Cardiac & Resuscitation, Exclusives, Heart of America, Patient Care, Top Story

Palm Beach County Sees Results After Instituting a Bundle of Care Approach to Resuscitation

Palm Beach County, Florida, is home to 1.4 million residents and is host to many more visitors each year as a major tourist destination. It’s a sprawling, multicultural and diverse socioeconomic demographic with extremes of age.

In 2015, based upon disappointing resuscitation rates, the bundle of care approach was instituted by the county’s new EMS medical directors. Within three months, resuscitation rates improved dramatically, and in the ensuing years, have remained at over double their prior level. How did this occur, and what are the implications for enhancing cardiac arrest survival across other jurisdictions?

In 2011, according to Florida EMSTARS (EMS Tracking and Reporting System), the odds that any EMS agency in the state would get return of spontaneous circulation (ROSC) for an adult with out-of-hospital cardiac arrest (OHCA) was a meager 6%. However, after widespread adoption of the 2010 American Heart Association ACLS guidelines, which emphasized compressions over ventilations, the statewide ROSC rate jumped to 17%.

This change provided an important clue into where the state’s EMS systems could find further improvement. Based upon root cause analysis, if an arrest is due to sudden loss of the cardiac “pump,” then efforts to restore or replace the function of the pump must be the focus of any resuscitative efforts. Specifically, it was hypothesized that further improvement could be made by concentrating on therapies aimed at enhancing the flow of blood to the heart and brain using the thoracic pump theory of CPR.

Included in our bundle of care was passive ventilation, delayed positive pressure ventilation, use of an impedance threshold device (ITD), a renewed focus on continuous chest compressions with early transition to mechanical CPR with the LUCAS device, and transport with the head and thorax in an elevated position to allow a drop in intracranial pressure and a potential improvement in cerebral perfusion.

Among 1,304 consecutive OHCA cases in 2014–2015, survival rates were fairly constant in 2014 (17.4% mean, range 15–20%) but rose steadily during the implementation of the bundle of care, with an ensuing sustained doubling of survival (36.0%; range 35–37%). Outcomes improved across subgroups while response intervals, indications for initiating CPR and bystander CPR rates were unchanged. Regionally, in 2015, hospital admission rates were found to remain proportional to neurologically intact discharge.1

We’ve continued to monitor success rates over the ensuing years and found that these results were maintained through all of 2016, indicating there is more than simply a Hawthorne effect (i.e., the observer effect) to the flow-focused bundles of care.2

Hospital outcomes weren’t consistently available during the study period, which limits the generalization that improved ROSC rates alone will equate to improved survival to hospital discharge. However, the immediate and sustained dramatic increase in ROSC suggests the need for further efforts to evaluate and enhance the flow-focused bundle of care approach.


1. Pepe P, Scheppke K, Antevy P, et al. How would use of flow-focused adjuncts, passive ventilation and head-up CPR affect all-rhythm cardiac arrest resuscitation rates in a large, complex EMS system? Circulation. 2016;134:A15255.

2. Pepe PE, Scheppke KA, Antevy P, et al. Confirming the safety and feasibility of a bundled resuscitation technique involving a head-up/torso-up mechanical chest compression technique for cardiopulmonary resuscitation. Prehosp Emerg Care. 2018;22(1):109–110.