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

Rialto Fire Department Changes the Paradigm of Cardiac Arrest

The Rialto, Calif., Fire Department (RFD) changed the way we view cardiac arrest. Our goal was to transform from the way we’ve “always done it,” which was resulting in 77% of our cardiac arrest patients never regaining a pulse, to a progressive bundle of care approach that utilizes the synergy of multiple small improvements for significant improvements in return of spontaneous circulation (ROSC)—eventually tripling of our survival to hospital discharge.

The RFD bundle of care, which we call our “resuscitation toolbox,” was implemented on the vision that survival from cardiac arrest should be the rule, not the exception. The toolbox leverages contemporary research and has forced us to “unlearn” our previous treatment paradigm, which resulted in a high cardiac arrest fatality rate.

Think about that: cardiac arrest shouldn’t be an almost uniformly fatal condition, and if any treatment for any condition is predominantly fatal, you should stop doing it, even if it’s the way you’ve always done it, or it’s the way everybody does it.

We can’t continue to view prehospital medicine this way. We must innovate. Using common and novel practices, we’ve found there’s no one silver bullet—the bundle is the key. We’ve expanded our understanding of who can survive cardiac arrest, with more than 20% of asystolic patients surviving to discharge in 2018.

How we do it is more important than what we do, and the quality of CPR can vary greatly throughout the country and the world. There are four components of CPR: 1) compression rate; 2) compression depth; 3) adequate recoil; and 4) limiting pauses. All four are required to perform-high quality CPR. This can only be accomplished with real-time CPR performance feedback.

Additionally, you must define, in writing, what your acceptable pauses in compressions are for your agency. If you don’t define the acceptable pauses there will be more of them than are acceptable. The four acceptable pauses in CPR in the city of Rialto are:

Place a feedback device = one-second pause;

Place a posterior defibrillation pad = five-second maximum pause;

Place a mechanical CPR device = five-second maximum pause; and =

Start mechanical CPR device = five-second maximum pause.

Acceptable pauses in your agency may be different, but they must be defined in writing as a beginning to changing the pervasive poor quality of CPR throughout the EMS system. This is just one example of the theory, “It’s not what you do, it’s how you do it,” but the quality of what we do must be continually evaluated and improved.

RFD implemented a “wheel of survival,” which outlines what we do and the order in which we do it. Each cog on the wheel is placed in an order consistent with the clinical evidence, which our data supports, suggesting the order in which we do things matters.

Promising Results

These tools, the quality of what we do, and the order in which we do it in, has resulted in ROSC rates in the city of Rialto averaging 51% for the past three years (2016–2018), regardless of the rhythm the patient was found in, if the arrest was witnessed, or if CPR was applied prior to arrival.

The RFD’s survival using the Utstein criteria is 44%. Survival to hospital discharge has ranged from 12–14% in all patients that received our bundle of care again regardless of rhythm, CPR prior to arrival, or downtime.

There’s still significant room for improvement in both our ROSC rates and our survival to discharge rate, and we’re sure 50% of what, how or when we’re doing it is wrong, we just don’t know which 50%.

We still don’t accept that over 80% of our cardiac arrest patients won’t survive to hospital discharge. We’ll continue to challenge our own assumptions, push the envelope and crunch the data to find the answers.

Download a PDF containing the RFD Wheel of Survival and Adult Non-Traumatic Cardiac Arrest Resuscitation Algorithm.


1. Powell J, Dearden K, Grayson S. Rialto’s Resuscitation Toolkit: Seven survivability tools lead to dramatic improvements in cardiac arrest outcomes. JEMS. 2017;42(12):28­–34.

2. Duchateau FX, Gueye P, Curac S, et al. Effect of the AutoPulse automated band chest compression device on hemodynamics in out-of-hospital cardiac arrest resuscitation. Intensive Care Med. 2010;36(7):1256­–1260.

3. Yannopoulus D, Aufderheide TP, Abella BS, et al. Quality CPR: An important effect modifier in cardiac arrest clinical outcomes and intervention effectiveness trials. Resuscitation. 2015;94:106­–113.

4. Farkus J. (July 2, 2014.) Preoxygenation and apneic oxygenation using a nasal cannula. PulmCrit (EMCrit). Retrieved Oct. 27, 2017, from

5. Kjærgaard B, Bavarskis E, Magnusdottir SO, et al. Four ways to ventilate during cardiopulmonary resuscitation in a porcine model: a randomized study. Scand J Trauma Resusc Emerg Med. 2016;24:67.

6. Langhelle A, Stromme T, Sunde K, et al. Inspiratory impedance threshold valve during CPR. Resuscitation. 2002;52(1):39­­–48.

7. Lurie KG, Mulligan KA, McKnite S, et al. Optimizing standard cardiopulmonary resuscitation with an inspiratory impedance threshold valve. Chest. 1998;113(4):1084­–1090.

8. Debaty G, Shin SD, Mtzger A, et al. Tilting for perfusion: Head-up position during cardiopulmonary resuscitation improves brain flow in a porcine model of cardiac arrest. Resuscitation. 2015;87:34­–38.

9. Frascone RJ. And the dead shall rise: Head-up CPR and the revolutionary research model used to develop it. JEMS. 2017;42(1):33–37.

10. Savastano S, Baldi E, Raimondi M, et al. End-tidal carbon dioxide and defibrillation success in out-of-hospital cardiac arrest. Resuscitation. 2017;121:71–75.

11. Wik L, Hansen TB, Fylling F, et al. Delaying defibrillation to give basic cardiopulmonary resuscitation to patients with out-of-hospital ventricular fibrillation: A randomized trial. JAMA. 2003;289(11):1389–1395.

12. Kodali BS, Urman RD. Capnography during cardiopulmonary resuscitation: Current evidence and future direction. J Emerg Trauma Shock. 2014;7(4):332–340.

13. White RD, Goodman BW, Svoboda MA. Neurologic recovery following prolonged out-of-hospital cardiac arrest with resuscitation guided by continuous capnography. Mayo Clin Proc. 2011;86(6):544–558.

14. Hagihara A, Hasegawa M, Abe T, et al. Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest. JAMA. 2012;307(11):1161­–1168.

15. Perkins GD, Ji C, Deakin CD, et al. A randomized trial of epinephrine in out-of-hospital cardiac arrest. N Engl J Med. 2018;379(8):711–721.