According to the American Heart Association (AHA), every year around 160,000 Americans experience ST-elevation myocardial infarction (STEMI), and around 360,000 have out-of-hospital cardiac arrest (OHCA). What’s more, many of these patients fail to receive the appropriate treatment needed within the recommended timeframe to save their life.
The AHA created Mission: Lifeline to encourage communities, EMS agencies
and hospitals to provide prompt, appropriate treatment for patients with STEMI, but more needed to be done. Last year, the AHA expanded Mission: Lifeline to encourage communities, EMS agencies and hospitals to provide prompt, appropriate treatment for patients with OHCA. And Graham Nichol, Medic One Foundation Endowed Chair in Prehospital Emergency Care and Professor of Medicine at the University of Washington, has led the charge for this expansion.
Opportunity for Improvement
“The Mission: Lifeline program is the American Heart Association’s quality improvement program for acute cardiac conditions,” Nichol says. “It began by focusing on heart attacks. My role has been to extend that to include out-of-
hospital cardiac arrest.”
A program like this can’t be successful without the assistance of EMS. In fact, EMS is a critical component in executing the program expansion into care for patients with OHCA and focuses on ensuring prompt, seamless and effective treatment to patients with STEMI or OHCA.
Whether serving densely populated metro areas, rural residents with issues regarding geographic access or communities in between, EMS challenges are unique for each setting. The AHA was the first national organization to help providers identify and implement policies and procedures that overcome barriers to timely access to appropriate STEMI and cardiac arrest care and empower them to save more lives.
“Mission: Lifeline began a few years ago focused on heart attacks. I recognized,
and the AHA agreed, that some of the strategies that are used to improve care for heart attack patients can be used to improve care for patients with cardiac arrest,” Nichol says. “That includes measuring the process and care, and then feeding that information back to providers. This can help them understand where the opportunities for improvement are and implement strategies to achieve those improvements.”
What Nichol wants to emphasize about the Mission: Lifeline program, and his involvement in incorporating out-of-hospital cardiac resuscitations into the process, is that it encourages all stakeholders to work together as a team, rather than independently. “In some communities, the opportunity is improving the number of people who are trained in CPR. In other communities, it’s improving the dispatch response. Still in other communities, it is improving hospital-based care,” he says. “But the only way we can understand where the opportunities are is if we measure the care throughout the continuum, and look at it together with all constituencies represented. This includes the community, EMS and hospitals all working together to achieve a common goal.”
Nichol stresses the need for EMS and hospitals to work together in harmony,
under a program such as Mission: Lifeline, because it’s such a common problem and community survival rates can vary so widely. He explains that OHCA is the third-leading cause of death in the United States.
“There’s a 500% variation in survival after cardiac arrest from one community to another, so it is a treatable condition,” Nichol says. “It continues to be a common problem, but we can do much better. The challenge, and the opportunity, for all of us are to work to achieve that potential in communities around the U.S.”
Nichol adds, “Some communities do have quite a good survival rate, but many do not. So we are trying to apply the lessons from one community to many other communities.” He points to Seattle as one example of a community where stakeholders work together so that outcomes improve for patients who experience out-of-hospital cardiac arrest. “The chance of survival after witnessed ventricular fibrillation in this community is more than 50%,” Nichol says.
The AHA uses this variance of survival rates from community to community to stress the importance of state and regional stakeholder cooperation. According to the AHA, “It’s important to remember that there is no ‘one-size-fits-all’” in an ideal STEMI system of care. “A city swelling with residents presents different
issues than a region where there is more wildlife or livestock than people. This is the reason that the AHA is dedicating resources to create state and regional STEMI stakeholder task forces to determine the appropriate actions for each region.”
The AHA considers first responders critical to the success and effectiveness of a STEMI care system, and recognizes the challenges that EMS faces when serving widely diverse metro or rural regions. The Association has made it a goal, through Mission: Lifeline, to help first responders solve the challenges they face in delivering appropriate STEMI, and now OHCA care, in order to save lives.
To this end, Mission: Lifeline outlines recommendations for quality improvement recognition and certification requirements. The program also delineates performance and compliance guidelines for EMT Basic or Intermediate Providers, EMT Paramedics, and patient and hospital transfers. Mission: Lifeline also outlines best protocols for emergency departments, including the establishment
of reperfusion checklists, standard pharmacological regimens, the establishment of clinical pathways and the use of single-call activation systems.
Mission: Lifeline supports standardized point-of-entry protocols, which are developed by state-based coalitions of EMS personnel, emergency physicians and cardiologists. It is these protocols that dictate when and whether a patient should be transported to the nearest hospital or STEMI-receiving, PCI-capable
hospital. The AHA is clear that this determination is made, in part, basedon the “acquisition, interpretation and transmission of the prehospital 12-lead ECG administered by EMS.”
Another unique aspect of the program is the communication between parties. Currently in most healthcare systems across the country, EMS providers don’t often get to find out what happens to a patient once they are transported and turned over to a hospital. Mission: Lifeline has made the communication between EMS, hospitals and other parties involved in a STEMI system of care as part of its initiative and works to make communication on patient outcomes between these parties more effective.
Nichol is the first to admit that while the program is funded by the AHA, as well as participating regional hospitals and sites, Mission: Lifeline is not as well-funded as he would like. “A lot of work is done by good will,” he says. “The people who are involved in the program are committed to improve the care of the patients they serve, so the program will continue, but we would be able to do more with more resources.” As a case in point, Nichol participates in the program as a volunteer.
Despite this, Nichol believes that the outcomes for OHCAs are improving. “Several years ago, the Resuscitation Outcomes Consortium (ROC), of which I am privileged to play a small role, reported survival after cardiac arrest in its communities,” he says. “We showed that out-of-hospital cardiac arrest was about 8% in those communities. It has since improved to about 10%. Is that good? On a relative level, yes it is. On an absolute level, no, it’s not. We have more work to do.”
But, “If we can keep achieving a 20% improvement over time, then many more people will be able to survive,” Nichol says. “So I’m challenged, not discouraged.” In fact, it is this challenge, and the knowledge that EMS can do better, that helps motivate Graham Nichol. “I’m driven by the knowledge that we have to do better because it’s such a common problem,” he says. “I know we can do better.”