Cardiac & Resuscitation, Patient Care, Trauma

Oklahoma City & Tulsa Reveal Playbook for Cardiac Arrest

Issue 9 and Volume 37.

As EMS professionals, we’re routinely challenged to successfully resuscitate victims of sudden cardiac arrest. Fortunately, our understanding of cardiac arrest pathophysiology continues to grow. More fortunate still, our enthusiasm in translating that understanding to effective therapies has never been greater.

In the August 2012 issue of JEMS, we introduced a comprehensive restructuring of the EMS System for Metropolitan Oklahoma City and Tulsa’s cardiac arrest program using a three-part approach: chest compression fundamentals, resuscitation team dynamics and accelerated feedback on resuscitation performance. We discussed the benefit of going “back to the basics” of chest compression fundamentals training, increasing our rate to 120 chest compressions per minute and using metronomes to attain and maintain that rate throughout resuscitations. Now, we share how those fundamentals were incorporated into a Resuscitation Team Playbook and how we use directed feedback to further refine resuscitation performance.

Step 2: Resuscitation Team Dynamics
Have you ever been a part of an EMS call that was particularly “busy” in activity, yet when the patient was transferred for further care, you started to think, “What did we actually get done?” Us too. In fact, it happens to all of us in the inherently challenging practice of EMS medicine. We believe what you do with those reflections can make all the difference in the world for future patients. We therefore chose to turn our reflections, and those of our colleagues, into a Resuscitation Team Playbook that channels individual enthusiasms into a carefully orchestrated team performance, often described favorably as “pit crew resuscitation.”

Figure 1 shows the positions used in our resuscitations, with roles defined for teams of one to six professionals. In our EMS system, we often start with resuscitation teams of two, three, or four, with subsequently arriving responders building that team to five or six actively contributing members. It’s rare in our system that one EMT or paramedic would be tasked with resuscitating a cardiac arrest patient alone, but it could happen for a brief period if a patient were to collapse at a nearly empty fire station or ambulance headquarters. We wanted to ensure we had all the possibilities covered, including the single rescuer scenario. Let’s review the key contributions provided by each position, so that you’ll be certain to include the care most likely to promote neurologically intact survival, regardless of resuscitation team size.

Position 1: Rapidly identifies arrest and initiates continuous chest compressions.
>> Alternates minutes of chest compressions with Position 2 over the course of the resuscitation.
>> When not compressing, assists with bag-valve-mask ventilations (squeezing the bag).
>> Minimizes pauses in chest compressions for rhythm determination and/or defibrillation.

Position 2: Applies automated external defibrillator or monitor/manual defibrillator.
>> Mirror image of Position 1.

Position 3: Provides airway management; avoids hyperventilation.

Position 4: Leads scene management.
>> Interface with family/bystanders for events preceding arrest and medical history.
>> Supervises positions 1–3 for continuous compressions, timely defibrillation, and no hyperventilation.

Position 5: Provides ALS support.
>> Rhythm determination and manual defibrillation.
>> Vascular access.
>> Medication administration.

Position 6: Provides ALS support.
>> Patient management leader.

At first, it looks like a lot of instruction—because it is. However, these directives simply expand in detail on the key contributions at each position. You may think this degree of directive is micromanaging hardworking EMS professionals who already know the right things to do in time-sensitive situations. You’re right; it actually is micromanaging, but let’s look at why cardiac arrest calls for no less.

Try this exercise, literally. Do 20 jumping jacks. What do you feel? Unless you’re in particularly athletic shape, you likely feel an increase in pulse and in respiratory rate and effort. Why? You’re compensating for an increased activity demand. The human body is amazing in its ability to compensate, even to some degree when severely ill or injured. But spontaneous circulation reflects an unforgiving light switch. When it’s “on,” compensation is at work. When it’s “off,” as in cardiac arrest, there’s complete loss of compensation … except for resuscitative efforts.

Thinking back to our understanding of cardiac arrest pathophysiology, we have to be precise in those efforts for our “compensation on loan” to work. The only way to make that happen comes when we use a carefully crafted plan (the playbook) and actively micromanage ourselves in each position (running the play). So in sum, it’s not micromanaging by others, it’s self-micromanaging, and it’s for all the right reasons.

We’ve definitely laid out a plan, but how do we know whether it’s the right plan? One quick answer you’ll say is by looking at neurologically intact survival rates—before and after adoption of this plan. In fact, that’s a great answer, but we think it comes up short as the lone answer.

In athletics, if a team loses a game, does that mean they played badly? Often, the answer is “not at all;” it may mean the team simply played a better team, or depending on how score is kept, the team may have started with a handicap that’s insurmountable. Ever start a resuscitation feeling that you were working with such a handicap? That’s where Step 3 comes into use in our cardiac arrest program.

Step 3: Feedback on Resuscitation Team Performance
Every high-performance professional values feedback designed to “build up” future abilities. Our feedback program channels that philosophy using proprietary software that captures data from the monitor/defibrillator throughout the resuscitation. Many EMS systems are using this type of capability, but the real value lies in merging data with a set of skilled clinical eyes, annotating the basic feedback forms. Credit goes to the Redmond, Wash., Medic One program for helping us see the full potential already in our grasp.

Only through annotating a case do specific gaps in compressions, changes in ventilation rates and timings of defibrillation really become clear. No “real world” resuscitation will ever be textbook perfect. Thus, only through analysis by an experienced clinician does variability reliably fall into the “makes sense” or “opportunity to reflect” categories. Without annotation, a “report card” gets generated without showing a valid grade … arguably pointless, right?

Our goal is to have an annotated resuscitation team performance feedback report available to the resuscitation team on its next shift after working a cardiac arrest. The report is sent with explanation through annotated comments and without discouraging remarks, even in areas for improvement. Those areas are self-evident, and we believe the best correction can come through team reflection.

So how are we doing in achieving our own goal? Currenrtly, just about 5% of the time. But here’s a key point, and one we’ve had to learn with hard experience: If you wait until everything is perfect to start improving, you never start improving. Like most EMS systems, we’re understaffed in comparison with our goals. However, we’re fortunate in being able to hire a new data specialist position that’s dedicated full-time in our Office of the Medical Director. This position will dramatically improve our feedback abilities, both in volume and timeliness.

Even with feedback 5% of the time, the results are encouraging. We’re routinely seeing chest compression fractions (CCF) (i.e., time in which chest compressions are actively occurring) above 90%. In fact, many resuscitations are being performed with CCFs above 95%. (To be clear, these cases reflect random analysis, not just review of clear survivors.) These numbers reflect CCF increases 5–15% above our historical baselines. Not surprisingly, return of spontaneous circulation (ROSC) rates have increased since we started resuscitation team dynamics in February. Although we anticipate cardiac arrest survival rates in 2012 to be rewarding, it’s still early, and we don’t want to report on incomplete data.

Conclusion (For Now)
Our EMS system, just like yours, is committed to attacking cardiac arrest and doing everything we can to help the suddenly dead become alive again. Focusing our energies (with encouragement from friends throughout EMS) on chest compression fundamentals, resuscitation team dynamics and better timely feedback on resuscitation team performance—all in support of patients and the EMS professionals caring for them—makes a lasting influence on cardiac arrest.