Improving patient outcomes with the Cardiac Advanced Life Support-Surgical (CALS-S) guideline

Approximately 395,000 patients per year undergo cardiac surgery in the US, with the incidence of postoperative cardiac arrest in adult patients ranging from 0.7% to 2.9%.1-6 Cardiac arrest after cardiac surgery typically is related to one of two types of reversible causes: electrophysiologic disturbances, such as dysrhythmias; or mechanical causes, such as graft malfunction, cardiac tamponade, bleeding, or tension pneumothorax.7 Around the world, outcomes for patients undergoing cardiac surgery who experience cardiac arrest are good but vary, with between 17% and 79% of patients surviving to discharge.8 Of these patients, 25% to 50% involve ventricular fibrillation (VF) and can be treated immediately with defibrillation.8 Additionally, both cardiac tamponade and major bleeding events respond to resuscitation and emergency resternotomy.8 The current American Heart Association (AHA) Advanced Cardiovascular Life Support (ACLS) guidelines do not specifically address cardiac arrests following cardiac surgery.9 In 2009, the European Association for Cardio-Thoracic Surgery published its Guideline for Resuscitation in Cardiac Arrest after Cardiac Surgery.8 Called CALS-S in the US, this guideline has been adopted in several prominent cardiac programs.10 Because of ACLS limitations, many US cardiac surgery programs, including this study hospital, have established their own cardiac arrest post cardiac surgery protocols that are not necessarily standardized or evidence-based.11 CALS-S provides an evidencebased protocol to improve outcomes for cardiac arrest in patients who have undergone cardiac surgery.8 Failure to rescue (FTR) is the occurrence of death after complications not present at the time of admission.12 In 2015, using modified ACLS guidelines at this study hospital, 1,097 patients underwent cardiac surgery, and 15 of these patients (1.4%) suffered a cardiac arrest after surgery. Of these, eight did not survive, translating to a pre-CALS-S implementation FTR rate of 53%. The nurse experience during cardiac arrest can be stressful and uncomfortable.13 Stress affects nurse performance and patient outcomes in cardiac arrest response.13 Previous nurse stress levels at this study hospital were unknown, but anecdotal evidence suggested some degree of stress and discomfort among cardiac surgery intensive care unit (CSICU) nurses. The purpose of this quality improvement project was to reduce the FTR rate for cardiac arrest in cardiac surgery patients by implementing an educational intervention to improve CSICU nurses’ comfort and confidence in using the CALS-S guideline when responding to such events.