In 2003, there was a cardiac arrest on a patient four hours post cardiac surgery in a large center in the north of the United Kingdom (UK). Over the next four hours, the patient’s chest was re-opened three times and eventually the patient was re-grafted in his ICU bed on cardio-pulmonary bypass. Many junior staff both medical and nursing reported they felt disorganized and of little help to the situation and would have performed much better if they had a defined and well-practiced role. Further research over the years demonstrated that there was an appreciable rate of Cardiac Arrest post Cardiac Surgery (up to 8% in the US in some hospitals) with a variable chance of survival and extreme morbidity in many survivors. In response to this, two surgeons from the UK created the Cardiac Surgery Advanced Life Support course (CALS).
Central to the teaching of such a course was the development of a protocol that addressed the unique set of challenges that was associated with cardiac arrest post cardiac surgery. This was accepted by the European Association of Cardiothoracic Surgeons (EACTS) audit and guidelines committee as a project in 2007. A multimodal methodology of systematic reviews, an international survey (of 350 surgeons), collaboration with the European Resuscitation Committee (ERC) and the International Liaison Committee on Resuscitation (ILCOR) and practical arrest moulages finally produced a guideline which was accepted two years after the project started. It became the European Association of Cardiothoracic Surgery’s official protocol in 2009 (European Journal of Cardio-Thoracic Surgery, Volume 36, Issue 1, 1 July 2009, Pages 3–28). This was accepted by the ERC and ILCOR over the next two years.
Academically it was realized that cardiac surgery around the world although similar had slight differences and thus there was a need to change (and update) the protocols for different areas. With that in mind the process was repeated again in America starting in 2014 with the setting up of a Resuscitation Taskforce of the Society of Thoracic Surgeons (STS). A similar process (now using a DELPHI methodology) was carried out and was accepted by the guidelines committee and published in March 2017 as The Society of Thoracic Surgeons Expert Consensus for the Resuscitation of Patients Who Arrest After Cardiac Surgery (The Society of Thoracic Surgeons Task Force on Resuscitation After Cardiac Surgery) (Annals of Thoracic Surgery, Volume 103, 1 March 2017, Pages 1005–20).
The process is being repeated again in Australia and New Zealand (with a similar methodology to the STS) by a multi-disciplinary body (The CALS-ANZ board) comprising of Cardiothoracic Surgeons, Intensivists, Anesthetists and Nursing Staff. It is ongoing at the time of writing (August 2018).
The core of the protocol is the understanding that most cardiac arrests in the early phase post-cardiac surgery are related to causes for which external cardiac compressions (CPR) are unable to provide any meaningful cardiac output (cardiac tamponade, hypovolemia, etc.). Thus, in this situation standard ALS protocols are completely ineffective. Due to the fact that a warm ischemic time of more than 5 minutes causes irreversible neurological injury, it is mandatory that re-sternotomy and if necessary internal cardiac massage occurs within five minutes of the cardiac arrest so as to ensure the best outcome for the patient.
In contrast to standard ALS teaching, CALS mandates that prior to basic life support attempts e.g. external CPR, etc. that 3 sequential DC shocks be given if the patient is in VF, an attempt at the external pacing via epicardial wires if the patient is in asystole or extreme bradycardia and finally if the patient is in PEA and they are externally paced that the pacemaker is turned off to exclude fine underlying VF.
CALS teaches a unique way of organizing staff to maximize efficiency in resuscitation and re-sternotomy in the event of a cardiac arrest. It suggests that there are six key roles of which two (team leader and ICU coordinator) are the most important. Each of these key roles is stand alone with an ethos of encouraging optimal team working by leadership (by the team leader) with active followership by all other roles. Furthermore, there needs to be readily available specialist equipment e.g. airway adjuncts, drugs, defibrillators, external pacing boxes, basic surgical re-sternotomy kit, etc. available to allow for timely resuscitation.
Educationally, there is a considerable literature to support the efficacy of the teaching of CALS. It is taught generally as a one-day course. The course is a mixture of a small number of didactic lectures with a large amount of practical teaching and group moulages of arrest and per-arrest scenarios taught in a variety of venues (from Simulation Centers to side rooms on ICU’s).
It is taught to all groups of staff involved in the care of cardiac surgical patients e.g. surgeons, anesthetists, intensivists, nurses, etc.Due to the large number of people needed to be trained the course is taught in two forms, Provider and Train the Trainer. Each course teaches 12 -30 providers using a staff of 3 – 5 trainers for every course. Each center carries out 3 – 5 courses a year.
Training is aided by eLearning courses (www.calselearning.com), manuals (available from www.Lulu.com) in a number of different languages, and the use of specially designed Re-sternotomy Mannikin and the ‘5 piece set’ (a basic surgical re-sternotomy kit) (www.calsindia-uk.com). For further information or assistance, please fill out the contact form.
Certification process is a key component of CALS programme in alignment with practice of major resuscitation councils. It allows maintenance of skills and knowledge base for all staff members. It offers better employment prospects. It demonstrates due diligence ffor the employer in the event of legal action against the employee. Each candidate will receive a CALS International Certificate with a unique international ID that is issued centrally by the CALS UK.
Variation in mortality between hospitals in similar healthcare systems is endemic worldwide. A means of studying variation in mortality is the use of the concept of failure to rescue (FTR), which gives a measure of the institutional success in treating commonly preventable deaths after surgery. As such FTR varies considerably amongst hospitals in the US (Ann Thor Surg, Volume 98, Issue 2, August 2014, Pages 534-540). The CALS protocols have been shown to have reduced the FTR after Cardiac Arrest in a large cardiac surgical program in the West Coast of the US (by 80% over a 3-year period). This is now being further studied by a 19-hospital group (the Virginia Cardiac Surgery Quality Initiative) in the North-Eastern USA.
CALS has become the standard of care for resuscitation post cardiac surgery in the UK and US. Courses occur throughout the UK, US, Europe, Australia, New Zealand and South Africa.It is mandatory for all cardiothoracic trainees in the UK and is being considered as such for all trainees in the US. In Australia and New Zealand, it is accepted by ANZICS as continuous professional activity. In Spain it is becoming mandated for all intensivists. The course is also run in South Africa and Pakistan. Further courses are planned to take place in India, China, Sweden, Mexico and Costa Rica.
CALS is taught in a growing number of “centers of excellence” around the world. At the time of writing there are 25 such centers in the US, 15 in the UK, four in Spain, one in South Africa, 1 in Malaysia and 11 in Australia and New Zealand. In late 2018 further centers will open in the US, Canada, the UK, Sweden, Spain and Mexico. During the faculty visit to India, major centres have expressed their willingness to become centres of excellence.
Centres of excellence can identify themselves as showing best practice in the field of cardiac surgery. It offers the institution, leadership and market differentiation in a competitive healthcare industry by showing credible evidence of good practice. It provides a sustaining model for training. It promotes a culture of education and research. It offers continuing educational and professional development for the staff members, thus enhancing the potential to recruit and retain employees.
If your organisation is interested to apply for Centre of Excellence status for CALS training, please fill out the contact form.
CALS courses throughout the world are ‘governed’ by CALS UK Ltd.Continual medical/nursing education and revalidation is maintained by a certification process for all providers (with yearly electronic updates and bi-annual course attendances) and trainers with a central database (in line with other International Resuscitation courses e.g. ALS, etc.) allowing tracking of all trainees and trainers.