Recent investigations have demonstrated that a handful of communities have achieved remarkable cardiac arrest survival rates exceeding 15%. However, most Americans still live in locations with survival rates that are much lower. Many of the communities with high survival rates have achieved improved cardiac arrest outcomes by focusing on the entire chain of survival; that is, they support a full bundle of interventions to provide the best resuscitation care for patients with cardiac arrest. This “bundle of care” approach usually includes:
a. an aggressive citizen CPR program,
b. outstanding EMS responders with a focus on high quality cardiac arrest care,
c. improved emergency department and hospital post-resuscitation care, and
d. a continuous quality improvement strategy that is data driven.
Partnerships in Pa.
Could we learn from these communities and apply the lessons learned to an entire state? The Commonwealth of Pennsylvania (Pa.) has joined with five other states and American Medical Response under the umbrella of the HeartRescue Project in an attempt to do exactly that. Along with the other site participants, Pennsylvania EMS stakeholders are working to learn from the successes in other communities and implement changes on a larger scale across the state.
As part of the HeartRescue Project launched in 2011, Pennsylvania and other sites intend to promote a higher level of cardiac arrest awareness, treatment, and measurement throughout the U.S. The Project’s goal is both ambitious and focused: to increase overall sudden cardiac arrest (SCA) survival-to-hospital-discharge by 50% over a five-year period in a given geographic area. The targeted 50% increase is above the current baseline; a region with a population of more than 12 million citizens and a current survival rate of 6% would aim to increase survival to 9%.
The Pa. HeartRescue Project team has established a partnership with the Pennsylvania Department of Health Bureau of EMS to address the leading cause of death and identify strategies to make improvements. “The Pa. Department of Health Bureau of EMS is honored to collaborate with the HeartRescue Project to identify best practices, collect quality data through the Cardiac Arrest Registry to Enhance Survival [CARES], and implement protocols that will ultimately change the way that EMS providers respond to SCA,” says Bureau of EMS Director Joseph W. Schmider.
Under the leadership of Schmider and Commonwealth EMS Medical Director Douglas F. Kupas, MD, the partners have established goals and developed training models to educate EMS providers on the optional primary sudden cardiac arrest statewide ALS protocol for adults, which focuses on high-performance CPR and describes system requirements for pre-approved high-functioning EMS agencies.
High-Performance Resuscitation Protocol
With mounting evidence of increased survival when a community and EMS system use compressions-only CPR for primary cardiac arrest, the Pennsylvania Department of Health developed an optional high-performance resuscitation protocol. Supporting the American Heart Association 2010 Guidelines, the protocol requires the development of a system, approval from regional EMS councils, high-performance CPR training and a strong quality improvement program with 100% patient outcome reporting.
The goal of the statewide protocol is to develop a standard of care that incorporates early bystander and dispatcher-assisted CPR and AED use; focuses on quality, uninterrupted chest compressions; and engages medical direction, EMS provider teamwork and high-performance resuscitation at the scene. It also recognizes the importance of post-resuscitation efforts in the hospital, such as therapeutic hypothermia and coronary catheterization centers that are available 24 hours a day, seven days a week. It also places a strong emphasis on quality data collection and management.
The protocol for high-functioning EMS agency designation requires compliance with all of the agency system requirements, including:
1. The EMS agency medical director must approve of agency participation and oversee education and quality improvement of primary cardiac arrest care.
2. Agency personnel must have initial and regular continuing education. Training should include teamwork simulations integrating QRS, BLS, and ALS crew members who regularly work together.
3. The EMS agency, overseen by the agency medical director, must perform a quality improvement (QI) review of care and outcome for every patient who receives CPR. This includes whether the initial dispatch categorized each case as a possible cardiac arrest and whether bystander CPR was done prior to EMS arrival.
a. The QI must be coordinated with local receiving hospitals to include hospital admission, discharge and condition information.
b. The QI must be coordinated with local Public-safety answering point/dispatch centers to review opportunities to assure optimal recognition of possible cardiac arrest cases and provision of dispatch-assisted CPR (including hands-only CPR when appropriate).
4. Primary cardiac arrest programs must be approved by the agency’s local EMS regional council. In addition, each agency must participate in the regional QI committee including submission of quarterly cardiac arrest QI summaries with the information required by the Bureau of EMS. Some of the agency QI requirements can be met by participation in the CARES program.
The new protocol, which was spearheaded by Kupas, has been promoted throughout Pennsylvania over the past year. In an effort to rollout an organized training for providers, the Department of Health has collaborated with the HeartRescue Project team to develop a Pennsylvania Resuscitation Academy, modeled after the previously established and highly successful Seattle Resuscitation Academy, to ensure better practices across the state in hopes to achieve our overall goal of improving response.
The Academy was developed to educate EMS managers, directors, medical directors and officers. It reinforces the benefits of high-functioning EMS agency system requirements, trains providers on high-performance CPR models and provides hands-on CPR quality practice sessions. The evidence-based training reinforces the pit crew model, which promotes teamwork, leadership, situational awareness and role assignment, and is designed to provide uniformity within a response team and improve efficiency in the field. With a strong emphasis on CPR quality, high-fidelity simulation is used to provide attendees with a significant amount of hands-on practice and scenario-based role playing. The Academy also enables providers from regions across the Commonwealth to discuss new therapies, provide feedback from the field and share best practices in an open forum.
To date, two Pennsylvania Resuscitation Academies have been successfully executed, hosting more than 100 providers from eight regional councils—with two additional academies planned for the fall of 2012.
A high-functioning EMS agency “train the trainer” course was developed as the next phase of the Resuscitation Academy. Interested EMS agencies will receive hands-on training to prepare agencies to meet the system requirements. Launched in August, the training program provides additional hands-on training and offers interested EMS agencies the resources needed to develop regularly scheduled high-performance CPR practice sessions and promote teamwork. On completion of the program, attendees receive toolkits that include practice scenarios, equipment checklists, pit-crew models and evaluation materials. Each agency will be equipped with resources that will enable them to implement a customized high-performance CPR model. Continuing education credit is available to all providers who attend these Pa. Resuscitation Academy and high-functioning EMS agency train-the trainer courses.
With the training models in place, the new Pennsylvania primary sudden cardiac arrest statewide ALS protocol is poised to have a significant impact on survival. Now, EMS providers are armed with a model that emphasizes teamwork, increases “hands-on” time on a patient, and focuses on quality improvement and data integrity. With proven successes in other communities through these strategies, it is the hope that Pennsylvania will be able to see similar improvements. “We are already beginning to see improved patient outcomes, when SCA victims receive prompt bystander CPR, EMS intervention with high-performance CPR in the field,“ Kupas says. “Increased instances of ROSC are occurring in the field, which enable post-resuscitation efforts to be continued in the emergency departments with progressive treatments, such as therapeutic hypothermia. Survivors are being discharged from the hospitals with positive neurologic outcomes and drastically improved quality of life.”
A strongly held mutual belief of the Pennsylvania Department of Health and Pa. HeartRescue Project is not only that SCA survival rates can reflect the overall effectiveness of an EMS system, but that such efforts can lead to a stronger EMS system overall—benefitting patients needing many different types of care. It’s the hope that the improved systems of care in Pennsylvania, combined with a community call-to-action and a strong emphasis on quality and measurement, will result in a cultural change that will have a positive effect on SCA survival.
Kathryn DiPuppo Tucker, BA, is program director of the Center for Resuscitation Science at the University of Pennsylvania.
Michael A. Ward, BS, EMT-B, is a well-known EMS blogger, textbook author and conference presenter. He is a former assistant professor of emergency medicine at George Washington University.
Benjamin S. Abella, MD, MPhil, is the clinical research director of the Center for Resuscitation Science at the University of Pennsylvania, where he clinically serves as an emergency department physician.
Lance B. Becker, MD, is professor of emergency medicine at the University of Pennsylvania. He was the founder and Director of the Emergency Resuscitation Center at the University of Chicago in Chicago and Argonne National Laboratory.