It Takes a System to Make a Save

No clinical condition has had more impact on defining the role and culture of modern EMS systems than cardiac arrest. More important, there’s no clinical condition that gives us such a tremendous opportunity to dramatically improve outcomes. Today we understand so much more about the pathophysiology of cardiac arrest and the principles that maximize the patient’s opportunity for a good outcome, but we haven’t truly realized the potential.

Yet.

At an industry level, the approach to managing cardiac arrest has had a profound influence on EMS system design, educational program development, and staffing and deployment decisions. Recognized early and managed effectively, SCA patients have significant potential to return to normal lives. When they’re not, death (or, worse, survival in a persistent neurologically vegetative state) is almost assured. To the general public, cardiac arrest has always been perceived (appropriately) as “the big one.” They expect us (again, appropriately) to be ready, trained, equipped and competent to care for this condition whenever and wherever it occurs. In the eyes of our communities, cardiac arrest is one of the main reasons we exist.

At home, in each of our agencies, we’re regularly tasked with evaluating and implementing evolving guidelines as well as local changes in our communities. When the science of resuscitation changes, treatment protocols change, new equipment or medication may be introduced, and educational efforts that include not only didactic information but some form of practical, hands-on experience are rolled out. While every system acknowledges the urgency of implementing new guidelines, we still collectively struggle to make significant changes in relatively short periods of time. For example, in a survey of 174 EMS agencies regarding the implementation of the 2005 AHA guidelines, the average time from release to guideline implementation was 416 days.¹

On an individual level, any practitioner involved in resuscitation efforts for any period of time has witnessed the tremendous changes in our approach to treating cardiac arrest. Remember the good old days of the “ABCs”? How about sodium bicarbonate, Isuprel, lidocaine or procainamide? In the more “advanced” systems, remember connecting patients to telemetry monitors, establishing connections with base hospitals and transmitting ventricular fibrillation tracings just to get orders to shock? Remember when automated defibrillators were first placed in the hands of lay rescuers? How about the perception of worsening care because we removed sacred mouth-to-mouth prearrival instructions? Who would have imagined our cardiology colleagues taking unconscious survivors of cardiac arrest to cath labs still comatose?

We’ve learned some important lessons in our quest to provide more effective care for these patients. As with most acute clinical conditions, we now understand there’s both an art and a science to resuscitation. But perhaps the most important lesson we’ve learned in our journey to provide better care for these patients is one that’s not so apparent.

The Problem

Sudden cardiac arrest remains one of the leading killers of Americans, affecting more than 350,000 people each year.² More than 90% of people who experience it don’t survive. In communities that don’t measure their cardiac arrest survival rates, it’s believed survival is much lower. Unfortunately our national survival rate hasn’t significantly changed in more than 30 years.

Modern CPR celebrated its 50th anniversary in 2010. In their landmark JAMA article from 1960, authors William Kouwenhoven, Guy Knickerbocker and James Jude documented 14 patients who survived cardiac arrest with application of closed-chest cardiac massage.³ Two years later monophasic waveform defibrillation was first described.⁴ And in 1966 the American Heart Association introduced its first cardiopulmonary resuscitation guidelines.⁵ Since those early beginnings of contemporary resuscitation efforts, the international resuscitation community has also developed and refined one of the most comprehensive evidence evaluation processes in organized medicine. The 2010 guidelines process involved more 350 resuscitation experts from 29 countries, who reviewed, analyzed and debated the literature for almost 3 years.⁶

So here’s the hard part: With so much attention and analysis into this challenging problem, why has our national survival rate remained so stubbornly low? And, even more intriguingly, why there is such significant variation in survival between communities? Consider the 2008 study led by Dr. Graham Nichol evaluating cardiac arrest survival in 10 communities containing 21.4 million people.⁷ With 20,520 cardiac arrests cumulatively evaluated, survival ranged from 3%–16.3%. What’s the secret? Why can one community realize such positive results while a seemingly equivalent community resuscitates so few?

We have better tools than ever to address this problem. But we need to figure out the best way in each community to use those tools to improve survival. A one-size-fits-all approach can’t be successful given our diversity of communities, rescuers and infrastructure.

The HeartRescue Project

Initiated and supported by the Medtronic Foundation, a passionate group of clinicians, academicians, administrators and researchers gave birth to the HeartRescue Project (www.heartrescueproject.com). Motivated to dramatically improve SCA survival, this group of individuals and their organizations have partnered to develop integrated community responses to sudden cardiac arrest. The goal of the project is powerful: a 50% increase in survival rates over five years in partner geographies. All the HeartRescue partners are committed to working collaboratively using shared approaches, innovative programs and dissemination of best practices.

The partners represent the states of Arizona, North Carolina, Pennsylvania, Washington, Minnesota, Illinois and the combined national communities served by American Medical Response. Each of the individual partners brings a unique set of skills to the group. They represent a diversity of populations, geographies and challenges. The HeartRescue Project is committed to the belief that sudden cardiac arrest is a very treatable condition. The project has adopted a common set of data elements to measure performance and outcomes, and uses the Cardiac Arrest Registry to Enhance Survival (CARES) database. Participants meet regularly by phone and in person to discuss performance and share innovations, successful approaches and challenges.

The AMR Approach

As a national organization, American Medical Response provides services to more than 2,100 communities across the United States. Based on historical clinical data, its 17,000 care providers will treat almost 25,000 cardiac arrests a year. This is more than 10% of all the arrests in the United States, and as the caregivers for these individuals, AMR is focused on doing everything it can to maximize their survival. We are committed to sharing our experiences, good and not so good, so others can learn from them, just as we learn from our partners.

One of the most important initial tasks in evaluating a community’s opportunity for improvement in resuscitation is identification of all possible participants in the resuscitation sequence. Improving survival requires improvement at all levels, from the bystanders on the street to the cardiologists in the cath labs. Changing just a single part of the system will do only that. To effect substantive changes, all parts and players must work together toward the same goal. Imagine assembling all the individuals responsible for a resuscitation event in your community. The list would be long:

• Bystander

• 9-1-1 communications/dispatch specialist

• First responder (BLS or ALS)

• Ambulance transport (ALS)

• Emergency department staff (physician, nurses, respiratory techs)

• Cardiologists and electrophysiologists

• Cardiac catheterization staff

• Critical care staff (physician, nurses, techs).

Which of the professionals above could you eliminate from the resuscitation and still have the same outcome? Obviously, none. Each of these individuals plays a critical role in ensuring the best possible result.

One of the components of the HeartRescue Project is diving deep into the intricacies of the resuscitation process. In the sequence above one should ask how the bystander was trained and by whom. What protocols do the 9-1-1 communications specialists use, and how do we know they’re using their tools effectively? What does the emergency department staff do when notified of incoming post-arrest patients? How and when do the cardiologists get notified? Asking detailed questions about every step of the process is making sure the “art” of system integration delivers the science we know makes a difference. The strengths and expertise of the individual partners create a unique “resuscitation co-op.” Lessons learned can be applied widely to other communities.

All HeartRescue partners have been replicating the “academy” structure so successfully mastered by Dr. Mickey Eisenberg, Ann Doll and others in Seattle (see www.resuscitationacademy.com). Their Resuscitation Academy has been offered multiple times, free of charge. They specialize in teaching strategies for “snatching life from the jaws of death,” sharing grassroots principles from some of the greatest minds in resuscitation today.

The Arizona SHARE Program, led by Ben Bobrow, MD, offers an annual CPR Dispatch Academy. This program recognizes the critical role 9-1-1 dispatchers play in SCA survival. It offers instruction to improve dispatcher-assistance programs, focusing on the latest CPR science and techniques dispatchers can use to save lives.

At the University of Pennsylvania, Ben Abella, MD, leads the Hypothermia and Resuscitation Training Institute (HART), an intensive two-day program teaching principles of post-arrest care, including the use of therapeutic hypothermia, cardiac catheterization and internal cardiac defibrillator evaluation.

AMR has been working to develop a Leadership Academy designed to help communities identify successful strategies for working together toward improving cardiac arrest survival. Development of a Leadership Academy recognizes the importance (and frankly the challenges) of the “art” of resuscitation and seeks to develop skills to help individuals forge collaborative relationships focused on a unified goal.

In addition to the academy strategy, AMR has committed to implementing the HeartRescue philosophy by educating 120 clinical leaders responsible for guiding the company’s clinical practices nationwide. Using an electronic grand rounds format, the program hosts nationally known speakers to discuss issues critical to SCA survival, including dispatcher-assisted CPR, on-scene resuscitation and capnography in the EMS world.

A new venture for AMR is the creation of dedicated HeartRescue communities. These are located in the geographies AMR serves, and include other first responder and fire partners, public safety personnel, city government leaders, hospital contacts, community service clubs, business owners and SCA survivors. In 2012 AMR launched 12 of these communities, engaging them to work together to develop strategies for implementing all manner of programs and initiatives that will improve survival. Examples of what they can do together include bystander CPR training, interagency training in pit crew-style resuscitation, and working to ensure that post-arrest care is well-defined, evidence-based and integrated into the system. Communities have been amazingly creative, developing programs that range from traditional bystander training to “CPR in a box” in Bozeman, MT, to “guerilla CPR” on the streets of Santa Barbara, CA.

Additionally, AMR has recognized the significant positive impact of celebration. In the field of medicine, the gold medal goes to those who save lives. Reuniting rescuers and patients along with their families and friends to celebrate lives saved not only recognizes our successes but motivates our colleagues and communities to do the same. These events remind us of the importance of what we do, our obligation to do it well and the emotional rewards of saving lives.

In keeping with our guiding principle of integrating the art and science of medicine, it’s important to keep a watchful eye on the evidence supporting practices in resuscitation. To this end AMR has introduced our HeartRescue communities to the Institute for Healthcare Improvement’s collaborative model for achieving breakthrough improvements. With so much good science at our fingertips, communities know what the best practices are in resuscitation science. The hard part for all of us now becomes figuring out how to make changes in our practices, and ensuring the changes we make are based on solid evidence and—most important—provide sustained improvement for our patients. In AMR, with leadership from an IHI advisor, we are guiding our practices through the process of applying and evaluating changes in their local settings. Using clinical evidence and best practices, our communities are implementing a series of measurable aims tracked over time and applied in a cycle of change. This promotes learning about how to apply key change ideas in organizations.

Conclusion

So, back to the question about the most important lesson we’ve learned on our journey to provide better care for patients. What’s the common denominator of successful systems and a cornerstone of the HeartRescue Project?

It’s all about the team. Those communities that truly integrate the entire healthcare system and honestly and openly collaborate to improve outcomes will. No one individual or agency can possibly be as effective as the collective expertise of all.

How do we know it works? In 2010 survival of witnessed arrests in AMR practices participating in CARES was 19%. In 2011, it was 33%.

We believe.

Our special thanks and gratitude to the 17,000 men and women of AMR Medicine and our HeartRescue colleagues nationally for the passion and drive to make a difference and for the privilege of spending time with you on the journey.

References

1. Bigham BL, Koprowicz K, Aufderheide TP, et al. Delayed prehospital implementation of the 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiac care. Prehosp Emerg Care 2010 Jul–Sep; 14(3): 355–60.

2. Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circ 2012 Jan 3; 125(1): e2–e220.

3. Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed-chest cardiac massage. JAMA 1960 Jul 9; 173: 1,064–67.

4. Shohet SB, Sweet RH. Cardiac resuscitation. The combined use of external cardiac massage, external cardiac defibrillation and external electric cardiac stimulation. N Engl J Med 1962 Nov 8; 267: 976–7.

5. Heart disease, cancer, and stroke amendments of 1965. An analysis prepared by the legislative department of the American Medical Association of public law 89-239, enacted October 6, 1965. RI Med J 1966 Jan; 49(1): 43 passim.

6. Field JM, Hazinski MF, Sayre MR, et al. Part 1: executive summary: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiac care. Circ 2010; 122: S640–S656.          

7. Nichol G, Thomas E, Callaway CW, et al. Regional variation in out-of-hospital cardiac arrest incidence and outcome. JAMA 2008 Sep 24; 300(12): 1,423–31.

Ed Racht, MD, is chief medical officer for American Medical Response. He has been an EMS physician for 25 years and served as medical director in private, fire-based, third-service, public utility and volunteer EMS systems. Most recently he was vice president of medical affairs/CMO for Piedmont Newnan Hospital in Georgia. He is a clinical associate professor of emergency medicine at UT Southwestern and served for 10 years as chair of the Texas EMS & Trauma Advisory Council.                                                                             

Lynn White, MS, CCRP, is national director of resuscitation and accountable care at AMR and holds an adjunct professor appointment with The Ohio State University College of Medicine. She was previously the clinical research manager for the Department of Emergency Medicine at The Ohio State University Medical Center, and now serves on the National Association of EMS Physicians’ Board of Directors and as education director for the Medtronic Foundation’s HeartRescue Program.