Administration and Leadership, Cardiac & Resuscitation

Lessons Learned from Five Years of the HeartRescue Project

Although there’s no single method for implementing best practices for treating out-of-hospital cardiac arrest (OHCA), the HeartRescue Project has shown that there are some fundamental pieces every EMS system—small or large, fire- or hospital-based, private or public—can employ. To make those changes and improve OHCA survival, each system needs a champion: an individual or group of people who decides the status quo is no longer acceptable.

Sometimes that champion is a local EMS medical director. At least as frequently, though, it has been the agency managers or EMS providers who carry the message and push for change. EMS medical directors establish protocols, but EMS providers carry out the work. The agency champion may also be the progressive battalion chief who has the chief’s ear or the EMT who’s ready to make a difference.

The HeartRescue Project’s partners have learned much about improvement from their shared experiences at all levels of the system. As with any practice of medicine, every EMS system faces different logistical, political, clinical and operational challenges. How a particular disease is approached within each community may vary greatly, but each system must strive to embrace the applicable evidence and best practices to maximize the potential for positive outcomes. Although systems differ, the HeartRescue Project believes that some truths about cardiac arrest survival are universal and no EMS system can afford to ignore them:

The basic principles of resuscitation are understood, but not always put into practice. There’s an art to practicing the science of resuscitation. For example, we know that chest compressions shouldn’t be interrupted and that pauses longer than 10 seconds are associated with poor outcomes.1 If we measure the pauses using CPR analytic tools, we can identify when they occur and develop strategies for reducing them. Such strategies include charging the defibrillator during compressions in the 10 seconds prior to defibrillation, which, with practice, can reduce that pause in compressions to three seconds.

The number of possible evidence-based improvements is large in any given system. Using the data to identify areas for improvement and then selecting one on which to focus is the secret to success.

Providing EMS systems with very specific options for improvement will enhance success. For EMS, it’s important that the foundation of resuscitation care is based on the best available evidence. This means putting aside traditional practices not supported by evidence and changing the focus to ensure evidence-based care is performed consistently.

Using a driver diagram is a great way to translate a high-level improvement goal into a logical set of specific, measurable goals and projects. (See Figure 1, below.) The diagram is a way of visualizing the primary factors that influence an outcome or goal, as well as the factors that influence the primary drivers. Breaking down the goal and the processes to achieve it creates a framework for improving and measuring and improving again.

Driver diagrams for cardiac arrest survival rates

Nothing measured, nothing gained. A critically important caveat is that the measurement must be pertinent, consistent and accurate. The HeartRescue Project has enthusiastically supported and embraced the use of the Cardiac Arrest Registry to Enhance Survival (CARES). Analyzing system data identifies areas for improvement and illustrates areas of success that convey a critical sense of accomplishment to the entire community. Areas of focus can include: bystander CPR rates, field resuscitation initiation and termination decisions, survival rates for EMS-witnessed cardiac arrest, chest compression fraction, and destination determination. The value of measuring performance isn’t only in the identification of the specific metrics, but also in establishing a culture of measurement and improvement that can adapt and expand to other aspects of the EMS system.

Resuscitation is a team sport. Coordination between all members of the team, especially when different agencies are involved in patient care, is critical and doesn’t happen by chance. Training to provide resuscitation care as a team helps to solidify expectations and allows for a much more integrated and consistent effort. Many communities have implemented very successful high-performance approaches to better choreograph resuscitation efforts between members of a diverse team.

Transparency is critically important— whether the results are good or not. In a culture where measurement and data sharing aren’t ingrained, transparency is essential to improvement efforts. In the 2005 USA Today series “Six Minutes to Live or Die,” Robert Davis exposed that many major U.S. cities didn’t even know their cardiac arrest survival rates.2 Among those that did, the rate varied widely. This was a much needed catalyst for a groundswell of measurement and improvement that continues today.

There’s a historical reluctance to publish less-than-stellar outcome data, particularly in EMS systems. Although the reasons are many, there’s a powerful movement within all of organized medicine to be accountable and transparent with data—be it good, bad or ugly. Acknowledging poor performance and being upfront about efforts to improve often lead to more positive results than attempting to hide those deficiencies. Making survival rates public information can be a call to action for the community and can improve public awareness of the problem. If survival rates are low, there are plenty of opportunities for improvement.

Sharing and celebrating achievements will lead to even more success. Ensuring that the victories are recognized in each community is important. Communities that host local survivor celebrations that include all players in the resuscitation find these events to be immensely powerful. They bring together all the stakeholders who make it possible to improve cardiac arrest care in the community. Building and maintaining meaningful relationships with key collaborators is the underlying secret to success when working to improve outcomes from sudden cardiac arrest. In this case, what EMS does alone is simply not enough; it truly takes a village—a coordinated chain of care in a community— to make meaningful improvements.

But it’s about even more than that. There are very few people who have an opportunity to truly save a life. When it happens, the trumpets should sound far and wide. It’s the epitome of combining sound science, a team approach and an integrated system of care. Our patients and their families will never, ever forget. Neither should we.

More on Leadership & Resuscitation on JEMS.com.

References

1. Brouwer TF, Walker RG, Chapman FW, et al. Association between chest compression interruptions and clinical outcomes of ventricular fibrillation out-of-hospital cardiac arrest. Circulation. 2015;132(11); 1030–1037.

2. Davis R. (May 20, 2005) Six minutes to live or die: Many lives are lost across USA because emergency services fail. USA Today. Retrived Oct. 7, 2015, from http://usatoday30.usatoday.com/news/nation/ems-day1-cover.htm.