Cooking the Books? Measuring Cardiac Arrest Survival Rates

I had the opportunity to attend a life-saving ceremony about 15 years ago. The EMS service involved was featuring and touting its EMTs and paramedics as walking messiahs who could bring virtually anyone back from the dead. One EMT or paramedic after another paraded onto the stage to receive a medal for bringing someone back to life after the patient’s heart and lungs stopped functioning. At one point, the ceremony was stopped, and the master of ceremonies asked one paramedic to turn and face the crowd as he proclaimed that this individual was responsible for saving eight people in the previous year.

Wow! That was fantastic. I thought this guy must be like one of those preachers I see on television who can lay hands on someone and cure a disease that had plagued the person for years.

The ceremony continued and the long line of employees continued to parade onto the stage as family, friends and fellow employees applauded their achievements. After the ceremony, there was plenty of picturing taking as the EMTs and paramedics held up their awards for the cameras or posed for group photos.

At the eat-and-greet function after the ceremony, I told the EMS division chief that it would be great if some of the cardiac arrest survivors could have been at the ceremony to be reunited with their rescuers. The division chief replied that the department could find only one such survivor and that the person was already scheduled to be out of the country on a cruise.

Wait a minute – you’re telling me that out of all these saves that you handed out medals for today, you could only find one patient? Yes, the division chief confirmed. I told him I did not understand. He explained that the agency defined a “save” as anytime a paramedic restored a heartbeat on a patient and the person made it to the floor of the hospital. He said the agency also considered anything a “save” if the emergency room restored a heartbeat and the patient made it to the floor after the crew began resuscitation efforts in the field.

What happens, I asked the division chief, if the patient dies on the hospital floor three days later or remains the rest of his or her life on a respirator because there is no brain function? The division chief said that his service still considered that a “save.” I left the ceremony a bit confused, since I considered a “save” someone who walked out of a hospital.

A series of articles in USA Today last year looked at the 50 most populous cities in the United States and found cardiac arrest survival rates ranging from nearly zero to claims by some cities of survival rates topping 20%. The series made some cities look terrible at saving victims of cardiac arrest while other cities like Seattle (45% save rate), Boston (40%) Kansas City (20%), San Francisco (22%), Houston (21%), Tulsa (26%) and Oklahoma City (27%) looked great. Why the discrepancy? Were the other cities so bad or were places like Seattle and Boston so good?

Part of the secret of success may be the system, but the way in which cities measure cardiac arrest survival rates can provide favorable or unfavorable statistics. It all depends on how some cities measure cardiac arrest survival or, as one may suggest, “cook the books.”

The cities that can claim cardiac arrest survival rates over 20% use a standard for measuring cardiac arrest survival called the Utstein template. In the 1980s, all around the world, the survival of cardiac arrest victims was measured in different ways and different formats. In response to these differences, the Utstein template came about after an international group of scientists met in June 1990 to address their concerns with research involving out-of-hospital cardiac arrest. These scientists met at the Utstein Abbey in Stavanger, Norway.

A second meeting was held in December 1990, in Brighton, England, and was referred to as the Utstein Consensus Conference. Recommendations from the follow-up conference were published simultaneously in American and European medical journals. The report included uniform definitions, terminology and recommended data sets (the “Utstein style”) to assist clinical investigators in reporting human resuscitation studies.

With the Utstein template, only those victims who have a good chance to be saved are counted. Further, the Utstein template counts only those survivors who leave the hospital without serious brain damage.

Looking at the Utstein template, you begin to realize how some cities have over a 20% survival rate while others linger below 5%. The Utstein template removes any victim who is in cardiac arrest because of trauma. Think about how many trauma victims you have seen survive cardiac arrest. If your experience is like mine, hardly any survive. If you measured cardiac arrest survival rates and included trauma victims, it would immediately lower your percentage.

The Utstein template counts only patients who suffered a witnessed arrest and had an initial EKG of ventricular fibrillation in the percentage numbers. Other rhythms like asystole are not counted. One benefit of a witnessed arrest is that there is a good possibility that a bystander started CPR, which also increases success percentages.

Unfortunately, few EMS systems in the U.S. use the Utstein template for determining survival of cardiac arrests in their communities. And since most EMS systems are judged based on their cardiac arrest survival rates, (although they usually make up less than 1% of calls), a low survival rate reflects poorly on the EMS system.

Bottom line – if you measure only those cardiac arrests that involved witnessed arrests and the patients were in ventricular defibrillation, your numbers would improve. Some people would say this is “cooking the books.” I’d say it is better to be accurate than to parade a bunch of people to receive medals when they really did not save anybody.