A woman finds her 55-year-old husband slumped over the sofa. He’s unresponsive, with snoring respirations. She immediately calls 9-1-1 and is instructed by a telecommunicator to move her husband from the sofa to the floor. She’s given simple assertive instructions to begin rapid, hard chest compressions, which she does for more than eight minutes until EMS arrives.
Within one minute of arrival, the EMTs confirm he’s unconscious and not breathing normally, attach their CPR pads and initiate uninterrupted CPR using real-time audiovisual CPR feedback technology while determining the heart rhythm is v fib. The EMTs perform two minutes of high-performance CPR–with appropriate rate, depth and recoil–then deliver a shock of 120 joules after only a five-second pre-shock pause, followed by a total of four more shocks integrated with two minutes of high-performance CPR.
Paramedics arrive seven minutes into the resuscitation and seamlessly coordinate with the BLS providers, establish intraosseous access, administer epinephrine and place an advanced airway without interrupting CPR. Rescuers provide two more shocks and note an abrupt rise in end-tidal carbon dioxide (EtCO2), then a return of circulation.
In the ambulance, the patient re- arrests and the crew immediately resumes high-performance CPR, continuing into the ED where he regains a sustained pulse and blood pressure, and a 12-lead ECG indicates an ST elevation myocardial infarction.
The patient receives a total of 27 minutes of high-performance CPR, all of it recorded and later reviewed by providers for ongoing quality assurance and training. Following 24 hours of hypothermia, the patient wakes up three days later and is discharged on day six with an automated internal cardiac defibrillator and without neurologic deficits.
As the above scenario illustrates, out-of- hospital cardiac arrest (OHCA) occurs randomly–anywhere, anytime, to anyone. EMS is the only component of our entire healthcare system that encompasses all of the most acute phases of emergency cardiac care, including the 9-1-1 call, dispatch of emergency rescuers, on-scene emergency medical treatments, and the initial management and rapid transport of critically ill patients to definitive care facilities. All these links in the chain of survival are interdependent. As the HeartRescue Project–a novel multi-state collaborative effort–has shown, careful implementation and iterative measurement of a system of cardiac resuscitation care are the keys to saving the most lives.1
The HeartRescue Project was designed around measuring and maximizing the quality of EMS and hospital care to increase survival with good neurologic outcome.1 For an OHCA victim whose heart is no longer pumping and who has only minutes to live, the effectiveness of an EMS system, determined by the multiple critical decisions, actions and performance of an integrated team of EMS providers, is what makes the greatest difference between life and death.
There are roughly 350,000 OHCA victims each year in the U.S.2 While there’s enormous variability between communities, the likelihood of surviving OHCA in most places in the U.S. is a meager 8%.3 Though such dismal outcomes are common, we know from the HeartRescue Project that this bleak result isn’t inevitable. In other words, we can do better–a lot better.
Some EMS systems have consistently shown they can achieve significantly higher survival rates.4–6 The large disparities in survival that exist in our communities are both unacceptable and fixable. It’s possible to dramatically improve the existing average OHCA survival rates with relatively modest modifications in our approach to prehospital resuscitation.
For decades it was believed that the primary modifiable factors associated with OHCA survival were time to initiating CPR and time to defibrillation. Clinical studies from the past several years also underscored the critical significance, not only of the time it takes to initiate CPR, but especially of the quality of CPR delivered during resuscitation. It has also come to light that, without a method to accurately measure and benchmark interventions like CPR, large-scale and lasting improvements are essentially impossible. Simply put long ago in the late 19th century by Lord Kelvin, “You can’t improve what you can’t measure.”
Monitoring CPR Quality
The American Heart Association (AHA) consensus statement states that CPR quality is the most critical aspect of cardiac resuscitation. It also recommends that each and every resuscitation attempt has the CPR quality monitored to maximize blood flow and survival.7
Maximizing cerebral and coronary perfusion pressures during CPR are the principal physiological goals and should be the focus during resuscitation. Although it will likely be feasible in the future, directly measuring perfusion can’t currently be done easily in the field. Thus, rescuers should use EtCO2 as a surrogate marker for perfusion and aim for a value of at least 20 mmHg.
The 2010 AHA guidelines stress five specific components of high-performance CPR that have been shown to improve hemodynamics and potential survival. (See Table 1.) Some of these CPR metrics–such as compression rate and depth–are interrelated and therefore shouldn’t be thought about in isolation.
Although high-performance CPR may sound simple, consistently delivering it in the chaotic atmosphere of real-life situations is challenging on many levels. So, the key question for all of us who respond to OHCA is, “How can we make sure we perform high- performance CPR during each and every resuscitation?”
The AHA makes several important recommendations regarding CPR performance and continuous quality improvement (CQI). “Every EMS system, hospital, and other professional rescuer program should have an ongoing CPR CQI program that provides feedback to the director, managers and providers. CPR CQI programs can and should implement systems to acquire and centrally store metrics of CPR performance. System-wide performance (which is optimally linked with survival rate) should be reviewed intermittently, deficiencies identified, and corrective action implemented.”7
There are now novel technologies that provide real-time feedback and post-event debriefing to help improve CPR performance. EMS vanguards are piloting techniques to maximize the usefulness of electronic CPR quality data both during an event and after for CQI.5 Given the insights into the high variability of manual CPR performance, along with recent discoveries in optimizing CPR delivery, real-time monitoring of CPR quality is arguably one of the most significant advancements in resuscitation practice in decades.5
Additional recommendations are that “EMS quality review meetings can serve as platforms to discuss selected cases of arrest care in detail and provide opportunities for feedback and reinforcement of quality goals. An effective tool to raise awareness and improve performance is through conducting debriefing sessions after resuscitation attempts. This is most beneficial if done soon after the event in a nonpunitive manner and with objective, easily interpreted data. Over time, lessons learned from both a system-wide evaluation of performance and individual performance of teams from immediate after-event debriefing can provide invaluable objective feedback to systems to pinpoint opportunities for targeted training.”7
Further key recommendations from the AHA consensus statement are:7
- At every cardiac arrest attended by professional rescuers, at least one modality of monitoring the team’s CPR performance should be used.
- CPR performance data should be captured in every cardiac arrest and use an ongoing CPR CQI program to optimize future resuscitative efforts.
- Strategies for continuous improvement in CPR quality should be implemented and education, maintenance of competency, and review of arrest characteristics that include available CPR quality metrics should be incorporated.
- CPR quality metrics should be included and collected in national registries and databases for reviewing, reporting and conducting research on resuscitation.
CPR quality data includes code summary information such as compression rate, depth and CPR fraction, or “hands on time.” Photo courtesy Bentley J. Bobrow
A Path Forward
In 2004, the Cardiac Arrest Registry to Enhance Survival (CARES) was established. CARES was developed to help communities determine standard outcome measures for OHCA locally, allowing for CQI efforts and benchmarking capability to improve care and increase survival. CARES has now collected over 120,000 cardiac arrest events and has grown to encompass more than 580 EMS agencies and over 1,000 hospitals in 37 states. The CARES network covers a population of over 75 million–roughly one quarter of the U.S. population.
While CARES began as an innovative and highly efficient public health surveillance and clinical information system focused exclusively on incidence and outcomes, it has recently evolved into a pioneering mechanism to help EMS agencies measure and improve essential aspects of their resuscitation care, such as CPR quality. The new CARES CPR Quality Module is a supplemental module under development, which will be ready for public use in late 2015. This module collects detailed CPR quality data, including code summary information such as compression rate, depth and CPR fraction, or “hands on time.” It will integrate the code summary data into CARES, allowing for greater access to data for CQI purposes.
The goal is to improve professional EMS CPR quality by collecting standard CPR clinical outcomes and providing uniform reporting metrics back to agencies to assist with their internal CQI efforts. The belief is that this mechanism will help increase compliance with national guidelines for CPR performance and, thus, improve outcomes on a national scale.
A custom XML file has been developed in collaboration with the National EMS Information System (NEMSIS) staff, which will provide a uniform method of measuring CPR quality metrics and an efficient method of data exchange from device to registry end user. The CPR metric data elements have been designed to be stored with the cardiac arrest patient’s patient care report. It can then be included in electronic CARES submission from the EMS agency or through manual entry into the CARES Web-based software. It’s the goal for the CPR metric data elements to be available directly from the monitor/defibrillator device used during the cardiac arrest. ZOLL and Physio-Control Inc. have committed to implement this capability within their products. When the CPR Quality Module is released, there will be highly publicized webinars and posted tutorials to assist agencies in getting started.
Putting it All Together
There’s a movement underway within the CARES network to combine several low-cost, highly effective cardiac resuscitation concepts focused on minimizing all interruptions in CPR into a bundle of CPR quality training and performance improvement interventions. This effort, dubbed the Alliance for Cardiac Arrest Treatment and Impacting Outcomes and Neurological Survival (ACTIONS), is designed to dramatically boost rates of survival from OHCA on a national scale.
The ACTIONS project is a partnership between CARES, EMS agencies participating in CARES, and the University of Arizona, and will be officially proposed to the National Institutes of Health as a prospective, controlled, before-after study. The uniqueness of ACTIONS is that any EMS agency participating in CARES and using CPR quality technologies can take part. The overarching goal will be to radically accelerate the implementation of relatively basic, but highly effective, EMS resuscitation therapies. We don’t need to wait decades–and ethically should avoid doing so–for the newest resuscitation concepts to take root passively. The ACTIONS project will use training, retraining, real-time audiovisual feedback, data collection and a specified CQI process to elevate survival rates much more quickly with what we know and with the technologies we have today.
While the science of CPR continues to advance, we have a remarkable opportunity to improve our CPR performance through this approach right now. Combining interactive training, data collection and performance feedback tools on a system-wide basis will allow us to transform OHCA survival and see many more victims walking out of the hospital neurologically intact and returning to a normal life.
1. van Diepen S, Abella BS, Bobrow BJ, et al. Multistate implementation of guideline-based cardiac resuscitation systems of care: Description of the HeartRescue project. Am Heart J. 2013;166(4):647–653,e642.
2. Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics–2013 update: A report from the American Heart Association. Circulation. 2013;127(1):e6–e245.
3. Nichol G, Thomas E, Callaway CW, et al. Regional variation in out-of-hospital cardiac arrest incidence and outcome. JAMA. 2008;300(12):1423–1431.
4. Rea TD, Helbock M, Perry S, et al. Increasing use of cardiopulmonary resuscitation during out-of-hospital ventricular fibrillation arrest: Survival implications of guideline changes. Circulation. 2006;114(25):2760–2765.
5. Bobrow BJ, Vadeboncoeur TF, Stolz U, et al. The influence of scenario-based training and real-time audiovisual feedback on out-of-hospital cardiopulmonary resuscitation quality and survival from out-of-hospital cardiac arrest. Ann Emerg Med. 2013;62(1):47–56,e41.
6. Hinchey PR, Myers JB, Lewis R, et al. Improved out-of-hospital cardiac arrest survival after the sequential implementation of 2005 AHA guidelines for compressions, ventilations, and induced hypothermia: The wake county experience. Ann Emerg Med. 2010;56(4):348–357.
7. Meaney PA, Bobrow BJ, Mancini ME, et al. Cardiopulmonary resuscitation quality: [corrected] Improving cardiac resuscitation outcomes both inside and outside the hospital: A consensus statement from the American Heart Association. Circulation. 2013;128(4):417–435.