Administration and Leadership, Cardiac & Resuscitation, Documentation & Patient Care Reporting, Patient Care

Identifying the Proper Metrics to Track Cardiac Arrest Improvement Efforts

Issue 12 and Volume 40.

Like many EMS responders across the nation, those in Cabarrus County, N.C., often didn’t know if a cardiac arrest patient they worked hard to resuscitate survived. When they transported a patient who had regained a pulse, their paramedics exited the hospital and never learned whether the patient ever walked out of the hospital neurologically intact.

That all changed a few years ago, when Cabarrus County—located just northeast of Charlotte—became a member of CARES, the Cardiac Arrest Registry to Enhance Survival.

“If you worked a code you never knew [the outcome] unless the crew called the hospital and asked,” says Will Cannon, a supervisor with Cabarrus EMS. “Participating in CARES provides us a wealth of information.”

Cabarrus EMS now uses data and reports from the CARES database to tailor improvements to training and patient care.

Agencies and hospitals that participate in CARES enter information about every worked, non-traumatic out-of-hospital cardiac arrest (OHCA) into the national database. Because EMS agencies must secure the participation of local hospitals prior to enrolling in CARES, the registry records contain information from initial dispatch through hospital disposition, making it possible for local agencies to know the outcome of each OHCA patient.

Knowing those outcomes is critical in determining whether resuscitation efforts are truly successful. Traditionally, EMS had to rely on using return of spontaneous circulation (ROSC) as an outcome measure. However, studies have shown that some interventions can increase ROSC rates but have no impact on survival.1,2

A patient-centered system will focus on improvements that don’t just achieve ROSC, but lead to cardiac arrest survivors walking out of the hospital. CARES also provides a template on what information is important to analyze and how to collect that data.

In Cabarrus County, having a database of cardiac arrest patients led to the discovery that, in certain parts of the county, the time from dispatch to chest compressions was consistently greater than other areas. That led to a decision to dispatch law enforcement officers, trained in CPR, on cardiac arrests in those specific areas. In the first few months, sheriff ’s deputies initiated CPR on two people who were later discharged from the hospital alive.

In addition, because most of North Carolina’s EMS systems participate in CARES, agencies like Cabarrus EMS can benchmark their performance with the rest of the state, comparing survival rates as well as other measures, such as bystander CPR, automated external defibrillator application or use of therapeutic hypothermia.

EMS agencies must use the right metrics to track improvement efforts in cardiac arrest survival.

CARES provides a template on what information is important to analyze and how to collect that data.


In nearby Mecklenburg County, which includes the city of Charlotte, measurement and data have driven quality improvement for several years. Medic, the county’s EMS agency, started entering data into CARES in 2010. But while the registry helped track many important metrics and made measuring survival easier, Medic also wanted a way to measure the processes that led to a higher survival—such as the rate of chest compressions and the minimization of pauses in CPR.

In 2009, Medic purchased and began utilizing Philips cardiac monitors that had the ability to measure CPR performance. The agency also implemented a pit-crew CPR program for better coordination of resuscitations

In the first year, Medic saw no difference in survival rates, said Steve Vandeventer, EMT-P, a paramedic and quality specialist at Medic. Then staff began delving deeper into the data, finding areas for improvement and tailoring training around those specific processes

Soon, they saw a significant improvement in their survival rates. To ensure these improvements would continue, Medic began using real-time feedback, with data displayed on the cardiac monitor to let responders performing chest compressions know how well they’re doing during resuscitative efforts.

“The ability to track and measure and make change off the metrics [was] truly a game changer in cardiac arrest resuscitation,” Vandeventer said.

This year, CARES is adding these metrics as part of a CPR Quality Module, making it easier for agencies to use the registry to measure how CPR quality impacts survival.


Other changes are coming to CARES. For several years, CARES has slowly grown to include more than 800 participating EMS agencies and more than 1,300 hospitals that are submitting outcome data. The registry includes information from more than 45,500 nontraumatic cardiac arrests from 2014 alone. Many of the largest EMS agencies in the nation are submitting to CARES—EMS agencies in CARES provide service to about 25% of the U.S. population.3

But many EMS agencies haven’t been able to participate in CARES, either because they didn’t know they could, or because they didn’t have the resources. This is now changing.

CARES, which was initially created by the U.S. Centers for Disease Control and Prevention (CDC) and Emory University in Atlanta, Ga., and now relies primarily on funding from corporate and philanthropic sponsors, recently announced a change in its participation and funding models. Individual agencies can become part of CARES by paying an annual subscription fee ranging from $1,000 to $5,000, depending on the population served. Entire states can become members for $15,000, provided they commit to supporting a CARES coordinator for the state. Once a state becomes a member of CARES, agencies within that state can submit data to the registry for no additional fee.

By participating in CARES, agencies receive much more than a database where they can store information on cardiac arrest patients. Although one of the most critical benefits for participating agencies is hospital outcome information, CARES also provides annual reports and the ability for agencies to benchmark local performance against state and national data.

Based at Emory University, CARES has a staff of technical experts and researchers who help agencies use the database and get the most from the data they enter. By participating in CARES, agencies also help expand a database that can be used for research to further improve resuscitation care.

Registries such as CARES provide a valuable, consistent and reliable way of measuring and analyzing data, which is why the Institute of Medicine (now the National Academy of Medicine) made the establishment of a national cardiac arrest registry one of its key recommendations in its recently released report, “Strategies to Improve Cardiac Arrest Survival: A Time to Act.”4

“The ultimate goal of CARES is to serve as a standard platform for quality assurance efforts and improve survival from OHCA,” says Bryan McNally, MD, executive director of CARES. “We’re excited to see that the NAM has recognized the importance of having a national registry for OHCA, and believe that CARES is well-positioned to be the registry for the U.S.”

For many agencies that use CARES, the data has become an integral part of the system. Field providers expect to see monthly reports and they compete to have the highest resuscitation rates. In addition, members of local government and the community have now become used to seeing CARES data— for many agencies, CARES provides a reliable performance metric they can report to taxpayers and political leaders who used to rely solely on response time as a method of evaluating an EMS system.

“Not only are the county manager and deputy county managers aware of CARES data, the commissioners are too,” says Cannon. “It’s given out in every department-head meeting.”

Many EMS directors have said that using CARES data, even if the same information could be available at the local level without using the registry, adds a level of validity when they report to municipal and hospital leaders.

The CARES stamp of approval assures these leaders that the data is being collected, measured and analyzed in a method that’s consistent with other jurisdictions. In the political and healthcare communities, this outside validation adds weight to the value of the information.

Without measurement and continuous quality improvement, EMS agencies have no way of knowing whether changes they make to training, practice or protocols are having the desired impacts.

In order for EMS systems to provide the highest-quality patient care and to prove their value to their communities, it’s critical that data collection and analysis are integral pieces of the quality improvement process.

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1. Hagihara A, Hasegawa M, Abe T, et al. Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest. JAMA. 2012;307(11):1161–1168.

2. Callaham M, Madsen CD, Barton CW, et al. A randomized clinical trial of high-dose epinephrine and norepinephrine vs standard-dose epinephrine in prehospital cardiac arrest. JAMA.1992;268(19):2667–2672.

3. CARES. (2013.) CARES Fact Sheet. My Cares. Retrieved Oct. 6, 2015, from

4. Institute of Medicine. (June 30, 2015.) Strategies to improve cardiac arrest survival: A time to act. National Academy of Sciences. Retrieved Oct. 1, 2015, from