Advanced Resuscitation Training (ART) at the Center for Resuscitation Science (CRS)

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. Finally, the training is adaptive to address the unique requirements of various providers and flexible to integrate CQI data and specific institutional needs, staffing, and workflow.

Step One:

Step Two:

Step Three:

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.

• A simplified and institution-specific approach to resuscitation, with consideration given to the specific equipment and capabilities of the response team.
• Integration of a broad spectrum of resuscitation concepts, from monitoring/surveillance and arrest prevention through critical care, arrest, post-resuscitative care, and end-of-life issues.
• The use of CQI data to modify treatment algorithms and training and guide new initiatives.
• A comprehensive approach to critical care education that relates three basic physiological processes (perfusion, oxygenation and ventilation).
• A flexible, adaptive curriculum that responds to the unique needs of trainees based on provider-type and specific patient characteristics.
• Adult learning principles including the use of expert physician and code RN instructors.

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 eight 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 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 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.

Since the initiation of the ART program:

• Cardiopulmonary arrest survival has doubled and is currently more than twice the national average (defined by the American Heart Association Get With The Guidelines).
• Neurologically intact arrest survival has tripled in non-ICU patients.
• The incidence of non-ICU arrests has decreased by more than 60%.
• The improved survival and decreased arrest incidence in non-ICU patients have dramatically enhanced patient safety.
• Expenditures for life support training have decreased by over 35%.

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.

• ART University employs a center-of-excellence model. Teams from various hospitals implementing ART can attend a workshop with the following objectives: 1) to understand the ART program and all of its components, 2) to review the science behind the various treatment algorithms, 3) to understand the principles behind the CQI Matrix, 4) to review training options, 5) to gain exposure to the various information technology support tools and training resources available through the ART program, and 6) to receive specific guidance on implementation strategies.

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.

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 $50,000 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.