Triple-board-certified, Dr. Joseph Ornato was one of the authors of the seminal ‘chain of survival’ paper 26 years ago.
Published in 1991 in Circulation, “Improving survival from sudden cardiac arrest: the “chain of survival” concept. A statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Association,”1 was authored by Drs. Richard Cummins, Joseph Ornato, William Thies and Paul Pepe.
The term ‘chain of survival’ provides a useful metaphor for the elements of the Emergency Cardiac Care (ECC) systems concept. The five links in the adult chain of survival are:
- Immediate recognition of cardiac arrest and activation of the emergency response system;
- Early cardiopulmonary resuscitation (CPR) with an emphasis on chest compressions;
- Rapid defibrillation;
- Effective advanced life support; and
- Integrated post-cardiac arrest care.
A similar 1991 article, “Improving Survival from Sudden Cardiac Arrest: The Role of the Automated External Defibrillator,”2 remains an important aspect of resuscitation plans in the EMS community, but has fallen through the planning and implementation cracks in many EMS systems.
Placing AEDs in strategic locations and training civilians to find and deploy them is a proven approach that has resulted in return of spontaneous circulation (ROSC) and neurologically-intact patient discharges in many notable EMS systems, including Richmond (Va.), San Diego (Calif.), Charlotte (N.C.), Miami (Fla.), Nashville (Tenn.), Chicago (Ill.), Minneapolis (Minn.), Dallas (Texas) and others.
Strategic AED Placement
In its first year of operation, the San Diego (Calif.) Fire Rescue Project Heart Beat program at San Diego International Airport increased cardiac arrest survival from a county-wide average of just under 5% to 75% survival (3 out of 4 arrests).
Project Heart Beat expanded from early public access defibrillation (PAD) programs at the airport, and is now a nationally- and internationally-known program, recognized as one of the best large community PAD programs by the International Association of Fire Chiefs (IAFC) and Sudden Cardiac Arrest Association (SCAA). In San Diego, 9,000 AEDs have been deployed and 163 lives have been saved because of it.
Charlotte/Mecklenburg County, N.C., is another great example of a well-designed EMS and public access defibrillation system that has been shown invaluable as a result of strategic AED deployment, aggressive training of citizen first responders and employees at locations (like Charlotte International Airport) and strategically-located response teams at the airport, have resulted in the 100% ROSC in resuscitation of airport cardiac arrests in 2016, with 5 of 6 (83%) for Utstein survival.
Richmond (Va.) Ambulance Authority’s Focus on Cardiac Care
Dr Ornato’s influence and guidance on the homefront is ever-present. In his own EMS system in Richmond, Va., a large number of AEDs have been deployed and dozens of lives saved.
Richmond Ambulance Authority, under the Medical Direction of Dr. Ornato, has an ever-present focus on cardiac care. Much of the effort is directed at relatively inexpensive, but nevertheless essential, public outreach.
After realizing that dedicated and CPR events or weeks didn’t attract many participants, RAA initiated its ‘Big Push’ campaign. Now, CPR can and will be taught any time, any place, anywhere and in any language.
The increasing Latino population has been the focus of considerable outreach for both CPR training and use of 9-1-1 services.3
CPR outreach has also extended into Richmond’s social housing system, where potential tenants are obliged to take part in a new tennant orientation that includes a hands-only CPR class delivered by RAA medics. To date, over 2,500 tenants have received training via this program.
Key partnerships have been integral to the RAA program. The Richmond Police Department runs citizen’s academies throughout the year in both English and Spanish, which include RAA’s CPR training. They’re also involved in one of the largest national Police events of the year: National Night Out (NNO). Held on the first Tuesday in August across the country, NNO is an opportunity to say ‘good bye’ to crime in communities, but RAA has realized it’s also an opportunity to say ‘hello’ to CPR.
Each NNO, RAA sends out 10 teams to deliver CPR classes to communities that are holding block parties. If the gathering was organized by a civic association or church, they leave a community kit consisting of ‘anytime’ hand-only CPR teaching kits.
When RAA delivers CPR training, they also inform citizens about the location of the PulsePoint Application. The City of Richmond has been an operating PulsePoint city for the last two years. Purchased and installed via generous funding from Richmond’s Retail Merchants Association, activations have sent citizen responders to deliver early and consistent CPR prior to the arrival of EMS.
In a state where registration of AEDs isn’t legislated, the creation of an up-to-the-minute AED registry via the PulsePoint app is a distinct advantage.
In terms of legislation, Virginia joined the growing number of states that now require CPR certification prior to the receipt of a high school diploma. The first class for whom this law applies is the class of 2020.
The RAA Board, of which Dr Ornato is a member, funded the upgrading of all Richmond Public Schools AEDs and the training of all Health staff as CPR instructors to pump prime the teaching process.
In a similar initiative in 2017, Dr. Ornato’s base hospital, VCU Health in partnership with RAA, equipped and trained all city public schools with hemorrhage control kits as part of the Stop the Bleed program.
In both cases, the location of every AED and hemorrhage kit is mapped in the dispatch system.
Resuscitation Research Continues
The December 2017 issue of JEMS and its accompanying 36-page supplement present articles on resuscitation processes and procedures that EMS systems should use as a roadmap to success in their EMS systems.
They represent game-changing information about the way EMS systems are dramatically improving their cardiac resuscitation, with up to 60% survival and little or no neurological deficit.
Many EMS systems continue to claim that it’s impossible to achieve more than 10-20% ROSC, and without an honest, close look at each system, it’s always been hard to refute those claims. After reading the December issue and the supplement, you’ll appreciate that there are some common threads among the EMS systems covered.
One significant thread is that there’s no single ‘magic bullet’ to counter sudden death but, rather, a series of actions and procedures that must occur to save the maximum number of lives.
A Lasting Impact
Dr. Ornato himself was saved by the coordinated prehospital/hospital resuscitation system he developed in the Richmond region. When he suffered a massive pulmonary embolism, he wouldn’t have survived if it weren’t for a system that featured rapid response and assessment, along with ALS care that delivered him to a specialty center where he could be resuscitated via rapid-sequence intubation (RSI), CPR, tPA, ECMO and cath lab care.
Progressive EMS systems have realized even greater success by instituting direct EMS-to-cardiac cath lab and ED Extracorpeal Membrane Oxygenation (ECMO) within 60–90 minutes of arrests. However, systems can also do better without a significant outlay of money through citizen awareness and fundraising campaigns, aggressive compression-only CPR training and the strategic deployment of AEDs throughout your EMS system.
The ‘chain of survival’ principles Dr. Ornato and his colleagues presented 26 years ago are still having an impact on cardiac survival. They remain the foundation of great success for many agencies.
1. Cummins RO, Ornato JP, Thies WH, Pepe PE. “Improving survival from sudden cardiac arrest: the “chain of survival” concept. A statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Association.” Circulation. 1991 May;83(5):1832-47.
2. Marenco JP, Wang PJ, Link MS, et al. “Improving survival from sudden cardiac arrest: The role of the automated external defibrillator.” JAMA. 2001;285(9):1193-1200.
3. Rains M, Ludin T, Patton J, et al. (May 2017.) “Where have they gone: A study of emergency medical services utilization by ethnicity in Richmond VA.” Virginia Commonwealth University. Retrieved Jan. 26, 2017, from http://wp.vcu.edu/rainsm/wp-content/uploads/sites/6392/2017/05/Latino-EMS-Utilization.pdf.