Now it is time to go after the higher hanging fruit. These six, more difficult steps will also likely lead to improved survival, but their implementation is more challenging and resource intensive.
Step 5: Voice Record All Attempted Resuscitations
All voice recordings in Seattle and King County are part of an ongoing cardiac arrest QI. Though some EMTs and paramedics may think that the recorded information will be used for disciplinary purposes, the goal of recording is simply to reconstruct the actual events of the resuscitation with accuracy. We have analyzed thousands of voice and ECG recordings and have never used them for any disciplinary action. Listening to a voice recording while viewing the patients’ cardiac rhythm makes the event vivid. You can tell the moment when the AED was attached and when ventilations were given. You can piece together the sequence and timing of events and deduce the reason for any delays (the dog was growling at the EMT, the patient had to be moved from the bathroom to the hallway, the oxygen tank ran out, and so on). A post-event digital readout of the heart rhythm, with the timing of the shocks, is useful, however nothing beats a voice recording of the event.
Some people believe that the only thing better might be a video recording, like those made by police cams, but this suggestion is problematic. Such a recording would be logistically challenging and intrusive, not to mention a violation of privacy. It would be only a matter of time before resuscitation videos began appearing on YouTube. Frankly, though, the most important objection to video recording is that they are not needed. A voice recording is enough to allow adequate reconstruction of the event. Voice and ECG recordings provide the crucial data allowing for the event to be accurately reviewed. When shared with EMTs and paramedics, it provides beneficial QI and teaching material. And it makes everyone want to do better the next time.
As an example, in one recording of cardiac arrest, the paramedic asked the EMT to stop CPR so he could intubate. Then a long pause ensued that lasted 65 seconds (with no CPR) before the paramedic asked the EMT to resume chest compression. The paramedic, when the tape was reviewed with him, could not believe how long the pause was. You can be sure this paramedic will do better the next time.
Many training officers in King County fire departments use the recordings for internal teaching. There is nothing like a real event to grab your attention—to make one breathe a sigh of relief when things go well and to cringe when they don’t.
Step 6: Begin or Expand a Program in Police Defibrillation
Providing police officers with CPR skills and training in the use of an AED has the potential to increase survival rates from cardiac arrest. Though the promise exists, law enforcements’ role in resuscitation and early defibrillation has been modest and inconsistent. Yet some communities that have embraced police defibrillation have seen dramatic improvements in survival. Perhaps the most notable community is Rochester, Minn. Our system in King County has also seen benefit with police response to cardiac arrest.
Embarking on a police defibrillation program is not without challenges, and some communities that have tried, have not seen much benefit. There are many issues to address: Support from the police chief and buy-in from the rank and file, support from the fire-department and/or EMS agency, initial and ongoing training and its costs, cost of AEDs, supervision, QI, and integration with EMS dispatching. In early 2010, we undertook police AED programs in Bellevue and Kent, two cities in suburban King County, Wash., each with approximately 100,000 residents. The program has contributed to the successful resuscitation of a handful of lives; and we believe further training (both for police and dispatchers) will lead to even more successful police defibrillations.
A few critical lessons we have learned might help other communities as they embark on police defibrillation. First, there must be total support from the police and EMS agencies. Ideally every police officer should be taught in person (rather than solely with video or Web based training) and given the chance to practice with the AED device. Second, the training message must be simple and involve two checks: “If the person does not respond and is not breathing normally, attach the AED.” Let it analyze and/or shock and then follow the CPR prompt. Third, we teach the police to provide chest compression only (most are relieved that they do not have to perform mouth-to-mouth ventilation). Fourth, we do not use voice recordings for police AEDs. The police find this a huge relief. Fifth, the dispatch center is key to achieving rapid police response. The police must be dispatched simultaneously with the first responding EMS agency. This is perhaps the most challenging issue in achieving a successful police defibrillation program. Our goal is for police to be dispatched only for true cardiac arrest events. Many times it is clear that the caller is reporting a cardiac arrest, but other times it takes some seconds (or longer) to confirm an arrest (remember that the EMT unit has already been dispatched under rapid dispatch). When the dispatcher waits to confirm cardiac arrest before dispatching police, the fire department will have had enough of a jump start to arrive before police. How to send police quickly, but not over-send, is a challenge we continue to work on.
Step 7: Establish a Public Access Defibrillation Program
Public access defibrillation (PAD) refers to placing AEDs in public locations and using them as elements of a community’s resuscitation chain. PAD is a difficult step, not necessarily because it is technically challenging, but rather because it involves widespread community effort and its effects are likely to be modest. Even with widespread dissemination of AEDs in public locations, there will be only a small increase in survival. The Public Access Defibrillation Trial was a multi-center trial demonstrating that sites with AEDs on the premises, and with staff trained in their use, had higher survival rates for VF than comparable sites without AEDs (the non-AED sites relied on the fire department or an EMS agency to bring an AED to the scene). Other studies reporting the use of AEDs in casinos and on airplanes also showed benefit.
There is an active PAD program in Seattle and King County, with more than 3,000 AEDs registered with EMS, as of 2012. Sites with AEDs include such places as the airports, health clubs, jails, community centers, senior centers, shopping malls, office buildings and ferryboats. The number of AEDs has increased significantly over the past decade. A study from Seattle and King County reporting on eight-years’ experience with PAD found that in 1999, 1.8% of VF arrests had an AED applied, compared to 8.8% in 2006. Survival among PAD cases was approximately 60%. The strategy of using public AEDs has merit, but enthusiasm must be tempered with awareness on the relatively small number of cardiac arrests—only 15%—that occur in public places (approximately 150 of 1,000 arrests per year in King County).
Though the absolute number is small, these are great saves. A cardiac arrest in public usually befalls an active person who is out in the community, and since most collapses in public are witnessed, CPR is often started quickly. The fact that these arrests have everything going for them—they are witnessed, they usually involve VF, CPR and defibrillation are started quickly, and there is probably less comorbidity—explains the excellent survival rate (and the typically good neurological recovery).
Residential facilities offer great potential for PAD programs. As incentives, an EMS agency could provide free training to residents and personnel and could offer to register the facility’s AED with the local dispatch center. The agency could also offer advice on where in the facility to place the AED. A residential community or an apartment or condominium building could establish an AED security system. In such a system, the AED would be placed in a locked box (all the residents would know the combination) in a central accessible location. This location would be registered with the dispatch center, and if a cardiac arrest occurred on the premises, someone at the scene would be instructed to get the AED.
Existing computer-aided dispatch programs allow dispatch centers to identify AEDs at particular locations (assuming that these AEDs are registered with the dispatch center) as well as any in close proximity. Wouldn’t it be amazing if a caller to 9-1-1 were informed that the doorman in the next building had an AED in his building’s lobby and was being called to bring it over? This idea is currently being tested in the King County Northeast Communications Center, and though this is not a formal test, it is offered as one idea for how a community can be creative with AEDs. And what if the dispatcher could automatically alert all staff responsible for AEDs within a certain radius? Thus a security guard in an adjoining building would get a phone text telling him or her that there was a cardiac arrest next door. This technology is commercially available and deployed in a few cities. New smart phone applications can pinpoint (registered) AED locations. Clearly, AEDs in the community have the potential to save lives. The challenge is to maximize this potential.
Step 8: Supplement Funding & Support Training & QI
When times are tight financially, usually the first things to be eliminated or reduced are budgets for training and QI. While these decisions may be penny wise and pound foolish, they nevertheless reflect the harsh realities and the need to preserve basic operational personnel. Thus, it is important to find additional sources of revenues. Charitable gifts can provide needed funds to support activities such as training and QI. These in turn provide the margin of excellence to boost a program to a higher level of performance.
The Medic One Foundation is an example of how fundraising can supplement a public EMS system. This foundation supports 100% of paramedic training in communities throughout King County and cardiac arrest QI for the Seattle Fire Department. In addition, it funds paramedic training for other agencies outside of King County, as well as provides equipment and research grants.
In order to solicit charitable gifts, EMS agencies can establish a separate nonprofit foundation or find an existing nonprofit that is willing to serve as a fiscal sponsor of your fundraising activities.
For example, an EMS agency could partner with a hospital foundation or auxiliary, fire department auxiliary or benevolent fund, or with a local community foundation.
Such an arrangement saves the local fire department the expense and effort establishing a nonprofit charitable organization.
Step 9: Institute Hypothermia in All Receiving Hospitals
Hypothermia is the standard of care for resuscitated ventricular fibrillation patients when they arrive at the hospital in a coma. Cooling the patient’s body for twenty-four hours after resuscitation, offers the promise of a modest improvement in chances of survival, and to date there is no indication of harm from this practice. The American Heart Association and the International Liaison Committee on Resuscitation have both endorsed it. Like any complex hospital procedure, proficiency requires written protocols, practice, and accountability.
As of 2013, most hospitals that receive resuscitated patients have hypothermia protocols in place. Lance Becker, director of the Center for Resuscitation Science at the University of Pennsylvania Perelman School of Medicine, is a leading proponent of hypothermia. He and his colleagues, on the basis of laboratory studies, have come to believe that the cells of vital organs do not die from insufficient oxygen; rather, they say, the harm occurs when oxygen is reintroduced. The benefit of cooling is that it inhibits many of the destructive reactions associated with reperfusion of blood and with the reintroduction of oxygen. The University of Pennsylvania Hypothermia and Resuscitation Training (HART) Institute offers an annual two-day “boot camp” designed to educate care providers on in-hospital care of cardiac arrest patients.
Hypothermia is a relatively recent addition to the armamentarium of resuscitation therapy. In 2002, two studies of hypothermia were published in the New England Journal of Medicine. Both studies randomized patients either to receive hypothermia or to not receive hypothermia (called normothermia), for VF patients who had been successfully defibrillated but were comatose when they arrived at the hospital. One of the studies, reporting data obtained from several centers in Europe, demonstrated favorable neurological outcomes six months after cardiac arrest when hypothermia treatment had been delivered: 55% of patients in the hypothermia group had favorable outcomes, compared to 39% in the control group. Mortality was also significantly lower in the hypothermia group than in the control group: 41% and 55%, respectively. The other study, this one from Australia, did not demonstrate a significant difference in survival among the hypothermia and normothermia groups, though the authors did report better neurological outcomes in the hypothermia group. This was a smaller study, with only 77 patients as opposed to the 275 patients in the European study. On the basis of these two studies, several national and international organizations, including the International Liaison Committee on Resuscitation and the American Heart Association, now recommend hypothermia protocols for patients who have suffered ventricular fibrillation and are initially resuscitated but are still in a coma when they reach the hospital.
Unresolved issues are whether patients should receive hypothermia in the prehospital setting and whether only VF patients should be eligible for hypothermia therapy. It is for this reason that hypothermia is placed in the difficult-steps category. Though the therapy is reasonably straightforward, the difficult part comes in knowing whether it is beneficial for prehospital use. There is currently no data to clarify whether hypothermia should begin in the field, either after return of spontaneous circulation or in the middle of a resuscitation—in other words, prior to return of a pulse and blood pressure. Francis Kim, MD, at the University of Washington, is currently studying the potential benefits of prehospital hypothermia for resuscitated VF patients. This is a randomized trial, and the results will not be known until later this year. Also unresolved is whether hospital hypothermia benefits patients who are resuscitated from asystole or pulseless electrical activity. Stay tuned on this issue.
Step 10: Work Toward a Culture of Excellence
Creating and nurturing a culture of excellence is perhaps the most difficult step. What is a culture of excellence? A culture of excellence an implicit awareness perceived by most or all members of the organization that high expectations and high performance define the standard of care. A culture of excellence requires a leader (or leaders) with an uncompromising vision. Ideally, the administrative director and the medical director should share this vision. Practically they should meet regularly—perhaps weekly—to jointly administer and plan all aspects of the EMS program. The two of them, together, should establish a long-term plan to create and maintain a culture of excellence. Some people would argue that a high-quality EMS system demands such a culture. An equal number would claim that creating a culture of excellence is extremely challenging. No doubt it is. Nevertheless, a culture of excellence, hard though it may be to define or measure, is probably a key factor separating great systems from those that are merely satisfactory.
Administrative and medical leadership together must enhance training and continuing education and make medical QI the means of constant improvement. Excellence also requires buy-in from the extended EMS family of dispatchers, EMTs, and paramedics. When EMS providers recognize the presence of sincere, mission-driven leadership, as opposed to lip service, they respond to the positive culture and contribute to it as well.
The Medical Model
A culture of excellence can be achieved in any organization model. However, we believe such a culture can more easily be accomplished in a system that is based on a medical model. What is meant by a medical model? It is a system in which a medical director plays a large role in determining and supervising the quality of medical care. Specifically, a medical model of EMS is a system in which the medical director is responsible for the seven areas listed in “Medical Director Areas of Responsibility,” on the next page.
There is an eighth optional area of responsibility, namely, ongoing research studies. Continuous studies (to push the envelope of knowledge) create a sense of being part of a larger enterprise and helps foster a desire to contribute new evidence-based knowledge to the world of EMS. These studies do not have to be randomized clinical trials. One can embark on small-scale projects and still make a contribution. The studies need not necessarily be published in peer-reviewed journals—merely sharing the findings with the personnel can be rewarding and help to achieve a sense of pride.
A medical model does not require that the physician director run the entire system. In fact, the less administrative involvement by the medical director, the better. The medical director should be responsible for the quality of medical care and establish high expectations and see that they are being met. The EMTs and paramedics must be accountable to the medical director for the quality of their care. The ideal system would have the administrative director responsible for budget, operations and personnel matters and the medical director responsible for patient care. And in the best of all words, the two would work closely in partnership since their responsibilities complement each other. The medical director should not deal with hiring, though he or she should have a say in who is hired. And we don’t expect the doctor to directly fire anyone, though we expect him or her to work with the administrative director to limit, suspend or terminate an EMT or paramedic whose medical care is substandard. In Seattle and King County, there is a phrase that encapsulates the critical role of the medical director: The EMT or paramedic practices under the medical license of the medical director. In essence, the clinical buck stops with the medical director.
How does one create a medical model? Certainly there is no guidebook to follow and probably many if not most EMS programs think they have a medical model. The test is whether the medical director has responsibility for all the seven areas above. Why stress the concept of the medical model? Because the medical director is so importantly involved in every link in the chain of survival and every piece of the frame of survival.
Medical directors are appointed in various ways. Whatever the process, the medical director must have the authority to supervise a system that uses a medical model of EMS care. The medical director must clearly state and constantly promote high expectations, and the EMTs and paramedics must be accountable to the medical director for their patient care.
It is desirable (though not always possible) that the medical director has an academic appointment and is jointly appointed by the EMS administrative director and by the academic dean or department chair. An academic appointment ensures accountability. Moreover, an academic physician is generally one who is committed to furthering learning, and one who probably has knowledge about epidemiological principles and research methodologies. This is not to say that every medical director must conduct research—far from it, but only that the director must understand the benefits and limitations of data, and know how to interpret (and not over-interpret) this information. An academic medical director has access to all the expertise of an academic medical center and can turn to colleagues in cardiology, anesthesiology, pediatrics, obstetrics, trauma surgery, endocrinology, biostatistics, epidemiology, preventive medicine, health services, and toxicology to get answers about clinical issues and to seek help in guiding policy.
What can a community do if it is geographically distant from an academic medical center? Many centers offer clinical appointments to individuals who are in service roles in the community, or who help with the teaching mission of the university. Many deans and department chairs in emergency medicine would welcome a conversation with a community’s elected officials or its EMS administrative director and would be pleased to help establish a clinical appointment for the community’s medical director. It is also advantageous for a community to partner with an academic medical center, which probably already serves as the region’s trauma center.
The EMS program can provide training opportunities for emergency medical residents and help partner with the medical school on EMS fellowships. The medical center can provide clinical expertise, communications expertise, database management, and managerial experience, and can cooperate with local medical directors to establish regional consortia of EMS medical directors and programs. An academic medical center, after all, has a mission to serve the larger community, and the goodwill and reciprocity generated by this kind of effort can reap big dividends.
Continuous Quality Improvement
A culture of excellence also demands ongoing quality improvement. The medical director, with the support of the administrative director, is responsible for conducting QI audits of the EMS system. The cultural norm says we (all of us who provide care) are measuring how we perform in order to perform even better.
Medical QI can involve any aspect of EMS care. As it relates to cardiac arrest, however, the substrate for continuous QI is the cardiac arrest registry. Without QI, the cardiac arrest registry is just a collection of facts. With QI, the registry becomes the basis for improvement.
QI can occur at the macro level (system level) or micro level (components of the system) and even at the level of an individual resuscitation. At the system level one should be able to determine the survival rate for witnessed VF. For the micro level, QI bores down to the components of the system.
For example, what is the average time to:
• CPR? Defibrillation? What percentage of arrests have bystander CPR?
• Telephone CPR? What is the average time to deliver CPR instructions? The time intervals from the 9-1-1 call to CPR and defibrillation are critical to measure. Measuring these time intervals can be challenging but without this information it will be like trying to solve a puzzle with several key pieces missing.
Most EMS systems report response time (time from call to arrival at scene). However, in many centers the actual call occurs seconds (sometimes a minute or more) before being keyed as an EMS call. Thus, the actual call occurred before the response time clock starts ticking. And arrival at scene occurs a minute or several minutes before someone touches the patient. Measuring time intervals in EMS is a maze. The point, however, is that there are unmeasured time intervals prior to the so-called response time and unmeasured time intervals after the response time.
What really matters is the interval from the first ring in the primary public safety answering point (PSAP) to contact with the patient including who starts CPR, when it starts, and the exact time of the first defibrillatory shock. At the level of individual cases, QI should routinely try to piece together the key interventions. This is particularly important for VF cases when the patient did not survive.
Every link and every sublink in the chain of survival can be studied; the number of possible QI projects is limited only by resources and by the accuracy of the registry’s data. An EMS system should never become complacent. There are always opportunities for improvement, and continuous QI is the way to bring it about.
Improve Skills Among Paramedics, EMTs & Dispatchers
Improvement in skills is another part of a culture of excellence. The cultural norm says that we (again all of us who provide care) train in order to improve our skills. Paramedics’ skills improve with a combination of training, continuing education, and actual performance. In Seattle and King County, paramedics are required to perform 12 intubations and 36 IVs every year to maintain certification. Paramedic staffing correlates directly with opportunities to perform critical skills. There are strong advocates for various types of paramedic staffing in EMS programs. In Seattle and King County, a tiered response system is utilized and paramedics are sent only to the most serious calls. Thus, they are able to maintain critical skills, such as endotracheal intubation and central vein IV placement. In other systems, a paramedic is sent to all EMS calls. These programs assume that service is thereby improved, since every call, regardless of the seriousness of the emergency, will have a paramedic in attendance. But the unintended consequence is less opportunity for any single paramedic to practice critical skills. It is unclear whether a high or low ratio of paramedics to total population served is associated with community cardiac arrest survival.
As for EMTs, the care provided by these personnel is the foundation for all subsequent care delivered during an attempted resuscitation. If that foundation is of poor quality, the entire care structure is jeopardized. EMTs can do a great deal to treat ventricular fibrillation definitively, or to prime the patient’s body with high-performance CPR for further intervention by paramedics. The details of CPR and defibrillation often determine the outcome, and the key to positive outcomes is training.
Emergency dispatchers are also members of the EMS team. They have the critical role of mobilizing the EMTs and paramedics and seeing that telephone CPR begins before EMS personnel show up. Dispatchers’ training, practice and skill review are as important to positive outcomes as high-performance CPR and defibrillation. A highly trained dispatcher can, with rapid dispatch, easily save 30–60 seconds in the initial dispatch and, by offering telephone CPR instructions, can significantly increase the likelihood of the patient’s survival.