This guide lists 10 steps that will lead to improved survival. There are four easy steps (the low-hanging fruit) and six more difficult steps (the higher-hanging fruit). But one community’s easy, may be another community’s difficult. An EMS director or manager, partnering with the medical director, must decide what can be achieved in his or her own community. Whether one selects an easy or more challenging step the key is to begin. Success with one step will create momentum for tackling others. The steps listed above provide the overview and general approach to implementation. Missing are detailed game plans as well as the specific tools to implement the programs. Reading a short description of high-performance CPR, or dispatcher-assisted CPR, or rapid dispatch may convince you of the importance and need of such programs but how do you bring them about?
The Resuscitation Academy began in 2009 with the goal to improve cardiac arrest survival. Its tag line is “Improving cardiac arrest survival, one community at a time.” It was apparent from the first Resuscitation Academy class in 2009 that the lectures, breakout sessions and workshops could only go so far. We, the faculty, needed to spell out the details of how to implement the various programs we were talking about. The Resuscitation Academy tool kits were developed to do just this. They provide a how to guide, for setting up various programs within local communities. But even tool kits have limitations and we realize how hard it can be for local communities to implement the various programs. We think more attention must be focused on the challenges of implementation and the need to mobilize local community resources. Thus the last portion of this chapter tries to shine a beacon on the difficult topic of implementation.
Three complementary features can enhance the likelihood of successful implementation. First, the core components (cardiac arrest registry, assertive dispatcher-assisted CPR, high-performance CPR and rapid dispatch) must be in place.
Second, there must be fidelity to the core components. The best way to achieve fidelity is to define performance standards and use QI to measure the actual performance. This makes sense since, as is all too common, there is a large gap between perceived performance and actual performance.
Third, the EMS program must adapt to the local situation. Again, this makes sense since only through mobilization of local resources can there be any chance of undertaking new initiatives. Change, always difficult, is best smoothed with local buy-in and support. Implementation is not easy and this guide concludes with five specific actions on how to implement changes in your local community.
The Four Actions
Action 1: Form an advisory board. We believe the most important ingredient in the sauce of implementation is a team effort with a shared vision. The vision can be as simple as improving survival from out-of-hospital cardiac arrest. The advisory board or steering committee (or whatever term you use) should ideally be led or co-led by the EMS director (or fire chief or chief of EMS operations) and the medical director with a core group consisting of the dispatch director, the head of EMT and paramedic training, the QI officer (if one exists), a representative of the local hospital (or local hospital association) and ideally a political leader (mayor or council member) and a citizen. The latter could be the head of a local philanthropic organization such as the Kiwanis or Rotary Club. This core group may be ad hoc or formal (in other words commissioned by the mayor or council with formal appointments), and all it takes is one fired-up individual to catalyze the initiative. Large communities should have a full- or at least a part-time staff person who is accountable to the advisory board and can keep everyone on task and maintain forward momentum. The staff person should be thought of as the site coordinator who works on behalf of the advisory board.
Action 2: Determine how to make it happen in your community. Every step in this chapter must be customized to the local system and its strengths. There is no one pattern. Rochester, Minn., has a completely different EMS system from Seattle and King County. And yet both achieve high survival rates proving that there is no ONE system. Each EMS leader must mobilize and strategize based on what is possible locally.
Action 3: Set specific goals. This group must be realistic. They will not transform their system overnight and they should set attainable goals achieved by plucking the low hanging fruits. Progress will likely be slow and iterative (step by step). But once on the path to improvement there is no stopping that community.
Action 4: Establish performance standards. For example earlier in this guide possible performance standards for dispatcher-assisted CPR and high-performance CPR were listed. Let everyone know what the standards are and why they matter. Then provide the training and support to meet these standards. Constant (and timely) feedback is also part of the equation.
There are regrettably few, if any, national performance standards for resuscitation. A 2011 consensus paper from the American Heart Association calls for specific benchmarks and quality improvement goals for out of hospital cardiac arrest. These goals span the spectrum from medical leadership to dispatch to EMS and hospital care. Whether one agrees with the specific goals, is in some way less important than the fact that performance standards are becoming part of the national dialogue on how to improve survival rates. The following list on the next page inclues possible standards for an urban EMS system and are meant to complement the 10 specific steps at the beginning of this guide. Note how the standards are weighted heavily toward bystander CPR (whether by a trained person or as a result of dispatcher assistance) and the rapid delivery of CPR and defibrillation standards that will surely lead to improved survival.
One might consider different standards for urban and rural EMS systems. But whatever the standards are, adherence to them should be mandatory, and reported to the members of the EMS agency and governing board:
• Bystander CPR in more than 60% of witnessed cardiac arrests;
• Dispatcher-assisted CPR in more than 50% of all cardiac arrests (excluding arrests when bystander CPR is in progress at the time of call);
• Less than five minutes between pickup of the call to 9-1-1 and the arrival of EMTs at the patient’s side more than 90% of the time;
• Less than six minutes between pickup of the call to 9-1-1 and the first defibrillatory shock more than 90% of the time;
• Less than ten minutes between pickup of the call to 9-1-1 and the arrival of paramedics at the patient’s side 90% of the time;
• Use of voice and heart rhythm recordings in all resuscitations;
• Medical directors review and critique of all resuscitations; and
• A community survival rate (discharge from hospital) of 25% for patients with witnessed ventricular fibrillation.
Action 5: Measure and improve. Ongoing measurement of survival and ongoing QI are vital. A cardiac arrest registry need not be onerous. It can take as little as 10–15 minutes to register the data. Similarly, analysis of cardiac arrest CPR performance or dispatch performance need not be exhaustive. Ten to fifteen minutes should provide the vital elements of QI and will certainly provide the information needed to monitor the system and allow for feedback to the individual EMS personnel and individual dispatchers. Praise is given for good performance, and for the less-than-good performance, we always stress the challenges of the task and ask how it can be done better the next time. We have never used QI information in a punitive or disciplinary manner.
These five implementation actions help define the frame of resuscitation. The metaphor of a chain of survival and a frame of survival fit nicely with the concepts of resuscitation. The chain of survival is all about the specific therapy, particularly providing CPR and defibrillation as rapidly as possible and with as much fidelity as possible. The frame of survival is all about the qualitative factors leadership, culture, ongoing training and QI. These are the stuff of implementation: establish an advisory board (leadership), set specific goals (vision), establish performance standards (culture), determine how to make it happen (training), measure and improve QI.
A Vision of the Future
We believe that survival from VF in many communities could reach 60%. Some communities are already near 50%. In King County we will approach 60% in the near future with meticulous application of high-performance CPR and intensive training in recognition of cardiac arrest and delivery of dispatcher-assisted CPR. For communities currently at the 10, 20, 30, or 40% survival rates, we cannot guarantee a sudden surge to 60%, but we do think dramatic increases in survival are possible. From the many inspiring success stories alumni have shared since attending the Resuscitation Academy, clearly this is evidence that improving survival rates from cardiac arrest is not only a possibility for the future, but can, with focused and concerted effort, be possible now.