Registering Change: CARES helps EMS improve performance on cardiac arrest calls

 

 
 
 

From the February 2010 Issue | Monday, March 8, 2010


A report by the University of Michigan Health System has found that survival from cardiac arrest remains at 7.6%. If the data from this and other similar studies is to be believed, this figure has not improved since the 1950s.

But a data tracking program based out of Atlanta aims to change all that.

The Cardiac Arrest Registry to Enhance Survival (CARES) has been designed to bring together disparate data sources, allowing EMS and other medical personnel to assess cardiac care from onset to hospital discharge.

"CARES is a surveillance registry that allows communities to measure and track cardiac arrest," says Bryan McNally, MD, MPH, assistant professor of emergency medicine at the Emory University School of Medicine and principal investigator for the CARES program. "It allows communities to track how many people are actually walking out of a hospital neurologically intact, and then being able to externally benchmark that against a larger data set."

In its sixth year, CARES is a cooperative agreement between the CDC and the Department of Emergency Medicine at Emory University School of Medicine. CARES is currently collecting data from 9-1-1 dispatches, EMS and receiving hospitals in 30 cities across the nation, linking the information into a single electronic record. Individual names are erased from the data, allowing participating agencies to freely view the data. Standard reports can be generated to highlight local cardiac arrest patterns, which help determine the effectiveness of EMS out-of-hospital cardiac care.

"Using Internet-based software, we tied together the three silos of data that have historically been unlinked," McNally says. "When EMS is involved in a cardiac event, they may be using a paper record system, a laptop in the field, or entering their data into a computer at the station or hospital. We've developed a solution for each of those to allow information to come into CARES, so as to minimize the burden for EMS and the hospital."

The program is having an impact. In the first two quarters of 2009, 27 patients who suffered out-of-hospital cardiac arrests walked out of Ventura County, Calif., hospitals. Angelo Salvucci, MD, FACEP, medical director for EMS for the County of Ventura, credits this patient survival to CARES.

"We've been looking at improving our cardiac arrest emergency response system," says Salvucci. "At the time, we didn't have a good way of determining the eventual outcome of the care that we provided. The CARES system was operational and looking to expand, so it was the perfect opportunity for us."

Ventura began examining its cardiac arrest outcomes in 2008. In the six-month period between July and December 2008, the survival rate for bystander-witnessed cardiac arrest from V fib/tach was 32%, which was just above the 28% mean of all the CARES sites. By using the data provided by CARES and improving CPR efforts and other training measures, Ventura County's survival rate jumped to 52%.

"It's pulling all the information together that is the magic in CARES," says Salvucci.

McNally agrees. "The capturing of data is the real innovation of CARES, and it's really the most basic step in beginning to understand how to improve survival in the community," he says. "You need to know what you're doing right and what you can improve upon. And it's those communities that are most interested in understanding how they are doing that are probably going to be the communities that are going to improve cardiac arrest survival in the future."

—Cynthia Kincaid

Report: States 'Inadequately Prepared'

The Federal Interagency Committee on Emergency Medical Services (FICEMS) released its annual report Nov. 12. In the 2009 document, FICEMS reported that most states were "inadequately prepared" for pandemic influenza. Its preparedness committee found most states have addressed basic procedures for infection control but not other activities, such as "just-in-time training."

FICEMS provides a detailed analysis of the gaps and recommends strategies with action steps to improve preparedness in these areas. These gaps include inadequate integration of EMS and 9-1-1 into pandemic influenza preparedness and community mitigation strategies, a lack of available personal protective equipment (PPE) for EMS providers, and the challenge of maintaining full operations with increased call volume as well as possibly decreased supplies and available employees. The group also noted a lack of just-in-time training and recommended medical directors include it when creating clinical standards and treatment protocols during pandemic influenza planning.

The following are the five strategies the FICEMS report recommends to fill in the gaps:

Improve federal financial and technical assistance for EMS and 9-1-1.

FICEMS tasks itself with developing processes to help coordinate grant money and recommends the CDC convene state and regional pandemic planning meetings.

Ensure provider protection and safety.

This means ensuring coordination between federal and state levels when strategic national stockpile resources are distributed and disseminating guidelines on PPE use to state EMS offices.

Improve medical oversight.

Grant programs for just-in-time training should be increased, and the CDC should provide EMS with medical oversight, as well as guidance for call center operation and coordinated EMS system management during a pandemic. Also, the CDC and FICEMS should create pandemic training modules for EMS and 9-1-1 medical directors.

Coordinate community mitigation strategies.

In addition to increased grant support for 9-1-1 and NEMSIS data on sentinel disease surveillance systems, the CDC should develop guidelines for integration of this data. Community mitigation guidance for EMS systems should also be developed, detailing the role of EMS and 9-1-1 "in sentinel surveillance, targeted antiviral prophylaxis, mass vaccination and treatment without transport."

Finally, NHTSA and FICEMS should create legislation and regulations to help states modify the EMS scope of practice during public health emergencies, such as an influenza pandemic.

Enhance continuity of operations and surge capacity.

Guidance for EMS systems to continue operations during a pandemic should address both business and operations continuity planning for EMS and 9-1-1, and states should include guidelines for temporary licensing of new EMS providers during a pandemic.

EMS Providers Deploy to Haiti

Initial reports from EMS providers responding in Haiti are trickling in. Among the groups responding are the Los Angeles County Fire Department Urban Search and Rescue Task Force; Fairfax County (Va.), urban search and rescue team (USAR); Bed-Stuy Volunteer Ambulance Corps, Miami-Dade Fire Rescue USAR, Giving Children Hope and GlobalMedic Rapid Response Team.

According to GlobalMedic's manager of emergency programs, Matt Capobianco, that team's doctor is working in the Port-au-Prince Adventist Hospital performing surgery with two medics assisting, but there are not enough medical personnel to care for the 500-plus patients showing up every day to the 71-bed hospital.

"Fractures and infections are common," says Capobianco. However, the needed antibiotics didn't show up until Jan. 18, six days after the initial quake.

Other medical supplies are running out, but corporations like Vidacare are donating equipment to help meet the need. That company has joined with Partners in Health to donate $50,000 worth of EZ-IO equipment. "This disaster affects us all, and it is our corporate duty to help," says Phil Faris, CEO of Vidacare Corporation.

For more in-depth coverage of EMS deployment to the region, read March JEMS and visit jems.com. For more on GlobalMedic, visit www.globalmedic.ca.

D.C. Still in the News

District of Columbia Fire & EMS (DCFEMS) was named in a wrongful death suit Dec. 9, along with its former medical directorJames Augustine, MD, who announced his resignation Dec. 1, citing health reasons.

Filed by Lolitha Givens, the suit seeks $17 million. Givens claims that her son, Edward Givens, died because the two DCFEMS paramedics who were dispatched to care for him in December 2008 did not recognize the severity of his condition. The suit claims paramedics advised him to take Pepto Bismol and failed to discuss the repercussions of not seeking further medical care.

As we reported in "From Worst to First?" (January 2009 JEMS), a similar suit stemming from the death of David Rosenbaum in 2006 prompted an overhaul of DCFEMS. In 2007, Mayor Adrian M. Fenty and Chief Dennis L. Rubin vowed to turn the EMS system into a world-class service and adopted a task force's recommendations. Augustine, who was a critical component of that plan, is sorry to go.

"It's been a great pleasure and honor working with the department," he says. "There have been a sequence of initiatives that have moved the department forward, and it's extraordinarily disappointing for me to leave before these all come to fruition."

Pro Bono

Not All Line-of-Duty Death Benefits are Created Equal

The hat you wear and the type of organization you work for may determine your eligibility for government-funded death benefits. Currently, only EMTs and paramedics who work or volunteer for government entities are eligible for death benefits under the federal Public Safety Officer Benefit (PSOB) program. Most states also offer benefits to the survivors of fallen public safety officers; however, state benefits are not uniform, and some may cover only police officers and firefighters.

The federal PSOB program provides a death benefit to eligible survivors of federal, state or local public safety officers whose death is the direct and proximate result of a personal (traumatic) injury sustained in the line of duty (certain fatal, line-of-duty heart attacks and strokes are also covered) (42 U.S.C. 3796, et seq). The program currently stops short of covering those in the private sector. However, that could soon change because the Senate Judiciary Committee recently gave the green light for floor debate on legislation that would extend the federal PSOB program to EMTs and paramedics who work or volunteer for nonprofit ambulance services (S. 1353, The Dale Long Emergency Medical Service Providers Protection Act). Nonetheless, until this legislation is passed, providers serving nonprofit organizations must look to their own state laws for government-provided death benefits.

In reviewing state laws, providers should check with their state EMS association or state EMS regulatory authority to verify the existence and extent of death benefits available to EMS providers. State-provided EMS death benefits range from no benefit at all to generous lump sum benefits to spouses and tuition reimbursement for surviving children (18 Del. C. 6701). Some states pay a death benefit only for firefighters and police officers, while others provide a benefit for any certified first responder. Some state laws may also draw a distinction, as the federal PSOB program does, between government and private providers.

Finally, be aware that state laws are usually very specific about when death benefits are payable and when a provider will be considered to be acting in the line of duty. Although some laws provide that an EMS provider is acting in the line of duty when performing such functions as training, fundraising and travel, other state laws may limit the benefit to instances in which a provider is directly engaged in patient care (West Virginia Fire and EMS Survivor Benefit Act; W. Va. Code 5H-1-1).

For more information regarding the federal PSOB program, visit the Department of Justice's Web site at: www.ojp.usdoj.gov/BJA/grant/psob/psob_main.html.

Pro Bono is written by attorneys Doug Wolfberg and Steve Wirth of Page,Wolfberg & Wirth LLC, a national EMS-industry law firm. Visit the firm's Web site at www.pwwemslaw.com for more EMS law information.

Quick Takes

Waiver May Allow Reimbursed Non-Hospital Transports

Secretary of Health and Human Services Kathleen Sebelius invoked her waiver authority under Section 1135 of the Social Security Act for the H1N1 pandemic Oct. 27, allowing ambulance service providers to obtain Medicare reimbursement for transporting patients to locations other than a hospital during the declared H1N1 national emergency. The waivers lift sanctions against "direction or relocation of an individual to another location to receive medical screening ... if the transfer is necessitated by the circumstances of the declared public health emergency for the 2009-H1N1 influenza pandemic." Providers are directed to make requests to their regional Centers for Medicare & Medicaid Services office to operate under the conditions allowed by the waiver. Visit www.cms.hhs.gov/H1N1/Downloads/1135WaiverSigned_H1N1.pdf for the entire waiver.

Know Your PatientsTrauma Costly to the Uninsured

A study of 687,091 adult trauma patients between 2002–2006 has revealed that those without insurance are probably more likely to die after admission to the hospital for their injuries. Further, the results held even after the researchers adjusted inclusion statistics to control for such factors as gender, age and race. It's currently unknown why this correlation exists. Authors of the study, published in the November issue of Archives of Surgery, note, "Treatment often is initiated before payer status is recognized; thus, this provokes the question of whether differences exist in processes of care during the hospital stay," and acknowledge that lack of insurance may not be the only contributing cause.

Researchers Dial in Patient Outcomes

Japanese researchers from Yokohama City University School of Medicine have developed a computer program that can tell which emergency callers are most critical—just by the information they provide over the phone. For the 687,091 calls analyzed, it also correctly predicted the likelihood that callers wouldn't survive more than 80% of the time. But lead author Kenji Ohshige has a more optimistic intent for the technology. "I would like to use it for quicker response to patients in critical condition, and [because] emergency service resources are limited, providing them efficiently is important," he says. The program uses primarily six types of information to make determinations: type of caller, age, consciousness level, breathing status and walking ability. The researchers plugged this information into Yokohama's computer-based triage emergency system to categorize callers according to severity and then compared its predictions with callers' actual outcomes.

Massachusetts Finds ED WaitsUnchanged After Diversion Halted

Almost one year after implementing a policy banning ambulance diversions from Massachusetts emergency departments (EDs), public health officials reported in December that the policy has not exacerbated overcrowding. Patients admitted to the hospital still spend about five to five and a half hours in the ED, while those sent home still spend about two and a half.

As Franklin Friedman, MD, the lead author of the Boston study that prompted Massachusetts to halt diversions, told JEMS in October, the problem "isn't ED overcrowding; it's hospital overcrowding." Other regions have found that hospitals have found ways to successfully address this problem when diversions aren't an option. Miami-Dade Fire Rescue worked with local EDs to cut diversion hours almost in half with no adverse effects, and Las Vegas EMS is in almost full compliance with a 2007 bill mandating that EMS patients be taken into the hospital within 30 minutes of ambulance arrival.

"The Champion's Kit" helps prevent infection: www.pdipdi.com/champions_kit.aspx

NAEMSP Dialog debuts http://groups.google.com/group/naemsp-dialog

EMS


Agenda Implementation listserv: www.nasemsd.org/EMSEducationImplementationPlanning/index.asp




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