cardiac activity associated with significant respiratory effort after cardiac arrest

References:

In-hospital cardiac arrest is an emergency situation that requires teamwork and appropriate sequential actions to rescue the patients.[1] Despite considerable efforts to improve the treatment of cardiac arrest, most reported survival outcome figures are poor.[2] Even in the hospitalised patients, the rate of successful CPR has been reported by some studies to be as low as 2–6%, although most studies report successful CPR outcome in the range of 13–59%.[3,4]

Very few studies are available in the literature on comparative CPR outcomes after formal resuscitation training. An in-hospital investigation demonstrated that cardiac arrest detected by an ACLS-trained nurse was strongly associated with a four-fold increase in survival to discharge. (38% vs. 10%) than those detected by a nurse without ACLS training.[5] This indicates that ACLS-trained nurses provided an independent contribution to increased survival rate.

Study by Saket Girotra, for the American Heart Association Get with the Guidelines–Resuscitation Investigators in “Trends in Survival after In-Hospital Cardiac Arrest “shows that the overall rate of survival to discharge improved significantly from 13.7% in 2000 to 22.3% in 2009. [6]

Conclusion:

Successful resuscitation after cardiac arrest requires early recognition of cardiac arrest, rapid activation of trained responders, timely initiation of BLS, early defibrillation and early ACLS.[7].Our study reveals that availability of logistics at all locations with  formal training of the CPR team will drastically improve the survival rates and survival to hospital discharge rates following resuscitation of cardiac arrest victims. The Quality Initiative under taken reinforces that  formal certified BLS and ACLS training/retraining with hands-on practice with periodic renewal are crucial in improving the outcomes of  ROSC and Survival rate 

Biblography

  1. Krittayaphong R, Saengsung P, Chawaruechai T, Yindeengam A, Udompunturak S. Factors predicting outcome of cardiopulmonary resuscitation in a developing country: The Siriraj cardiopulmonary resuscitation registry.J Med Assoc Thai. 2009;92:61823.[PubMed]
  2. Jacobs I, Nadkarni V, Bahr J, Berg RA, Billi JE, Bossaert L, et al. Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries. A statement for healthcare professionals from a task force of the international liaison committee on resuscitation. (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa) Resuscitation. 2004;63:233–49. [PubMed]
  3. Borimnejad L, Nasrabadi AN, Mohammadi H, Kheirati L. Improving the outcomes of CPR: A report of a reform in the organization of emergency response. Internet J Emer Med. 2008;4:2.
  4. Berger R, Kelley M. Survival after in-hospital cardiopulmonary arrest of noncritically ill patients. Chest. 1994;106:872–9. [PubMed]
  5. Dane FC, Russell-Lindgren KS, Parish DC, Durham MD, Brown TD. In-hospital resuscitation: Association between ACLS training and survival to discharge. Resuscitation. 2000;47:83–7. [PubMed]
  6. Saket Girotra, M.D., Brahmajee K. Nallamothu, M.D., M.P.H., John A. Spertus, M.D., M.P.H., Yan Li, Ph.D., Harlan M. Krumholz, M.D., and Paul S. Chan, M.D., for the American Heart Association Get with the Guidelines–Resuscitation Investigators.
  7. Doig CJ, Boiteau PJ, Sandham JD. A 2-year prospective cohort study of cardiac resuscitation in a major Canadian hospital. Clin Invest Med. 2000;23:132–43. [PubMed]