In 2009, Mecklenburg EMS Agency (Medic) began a journey to further improve survival from out-of-hospital cardiac arrest (OHCA) in their community (Mecklenburg County, N.C). Over a four-year period Medic engaged multiple county first responder agencies, principally the Charlotte Fire Department, and moved along a pathway of learning and improvement. This learning lead to a concept that is becoming less unique to healthcare but is more often discussed in the manufacturing industry. Like in manufacturing, variation in systems and processes are what drive results in healthcare. That is, if you standardize work and reduce variation in an EMS system, you will see improvements in your processes and systems, and those improvements will benefit your patients.
This journey of translating research into practice by understanding and reducing variation led to seven consecutive months of OHCA survival rates above 50% in a community that hadn’t exceeded rates in the mid-30th percentile.
Medic has provided EMS in Mecklenburg County, N.C, which includes the city of Charlotte, for 35 years. In 2012, this community had a population of nearly 1 million people. This year, Medic will respond to at least 115,000 calls for service, which will result in roughly 82,000 transports to area hospitals.
With a fleet of more than 80 transport units, two mass casualty buses, one alert vehicle and several specialized paramedic teams, Medic is prepared to respond to any type of medical emergency. It has a strong partnership with county and city first responders and both area hospital systems, Carolinas HealthCare System and Novant Health.
The Medic leadership team defines excellence by several agency pillar goals. These goals are monitored by Medic’s leadership and agency board. Three of these pillar goals directly relate to overall cardiac arrest performance and response—a key area of focus and research for Medic.
Cardiac Arrest Science
Medic’s research and improvement initiatives continue to be focused on OHCA because it remains a leading cause of mortality worldwide.1–4 Cardiovascular disease claims 2,400 lives each day, amounting to an annual death toll of more than 875,000 in the U.S. Nearly 295,000 of those deaths result from OHCA.5 Over the past decade, the management of OHCA has changed from a focus on early advanced interventions to improving bystander CPR and public access defibrillation, the first links in the American Heart Association’s (AHA) “Chain of Survival.”6–8
It has also been demonstrated that the early application of an automated external defibrillator (AED) by first responders and basic-level providers can increase survival.9 Research has shown that minimally interrupted cardiac resuscitation or cardiocerebral resuscitation (CCR) significantly improves OHCA survival.10–12 Recent research suggests that the key interventions related to survival in OHCA are time off the chest during CPR, timely manual defibrillation and reducing hyperventilation.13–18 Despite these recommended changes in resuscitation methods, survival rates remain poor.19,20
EMS and emergency medicine in general spend a tremendous amount of resources researching the component pieces of OHCA to assess which ones are associated with improved survival. The American Heart Association (AHA) makes frequent changes to recommended resuscitation algorithms to stay current with the state of the science. However, what may be lacking in EMS is a comprehensive strategy for applying AHA changes into a resuscitation protocol, and tracking performance of those skills that have been shown to improve survival.
If you asked prehospital providers the principles of OHCA treatment, the majority would recite the AHA guidelines along with a “pit crew” approach and induction of therapeutic hypothermia. Although the knowledge exists, translating the principles into practice as part of a complete resuscitation strategy can be challenging.
Road to OHCA Improvement
Medic’s journey began with education on the best practices related to OHCA resuscitation. Mickey Eisenberg, MD, PhD, his team at King County (Wash.) EMS and his colleagues at Seattle Fire Department arguably have the most sustainably successful cardiac arrest resuscitation program in the country. This organization’s success provided a framework from which Medic was able to learn about the process related to achieving outstanding OHCA outcomes.
Specifically, Eisenberg and his colleagues support the growth of EMS through their Resuscitation Academy, taught by Eisenberg and other renowned researchers in the field of OHCA resuscitation. Throughout four days, members of Medic’s leadership and quality improvement department received foundational knowledge of King County/Seattle’s approach to applying resuscitation science to their EMS system.
One of the primary principles learned was educating prehospital providers on the science behind CPR, not just the act of performing the skill. With this foundation, Medic’s leadership began transforming their resuscitation process and identifying improvement initiatives.
Measure, then Improve
Eisenberg and his colleagues also stressed the first step in any improvement initiative needs to be measurement. When you measure your processes, you can more fully appreciate your performance, and improvement relies on the ability to measure the change. Previously, Medic didn’t report to any regional or national database for cardiac arrest outcomes, making comparison between similar services difficult.
In January 2010, Medic began measuring its providers’ performance on OHCA using a standard template and data collection process by enrolling in the Cardiac Arrest Registry to Enhance Survival (CARES).21 The CARES registry provided Medic with the common data definition needed to accurately track outcomes and survival from OHCA, and draw comparisons to other EMS agencies; however, CARES didn’t provide Medic with data relative to their process measures. Joe Penner, Medic’s executive director, challenged his team to better understand why some patients survived while others didn’t. If clarity could be obtained on a key set of process measures influencing cardiac arrest survival, then a framework could be developed to demonstrate improvement in OHCA performance.
Focused Cardiac Arrest Resuscitation
Medic had been focused on OHCA as a performance measure for several years, implementing a prehospital therapeutic hypothermia protocol in April 2009 and a focused cardiac arrest “pit crew” protocol the following August. The focused cardiac arrest protocol encompassed other current best practices, including using minimally interrupted chest compressions, limiting time to defibrillation and controlling ventilation rate. The Institute for Healthcare Improvement’s reliability theory white paper aimed at reduction of variation also influenced how the above strategies were developed.22
In June 2009, Medic began educating all personnel, to include more than 2,000 first responders in Charlotte and across Mecklenburg County, on the focused cardiac arrest protocol. The emphasis of this training was a focus on the importance of quality chest compressions and early defibrillation. Using this “CPR first” mentality, each rescuer on the scene was assigned a role dependent on their position on the ambulance or first responder apparatus. This allowed individuals to know what they were responsible for on every cardiac arrest.
Medic then began to interview all crews involved in a resuscitation effort to determine how the new process functioned. Patient outcomes were also collected. Although these data showed modest improvement in survival, it also revealed that providers weren’t consistently following Medic’s protocol. All responders were reeducated using the same methodology, followed by another period of data collection.
Focused cardiac arrest, specifically the “pit crew” mentality, was an early obstacle to OHCA improvement. Assigning roles reduced distraction but didn’t yield the great improvement Medic had envisioned. Medic originally hypothesized that if their cardiac arrest strategy mirrored Seattle’s, the results would match. The “pit crew” approach to resuscitation is a great method to standardize work on an OHCA scene by lessening distractions and improving focus. Although this approach may provide direction to providers and give them a job duty, it doesn’t innately tell them the performance expectations of their job. Medic officials came to realize that the efficiency of the care provided is paramount; it was essential to determine what each provider should be doing and define the performance of each role. Being assigned a role was not a sufficient-enough change to see improvement.
Data Collection & Provider Feedback
Medic deploys a quality CPR feedback device connected to the agency’s cardiac monitor on every resuscitation attempt. This device is placed in the center of the patient’s chest and uses accelerometer technology to assess compression rate, depth and no-flow time, which is the time in which compressions are not performed. A screen on the device provides feedback, and the cardiac monitor delivers CPR waveform and audio feedback. These devices were designed to provide real-time feedback, which can be used to correct performances as needed.23
Data from this device is stored in the cardiac monitor and is available for post-arrest performance review. Collecting this data system-wide was paramount for Medic to determine overall CPR performance and identify areas in need of improvement. A process was developed for all cardiac arrest data to be imported into a central database so individual and system-wide analysis could be performed.
Providing retrospective feedback on more than 500 OHCA cases per year proved difficult due to the sheer number of providers performing CPR across different agencies during a variety of shifts in various locations. Initial attempts at feedback began with case debriefings by an education and quality specialist; however, this method was time consuming and inefficient. Medic also tried a case-by-case approach, debriefing those events that didn’t “feel” right or identifying “good” performance and trying to elicit what worked on that particular call. One positive result was an increase in the number of paramedics who approached an education and quality specialist to debrief their most recent OHCA. Employees wanted to know if the patient survived, how they performed and what they could do to improve next time. Although Medic had not landed on an efficient form of feedback, administrators were starting to see a willingness to improve among the agency’s providers.
Refocusing on Resuscitation
As Medic analyzed the data and feedback received, it became clear the “pit crew” protocol was not transferring to practice; it was a process that needed fine-tuning. During reeducation of the protocol, Medic had incorporated all of the current best practices. But was as much time spent on the performance components critical to resuscitation? Medic had simply assigned roles and educated providers about the need to rotate and limit time off the chest, but didn’t define how the process would look. There was no standard approach for each task to be performed, which led to varying results.
In July 2011, Medic created and delivered a “refocused” cardiac arrest protocol to all personnel and county first responders. The key components of this update included mandating rotation through CPR, instructing the compressor to verbally count compressions, ventilating on every 20th compression, pre-charging the defibrillator at the 180th compression in a cycle and requiring all resuscitation attempts occur on scene for at least 20 minutes or until return of spontaneous circulation prior to transport.
It became clear through reading the literature and observing performances that providers were becoming fatigued while doing CPR. Medic’s data showed compression rate and depth decreased over time, yet providers didn’t notice until the debriefing session. Initially, focused cardiac arrest assignments were set up so that two first responders would rotate through compressions and ventilations at their discretion. In the updated protocol, three first responders and the Medic EMT-Basic were tasked to perform the CPR rotation with a mandated rotation at every 200 compressions. This allowed for a rest phase and increased the reliability of quality chest compressions. (See Figures 1a and 1b, p. 72.)
Medic requires a 200-continuous-compression cycle and verbal communication of every 20th compression delivered. Counting is an auditory cue providing a time count of the CPR cycle, triggering other tasks. The individual in charge of ventilation knows to only ventilate every 20 compressions; this prevents hyperventilation of the patient. When the compressor reaches 180 compressions, this prompts several actions. Those providing CPR know to prepare for rotation, and the paramedic feels for a pulse with compressions and pre-charges the defibrillator.
By pre-charging the defibrillator, the time to defibrillation is reduced because the paramedic only needs to determine if there’s a pulse without compressions, interpret the rhythm, clear the patient and press the discharge button. If the patient doesn’t need a shock, the paramedic simply dumps the charge and compressions resume. Medic emphasized the importance of following this process for all OHCAs, not just those that present in a shockable rhythm.
Quality Improvement Measures
After fine-tuning the process of the focused cardiac arrest protocol, Medic was prepared for the next step—focusing again on what and how to communicate performance expectations to providers. Identifying what to communicate turned out to be easier than expected because the current scientific literature discusses several key components of a successful resuscitation.15–17,24–26 Using this knowledge, Medic isolated four key performance metrics to evaluate: average compression rate, frequency of adequate compression depth, time to defibrillation and flow time.
Performance goals for each metric were set by Medic Medical Director Doug Swanson, MD. (See Table 1, p. 75.) Armed with obtainable metrics and set goals for each metric, the quality improvement (QI) department began to track and report performance to Medic’s leadership team and field providers. Cases not meeting these goals were reviewed by a QI staff member to identify barriers to the process. System-wide areas for improvement were also identified by tracking this data over time. Using historical data, Medic was able to track the effect of each change on both performance metrics and survival. Each time Medic refined the process, officials observed a corresponding improvement in overall performance and survival. (See Figure 2, at left, and Figure 3, below.)
As stated, Medic has yet to land on an efficient system for performance feedback to field providers. This data may be viewed as punitive and affect the culture of an organization, while feedback on patient survival and neurological function is generally well-received. Some at Medic have questioned the value of retrospective feedback for a prospective problem. In other words, by the time the provider receives the feedback through a debriefing process, the patient outcome has already been determined. Will feedback change performance for future patients the crew may have, especially in a large system where the next cardiac arrest could be weeks or months away?
Retrospective feedback surrounding cardiac arrest performance has been shown to be valuable in some EMS systems. This sparked a debate at Medic: Is it better to invest resources to identify process changes that could be made to improve CPR quality as it’s happening? Does reporting system-wide aggregated data provide enough information to drive performance? Is retrospective feedback worth the resources required to deliver that feedback? Each question presented potential barriers to creating an efficient and valuable feedback process.
Using the four performance metrics, Medic decided to focus training on CPR depth and time to defibrillation in upcoming continuing education classes. In July 2012, Medic’s first responders were retrained in performing high-quality CPR at adequate depth and reducing rotation time between compression cycles, while paramedics were trained on reducing time to defibrillation and pre-charging the defibrillator at the 180th compression. Following this intervention, Medic achieved seven consecutive months of Utstein cardiac arrest survival rates above 50%, and a 12-month average of 51.1%.
Increasing cardiac arrest survival led to an understanding that the process surrounding CPR performance is as influential as the individual metrics. A simple mantra is “the results you achieve are directly related to the process you implement.” It’s critical to stop relying on buzzwords such as “pit crew,” “push hard, push fast, don’t stop,” “rotate” and “limit time to defibrillation” as drivers of positive patient outcomes.
Although these methods are founded in science, they can be challenging to implement with any level of consistency. It’s not enough for instructors to teach the principles. Instruction on the process is also necessary to achieve the expected outcomes. By incorporating the current science and recommendations into a reliable process or protocol, agencies can arm prehospital providers with a blueprint for success. These changes aren’t easily accepted by field providers or administrators, but through hard work and thoughtful design, EMS can improve cardiac arrest survival in the U.S. well beyond current levels.
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