Cardiac & Resuscitation, Training

A Statewide Approach to Improving Survival from Cardiac Arrest

The HeartRescue Project has focused on implementing evidence-based interventions with the greatest impact on cardiac arrest survival rates, such as minimally-interrupted chest compressions. Although this sounds simple, it’s not easy in practice. There are multiple reasons trained rescuers interrupt CPR (e.g., pulse checks, intubation, rhythm analysis, interventions) and over-ventilate—another deadly error. These mistakes are common and deeply ingrained in many providers and EMS systems and are a major contributing factor to the poor survival rates in many communities. Improvements in these areas in your EMS system can save lives.

Although many EMS systems have adopted protocols incorporating high-performance CPR, there’s a recognized need for more standardized training on team-based resuscitation. In fact, in the Institute of Medicine’s recent comprehensive report on cardiac arrest, the authors recommend the creation of standardized definitions and a curriculum for training EMTs in high-performance CPR.1

Performance Over Protocol

Although incorporating these concepts in protocols is critical, actual high-quality performance is far more important. To achieve these goals, providers need to understand not only the scientific rationale behind high-performance CPR but also the real-life ways to deliver it during each and every resuscitation. Perhaps most important, the complex psychomotor skills necessary to meeting the high-performance CPR targets require significant training and frequent practice.

EMS is a team job that requires specific teamwork skills to effectively orchestrate a resuscitation. All too frequently, we’ve not paid attention to mastering these skills or individual psychomotor skills. The bottom line is that just knowing the science isn’t enough: Applying it through practice and self-evaluation is what saves lives.

A protocol can list the steps that need to be taken, but it can’t address every aspect of team-oriented resuscitation. In many systems, protocols are no more than a list of steps that imply an order for treatments to be given without providing flexibility for a team or focusing on critical principles that are known to be important. Ideal protocols identify important principles that are supported by the science, but these principles can be accomplished in different ways by varying EMS crew configurations. Ideal protocols also diminish unwarranted variation and emphasize principles that are important to patient safety.

In Arizona, the approach has been to work with individual EMS agencies on the concepts and training, while at the same time performing ongoing measurement and continuous CPR quality improvement at the state level. Arizona state EMS leaders believed this was so important that they developed a “High-Performance CPR University” using a high-fidelity simulation center designed specifically for EMS providers to learn and practice these skills. The result of these efforts has been a quadrupling of survival rates.

Although some states take a “home rule” approach to protocols, where each local EMS agency or medical director has the authority to develop the agency’s protocols, others adopt statewide protocols. In many cases, this provides additional challenges—writing and publishing a set of EMS protocols isn’t inherently difficult, but it often leaves room for wide interpretation. Unlike an individual agency rolling out a new protocol, where training can be conducted for each provider in-person with a medical director or training officer, statewide protocols often impact thousands of providers. At the same time, statewide protocols offer a unique opportunity to rapidly disseminate evidence-based best practices to a large audience and ensure a coordinated approach when multiple agencies work together to resuscitate a patient.

Encouraging Learning Healthcare Systems

Pit-crew CPR example for EMS

In the past, healthcare providers from EMS through ED staff frequently felt like they were just going through the motions when treating patients of sudden cardiac arrest (SCA), but new approaches to resuscitation technique and teamwork have led to dramatic changes in survival from SCA in many EMS systems. To move an EMS agency from going through the motions to actually improving outcomes, however, requires commitment to honest self-evaluation, team-based learning and a realization that increased effort can make a meaningful impact on survival.

In a recent report, the Institute of Medicine described the characteristics of a continuously learning healthcare system.2 Providing high-quality medical care is a constantly evolving effort; a slow-moving process to occasionally update guidelines isn’t sufficient. Instead, a learning healthcare system requires a culture, leadership and incentives that use science and evidence in a cycle that drives continuous improvement in outcomes for patients, the community and the healthcare providers.

Exceptional continuously learning healthcare systems have some attributes that are different from traditional educational systems. Characteristics of an exceptional learning EMS system with regard to cardiac arrest care include:

  • A distinct and explicit goal of increasing the percentage of people who survive SCA with good neurologic outcome;
  • Leaders who remove administrative and operational barriers to best care;
  • A focus on education and training that targets specific small changes to improve competency, such as high-quality chest compressions or a specific ventilation technique;
  • Regular access to data on team performance;
  • Educational material provided in various forms and frequently reinforced;
  • An expectation that there will be frequent trials of new practices and adjustments to patient care and an ability to adapt to new techniques and principles as best practices are identified; and
  • A collaborative approach that welcomes all willing providers and agencies rather than develops exclusionary rules.

Training as the Keystone

Pennsylvania has the largest population that falls under a single set of statewide EMS protocols followed by all EMS providers. When leaders of the state’s EMS community decided to implement high-performance pit-crew CPR, they knew it would be a challenge to educate tens of thousands of EMS practitioners in more than 1,000 EMS agencies.

In Pennsylvania, changing the protocols was just the first step toward changing performance and attitudes. To improve resuscitation care across the state, the Pennsylvania Bureau of EMS worked with the Pennsylvania HeartRescue team. One of the initial steps was to hold a series of Resuscitation Academies within the state. These were initially used to generate enthusiasm and to accelerate acceptance of changes to the EMS approach to treating sudden cardiac arrest. In anticipation of the 2013 protocol update, later academies focused on a train-the-trainer model to develop instructors for statewide EMS resuscitation courses. A four-step approach was developed to educate the commonwealth’s EMS providers to the new protocols:

  1. Resuscitation Academies and train-the-trainer sessions were provided for EMS educators from all regions.
  2. A 90-minute “Taking the Science to the Pit Crew” training course provided background on the most current science regarding resuscitation care, and provided tips to incorporate the principles of SCA care in the setting of an efficient, high-functioning team. This course was required for both BLS and ALS providers as part of the update to the statewide protocols, and it was available via the Pennsylvania Bureau of EMS’ online learning management system or in many classroom presentations. More than 20,000 EMS providers completed the training in 2013.
  3. A high-fidelity simulation course provided an opportunity for hands-on application of the 2013 protocols with reinforcement of technical skills related to quality CPR and practicing of teamwork principles. In 2013, more than 7,000 EMS providers in Pennsylvania participated in these training sessions.
  4. EMS agencies were encouraged to provide low-fidelity CPR manikins for providers to practice high-quality chest compressions, ventilation skills and team roles regularly during shift changes and other opportunities.

In addition to the continuing education course curricula, the Pennsylvania HeartRescue Project provided many resources for EMS agencies to assist them in implementing the new cardiac arrest protocols. These included:

  • Pit crew diagrams with defined positions and roles for BLS, ALS and mixed crews of 2–6 responders—see example above;
  • Laminated checklists of best practices for cardiac arrest care and return of spontaneous circulation;
  • Clinical cases and objective assessment tools for high-fidelity simulation scenarios;
  • EMS agency checklists to guide agency-specific expectations during cardiac arrest;
  • Course facilitator information including a sample agenda, scenarios for practice sessions, facilitator notes, a medical director checklist and a course evaluation.

In addition, a statewide contest was held to produce a video demonstrating the new protocols and team-oriented approach to cardiac arrest. Agencies across the state submitted entries in hopes of being selected and receiving funds for training equipment. The video contest ended up serving multiple purposes; not only was a video produced that could be used throughout Pennsylvania and beyond to teach resuscitation techniques, but by watching the entries, state officials and educators were able to see some of the areas for improvement that needed to be addressed. (These materials can be found at

Not the End, But the Beginning

Implementing the new protocols in Pennsylvania was merely the first step in changing how providers treat cardiac arrest and improving patients’ chances of survival. Any major change in how treatment is delivered needs to be accompanied by massive training efforts and continuous monitoring and evaluation. But the early results are encouraging. EMTs and paramedics have embraced the pit crew concept, the use of checklists and a focus on the interventions with the greatest impact. And veteran EMS providers who once thought of cardiac arrests as futile are now seeing patients walk out of the hospital.

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1. Institute of Medicine. (June 30, 2015.) Strategies to improve cardiac arrest survival: A time to act. National Academy of Sciences. Retrieved Oct. 6, 2015, from

2. Institute of Medicine. (Sept. 6, 2012.) Best care at lower cost: The path to continuously learning health care in America. National Academy of Sciences. Retrieved Oct. 6, 2015, from