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Workshop Convenes on Strategies to Improve Cardiac Arrest Survival
"It is not a failure of knowledge, but a failure of action.” —Art Kellerman, MD, MPH, Dean of the Uniformed Services University of the Health Sciences, Bethesda, MD
The number of people who die every day from sudden cardiac arrest is equivalent to the crashing of two fully-loaded 747s: approximately 1,500 victims.
This shocking analogy often used by medical and policy experts in cardiac arrest resuscitation highlights the devastating toll of sudden cardiac arrest (SCA). Even more alarming is that in spite of proven and widely-available treatments for SCA, overall survival rates haven’t improved much in the past 30 years. While some communities boast survival rates as high as 60%, others are stuck at a mere 8%–10%.
To address these issues, the Institute of Medicine (IOM) convened a workshop on July 11 and 12 at the National Academies of Sciences in Washington, D.C. Various stakeholders gathered at the event to formulate actionable plans for improving the nation’s outcomes for SCA.
Workshop attendees first and foremost acknowledged the need for a fundamental shift in thinking regarding the treatment and standardization of SCA.
Tom Aufderheide, MD, director of the NIH-funded Resuscitation Research Center in the Department of Emergency Medicine at the Medical College of Wisconsin and chair of the workshop's planning committee, stressed that in order for real progress to happen, changes must occur in the way that people think about SCA.
“All of those involved in the chain of survival must change their culture,” he says. “The layperson, the 9-1-1 dispatchers, the EMS systems, the hospitals—if we continue to operate in the same way, our survival rates will not improve.”
The workshop was driven by the IOM’s June 2015 publication, Strategies to Improve Cardiac Arrest Survival: A Time to Act. Participants focused on how to make these proven strategies a reality for the whole nation.
The report highlights a number of findings that affect SCA survival rates, such as the importance of dispatcher-assisted and bystander CPR.
Paul Pepe, MD, MPH, FACEP, regional director for Out of Hospital Mobile Care Systems and Disaster/Event Preparedness at UTSW Medical Center and a facilitator of the IOM workshop, argued that agencies need to work on breaking down the psychological barriers to doing CPR on a stranger. Some dispatchers still remain reluctant to coach callers in chest compressions, and bystanders are often hesitant to invade a victim’s personal space. But cities like Seattle with high survival rates find success in using models similar to “NO? NO? GO!”, where the dispatcher asks: “Is the victim responding? Is the victim breathing normally?” If both answers are no, CPR is a “go.”
With less than 50% of dispatch centers offering CPR on the phone to their callers, it is clear to Drew Dawson that agencies may not realize the potential return on investment for this type of policy.
“It is almost a no-brainer,” he said, calling on the National Highway Traffic Safety Administration (NHTSA), his former employer, to make Telephone CPR (TCPR) training a national priority. “[TCPR] is highly efficient and the multiplier factor for training dispatchers in incredible. If you train just a few dispatchers, it increases the survival rate of patients.”
Dawson, who also defined the dispatcher as “the most important first responder,” promoted the formulation of regional 911 Centers of Life-Saving Excellence, where callers could receive effective instructions from experienced dispatchers. These centers could improve SCA survival rates in smaller communities where funding, training and quality improvement are problematic or minimal.
Jennifer Chap was assisted with CPR by a 9-1-1 dispatcher in Orlando, FL, which helped her husband survive an SCA in their home. She told the audience at the workshop that it was important for dispatchers to be clear and honest.
“They told me I would have to press down 2 inches on his chest,” Chap says. “And they also said I had to be prepared to do 600 compressions, which was scary, but was a necessary piece of information.”
The IOM also highlighted Continuous Quality Improvement (CQI) programs as another essential step in improving SCA survival. According to Ben Bobrow, MD, FACEP, FAAEM, FAHA, medical director for the Bureau of EMS and Trauma System for the Arizona Department of Health Services, CQI may be the most important determinant in raising survival rates. He cited the success of Door-to-Balloon benchmarks for STEMI to encourage measuring performance in SCA.
“For STEMI, we set performance measures, held people publicly accountable and everyone figured it out,” says Bobrow.
Committee members acknowledged the numerous hurdles to collecting quality improvement data. Peter Taillac, MD, medical director for the National Association of State EMS Officials, (NASEMSO), shared the success of his organization’s initiative, EMS Compass, as an example of establishing standardized performance measures for the nation. Taillac said that for EMS agencies, putting the CQI pieces together is a difficult task.
“This takes work, this takes money,” he says. “Can we require it? We have to be aware of agencies that have limited resources.”
Overall, in both the written report and at the two-day conference, among both the committee members and workshop participants, the tone was one of urgency for improving the response to SCA.
“We need to make it become a public health issue,” says Dawson. “It should not be an epidemic of unnecessary deaths.”
And while science, policy and numbers were at the forefront of this workshop, the human aspect of SCA also stood out. In attendance were several cardiac arrest survivors and those who have performed bystander CPR.
Gene Johnson is a cardiac arrest survivor and chair of the Minnesota Sudden Cardiac Arrest Survivor Network. He was most impressed by the numerous advances in care over the 14 years since his cardiac arrest in 2002. Johnson also noted that he was thrilled to still be involved in the cause.
“It’s my 14th birthday,’” Johnson said. “I feel great.”
Hilary Gates, MA Ed., NRP, is a paramedic in Alexandria, VA. She is an EMT instructor and teaches in the School of Education at American University. She began her career as a volunteer with the Bethesda-Chevy Chase Rescue Squad. Gates has experience as an EMS educator, symposium presenter, and is involved in quality management and training for the fire department.
