The Resuscitation Academy

   One of the greatest challenges of any EMS clinical manager is to find ways to test and improve the efficacy of their system.

   Across the country, we commonly use benchmarks such as dispatch times, as they are one of the few things measured across virtually all U.S. systems, and can be among the most accurately measured and tracked. Within the past decade, however, a trend is emerging to collect data on successful cardiac arrest resuscitations, with many systems publishing their rates. At least one EMS system is promoting rates of resuscitation from bystander-witnessed ventricular fibrillation cardiac arrest as the best benchmark for managing system efficacy.

   "Any witnessed cardiac arrest with VF as the presenting rhythm is a patient you could save," says Mickey Eisenberg, MD, author of the 2009 book Resuscitate! How Your Community Can Improve Survival from Sudden Cardiac Arrest and the medical director of King County EMS in Washington. The work of Eisenberg and fellow MD Michael Copass, medical director for the Seattle Fire Department's Medic One program, has helped produce consistent witnessed VF arrest save rates of better than 45% since 2005. Seattle and King County are perennially among the national leaders in this category.

   These widely publicized statistics have caused a number of administrators from other cities to visit the Seattle-area programs to get a sense of their success. Program administrators from Maryland to Japan have sought to learn from them, and gather information to take back to their own communities. During their time, they have ridden with Medic One staff and observed their culture, ideologies and initiatives.

   Because of a strong belief in their methods of system management (and a consistent stream of visitors from around the world), the Seattle and King County Medic One programs, under the direction of Copass and Eisenberg, created a "Resuscitation Academy"--a weeklong training program for middle managers that presents the basics of resuscitation science and an in-depth overview of the systems in Seattle and King County.

   Conducted through joint funding from the Medic One Foundation and the Life Sciences Discovery Fund, the five-day academy is focused on teaching the tenets of the resuscitation system in Seattle and King County. Students attend lectures each morning on the finer points of data collection, cardiac arrest quality assurance and improvement, public and police defibrillation, CPR science and public CPR education. Each morning session contains a specific theme that points the academy "fellow" toward understanding the culture of excellence in the region. Each afternoon has a specific "breakout session" with a specific topic delivered by a field expert. Additionally, members can ride along with the paramedics of Seattle FD Medic One to more tangibly observe that culture of excellence at work. These administrators can hear area paramedics discuss a very real belief we all learned at the academy: that with the right system in place for resuscitation success, witnessed VF arrest is a recoverable disease.

How am I doing?

   Here are the big questions, then: What is Seattle doing so differently, and what can I do in my home area to have greater success?

   To answer the second question first, as with any QA-driven initiative, every EMS manager must sit down and determine how well they are currently doing in the resuscitation of out-of-hospital cardiac arrest (OHCA) victims. Evaluating OHCA performance is especially challenging, requiring collection of data and knowing the hospital outcomes of EMS-transported OHCA victims.

   This can be accomplished through a cardiac arrest registry. Several models of cardiac arrest registries exist, with CARES being the most prominent. In 2004, the Centers for Disease Control and Prevention (CDC) collaborated with Emory University and the American Heart Association to develop a registry that could help track and increase OHCA survival rates. CARES (for the Cardiac Arrest Registry to Enhance Survival, https://mycares.net) is a secure Web-based data management system in which participating communities enter local data and generate their own reports. Communities can compare their EMS systems'cardiac arrest performance to others', locally and nationally, by comparing aggregate statistics. In this way, they can discover promising practices that can improve their emergency cardiac care.

   The CDC pilot-tested CARES in the Atlanta area in 2005. The next year, the registry expanded to six additional areas. By June 2009, CARES included 28 participating communities in 17 states and the District of Columbia.

   The CARES project is an important component of our overall goal: a collective effort to track each cardiac arrest, with similar collection procedures, and see what each patient's long-term outcomes are. This allows EMS managers to gauge their effectiveness at cardiac arrest survival.

   Once your service can establish what its community effect is, consider publishing your results. Nationally, only 50 communities have published their cardiac arrest resuscitation statistics, and more must do the same. We are responsible to our communities, and they have a right to know how effective their EMS service is at cardiac arrest resuscitation.

   Nationally, these 50 systems demonstrate significant statistical disparities. While it seems terrible to suggest a location in which to have a cardiac arrest, King County and Seattle, with their 47% survival rate, might be better for you than Detroit, where the rate is 0%.

   Publishing your resuscitation rates to your community is important. It shows not only your efficacy in cardiac arrest management, but also your commitment to improvement.

Taking It Home

   As academy attendees return home, the real challenge begins: the planning and eventual implementation of new procedures in their home regions. Anyone looking to be a true agent of change with resuscitation initiatives is going to face some challenges. But improvement of OHCA survival is not as overwhelmingly difficult as one might imagine. In Resuscitate!, Eisenberg identifies a number of projects you might undertake to improve your community's resuscitation outcomes.

Identify the stakeholders

   Making any systemic change can be a nightmare without complete buy-in from everyone involved. In resuscitation that reaches from arrest to discharge: EMS agencies, first responders, hospitals, dispatch centers, cardiology services and cardiovascular specialists are just a few of the kinds of people and organizations to consider bringing together to discuss resuscitation in your area. Clinical organization is the absolute key to success.

Participate in a cardiac arrest QI program

   The King County/Seattle model for resuscitation continues to promote data collection to evaluate program success. The development of a focused cardiac arrest CQI program is vital to improvement. This includes collecting and evaluating monitor and AED downloads, call dispatch records, EMS documentation and patient outcomes. Documenting your performance is essential to improving your SCA management.

Promote Public Access Defibrillation

   Intrinsic to cardiac arrest resuscitation is having a well-developed model for early defibrillation. Reducing arrest-to-defibrillation times holds significant weight in morbidity reduction. Sadly, only a handful of cities have any kind of well-coordinated public access defibrillation effort. But evidence shows that with well-coordinated PAD programs, combined with aggressive CPR education programs, you can double your resuscitation rate. Considering this, PAD programs should be a big part of any resuscitation system. For a good example of a public access defibrillation program, look into San Diego's Project Heart Beat, www.sdprojectheartbeat.com.

Police AEDs

   In most emergency response systems, the local police department can arrive faster than other agencies. This is due to the roaming nature of police work, and because traditional public safety models have significantly more police officers than EMS units. Several U.S. jurisdictions have given their police responders CPR and AED training, and equipped them with AEDs. While not all systems have monitored their results, those that have all report significant increases in resuscitation due to reduced arrest-to-defibrillation times. In Miami-Dade County, FL, police AED use was linked to an 8% increase in their area's resuscitation rate, and leaders in Rochester, MN, have attributed their 43%-47% resuscitation rate for witnessed VF arrests in part to their aggressive police AED program.

Monitor and improve "CPR Density"

   Several studies have indicated that improving the overall time of compressions--that is, the percentage of time the hands are actually on the chest, or CPR density--is important in resuscitation. Articles indicate that perfect standard CPR only provides compressions between 50%-65% of the actual performance time. Retrospective study has shown increased density directly correlates to survival, and BLS compression goals are around 85%.

   To improve CPR density, conduct a CPR drill with your staff, and see how long it takes your AED to advise that it's OK to touch the patient, and then to begin CPR.

Conclusion

   While the Seattle and King County Medic One systems have developed their Resuscitation Academy around patients'medical needs, it is also a great way to highlight a culture of success. Studying the system on paper certainly pales in comparison to listening to street providers explain it.

   No matter how you work to improve your cardiac arrest performance, be reminded of a bigger message: Collect data, measure and evaluate your results, then make decisions on the future of your program based on concrete methods. Let's take the time to fully embrace evidence-based medicine in all aspects of our clinical methodology, and we can ensure the next generation of lifesavers enters a profession with a culture of smart decisions.

For more on the Resuscitation Academy, visit https://resuscitationacademy.org.

James Weber, EMT, AS, is a training coordinator and author from Lancaster, PA. His work is concentrated on prevention of injury and illness, community organization and development, and expanded use of laypersons in the public safety model. Contact him at jweber@manheimtown shipems.org.

Sidebar: My Time at the Academy by Gary Strong, EMT-P

It is well known outside the U.S. that Seattle and King County are probably the best places in the world to survive a sudden shockable cardiac arrest. For more than 40 years, Medic One has been working in a culture of constant self improvement, looking for new ways to increase survival from ventricular fibrillation. The survival-to-discharge rate in Seattle and King County is around 46%. In Wellington, New Zealand, we achieve around 12%-13%, which is not bad by comparison with some other major cities (e.g., New York, 5%; Los Angeles, 7%; London, 15%). But we want to do much, much better. So my chief, Alan O’Beirne, wrote to Seattle to ask for a few tips. Their response was an invitation to send a representative to the Resuscitation Academy, a fantastic opportunity to learn about the systems in place in Seattle and King County, review the many factors that led to their success, and interpret and apply them back home in Wellington.

I was the lucky one who got to go to Seattle. Spending a week learning from the likes of Drs. Michael Copass, Mickey Eisenberg, Leonard Cobb, Tom Rea and Peter Kudenchuk, along with the paramedics and instructors of Seattle and King County, is an experience I will never forget.

Essentially, the culture in Seattle and King County can be summed up in two words, repeated over and over: measure, improve; measure, improve; measure, improve. This culture runs right through both organizations, from the medical and organizational leaders through the EMTs and paramedics and those who collect and analyze the data.

Above all what they measure are the factors that save lives: time to CPR, time to defibrillation, and quality and consistency of CPR. Large amounts of data are collected for every cardiac arrest, and the results are fed back to the EMTs and paramedics, whose expectations are high: Every sudden cardiac arrest is treated as an event they are confident they can reverse.

In Wellington we have started by enhancing our capacity for data collection and improving our ability to feed back cardiac arrest performance to our paramedics. It is clear that we also need to focus on ways of shortening our times to CPR and times to defibrillation, and we will be using our strong links with the local community to improve public awareness, community CPR and public access defibrillation. Eisenberg argues that "a community that can successfully respond to and manage this emergency is likely to perform well on the other 99% of emergencies." I'll buy that. Successful performance in managing cardiac arrest requires strong leadership, good training, clear expectations for paramedics and EMTs, attention to detail, good feedback systems and, above all, the desire to achieve the best possible outcome for every patient.

Gary Strong, EMT-P, is education director for Wellington Free Ambulance in New Zealand.

Sidebar: My Time at the Academy by Curtis Sandy, MD

When thinking about cardiac arrest survival, most in EMS immediately look to the Seattle-area agencies as leaders in both research and success. Many agencies across the nation and internationally have traveled to Seattle to learn the secrets of this success to help make improvements in their own agencies. To formalize this program, the Resuscitation Academy was developed to allow for discussion of cardiac arrest and provide an in-depth behind-the-scenes look at Seattle's and King County's Medic One programs.

For five days in March, I and 18 others participated in the academy, attending lectures, breakout sessions and small group discussions focusing on the full spectrum of cardiac arrest care. The mornings consisted of lectures covering the science of CPR and other related research and addressing the entire chain of survival from scientific and practical standpoints. The afternoons were spent in medic ride-alongs or small group sessions focusing on quality improvement, telephone CPR, public AED and "picture-perfect" CPR.

Many thanks are owed to the physicians, staff and medics at Seattle Medic One and King County Medic One for opening up their systems to such inspection. Most surprising is that attendance at the academy carries no registration or tuition fees.

The academy brought together medical directors and EMS agency directors from across the country. The number is kept to less than 20 to allow for a cohesive environment and plenty of opportunity for individual discussion with physicians and faculty. Participants represented both large urban departments and small rural agencies from across the U.S. and as far away as New Zealand. This diversity allowed for much discussion and opportunities for networking, especially during the free evenings.

If you're applying to attend the academy, recruit others from your agency to go as well. I suggest the medical director and chief officer responsible for either operations, quality improvement or training. While some of the tools you'll learn are small and seem simple to implement, it will indeed take a two-pronged approach, clinically and operationally, to institute systemic changes within most agencies.

I came away from the academy committed to an increased focus on my agency's response to cardiac arrest. The topics that resonated the most for me were the four elements Seattle has added as the "box" that surrounds the chain of survival. These elements are quality improvement, training, leadership and a culture of excellence. Truly, the focus on these four elements is a main contributor to the success Seattle has seen. There is indeed a culture of excellence instilled throughout the system. It starts in paramedic school and is still apparent with the seasoned veteran. This culture begins with a standard set by the leadership and medical director and then is emphasized throughout all avenues of performance. All critical calls are reviewed, and providers get feedback on their performance against the standard.

The administrative and financial support for quality improvement is not usually seen in most EMS systems, and the commitment to data acquisition and analysis for each and every cardiac arrest call is admirable. This in-depth analysis, including monitoring CPR density and accounting for every interruption in CPR, provides a wealth of information regarding provider performance. Then providing feedback to individual providers regarding their performance on individual calls really closes the loop. I believe this level of feedback is probably the single most productive element in improving and maintaining this level of excellence they have achieved. If every EMS system could secure the financial resources for a similar quality improvement program, I believe we would see great improvements across the nation in our EMS outcomes, not only for cardiac arrest but also for trauma and other time-sensitive illnesses.

Physician leadership and intensive oversight are hallmarks of the system. Medical director review of all cardiac arrests with provider feedback is crucial to the QI process. Physician leaders also empower their providers to think critically and actively participate in the progressive advancement of the system' medical practices.

For 50 years CPR has been a tool for the medical community to combat sudden cardiac arrest. Unfortunately, there still exists a large disparity in save rates from ventricular fibrillation arrests across the U.S. The Resuscitation Academy is a crucial step in combating this disparity and helping improve EMS resuscitation rates. By learning from the leaders in resuscitation care, academy attendees can implement small but crucial changes to their systems and hopefully make large changes in the survival of their patients.

Curtis Sandy, MD, is medical director for Bannock County Ambulance, Pocatello, ID.