 Good morning, everyone. This is Ariana patient safety move foundation. We're about 5 minutes out from starting the webinar. We'll start promptly at the top of the hour. So, just wanted to acknowledge you all who have joined on time this morning. Please remember to do keep yourself muted to ensure that we don't have any background noise. You're all being muted on entry, but we'll get started in about 5 minutes. Thank you. If you can, please make sure to stay muted. That'll help our audio quality. So, we'll, we'll mute you if we hear any background noise, but would appreciate if you can stay muted. Thank you. Okay, good morning. This is Ariana long late from the patient safety movement foundation, or I should say good afternoon depending on where you are in the world. We are welcoming welcoming you this morning to the advanced resuscitation training or our system of care for reducing preventable death webinar. One of the patient safety movements quarterly webinars and we'll have an expert presenter today, Dr. Dan Davis, who's the founder of the UCSD center for resuscitation sciences. So, we're going to get started this morning. So, this is just a kind of disclosure slide for our CMEs and so we have some learning objectives. For you all to use and apply the integrated approach to reducing preventable death to identify the broad categories of unanticipated arrests to determine the value and core objectives and cardiac arrest resuscitation and to recognize the structural, operational, educational and technological barriers and opportunities to a systems of care approach to resuscitation. So, just to get started, we're going to go through some housekeeping. Everyone has been muted on entry. We do this because we record these webinars and upload them on YouTube later. So, in order to keep the integrity of our audio, please do stay muted. At the end, we will have time for a Q and a Q and a and so we will try to open it up for people to speak. There are two options for this. One is you can raise your hand if you are dialed in and logged in on the web. On your browser, you can raise your hand virtually. So, there are some directions here. You can click on the raise hand button, which will place a small hand icon next to your name in the participant list. And that would allow us at the end. To allow you to speak. The other option is if it becomes too loud. You can use the chat feature. This is what we're used to using. So, please feel free at any time throughout the presentation to leave a comment. If it generates a question for you and we will acknowledge those questions at the end. Also, this quarterly webinar does allow you to claim CMEs, continuing medical education credits, that we'll be sending out an email from the Patient Safety Movement Foundation after the call on how you can claim that through MedStar, which is our accrediting body. So, going through our agenda, I'll give a real quick introduction to the Patient Safety Movement Foundation for those of you who are newer to our network and joining us maybe for the 1st time. I'll also explain what our actionable patient safety solutions or apps are. We'll then have 40 minutes of the expert presentation led by Dr. David and then we'll have 10 minutes at the end for Q and a. So, the Patient Safety Movement Foundation has a very bold goal of 0 preventable debt and we believe that 0 is the only acceptable goal because 1 preventable patient death is 1 too many. And so what we're trying to do is foster new efforts and build on to existing platforms and programs through commitments to 0. So we're not membership based. We're commitment based. We want people to take action. So, we work with 5 main groups. So we're going to run through who can take action. So the 1st group, we'll just stay here 1st group is hospitals and healthcare organizations. And so we ask hospitals and those healthcare organizations or health systems to make commitments. And what that means is they share with us publicly what they're doing to improve patient safety. What programs they're really proud of so that we can share that and kind of bridge the gaps ensuring that any information that might be helpful to anyone else across the world can be easily shared in a shared learning network. The 2nd group that we work with our committed partners and the way that I think about this group is anyone who would be willing to wave a patient safety flag should 1 exist. We want to figure out what those partners are doing to improve patient safety and work together. So those groups might include professional organizations, societies, other nonprofits working in patient safety advocacy groups. And we ask them to sign a commitment to action letter where they detail out what they're working on that's in alignment with the patient safety movement foundation. The 3rd group that we engage with our healthcare technology companies. This makes us pretty unique from other organizations out there. We have a heavy focus on interoperability and what organizations and companies can do to help free up that data. So, any company that creates a device that could share data, we ask to sign an open data pledge, which says that that company will not willingly or knowingly block or interfere that data sharing piece. And they won't charge on top of the product that they're manufacturing in order to improve patient safety. The 4th group are patient and family advocates. One easy way for these, these individuals to get involved is by sharing their story, letting people know that this is still happening and that it should not be happening. Another way is by utilizing resources and also helping identify resources for us. What do you all as patients and family members know that we can help spread and share with others. And then there we go. And then the actionable patient safety solutions are apps. We call them APSF for short. We have 18 in total challenges. So those are what you can see displayed here. And then we have solutions under each one of these. So in total, we have 34 solutions addressing these 18 challenges. An example of an actionable patient safety solutions that has multiple solutions would be airway safety or medication safety. For airway safety, we focus on unplanned extubation, as well as just say for airway management, whereas medication safety, we focus on pediatric adverse drug events, drug shortages, antimicrobial stewardship. So that's how it adds up to the 34. And today we're focused on the systematic prevention and resuscitation and in hospital cardiac arrest and the art program as a way to to kind of utilize and help improve patient safety in that area. So, if you all haven't checked out the actionable patient safety solutions, they are freely downloadable on our website, and we'd encourage you to share them through your networks and within your hospitals, if that's where you are. So, just to share some impact of the patient safety movement foundation since we were started in 2012. We have made great progress getting our organization specifically in this case on this slide hospitals to commit to zero share with us what they're doing to improve patient safety. So we now have over 4,710 hospitals that have made these public commitments to zero. Those hospitals also share with us annually how many lives they believe to be saved within their organization as they make commitments through the patient safety movement foundation. These numbers are self reported. So we do not go in and audit them, but we're really proud to say that last year alone 90,146 lives were saved by the work of these hospitals and they'll share this information based on methodology that they have. So, if they don't have methodology, we can't claim those lives saved. We go through a very rigorous process to ensure that we're being very conservative when we report these numbers. So, with that, we are really excited to have Dr. Davis with us. Dr. Davis is the founder of the UCSC Center for resuscitation science. He completed his undergrad training at UCLA, where he was a national merit, regents and alumni scholar, as well as a varsity member of the 1987 and see a national champion volleyball team. He attended UCSC School of medicine where he remained for his residency training and emergency medicine as a third year resident who is recognized as the UCSC Medical Center House Officer of the year for the first in his department. During his senior year, he served as chief resident and was named outstanding emergency medicine, red, excuse me, medicine resident. As a resident, Dr. Davis developed research interests and brain injury and resuscitation and was recognized nationally as the 1999 recipient of the council of residency directors, academic achievement awards. This research interest has been cultivated as a faculty member and he took a principal role in the San Diego paramedic RSI trial under the guidance of Dr. Coates of the USD division of trauma. This endeavor has already resulted in several published manuscripts with others in preparation that together should definitively illuminate the safety and effectiveness of rapid sequence intubation by paramedics in the pre-hospital arena. In 2001 and 2002, Dr. Davis is the recipient of the SAEM scholarly sabbatical grant and in the current year was the recipient of the UCSC Rosen faculty research development grant. These scholarly grants have afforded him the opportunity to work with an established investigator in brain injury at UCSC Dr. Piyush Patel. Dr. Davis was involved in a series of investigations exploring the relative roles of excitotoxicity and apoptosis in ischemic brain injury. He took a lead role on a project using microarray analysis to identify gene candidates that mediate neuronal ischemic preconditioning. It is anticipated that this line of investigation will lead to sustainable grant support. Dr. Davis received a 2003 SAEM young investigator award and all sorts of other awards. He's currently the principal investigator and EMS operations chair for the prestigious resuscitation outcomes consortium. And so to date, Dr. Davis has over 100 published journal articles, abstracts and book chapters and serves as the editor of the difficult airways section of the Journal of Emergency Medicine. He currently, he is currently conducting studies using grant support from multiple external agencies, including the NIH, AHA, Department of Defense, Zoll Medical, UC Regents, Care Fusion and MassMill Corporation. Within his department, Dr. Davis has served as ultrasound co-director, medical student director, founder and director of the UCSC Emergency Medicine Research Associate Program and based hospital medical director. He's currently the UCSC resuscitation director, founder director of the UCSC Center for Resuscitation Science, Scientific Advisor for Air Methods Corporation and Regional Medical Director for Mercy Air Medical Services. He's also the principal investigator for the prestigious resuscitation outcomes consortium grant. Perhaps his most impactful work to date has been development of the advanced resuscitation training or art program, which we're going to be talking about today, which uniquely links performance improvement data to training to research, excuse me, to reduce preventable deaths in the hospital and pre-hospital environments. He speaks internationally on the topics of resuscitation, ventilation, traumatic brain injury and pre-hospital medicine. So with that, welcome Dr. Davis and we'll pass it over to you to take it from here. All right. Well, thank you very much and I appreciate everyone logging in this morning or this afternoon or this evening to learn a little bit more about what we're doing with the advanced resuscitation training program. As Ariana went past these slides, the disclosure slides, it's worth me mentioning that I do have a conflict of interest in the wake of the early success of this program. The University of California at San Diego insisted that I step out of the university to commercialize this program and offer training solutions as well as consulting. And so that does represent a conflict of interest and it's ultimately what linked me up to the patient safety movement. And so I'll touch back on that at the very end. Let's make sure I can advance the slides. Let's see. You may have to hand me over and troll because nothing's happening when I try and there we go. Perfect. All right. So the advanced resuscitation training program is what I would call a system of care. And to some degree, the way it interfaces with the other apps that Ariana mentioned is that it can be an overlay to help facilitate the implementation and ultimately document the effectiveness of each of the other apps. So in that sense, it ends up being a little different in that it's not focused on a particular clinical problem but instead on setting up what I call again a system of care that helps a hospital or an EMS agency take on the other clinical problems represented by the other apps. And so the concepts that we're going to explore is this idea of an architecture or a system of care, along with the inputs are efferents, and then the outputs are a fair and. And then I'm going to review some of the early outcomes as we've piloted this and established a proof of concept in other hospitals and EMS systems. Now the development of the program was in some ways generated by a CLS and BLS which with well about whichever one is familiar. But we decided to take a couple of steps backwards and look at a broader issue of preventable death, which has been a hot topic in the last decade and a half or so. And the most recent estimates suggest more than 400,000 preventable deaths per year. Now, I'll give you the punchline, and it turns out that if we backwards extrapolate the number of lives saved at the pilot hospitals for art, we can prevent almost all of these 400,000 deaths, which is a little bit of an optimistic estimate. But as Arianna already said, their goal is zero preventable deaths, and this may represent one strategy to accomplish that. But the idea that we were going to focus not just on the resuscitation of patients already in cardiac arrest, but that we were going to try and prevent arrest, but link that to the same system of care as cardiac arrest represented a novel approach. This is going to become incredibly important as we move forward. This is one of my favorite graphs of all time, which was provided by the United Nations. And the map on the background doesn't represent anything other than an interesting backdrop. And so there's nothing about the western hemisphere on the left or the east on the right just makes an interesting and pretty background. But what we see here is the world's population from 1950 and then speculated through the year 2050 and differentiated into those less than age five and those greater than age 65. And for the first time in the history of humans on the planet, we're going to see our species dominated by the elderly. And that has lots of social implications, but from for those of us in health care, that has huge implications with regard to resource allocation and the importance of establishing systems of care and strategies that are not only effective at reducing excess morbidity and mortality, but that are also cost effective what's now being termed healthcare value. And on a reference, we're sort of at the crossing point right now. And so we've got some interesting decades left to come. And for those of us on the call, I suspect we may end up being patients in the year 2050 rather than healthcare providers. So far, our efforts and resuscitation have been mixed at best and disappointing probably for those of us who have dedicated their lives to this. If you look at some of the large databases, and if we rely on our ability to resuscitate patients in cardiac arrest, you can see that the largest databases available suggest they're actually going backwards. And there's some rational explanations for this in out of hospital cardiac arrest, the incidence of shockable rhythms with which we have the most success has plummeted in the last 20 years to where less than 20% of initial rhythms for patients in out of hospital cardiac arrest are shockable when just 20 years ago it was more than half. And in hospital we've seen a gradual increase in the sickness of the patients and the age of the patients and the number of comorbidities. So it's not a complete surprise that we don't do as well in resuscitation as we perhaps did 1020 years ago, but it's been disappointing because we think we're learning lots about cardiac arrest and the optimal ways to resuscitate patients and yet it doesn't seem to be playing out as an increase in survivability across the board. In 2005, for those of you who've been practicing for a little while, we went through what we call the Renaissance in resuscitation where we focus the tension back on the basics on the classics of good chest compressions and optimal ventilations. But you can see from the title of this paper that we wrote, we did not see this sudden increase or even a trend increase in survivability for patients in cardiac arrest following implementation of those 2005 guidelines. In the interim, hospitals have implemented rapid response teams, which represent specialty teams that go out and assess patients who are deemed to be at risk. And the early reviews on these rapid response teams are that they haven't been as effective as we had hoped, and that you can see from the title of this meta analysis, although they make sense, the robust evidence to support their effectiveness is truly lacking. Now my own path led me through science and you heard some of the early experiences recounted by Arianna at the beginning, and it too was a disappointment and that all of our interventions either had no effect or actually decreased survival, which was counter to what I went into resuscitation for. Here you see the cardiac arrest interventions. And on the next slide, the trauma interventions where nothing we seem to think was going to revolutionize care had the intended effect. And that's really been the story of resuscitation science, the things that seem to work well in animals or in the lab or even in small clinical trials, when they're ultimately rolled out across the board, haven't had the impact that we've been looking for. And so it's really been a disappointment and somewhat ironic for myself that the biggest impact that I've been able to have is not through the research but through the implementation of a novel training and system of care program focused on resuscitation. So this is our logo, and you can see from the motto people should not die before they are done living a bit of a play on words to reflect that not only are we focused on resuscitating patients in cardiac arrest but preventing premature death, and then even acknowledging quality of life. And just to give you a sense of the effectiveness. This looks at the best available literature on the left for patients in cardiac arrest from around the world. And then the early data from our pilot sites on the right. And again, this is EMS or out of hospital cardiac arrest, but the average outcomes have fully been twice as effective. As what we've seen published from around the world. And if we look at in hospital cardiac arrest where we have less available data. You can see that outcomes for the published literature versus our pilot sites are dramatically different and that we routinely can increase survivability to greater than 40% even after a single round of the training. In our hospital at UC San Diego, we saw a dramatic decrease in the incidence of cardiac arrest, which we believe is even more important. And that the best arrest is the one that never happens. And that when we piloted this within the University of California system, you can see which of the five hospitals did not implement a prevention strategy and the other four that did with the regard to the incidence of cardiac arrest. So what is the secret to this, this success, what are we doing that's different. I'm not even sure that I completely understand, but one of the important concepts behind the advanced resuscitation training program is that we've broken away from the one size fits all approach to resuscitation training. So here you see, you know, the same costume, but on two different sized individuals and two different results. The idea that we're going to tailor the training to the institution. And I'll explain what that means and how we develop our database and use that to modify the training. But what it first requires is an infrastructure or a system in place that allows you some control over training of other interventions and access to the data that's going to ultimately guide your efforts. The toolkit is what the University of California essentially set me up into the world to propagate. And that's something that we've slowly developed and it has been equally effective at other institutions. That includes even technology and that Ariana said is one of the things that makes the patient safety movement unique, and that they've engaged the the industry of monitoring and medical informatics to try and keep them as part of a team as opposed to keeping them separate because they may be motivated by profits as opposed to hospitals which I suppose are probably motivated by profits too, but aren't supposed to be. The training is a clear part of the toolkit. And then the data collection, which I'll explain in more detail in a second that ultimately all links together in that what happens over time is you create a culture of resuscitation and patient safety. That's hard to put into a recipe or a formula, but it's one of those things where you know it when it happens and it has happened inevitably within even the first few rounds of training. The mission of the program is to prevent preventable death to resuscitate patients who are resuscitable and to be able to recognize when futility is present and be able to have those discussions with the patient or the family or even the primary team. So that's reflective of the motto that patients should not die before they are done living. And I think that's important to keep in mind. The basic model is as a scaffolding, which takes a very broad definition of resuscitation, not just waiting till patients die, but trying to resuscitate and even prevent cardiac arrest. The specificity comes with the specific technology for that institution, the data coming from that institution, the ability to modify treatment algorithms based on performance improvement data and technology, and ultimately influence the content of education and the format of education. And ultimately it's the outcomes that determine whether you're doing it right. And if something's not working, you try something else. We call this approach the enchilada because an enchilada no matter where you slice it has some basic ingredients, a tortilla, beans, cheese, maybe a meat or some guacamole on top. And that represents the idea of the inputs and outputs, the afference and efference, which the inputs could be internal from your own data or external from the scientific literature or even from your technology. And then the things that you do with that, certainly you influence training, launch special projects, and it may be get additional technology. And then the longitudinal aspect of an enchilada represents the path of a patient through the hospital from the initial screening and the emergency department, perhaps through decisions about how to monitor early recognition, the critical care, the cardiac arrest, resuscitation, post-arrest care, and again, even the end of life discussions. And so when you put that into a grid, it outlines or it maps out the different things that ought to be considered under a resuscitation system of care. And although it seems fairly complex and almost overwhelming, you'll find that almost all of these things are being considered by hospitals as we speak. They're not necessarily new things. They just haven't been coordinated under a single program. And that's again one of the things that makes this approach unique. The stuff that we're using for aference include the data that I'll outline in a second, the idea that it needs to be adaptive to the institution. So not every institution can collect chest compression depth today, maybe in five or 10 years, but that we have to be sensitive to the resources available in each hospital and the culture in each hospital, but that we gently encourage an evolution towards what we think is the ideal. And so that's the balance point between adaptivity and evolutionary. And then all the analytics that help you analyze the data. And so these are the data that we collect. The term DECO stands for Database to Enhance Clinical Outcomes, and it plays off the idea of art. But the kind of data that we collect on patients who have had some sort of an event, whether it's a cardiac arrest or even a rapid response activation, the demographics, the events that were happening upstream of the incident. If it was a cardiac arrest, intra arrest of data, including things like chest compression depth, rate, recoil velocity, things that very few hospitals are currently collecting, but hopefully one day will. If the patient survived, then post arrest care, any process issues that were identified during the event, and then ultimately we follow the patients clinically and try and make some determinations that you'll see in a second. This is another way of looking at the same concept where there's events. We have primary database entry and a review. Sometimes we have to react to a specific case, either through the debriefing, which we try to do every single time, or even communicating to the leadership of that unit or risk management, hopefully not too often. But then we include the data in a database that's used in combination with the emerging science to give a big picture response, which may include changes to our algorithms, changes to training, and then ultimately launching special initiatives if we see a particular pattern that's concerning. This is a more complex version of the same thing that shows where we're getting the data, and then what we do with it specifically, but ultimately it's the same concept that we're collecting certain data surrounding each event, combining it with a clinical interpretation, and then feeding it back either on a case specific or in some sort of summary that we're using to guide decisions about the program and also to benchmark and give us a dashboard for the leadership of the hospital. So this just represents a basic CQI loop, but it hasn't really been done effectively in the resuscitation arena previously, and this is a lot of what makes the program effective. And I'm going to show you how we use this data as we go forward here. And what we do with it, again, we have to be sensitive to what each institution has available. So not everyone has access to a simulation center. Not everyone is moving towards online training. Sometimes it just defaults back to a standard life support training class. So adaptivity being able to adapt to the curriculum to each institution is an important piece. And ultimately we can get down to adaptivity at the unit or even the specific provider providing remediation for individuals who are struggling or addressing different topics for different units in the hospital depending on what patterns that we're seeing. We adapt the curriculum to our performance improvement data to the technology that's available, and we try to be flexible with regard to the format of training. I'll show you the modularity in a second, but the idea that you have a broad swath of training materials to choose from. And then the paradigms that we use for different aspects of resuscitation, which again will make more sense in a second, but reflect my bias towards cognitive psychology. And that brings up how we teach not only with regard to the adaptivity, but even the format so that different classes are held in different locations. Part of that is a nod to trying to be cost effective and get the most out of our resources with the assumption that we only have a certain amount of resource available. So let's make sure that it counts and make sure that it's effective. And then again this idea that we need to get inside people's heads and figure out what is it that's gone wrong with training in the past and how can we improve on that and ultimately use our data to demonstrate that it's effective. The idea of a modular curriculum, this is our barn, which looks like a custom built barn, but if you look from the backside, you see that it's just panels that were assembled in a factory somewhere and are made in piece together to meet our individual needs. Very much like the curriculum that I'm describing where you may have an infinite array of training materials available. But that here you're seeing a very specific construct of a curriculum for airway management that takes pieces of the curriculum integrates with cases and ultimately puts them together either for new hires for recurrent training or even remediation. And that it's that modularity that provides some consistency but also the adaptivity to address very specific needs. All right, so let's dive a little bit deeper into the curriculum and you can see how broad of a definition of resuscitation we're using. So in addition to the traditional cardiac arrest, where the paradigm we use is called CPR Island and I'll show you the algorithm in a second. We also have modules on arrest prevention on critical care on airway management. So we're trying to cover the most vulnerable areas of the hospital and resuscitation in general. From the standpoint of the individual, instead of taking four or five or 10 or 12 different courses, they're taking a single course that's addressing different needs based on where they work and the problems that we're seeing. And so I'm going to introduce you to the paradigm behind each one and then show you the effectiveness. So the paradigm to try to reduce preventable death, which is probably most relevant to the discussion today. We call the theory of everything which the movie version documented Stephen Hawking's attempt to describe the universe with a single equation. So for us, that was a single representation of how patients die in the hospital. So what we're trying to prevent is the cardiac arrest we identified for physiologic pathways into cardiac arrest, a circulatory arrest, which is a drop in blood pressure, a disrhythmic arrest, which is exactly what we describe a respiratory arrest involving a drop in oxygenation and then rarely a primary brain injury leading to herniation and a neurologic arrest. These four patterns were then used to generate the materials to teach people pattern recognition at the bedside, as opposed to simply memorizing thresholds or calculating scoring systems or using proprietary algorithms, but instead trying to foster clinical judgment and account for the decreasing level of experience by many bedside providers. If we take it a level up, we identify different diagnoses or clinical conditions that produce each of these things. So for example, drop in blood pressure could be from bleeding from sepsis from trauma related things like tamponade or congestive heart failure. Whereas a respiratory arrest could be from underlying lung disease or even an obstructed airway from narcotic administration. And so these become the guide for the data collection system and I'll show you how that works in a second. We can even anticipate these things by looking at risk factors for each of those clinical conditions. And that when you put all of this together, it becomes a data roadmap for identifying patients at risk and then identifying the early signs and symptoms of deterioration. Now the nurses generally wanted some specificity. They wanted to know that this was true and that was really happening before they called for help. So we added what we called aim and then shoot aim was to try to drill down to make sure that this is real and not just some sort of random noise in the system and then shoot was to try and reverse the deterioration. So when considered together this theory of everything becomes a roadmap for all things related to patient deterioration in the hospital and you can essentially map out the apps from the patient safety movement into this grid. As well as our data collection and even the intervention and protocols for our rapid response team. For cardiac arrest, we define an algorithm of CPR Island, the idea that if a patient's in cardiac arrest, you take them to CPR Island and that there are only two reasons that you would leave the island to actually deliver a shock or reperfusion. So a very simple algorithm but that starts to get complicated for the code leader when you integrate some of the technology like in title co2 and CPR feedback so the simplicity is greatly appreciated for each institution then you fill in some of their blanks with regard to their specific protocols which even the American Heart guidelines do not necessarily tell you for sure whether you should or shouldn't use epi and how you should do your compressions and ventilations but give you several options and so this allows us to adapt the algorithm teach institution. For critical care we use this balancing act of perfusion oxygenation and ventilation. The idea that critical care is a constant risk benefit analysis balancing different physiologic processes. In our airway management algorithm which looks fairly complex but actually becomes much simpler once you understand the different tiers and the different branch points has been used successfully for anesthesia for emergency medicine and for flight crews out in the field. This is the idea of a modular curriculum, the idea that you're in a shopping center or supermarket and you go down the CPR Island pick out some materials regarding CPR depth and maybe some some skills sessions and simulations, and that you can assemble a curriculum for each type of person in the hospital or each unit based on the perceived needs which are often being driven by the data collection. And that includes different slide sets that includes video materials. And that includes even a little vignettes that try and bring some light to the situation even though it's a fairly heavy topic because we found that these discordant images are often more memorable. Because they are so different than than the topics that they're addressing. So here you see the God of ventilation giving some guidance to a guy who holds the bag and squeezes it too long, increasing inter thoracic pressure in the process. You can integrate more sophisticated tools to guide CPR whether that's solely during training like this mannequin, or in real time like you see in the defibrillator on the left, giving you real time feedback we found it takes some specific training to be able to integrate that effectively into clinical practice. And then ultimately simulation, which many but not all hospitals now have access to, but need to be integrated with the curriculum to ensure that the core concepts are being underscored and reinforced. So let's look at the outcomes which hopefully will convince you that this sort of an approach is potentially one solution for the problem of untimely patient death and appreciate the magnitude of the changes in outcomes, the consistency across different institutions. And I'm going to show you how it aligns with some of the other quality metrics, including pay for performance. So here you see UCSB's initial graph of the etiologies of cardiac arrest, which if you look at the etiologies included here, they map out to our theory of everything which represents that integration of data collection and the clinical training. We decided to target these three initially as ones we thought we could reduce. And so that gives us a little bit of a roadmap and then you can see from the first year to the second year that in some cases we were effective and other cases not so much. And so the process of running a system of care in resuscitation and arrest reduction involves constantly looking at your data for the low hanging fruit for the opportunities to then go back and try something different. So cardiac arrest survival, these were our initial survival rates after we decided we were going to target these bagel events as well as respiratory arrests. And after the first year, we saw improvements in most of the areas, but we actually saw the V-Fib V-TAC survival rates go down when we went to a one shock at a time approach that the American Heart Guidelines advocated. So this represents a change then in our algorithm where we went back to stack shocks for monitored or witnessed arrests, continued to reinforce the other concepts. And after the third year, we saw survival go back up with V-Fib continue to improve or maintain in the other areas. So again, a very simple CQI loop, but it hasn't really been done in the area of resuscitation before. And together that led to a dramatic improvement, not only in arrest survival and a reduction in arrest incidents, but as you'll see in a second, an actual reduction in overall hospital mortality. We can get very specific. So in this case, we're looking at chest compression fraction, a very specific element of CPR before and after the program. Or in this case, in a group of emergency physicians and nurses, looking at the percentage of chest compressions with the optimal rate and depth, which at baseline was very poor. But then after the training, I went to nearly 100% for most patients or most providers. The survival from cardiac arrest in our hospital continued to ratchet up and up, but was already ahead of the national average to start. So this isn't necessarily just for hospitals that are struggling, but that everyone has opportunities for improvement and that overall mortality decreased by about 25%, which is very exciting, not only because that represents a quarter of the patients who die in the hospital, but also for the hospital's sake, because now mortality is part of the formula for Medicare reimbursement. It meant literally millions of dollars coming back to the hospital. And that UC San Diego as compared to the other UC hospitals had the best performance when we first started this program almost a decade ago in the wake of the program implementation, but also the fastest rate of improvement as opposed to the sister institutions. And that within the state of the California, we had the lowest mortality index or risk adjusted mortality, which again is now tied to Medicare reimbursement. And then across the country is part of a database. We went from kind of middle of the pack to one of the top five performing institutions with overall quality. And we've piloted this in other areas of the country and other types of institutions. We've seen remarkable consistency, even after the first round of training with regard to arrest survival. Here you see one particular hospital. They go year over year increasing their survival to discharge. And here's a hospital in Louisiana, which was able to reduce the incidence of cardiac arrest by layering this curriculum on top of their rapid response program. And then we can get very specific with certain techniques in this case, intubation success among flight nurses and paramedics, who's success rates even under the worst conditions out in the field, mostly with trauma patients are actually higher in their survival. Are actually higher than the success rates for anesthesiologists in the operating room. So this will be the last slide just kind of describing the process of implementing a program like this. And this is something that we're certainly willing to help you with and you can contact me. I'll give you my email address in a second here or reach me through the patient safety movement in Ariana. But I really just want to encourage hospitals to start thinking about this kind of system of care or a programmatic approach to resuscitation. Where we have this architecture that links together data and training and brings in technology in the scientific literature and creates a an organized system of training materials to address any problems that arise. And that includes the slides, the videos, skill sets, simulations, all of these things that we've been talking about. The database and analytics to not only document the effectiveness but also provide a roadmap and identify opportunity areas. And there are now increasing number of consultants available to help with this process or actual training available to get you started. And that's something that I'm willing to help with. And I hope as we move forward, there will be a growing community of hospitals and EMS agencies that are taking this on and breaking from the traditional approach to life support training and encouraging each other and sharing ideas, which we would call a community. So that's the last slide that I have and I'll I'll hand it back over to Ariana and her crew to help field the questions, but just so that you have my contact information, my email address is my name Daniel Davis MD. All one word with no underscores or periods or anything just Daniel Davis MD at gmail.com. So if you have any questions or if you want some additional information or I don't know if you have access to the slides, but I'm certainly willing to provide the slides. If that's something of interest to you. So thank you very much for sticking with me to the end here and Ariana and I hand it back to you. Great. Thank you, Dr. Davis. What a wonderful presentation and obviously we can tell that you're so passionate about this and it's been fantastic to see the outcomes from being able to implement this. I hope everyone else on the line has found as much value as I have in absorbing this. We do have about 15 minutes for questions. And so we did just receive our first question through the chat box. Remember, please feel free to send your your questions through chat or if you'd like to raise your hand, we'll be looking for hands to be raised. So the first question comes from Jennifer Johnson. She asks what strategy was used to repurpose staff ACLS BLS PALS training dollars to fund this program. So we had sort of a fortunate occurrence that at the time was seen as disastrous in that the same month that the American Heart Association came in and saw what we were doing which was originally under the banner of ACLS and BLS, but that we had tweaked, which I found was not necessarily welcomed with open arms that they came in and said, you know, you can't do this and call it ACLS and BLS because you're giving a card that certifies that somebody took this class means that they took the class that the American Heart Association, you know, sent you and not your own version of that and although they understood my efforts to improve outcomes and were impressed with the outcomes that ultimately you couldn't call it ACLS because it had become so different. And so we thought that that would shut down the whole program because who wouldn't have ACLS and BLS as the core of their hospital certification process. Well, then the Joint Commission came in a couple of weeks later and saw a resuscitation and saw two groups of people, one who had been trained by the local AHA outpost and one who had been trained by our program which didn't even have a name yet, and saw a dramatic difference in their level of competency and their comfort and their awareness of what was going on during the event and ended up learning about the program and anointing it their best practice model which now is called their Good Practices Database. And so it was the Joint Commission that told us you need to keep doing this, you need to expand it into all your clinic areas and you need to try and get other hospitals to follow this sort of a model. And so that's all our hospital needed to hear in order to say okay from this point forward, we're going to take all the dollars that we were spending on ACLS and BLS and reallocate those towards this program and that was the way it was presented back to me as you can use the same pot of money. One thing we found is we didn't have any idea how much was being paid because a lot of folks were out there taking classes and then submitting their receipts for reimbursement from their units. So my big mistake was I ended up showing that you could do this for what I thought was the ACLS, BLS, PALS budget turned out to be about 25% under budget once we finally got all the returns but once you show you can do something for less you'll never get that money back. So for us there was a very distinct flipping of the switch, and it wasn't until later that we realized how much the hospital was recouping with regard to pay for performance reimbursement or the other big area that we were saving money with this program was in medical legal expenses because the University of California itself is insured and that our payouts were reduced by 95% in the wake of the program so it was an easy sell for our hospital because we had the joint commission saying you need to do this and then all of the the financial incentives came later. I've found going forward that about half the hospitals are brave enough to say we're going to do something besides traditional life support training and they're willing to make a swap and others that want to use this sort of training a supplementary. I don't want everyone to take the basic life support training and then use this to train specific people like the code team members or to use it as sort of reinforcement of the core concepts because the core concepts are not dramatically different than what is taught within ACLS and BLS. But it's really a more effective strategy and then we go much broader in covering the prevention aspects as well. So if you're looking for more specifics for your institution then again contact me because it helps once I kind of know what type of institution it is and then you can get to what really motivates the institution to want to make a change. So my again my address is Daniel Davis MD at gmail.com. Great. Thanks Dr. Davis. We have two more questions. Next one's from Jean McCarthy. She says if I heard correctly at the beginning of your presentation you mentioned a decline in shockable rhythms over some period of time but I didn't catch the reason for this. That's a good question that mostly applies to the out of hospital arrest population where at least two dozen different cities or EMS agencies have documented that in a 10 to 20 year period, the incidence of ventricular fibrillation as the primary arrest rhythm has gone from more than 60% down to our most recent data less than 20%. And we think that that has to do with patients being more aggressive in going to the emergency room when they have an elephant sitting on their chest. It may have something to do with the increased use of medications like beta blockers which reduce the likelihood of somebody flipping into ventricular fibrillation. And in some places, the response times have actually gone up for certain patient populations and the longer you wait, the more likely V fib. If you were there when the first few minutes becomes PA or assistively, but that's really a function of out of hospital cardiac arrest for in hospital. It really depends on what types of patients you have and we saw a spike in the incidence of our V fib arrest rate. When we opened the cardiovascular center, which attracted some of the sickest patients in San Diego County to our hospital, but also then give us a different risk profile and we saw an increase in the V fib arrest rate along with the increase in patient volume. Great. Thanks for answering that question. Next question is from William Schneiderman. He said, Dr. Davis, thank you for an excellent presentation. How were you able to capture your EMS agency and EMS providers interest or captivate their attention in patient safety? Do you have a suggestion or two for captivating this group's interest in patient safety and their commitment to patient safety in the pre hospital arena? Yeah, that's a that's a really good question. And that's at the essence of my belief in cognitive psychology, which I use a shorthand for the idea that what I think is broken in current life support education is this idea that you need to capture people's imaginations and their passions before they're going to be receptive to anything else that you have to say and you have to convince people that this is more than just a regulatory requirement to take this training, but that people's lives are at stake. And I will use anything. This is sort of an in justifies the means kind of approach. I'll use anything to try to capture people's spirits in the sense I found that deep down most providers really want to have an impact, but that they've been burned for so many years of seeing, you know, the guidelines flip and flop or seeing the outcomes that have been improved that they're reluctant to actually put any hope in this training. And so making them feel like they're part of a movement, showing these other outcomes and saying, you know, these are real people that are going home to their families and I'm not above using an anecdote, which has been kind of discouraged in the traditional CLS classwork. But if you can use anecdotes to illustrate something very specific, whether it's the impact of this training, or the impact of one specific point that we're trying to emphasize. They're willing to bring people around and they're reluctantly willing to give you a shot and see if it works. Now one eerie coincidence every place that we've gone has had a very high profile save within days to a week of the training, and that suddenly everyone sees this as something different something that you do. And that's the best thing that can happen to an institution is that people see it as something different, not just the same old thing that changes every five years and you wait long enough will go back to what you were doing, you know, when you first learned 20 years ago. That's a lot of my own focus and it calls on my undergraduate degree in psychology to try and get people to believe in the system and reinforce that and then increase their receptivity to what you have to say. Great. Thanks, Dr. Davis. That concludes the chat questions that we had. If anyone would like to try to take themselves off of mute. If you have any questions, I don't see any hands were raised, but we do have about six minutes left. So I'll just pause. Please feel free to unmute yourself if you have a question and you can speak up. Okay. I haven't heard anything. So we'll just move on to our last slide. So I wanted to remind you all that we have one of our two main meetings of the year to say September 17, which is just in a few weeks here. And it's on World Patient Safety Day. It'll be here at the University of California Irvine. We have a few spots left. It is free registration. So if you'd like to join us, you are more than welcome. Our next quarterly webinar will be in December. We haven't set the date or the speaker yet. So stay tuned for that. And our World Patient Safety Science and Technology Summit, our big event of the year is coming up March 5 through the 7th of 2020 also in Southern California Huntington Beach. It'll be lovely here in March, maybe snowing in other parts of the country, but hope that you can make it. I did notice that there was one more question that came in from Jennifer Johnson. So since we do have four minutes, I'll repeat this to Dr. Davis and see if we can get one more in here before we close. So Jennifer Johnson has asked, have each of the facilities that you've worked with developed their own unique database to study their cardiac arrest data? So I developed a database in Excel with a lot of formulas and things and our grant within the University of California was to test that database across the five sister institutions and focus on data collection with some of them also doing training like I showed you, but that wasn't necessarily part of the grant. So we've refined it and we have it as a kind of tiered program where initially the focus is on just capturing the events and trying to categorize the etiology of arrest. And then as time goes on, trying to become more sophisticated either with regard to CPR data or some of the actual performance data from the team that was involved in the resuscitation. So we've sort of refined that database and our next step is to put it into a format that uses all the right firewalls and is in the cloud, et cetera, et cetera. So we're hopefully close to doing that. In the interim, the hospitals that are participating in our pilots are using my original Excel spreadsheets, but they're keeping the data locally because we don't have all those firewalls and all of that. So they provide to me summary data so we can look at how they perform relative to each other, but they're keeping the data using our Excel spreadsheet and our manual of operations and data definitions. They're keeping all of that locally. Great. Thanks Dr. Davis and thank you everyone for your questions through the chat box. With that, I think we'll close for the day. So Dr. Davis, again, thank you so much for your passion and knowledge around this area. It's been a wonderful quarterly webinar topic for us to focus on. And so remember, for those of you who want to claim CMEs, we will be sending out an email in the next day or so and we'll be uploading this onto YouTube so that if anyone would like to share it with colleagues or absorb it again later. You'll have access to do so. I've also shared Dr. Davis's email in the chat box. If anyone was looking to email him, I know you've mentioned it a few times. So thank you so much. Have a great rest of your day. And we look forward to hopefully having you on our next webinar in December. Take care.