Reflecting on a 25-year career in EMS, a seasoned street medic compared the “bad old days” of out-of-hospital cardiac arrest (OHCA) resuscitation to the “Bring Out Your Dead” scene from the film Monty Python and the Holy Grail. “You’d bring ’em down to the ambulance, perform some compressions, and work on a tube. Usually the [ED] team would have ceased efforts before we finished our paperwork,” she said.
Indeed, survivors were an anomaly prior to the advent of high-performance CPR and a systems approach to resuscitation.1 But as evidenced by high-performing agencies, a new paradigm is emerging; EMS crews in these agencies now expect their patients to survive.
The blueprint for improving OHCA survival is now widely known: bystander CPR, a team-based resuscitation strategy, early defibrillation, un-interrupted compressions and so on. The challenge is to implement these effective strategies when, for too long, death has been the expected—and accepted— outcome. The most difficult obstacle to overcome is changing the mindset of frontline EMS providers and EMS leaders and convincing them that life can be snatched from the jaws of death.
Clear Path to Success
Successful EMS agencies are all alike; unsuccessful agencies are each unsuccessful in their own way. EMS agencies with a high cardiac arrest survival rate share several characteristics. They emphasize teamwork and appreciate that a systems approach provides the best chance for a patient with any critical illness, including cardiac arrest. Bystander CPR (either by a trained layperson or through over-the-phone instructions), high-performance CPR by EMS, data collection and a robust quality improvement process are requisite traits found in successful agencies.
Although the key steps to implement these strategies can be listed in detail, there’s no uniform blueprint on how to get buy-in at your agency. That is, how do you motivate leadership and rank-and-file staff that past practice can be improved and lives can be saved? EMS providers need to believe cardiac arrest is a treatable illness for which they have the cure. In Illinois, here’s how two very different agencies are tackling this challenge to improve cardiac arrest resuscitation.
Lieutenant Mark Duke oversees EMS training for Orland Park Fire Department, a fire-based agency providing EMS services to a population of 75,000. All firefighters are crossed-trained as paramedics. Fire Chief Ray Kay’s first task for Duke was to improve cardiac arrest survival.
“At the time we took a passive role in developing strategies for improvement. We just followed our protocols,” Duke said. He struggled with his assignment until he and Chief Kay attended the Resuscitation Academy in Seattle, Washington.
For many years, Medic One—the EMS system in Seattle and greater King County—has pushed to improve care for critically ill patients, using cardiac arrest as a benchmark condition to measure its success. Over the decades, survival has made step-by-step progress such that now persons who suffer witnessed out-of-hospital v fib cardiac arrest should expect to live: they have a greater than 50% chance of not just surviving, but walking out of the hospital and resuming their lives. Although that rate has exceeded 50% only in the past few years, the emergency response system—the telecommunicators, the EMTs, the paramedics and the hospital staff— has for a long time held the expectation that these patients should survive. Perhaps it’s this expectation of success that’s the “pixie dust” that has led to such good outcomes over the years in Seattle and King County.
But this attitude doesn’t just come from the crisp, clear Pacific Northwest air. The Seattle-King County EMS system is fortunate to have a strong tradition of leadership with well-trained providers who collectively work together to focus on health-related outcomes like the rate of survival from cardiac arrest. Indeed, the region maintains a registry of all treated cardiac arrests—an essential tool for effective improvement—and uses this information to refine resuscitation efforts through the entire chain of survival from layperson to hospital care.
For years Seattle-King County Medic One was legendary for its high OHCA survival rates. But we’re witnessing a new era of resuscitation. Today, the pixie dust is no longer exclusive to Medic One and the handful of other agencies that saw similarly high survival rates. Many communities across the United States and around the world now have both the personnel and operational tools in place to succeed. The expectation of success drives high performance and has produced a culture of excellence.
One forum that’s helped change attitudes is the Resuscitation Academy. The Academy moves the science of resuscitation into clinical practice by challenging EMS leaders to think about how they can improve their programmatic efforts. The goal is to provide the tools for resuscitation leaders to go back home and make positive changes.
Started as the brainchild of Mickey Eisenberg, MD, PhD, and Michael Copass, MD, the Seattle-based Academy has involved over 500 participants from around the U.S. and the world. With the help of the HeartRescue Project, the Academy has been offered across the nation and even in Europe and Asia as communities work to save more lives from cardiac arrest.
Meanwhile, in Illinois
When Duke and Kay returned to Orland Park after attending the Resuscitation Academy in the Emerald City, they were infused with a newfound enthusiasm.
“We left inspired and ready to implement all the strategies for success,” Duke said.
But the department rank and file didn’t initially share their enthusiasm. Only after receiving a lecture on the “Science of CPR” from an outside instructor did their suspicion and apathy begin to thaw.
“Hearing the message from an outside source was important in swaying our people that this wasn’t just my harebrained idea,” Duke said.
The momentum increased after Orland Park began collecting data and reporting quality measures to its members. “Firefighters are naturally competitive,” Duke said. “We drew upon that competitive spirit with cardiac arrest performance. No one wants to be second best.”
Against the Wind
Serving as an example in Eisenberg’s book, Resuscitate!, of a location where you should “try not to be” when you experience cardiac arrest has persistently vexed Chicago EMS, a consortium between Chicago Fire Department (CFD) and the city’s EMS medical directors.2 “I knew we had the potential to significantly improve our survival rate,” said the CFD’s Director of Medical Administration and Regulatory Compliance Leslee Stein-Spencer, RN, MS.
But making changes in one of the nation’s largest EMS systems is no easy task. The CFD is a fire-based system, with both BLS and ALS fire suppression companies staffed with FF/EMT-Bs and FF/paramedics and ALS ambulances staffed by single-role paramedics. Change means educating and changing the practice of more than 5,000 members. In such a large agency, the first step is getting support from the top brass—in this case, the fire commissioner. Commissioner Jose Santiago readily understood the scope of the problem and recognized the potential to save lives. He agreed to make improving cardiac arrest survival a top priority for the department.
Similar to the experience at Orland Park, the introduction of the initial training on high-performance CPR was met with a tepid response.
“I think a lot of people just heard they are being expected to work arrests in front of the family instead of the comfort of their ambulance,” said the CFD’s Assistant Deputy Fire Commissioner Mary Sheridan. “That was a huge culture change.”
PowerPoint presentations don’t win hearts, but results do. An integral part of Chicago’s improvement strategy has been participating in CARES, the Cardiac Arrest Registry to Enhance Survival. Linking prehospital and hospital data gives the ability to provide consistent feedback to crews on patient outcomes.
A poignant example of this feedback occurred at a recent ceremony where survivors met the crews responsible for saving them. If there were any residual doubts in the audience on the value of improving survival rates, they were quickly erased when a 33-year-old mother who survived a cardiac arrest took the stage with her 2-yearold child.
“It is so important we all remember why we do what we do,” Sheridan said. “I can’t think of a better reminder than seeing that mom with her child.”
The Winds of Change
Emergency systems are increasingly cultivating this expectation through teamwork and leadership, discipline and training, objective measurement, and sometimes with help from colleagues in neighboring jurisdictions or across the country. They’re also asking the important—and humbling—question: How can we improve?
Look at Anchorage, Alaska; Charlotte, N.C.; Snohomish County, Wash.; Mesa, Ariz.; Howard County, Md.; Boston and Oklahoma City, among others—emergency systems where witnessed v fib survival approaches or exceeds 50% as a consequence of the collective commitment to measure and improve resuscitation and an expectation that cardiac arrest patients will survive. And Copenhagen, Denmark; Seoul, Korea; London; and Osaka, Japan—all large international cities where EMS culture and expectations have changed. And Chicago—yes, Chicago—a community challenged by big buildings, big traffic and, often, big politics. The Windy City has made strides that only a few years ago would have been judged near impossible. With an overall survival rate now approaching 8%, Eisenberg will need to make changes in future editions of Resuscitate!
So maybe the pixie dust is indeed the expectation of success: An EMS culture that sees cardiac arrest as a survivable condition that we can reverse; commitment from the grass roots of the organization to the highest leadership levels to provide the very best care; and the collective culture of excellence that comes from working together to save a life. Success breeds success.
Seattle and King County have a lot more competition at the top these days, and there’s plenty of room for everyone to join them.
1. Bobrow BJ, Clark LL, Ewy GA, et al. Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest. JAMA. 2008;299(10):1158–1165.
2. Eisenberg MS: Resuscitate! How your community can improve survival from sudden cardiac arrest. University of Washington Press: Seattle, p. 120, 2009.