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Improved CPR technique takes root at Stanford

High performance CPR, which eliminates unnecessary pauses and utilizes a team approach, is thought to improve survival rates.

CPR is known for its subpar survival rates; statistics vary, but less than half of those who receive resuscitation survive. But now, physicians, nurses and others at the Stanford Department of Emergency Medicine are among those learning a new technique called high performance CPR.

Emergency medicine physician Kathy Staats, MD, discovered high performance CPR in 2014 after one of her relatives suffered a heart attack in the Pacific Northwest and received HP-CPR. He survived and made a full recovery thanks in part to the innovative technique.

Impressed by these positive results, Staats attended a HP-CPR training at the Resuscitation Academy in Seattle, where the procedure originated. When Staats began work at Stanford, she was pleased to find a fellow HP-CPR enthusiast in Stanford emergency medicine resident Keir Warner, MD, who taught at the Academy before medical school. Together, they launched a pilot initiative to train Department of Emergency Medicine physicians, nurses, and technicians on the new protocol.

HP-CPR differs from traditional CPR in several respects, most notably in a team approach and attention to steps that eliminate unnecessary pauses, Warner told me.

Traditional CPR often involves pauses in compressions to transition between pulse checks, breaths, shocks and procedures. But it's now known that reducing interruptions and increasing the total time compressions are underway during CPR leads to increased odds of survival and better long-term outcomes.

In HP-CPR, multiple people act simultaneously to complete treatment in a coordinated approach to optimize a patient's resuscitation. An ideal team consists of three emergency medicine technicians who rotate compressions, a coach to keep time and call out steps, a nurse to record actions and medications, a procedural nurse, a respiratory therapist, and physician to lead the resuscitation efforts, Staats explained.

Once chest compressions start, the goal is to administer compressions without pause greater than 90 percent of the time, and limit rescue breaths to just one second each, Staats said.

Rescuers must compress the chest quickly and forcefully to a depth of 2-2.5 inches and allow full recoil (or return to level, allowing blood to refill the heart chambers) to circulate oxygenated blood throughout the body, she said. And the person performing chest compressions needs to sustain a high level of precision and timing while minimizing breaks: a taxing challenge when seconds and millimeters can make a difference. Three compressors take turns to prevent fatigue from impacting efficacy, Staats explained. 

Choreography is key as team members rotate through different roles in a specific and timed sequence of compression, pulse checks and rescue breaths akin to a complicated dance. To that end, the department has revisited technology from a bygone era and purchased a metronome for every room in the ED. (Doctors also use their phone at times to keep consistent rhythm.)

The shift to a team approach requires a change in focus. "The old mentality was that the doctor was star of show in resuscitating, but that is no longer the case," Staats said. "Complex procedures have their place in health care, but in most cardiac arrests, the two things that really improve outcomes are good CPR and early defibrillation. It's the compressors, generally our technicians, that most contribute to survival."

The effort to systemically teach HP-CPR -- as taught by Seattle's Resuscitation Academy, based on American Heart Association standards --and measure the outcomes is still in a pilot phase at Stanford, Staats said.

Traditional CPR still serves an important role outside of the hospital, when just one or two individuals might be available to assist. But in the emergency department, HP-CPR offers an important alternative, Staats and Warner said.

"The goal is no longer just to save the life and restart the heart. The goal is to get people back to their normal lives. To get them home to their families quickly, with minimal impact," Warner said.

Photo of Kathy Staats and Phillip Harter, MD, by Susan Coppa

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