High-performance CPR reqiures substantial psychomotor skill, training and teamwork. Photo courtesy Acadian Ambulance
Nearly half a century ago, in response to a report demonstrating that approximately 60% of American World War II soldiers died within the first hour of having a myocardial infarction, the distinguished cardiologist James Francis “Frank” Pantridge, MD, quipped to his colleague: “Well, if that is so, we’d better go outside and pick ‘em up, hadn’t we?” With this novel idea, the field of prehospital medicine was born, as was much of our current paradigm of how to save lives from out-of-hospital cardiac arrest (OHCA).1
Approximately 1,000 people will suffer OHCA today in the U.S. The vast majority will be raced Code 3 to the closest hospital for treatment. Despite intensive EMS resources and valiant resuscitation efforts, not to mention placing our EMS providers and the public at risk, 94% of these people will still die.2
Since the response to OHCA tests the integrity of each element of our EMS systems (e.g., community CPR, 9-1-1, EMS and hospital care), EMS leaders have proposed that witnessed v fib survival to hospital discharge represents the most quantifiable benchmark of a system’s effectiveness. Having a binary outcome such as survival vs. death for one of the leading causes of mortality makes OHCA a logical EMS system yardstick.
Yet, after five decades of resuscitation research, widespread CPR training (and too many sets of guidelines to count), the trajectory of prehospital cardiac arrest survival hasn’t appreciably improved.3 Even more disconcerting is that the majority of EMS systems in the U.S. don’t routinely measure their OHCA incidence and survival.4
OHCA is our most time-sensitive emergency condition—the likelihood of survival falls by an estimated 5–10% per minute in the absence of CPR.5 This, coupled with the preponderance of events occurring in the home and EMS response times (collapse to first defibrillator shock) frequently exceeding 10 minutes due to traffic, contributes to the dismal outcomes. However, we know a synchronized system of care implemented with continuous quality improvement measures works. In Seattle/ King County, Wash., survival from witnessed v fib arrests was 62% in 2014, proving it’s possible to save many more lives than we are.6 Yet five-fold differences in survival exist across communities in North America and are unacceptable.7 The achievements of the HeartRescue Project (www.heartrescueproject.com), where communities across the U.S. have embraced a commitment to measure and improve their resuscitation systems of care, highlights the potential for widespread success.
The Institute of Medicine (IOM) recently published evidence-based recommendations to enhance cardiac resuscitation outcomes in a report titled, “Strategies to Improve Cardiac Arrest Survival: A Time to Act.”4 The 440-page report contends that, as a nation, we’re emphatically falling short in our efforts to maximize survival and functional outcomes from cardiac arrest. It assesses both EMS and in-hospital resuscitation systems of care by appraising the strengths and weaknesses of existing data collection systems, variations in outcomes, approaches to overcoming obstacles to high-quality care, and methods to improve the provision and effectiveness of CPR and automated external defibrillators (AEDs) by the public. Also described are newer therapies such as targeted temperature management, emergency cardiopulmonary bypass resuscitation, and other novel treatment paradigms, asking how discoveries in resuscitation science can support the rapid implementation of new treatments.
The report recommends the following:
- Establish a national cardiac arrest registry;
- Implement standard definitions and criteria related to cardiac arrest;
- Enhance performance of EMS systems;
- Establish a strategy to improve in-hospital care;
- Accelerate research on pathophysiology and new therapies;
- Accelerate research on evaluation and adoption of cardiac arrest therapies;
- Foster a culture of action through public awareness and training; and
- Create a national cardiac arrest collaborative.
FOUR WAYS TO INCREASE SAVES
Although the IOM report examines the entire resuscitation problem from multiple perspectives, we believe there are four tangible, focused interventions that will reap high rewards in terms of improved cardiac arrest survival in any community. Additionally, we view EMS medical directors as distinctively situated to lead the implementation of these simple but lifesaving prehospital interventions.
1. High-Performance CPR
High-performance CPR—the provision of minimally interrupted chest compressions with the correct target rate, depth and chest wall release, coordinated with the correct rate, timing and tidal volume of ventilations, synchronized with defibrillation attempts— requires substantial psychomotor skill, training and teamwork. (See Table 1.) High-performance CPR strongly impacts outcomes but isn’t uniformly provided during resuscitations, and this is one of the main reasons for the large disparities in outcomes between communities.8
There are multiple reasons EMS doesn’t routinely deliver high-performance CPR. The relatively small number of resuscitations the average EMS provider performs is one of them. Because high-performance CPR is a complex psychomotor skill, it deteriorates quickly. The relatively low frequency—typically every two years—of psychomotor skill CPR training providers receive contributes to reduced resuscitation proficiency. High-performance CPR also requires EMTs and paramedics to work synchronously in teams with outstanding communication and with a clear understanding of the different roles of each provider, often in very challenging environments.
Another major barrier to improving resuscitation performance is the lack of CPR quality measurement. Without the opportunity to see or discuss any empirical CPR quality data to tell them otherwise, providers believe they’re providing satisfactory CPR and don’t perceive a problem. However, unless EMS agencies are committed to evaluating CPR quality, chances are they’re not achieving the CPR benchmarks.
Without these core elements of frequent, realistic team training and ongoing CPR measurement and feedback, chest compressions are repeatedly paused (often for prolonged periods) and excessive ventilation commonly occurs.9,10 Both lead to unwarranted interruptions in cerebral and myocardial blood flow and poor patient outcomes.11 This led the American Heart Association to recommend CPR quality be monitored for all resuscitation attempts both inside and outside the hospital setting.8
In addition, the practice of debriefing with EMTs and paramedics is an effective method to improve team CPR performance and “close the loop” with providers.12,13 Debriefing entails a dedicated dialogue after a cardiac arrest event in which individual actions and overall team performance are openly reviewed in a nonpunitive, constructive manner. CPR performance data can be downloaded, evaluated and joined into the debriefing session. A number of simulation studies among pediatric and adult cardiac arrest rescuers showed significant improvements in CPR performance using this technique.12,13 Our experience is that when EMTs are given the data in the right manner, it motivates them to improve. This iterative process to measure and improve CPR performance is a unifying theme of the EMS systems with the best outcomes, and needs to be set as an expectation.
2. 9-1-1 Telecommunicator CPR
The best CPR will have little impact on survival if there’s no bystander CPR provided prior to EMS arrival. Bystander CPR can more than double the chance of OHCA survival and good functional outcome,3 yet on average only about 40% of patients receive this care in the U.S.14 Public CPR training will continue to save many lives, but panic often prevents even CPR-trained lay rescuers from acting in an emergency.
The vast majority of people have a cellphone in their possession (sometimes several) and know to call 9-1-1 in an emergency. These dispatch centers are staffed 24/7, and a single 9-1-1 center has the potential to assure bystander CPR for nearly every cardiac arrest in their community. This underscores the potential of telecommunicator CPR (TCPR), where trained, confident 9-1-1 call-takers can identify OHCA early in calls, calm bystanders, and coach them to start and continue CPR through standardized instructions. TCPR is thus associated with dramatic increases in bystander CPR and survival.15–17
Similar to high-performance CPR, TCPR is a quantifiable intervention and the quality of instruction influences outcomes. Consider, for example, assertive, focused, confident CPR instructions given 60 seconds into the 9-1-1 call compared with disorganized, harried or hesitant CPR instructions given at minute 7 of a call. The first is lifesaving and the latter has little or no benefit. It’s striking that while the majority of 9-1-1 centers responding to a nationwide survey reported that they provide pre-EMS arrival CPR instructions, their training, protocols, measurement and quality improvement processes varied immensely.18 TCPR performance standards have been proposed to help normalize and improve the effectiveness of this intervention. (See Table 2.)
EMS medical directors have an enormous opportunity to work closely with 9-1-1 centers to assure this intervention is performed in a consistent manner and is continuously measured for quality. Moreover, we’re best positioned to educate policymakers and the public on the lifesaving potential of TCPR and the need for ample resources to carry out this activity.
3. System Measurement & Quality Improvement
Without the ability to measure, EMS systems can’t improve their survival rates. Systems must participate in a registry—either self-developed or other—that accurately reports OHCA incidence and processes of care. Linking process and outcome data allows us to recognize system strengths and weaknesses and determine best practices to improve care and outcomes.
One option available is the Cardiac Arrest Registry to Enhance Survival (CARES), which allows communities without their own registries to measure their OHCA incidence and outcomes and compare them with others. The registry currently covers approximately 80 million citizens, roughly a quarter of the U.S. population.
4. Medical Director Leadership
EMS medical directors are ideally suited to improve OHCA survival in their communities. They understand the science and practice of resuscitation as well as the system issues and challenges. Resuscitation vanguards and champions are common to all of the highestperforming EMS systems. They’re the essential superglue to the EMS systems— envisioning the larger goals and engaging the various stakeholders to work in an integrated manner. Just as important, this leadership can provide accountability by asking tough questions of all stakeholders and providing the rationale for improvement.
Although the IOM report describes the numerous challenges to improving OHCA survival, the authors of this article believe: EMS systems of all sizes can and should save many more lives than they presently do. Our hospitals and outpatient clinics can address nearly every other major public health problem, but EMS is in an exclusive position to save lives from OHCA. Medical directors should embrace the enormous opportunity to save so many lives and help countless patients return home to their families and communities.
Fifty years after the first mobile coronary care unit, it would be fascinating to overhear Pantridge bantering with his colleagues about the current status of prehospital care, particularly whether we’ve fulfilled the lifesaving potential of his monumental breakthrough.
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