The Medtronic Foundation’s Joan Mellor oversees the Foundation’s HeartRescue Project, a collaborative initiative designed to improve how SCA is recognized, treated and measured in the U.S. Most importantly, it’s an ambitious effort to change the way we collectively respond to sudden cardiac arrest (SCA). Partners involved in the project are working to improve SCA survival rates by 50% over five years by implementing measurable, evidence-based best practices among citizen bystanders; prehospital responders such as police, fire and EMS; and hospitals.
Despite years of working to reduce the high death rate from SCA, Mellor has high hopes that the rates can be significantly improved. “It’s been such a tough disease to tackle, and nobody has been able to do it in a way that is really scalable,” she says. “And yet several communities across the country, including places like Arizona and Seattle-King County in Washington, have proven that increasing survival rates is possible.”
Mellor was pleased to participate in this special editorial supplement to JEMS and speak about the HeartRescue Project and what she thinks it will take to achieve a reduction in SCA deaths on a national scale.
HeartRescue Project Partners
Six statewide partners are centered in leading universities; in addition, American Medical Response is a partner serving more than 2,000 communities.
Q: What is the HeartRescue Project?
A: The HeartRescue Project is an initiative designed to improve survival from SCA in the U.S. Remarkably, even though nearly 400,000 people die annually from SCA, and U.S. survival rates are between 8–10%., this survival rate hasn’t changed in 30 years, except in a few pockets of communities that have significantly higher survival rates than the national average.
In 2010, the Medtronic Foundation made the decision to recruit and work directly with partners known for their leadership in resuscitation, who in turn would coordinate activities to definitively improve survival in their respective geographies. The current partners include leading universities in six states and American Medical Response, which responds to 25,000 SCAs annually in 2,000 communities throughout the U.S.
These partners have accepted a common challenge to improve cardiac arrest survival by 50% over five years in their geographic service areas. Each partner is being asked to develop and expand SCA response systems by coordinating measurement, education, training and the application of evidence-based best practices among the general public, first responders, EMS and hospitals. They’re also being asked to connect bystander, prehospital and hospital response by applying published science to strengthen the chain of survival.
Every step in the chain of survival counts. There is bystander response, which includes early recognition of SCA, early initiation of bystander CPR and easy access to AEDs. There’s prehospital response, including dispatchers who can recognize SCA and quickly get someone to start chest compressions. That alone is a huge opportunity to improve SCA survival rates. Then we need the EMS team to perform high-quality CPR, to provide defibrillation care and then early advanced care.
Finally, when patients are transported, is the hospital ready for them? Is that person getting triaged to a resuscitation center of excellence? Is there in-hospital hypothermia? Is there 24/7 access to a cath lab? Is the patient receiving post-survival treatments appropriate for their underlying condition? And are the patients and families receiving education and support to manage their disease?
Q: Why are measurement and data so important to this initiative?
A: We can’t improve what we don’t measure. And SCA is not currently a reportable condition in this country. So a core element of the HeartRescue Project is to measure cardiac arrest performance and outcomes.
Our partners are committed to helping define a data dictionary to make sure we’re measuring things consistently. They are also working with the EMS agencies, hospitals and other agencies to not only get outcomes data through electronic patient care reports, but to add elements from the dictionary to their patient care reports so we are getting key information that helps us improve survival.
The information being collected is comprehensive but not overly burdensome in terms of data elements requested for each case of SCA. Some of the key questions include:
• Did a bystander start CPR?
• Was an AED used? If so, by whom?
• Did the patient arrive alive at the hospital?
• Did they receive hypothermia?
• Did they receive appropriate post-resuscitative care?
• Did they get discharged alive?
The goal is to measure the continuum of care for patients who have suffered cardiac arrest. Then we have to make sure that data gets back to the EMS and hospital providers so they can use it to improve what they’re doing.
All data collected at the state level is then put into the Cardiac Arrest Registry to Enhance Survival (CARES) surveillance registry.
Q: What makes the HeartRescue Project different from other efforts to improve SCA survival?
A: Some of the core features of the HeartRescue Project are that we have publicly stated measurable goals, we focus on data collection and it’s highly collaborative. We’re bringing together hundreds of stakeholders in each state with a focus on one goal, which is reducing deaths from SCA.
At the outset of the project we wanted to work with leaders in resuscitation who could help us replicate the great work they were already doing, typically at the community level, but then spreading it across the state. Through their leadership, they’re creating teams of bystanders, as well as EMS and in-hospital providers, to work together so it becomes a collective project that has collective impact. This is different from an individual community taking this on. We’re asking our partners to be a hub for a state, to partner with and collaborate with other agencies and organizations.
The reality is that we haven’t been able to improve survival in 30 years on a broad-based scale. So how are we going to do it today? We believe there has to be partnerships built between the bystander, prehospital and hospital response levels. Working together on implementing best practices and measuring progress will make the difference.
Q: Are SCA survival rates an indicator of overall EMS system effectiveness?
A: I believe they are. If you improve your ability to treat SCA—what some consider the most serious, time-sensitive problem that exists at the acute care level—then it stands to reason it’s going to improve your entire EMS system. Sometimes EMS providers will say, “We can’t focus this much time and energy on 1% of our calls.” But if you can tackle the toughest cases, you are likely going to be improving care for all your patients.
When you address cardiac arrest, you’re also creating a network of care that you can now apply to other diseases. For example, in areas that have a ST-segment elevation myocardial infarction (STEMI) network, they already have great relationships between prehospital providers and hospitals. So it’s much easier to dovetail resuscitation efforts into that, and vice versa.
Take the case of Arizona, for example. They’ve created a wonderful statewide SCA system of care. Now they’re applying this network of collaboration and relationships to traumatic brain injury with great success. We’re starting to see stroke, STEMI, cardiac arrest and even trauma and traumatic brain injury connecting with one another into larger acute care systems.
Some people think it’s a lost cause, that SCA isn’t treatable. But we know, through the experience of our partners, that it is. We need to instill that in the consciousness of our prehospital and hospital systems, as well as in the minds of the general public. We need to believe we can make a difference. Our partners are charged with creating more believers through proof of success.
Q: Are there any success stories yet?
A: The success stories right now are foundational. All the states that are involved are working toward developing a network of EMS providers and hospitals that agree to collect the same data and are starting to put the data into the system. That’s huge. In just a year and a half, all five of our original partner states are covering at least 50% of their population in terms of outcomes data collection.
The other success so far is that communities around each state are embracing the concept and starting to work together at each level of response and as whole teams across geographies. The Resuscitation Academies are a huge success. They started in Seattle several years ago and are now offered through partner collaborations by every HeartRescue partner. They were initially intended to educate EMS medical directors about best practices for resuscitation; now there are Resuscitation Academies for dispatchers to learn about best practices in dispatch-assisted CPR, for EMS providers to learn high-performance CPR and for hospital staff to teach post-resuscitative care, including in-hospital hypothermia. Measurement is one piece. Education and sharing of best practices among the sites is the other.
Q: How important is bystander CPR to improving survival?
A: We can’t improve survival without bystanders. The chances of survival double if a bystander provides timely CPR. Bystanders also need to call 9-1-1 and ask for an automated external defibrillator (AED). None of this works without the bystander.
All of the partners are taking on bystander CPR in a way that fits for that state. For example, in Arizona, they’ve done public awareness campaigns through the Department of Health to increase hands-only CPR. Their next step is to improve dispatcher-assisted CPR, which means training dispatchers in recognizing cardiac arrest and instructing bystanders to start CPR as quickly as possible.
Other states are focusing on the Internet and social media. In Philadelphia, they’ve run a contest in which citizens were asked to locate and snap pictures of AEDs in the community to upload to a citywide map. In Minnesota, they’re doing CPR awareness through flash mobs at the Mall of America. They all have their own local twist.
At the national level, we’re also helping out by creating the interactive Save-A-Life Simulator, which teaches you the basics of bystander response by immersing you in a local mall where you have just witnessed an SCA and are asked to make a series of decisions about how to respond. It’s a groundbreaking way to reach more bystanders through social media and has already reached more than 1.5 million people.
Q: How important is dispatcher-assisted CPR to improving rates of bystander CPR?
A: It’s very important and a great way to effectively create systemic improvements. In Seattle, the overall bystander CPR rate is 60% for witnessed SCA; more than one-third of that is due to dispatcher assistance. They do a good job of training their dispatchers: Dispatchers know how to recognize it, give clear instructions and give the bystander enough confidence to try it.
The American Heart Association has released recommendations for dispatcher-assisted CPR. There are basically two questions: The dispatcher should ask if the person is responsive and if they are breathing normally. If the answer is “no” to both questions, the bystander should be directed to start chest compressions. However, some dispatch organizations may use dispatch software that includes more than these two questions.
No matter what protocol is used, a quality assurance process for reviewing cardiac arrest calls is recommended to minimize the time between 9-1-1 call and first compressions and ultimately save more lives.
Q: Why is it important to hold Survivor Summits?
A: Survivor Summits are important because SCA doesn’t have pink ribbons or three-day walks; there is no such voice for this problem. Of course I support breast cancer and other types of research, but 40,000 people in the U.S. die annually of breast cancer, while 400,000 die of out-of-hospital cardiac arrest. We need to continue to build a patient community of people who have been affected by SCA so they can support one another and become the voice that affects policy and healthcare decisions about treating this disease so more people survive.
If you think of other diseases, such as cystic fibrosis or pediatric leukemia, these are diseases that didn’t have long-term survival rates in the ’60s and ’70s. But as better care progressed and more patients survived, they started creating support groups and registries and organizing as patient communities to advocate for continued research and funding.
We’re now starting to see this gradually build among survivors of SCA, with groups like the Sudden Cardiac Arrest Association and the Sudden Cardiac Arrest Foundation. Survivors are powerful advocates, and the more we can support their efforts to organize and strengthen their national presence, the better.
Visit HeartRescue Project at www.heartrescueproject.com for more information and to download the Community SCA Response Planning Guide. Go to www.heartrescuenow.com to experience the Save-A-Life Simulator.
Jenifer Goodwin is associate editor of the monthly newsletter Best Practices in Emergency Services.
Disclosure: The author has reported no conflicts of interest with the sponsors of this supplement.