Administration and Leadership, Cardiac & Resuscitation

EMS & Hospital Collaborations Strengthen Relationships and Improve Care in North Carolina

In North Carolina, the Regional Approach to Cardiovascular Emergencies (RACE) system was used to develop collaboration between first responders, EMS and emergency and cardiology departments. Initially, the RACE project was established in 2003 to treat acute ST-segment elevation myocardial infarction (STEMI), but in 2010, with the help of the HeartRescue Project, it was expanded to improve regional care for out-of-hospital cardiac arrest patients.

System Design & Improvement Efforts

The RACE project began by developing coordinated and pre-specified plans for the diagnosis and rapid reperfusion of STEMI patients, starting with 10 hospitals in a single region and eventually encompassing 119 hospitals and 540 EMS agencies across the entire state.

The major tenet of this system is to “move care forward,” training and empowering field paramedics to diagnose STEMI and activate cardiac catheterization teams from the scene. This coordinated effort was strengthened by the creation of common protocols supported by all institutions, and fostering ongoing feedback to participating paramedics and EMS training directors. Leadership support was established from the North Carolina Chapter of the American College of Cardiology, the four North Carolina medical schools, and local physician, hospital, and EMS medical and training directors. The core leadership team conferred on weekly calls and regional calls occurred as needed; quarterly regional and statewide in-person meetings continue today.

The entire system was built and administered by dedicated regional emergency cardiac care coordinators established by a state operations manual. Perhaps as important as establishing leadership was embedding a central data repository for each RACE project. RACE initially utilized the National Registry for Myocardial Infarction. When emergency responders joined RACE, the Acute Coronary Treatment and Intervention Outcomes Network Registry—Get With The Guidelines (ACTION Registry-GWTG) was instituted as the main data collection instrument and central data repository. It requires all participating primary percutaneous coronary intervention hospitals to participate and contribute to statewide reports.

Using Data to Encourage Communication

The data collected was used to monitor and report treatment rates and times to all staff involved in patient care—EMS agencies, ED staff and emergency medicine physicians, cardiologists, catheterization laboratory staff, cardiology unit staff, and hospital system coordinators. Individual system performance was benchmarked to state results, so each hospital could see how its metrics compared to the other hospitals around the state. If one hospital had long ED times compared to others in the state, its staff would confer with others who were having more success to find out how its protocols and practices differed; the department could then initiate changes and observe the improvements.

Regional Approach to Cardiovascular Emergencies

Along with feedback from the RACE leadership team, including the overall performance metrics, each hospital had a RACE coordinator who provided feedback regarding its own patients to all members of the team who had been involved in their care. This continuous feedback to the entire system of care became the main instrument to illustrate how all links of patient care were equally important to achieve the goal: to improve patient care and outcomes.

The key change was to provide feedback that both illustrated their own efforts (e.g., time on scene for EMS agencies) as well as the overall results (e.g., patient outcomes). This model not only allowed all staff involved to see how improving their own efforts contributed to improving patient care, but also how important each person’s performance was to the performance of the entire team.

Further, since each hospital provided feedback to everyone involved in caring for its patients, relationships were established locally between EMS systems and hospital staff, based on these feedback loops. The RACE regional and state coordinators were the change agents who had the pivotal role of coordinating the regional plan as well as providing feedback on performance to all staff involved. As a result of the statewide implementation of the program, rapid diagnosis and treatment of STEMI became an embedded standard of care that’s independent of healthcare organization or geographic location.1 Through this work, the RACE system established strong relationships and collaboration with EMS, ED staff, emergency medicine physicians, cardiologists, hospital system coordinators and physician leaders from multiple institutions across the state. Due to the success of the RACE system, the American Heart Association Mission: Lifeline program adopted many of its features.2,3 Furthermore, the RACE system was scaled nationally through the STEMI Accelerator projects, and extended to coordinate cardiac arrest.

HeartRescue Joins the RACE

In 2010, only three out of 100 counties in North Carolina were reporting data to the Cardiac Arrest Registry to Enhance Survival (CARES), and no mechanism existed to evaluate system performance, report patient outcomes or provide feedback across all links in the chain of patient care. For EMS, this meant the staff involved in prehospital resuscitation attempts would rarely know if the patient survived or what could have been done to improve patient care in general. As it had been with myocardial infarction patients, there was a general lack of “team spirit” across different groups of care—dispatch, first responders, paramedics, EDs and cardiology services. The communication and feedback loop thus needed to start by establishing data collection involving every link in the chain of survival.

Building on the RACE system, the next step was to take advantage of previously established relationships with hospital system coordinators, physician leaders and EMS, and to bring 911 telecommunicators and first responders into the fold. The feedback loop reporting rates of process metrics as well as overall patient outcomes to all staff involved in patient care was once again pivotal for establishing relationships between multiple layers of prehospital and hospital personnel. This was particularly important since many in-hospital staff never considered themselves part of the EMS system and EMS rarely received any feedback on patient outcomes. The state coordinator continues to be our champion for coordinating the regional plan, education, and feedback on performance.

Today, 73 counties in the state provide EMS, hospital and outcome data on cardiac arrest care as part of RACE. Recognizing the importance of each piece of the patient care continuum, as well as continuously working to empower each of them and bring them together to collaborate on improvement efforts and celebrate successes are the keys to improving survival from cardiac arrest.

Although bringing everyone together and building these relationships presented some challenges, the investment of time and effort was well worth it. These collaborations between hospitals, EMS, first responders and others initially benefited STEMI patients, but once those relationships were built, they provided the foundation for other improvement efforts, such as the statewide cardiac arrest program. And it won’t stop there—the North Carolina team is now pursuing funding to use a similar model to develop a statewide stroke system of care.

Lessons Learned

To give victims of out-of-hospital cardiac arrest the best chance of a positive outcome, every member of the team needs to be aware of and engaged in coordinated plans to provide the most successful resuscitation efforts. As most victims of cardiac arrest die before hospital admission, intense focus on the prehospital response provides the greatest opportunity for improving outcomes. Ongoing feedback of benchmarked data centered on lifesaving processes for each point of care identifies opportunities to strengthen the system of care and significantly improve survival rates. These efforts are most successful when led by passionate local and regional leaders that span all institutions and agencies, and maintained by dedicated emergency care coordinators who are experts in data measurement, collaboration and systems improvement.

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1. Jollis JG, Al-Khalidi HR, Monk L, et al. Expansion of a regional ST-segment-elevation myocardial infarction system to an entire state. Circulation. 2012;126(2):189–195.

2. Jollis JG, Roettig ML, Aluko AO, et al. Implementation of a statewide system for coronary reperfusion for ST-segment elevation myocardial infarction. JAMA. 2007;298(20):2371–2380.

3. Jacobs AK, Antman EM, Faxon DP, et al. Development of systems of care for ST-elevation myocardial infarction patients: Executive summary. Circulation. 2007;116(2):217–230.