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On the surface, Advanced Resuscitation Training (ART) and Basic Resuscitation Training (BART) may appear to be alternatives to the Advanced Cardiac Life Support (ACLS) and Basic Life Support (BLS) courses from the American Heart Association. However, ART is actually a resuscitation management program for hospitals, clinics, and EMS agencies rather than a specific course. A broad definition of resuscitation is used for both the inpatient and out-of-hospital environments. Inpatient ART considers a spectrum of resuscitation issues – from surveillance and monitoring of all patients through critical care, cardiopulmonary arrest and post-resuscitative care. Out-of-hospital ART includes cardiopulmonary arrest, prevention of arrest in critically ill patients, advanced procedures such as airway management and intubation, and sophisticated monitoring strategies. In addition, the ART program integrates adult and pediatric resuscitation, medical and surgical/trauma patients, and end-of-life issues. Finally, the training is adaptive to address the unique requirements of various providers and flexible to integrate CQI data and specific institutional needs.
Resuscitation events are relatively infrequent, with each provider participating in only a few events each year. Resuscitation performance is strongly linked to patient outcomes, underscoring the importance of optimal training and effective treatment algorithms. Integrating the broad scope of resuscitation under a single, unified curriculum enhances provider understanding of key concepts and ultimately clinical performance.
The ART program empowers health care providers by creating a “culture of resuscitation” that serves to enhance patient safety in unprecedented fashion. Unlike the existing model of life support training, the ART program recognizes the complexity of deterioration and incorporates cardiopulmonary arrest prevention. The program employs an original “Integrated Critical Care Model” to integrate multiple components of resuscitation science and defines a new paradigm for inpatient and prehospital medicine.
The ART program links CQI with training, treatment algorithms, and special projects and initiatives. At the center of the CQI process is the ART Matrix, which represents a sophisticated taxonomy to describe the various etiologies of cardiopulmonary arrest. The Matrix is hierarchical and categorizes resuscitation events into discrete boxes.
The effectiveness of ART is best reflected by the results achieved at UC San Diego Medical Center (see graph below). ART has reduced the incidence of cardiopulmonary arrest by almost 50 percent. This reduction in arrest frequency has occurred predominantly in the non-ICU environment where the current incidence of arrests is about one-quarter of baseline. These results support the IOM goals of reducing preventable arrests and fostering an environment of enhanced patient safety. For the remaining patients who suffer cardiopulmonary arrest, neurologically intact survival has more than doubled. Survival-to-discharge rates have been sustained at a level more than twice that of the benchmark established by the American Heart Association’s Get With The Guidelines database for five consecutive years. The ART program has resulted in a 20 percent reduction in overall hospital mortality.
As a result, ART has been designated as a Best Practices Model by the Joint Commission and recognized as a Best Patient Safety Initiative by both the National Association of Public Hospitals and the University of California Regents. Most recently, UC San Diego Health System received a Quality Leadership Award from the University Health System Consortium (UHC) based on rapid improvements in overall mortality and patient safety and a top-five ranking in overall quality of care. Perhaps the most telling statistic for ART is that observed mortality at UC San Diego Health System is 38 percent below expected values, leading to UC San Diego’s recognition as one of the safest hospitals in the county, state and country.
In the pre-hospital environment, ART training has resulted in similar outcomes. For patients arresting in the presence of air medical providers, survival-to-ED-admission more than doubled following training. Survival from out-of-hospital cardiac arrest increased 50 percent following ART training in a cohort of San Diego County EMS agencies, and survival among patients arriving to the UC San Diego Emergency Department with ongoing chest compressions rose from zero to more than 9 percent.
The UC San Diego Center for Resuscitation Science teamed with the Society of Hospital Medicine to compete for a federal grant to disseminate the ART program nationwide. The project was termed Hospital Enactment of Advanced Resuscitation Training (HEART) and was designed to accelerate the development of the ART infrastructure and demonstrate feasibility in a group of 15 hospitals across the country. Although very little time was allotted between announcement of the grant program and submission of applications, the HEART program was able to enlist support from an impressive group of organizations that guide inpatient medicine: American College of Cardiology, Society of Hospital Medicine, American College of Emergency Physicians, Society of Critical Care Medicine, American College of Surgeons, American Association of Critical-Care Nurses, Emergency Nurses Association, American Association of Respiratory Care, University HealthSystem Consortium, American Hospital Association, HCA Healthcare, United Healthcare, VA Medical Center, Hospital Alliance for Resuscitation Quality, Sansio, and Summit Performance Group. In addition, the HEART project attracted a team of world leaders in resuscitation science as coinvestigators and advisers. This reflects the broad support the ART program achieved and the universal dissatisfaction with the current standard.
The three main components to facilitate broad implementation of the ART program include: 1) ART University, 2) a Mentored Implementation program, and 3) information technology resources to facilitate ART implementation and maintenance, training, and CQI.
The ART program may actually cost less than current life-support training expenditures. At UC San Diego we spent a mean of $170 per inpatient provider under the traditional resuscitation training model. The annual cost of the ART program, including leadership, CQI support, trainers, and administration, averages approximately $120 per inpatient provider. It is anticipated that each participating institution will reallocate a portion of this savings to support the ART infrastructure through a licensing fee. There are no for-profit entities involved in the ART program, consistent with our goal of creating a sustainable and affordable model that improves resuscitation outcomes.
While a 40 percent savings in life support training is substantial, the real financial benefit of the ART program lies in the preventable deaths avoided. More than 70 deaths are prevented at UC San Diego each year compared to our baseline. The Agency for Healthcare Research and Quality estimates unexpected inpatient deaths cost $50,0000 in the short term. This means the ART program saves our institution $3.5 million annually. In addition, savings in prevented lawsuits and decreased premiums will also be substantially greater than the decrease in training costs. It is no coincidence that our first grant was awarded by the UC Regents liability carrier. Finally, pay-for-performance and value-based purchasing will incentivize programs that improve mortality and enhance patient safety.
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