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Whatcom County Faces Challenges Despite Improvements Resulting from a Bundle of Care Approach to OHCA

Whatcom County, Washington, is the furthermost northwest county in the continental United States. The county covers over 2,200 square miles and has a population of approximately 250,000 people, of which 150,000 are within the city of Bellingham. Whatcom County is the state’s 12th largest county, part of which is only accessible by land through Canada.

Whatcom County’s ALS program began in 1974. Over the years, the manner
in which care has been delivered has steadily improved.

In 1996, all BLS response units were equipped with an AED and a strong community effort to provide CPR training was initiated. Then, in 2006, a BLS transport system was created comprising of 49 potential response units divided along fire district/city lines. Today, all BLS providers are AED-equipped and trained in high-performance CPR.

Prior to 2006, we estimated the return of spontaneous circulation rate was 16%. We subsequently participated in the ResQTrial, a study of active compression-decompression (ACD) CPR with the use of an impedance threshold device (ITD-16). During this time, our overall survival to hospital discharge rate with favorable neurological function was > 12%.

Currently we deploy ACD+ITD-16 CPR as well as LUCAS devices, which are used during transport. Data is now collected for each ALS agency and from our one receiving hospital. This data is then put into the Cardiac Arrest Registry to Enhance Survival (CARES). We’re also moving toward an effective electronic health record (EHR) that will cover our entire ALS and BLS system.

As we all know, EMS response isn’t instantaneous, and therefore can’t succeed without an exceptional dispatch team. All of our dispatchers are trained as EMTs and are Priority Dispatch-certified. Hospital prearrival instructions and telephone CPR are both mandated and reviewed. EMS dispatch has both administrative and—unique for Washington state—physician oversight.

Whatcom County has a community hospital that’s a Level 1 cardiac and a Level 2 trauma center. The next nearest Level 1 cardiac center is over 70 miles away. Progressively, EMS and the hospital have worked to provide immediate response for cath codes (STEMI) and select post-arrest patients 24/7. In addition, in the past several years, we’ve selectively taken patients with signs of life, but refractory rhythm, directly to the cath lab. Some have had percutaneous coronary intervention (PCI) with ongoing mechanical CPR, a few have been transitioned to mechanical support (Impella or ECMO).

In 2008, we began a post-arrest targeted temperature management program. Initially, we were using topical blankets and now are using an esophageal temperature management device. To date we have cooled over 820 patients. The survival to hospital discharge rates are between 48% and 52% with modified Rankin scale (mRS) scores of 2 or less. One confounder to our data remains the number of patients presenting with cardiac arrest who may have drug use as the inciting cause.

Although all of this has promise, we have several significant areas of weakness, particularly with our public response. In 2013, with the help of enlightened legislators, we created a mandatory CPR requirement for all high school students in both the eighth and 12th grade. We’ve found, however, that this doesn’t cover the majority of our community. To try and correct this, we’re focusing on holding more CPR classes provided by fire agencies, social clubs, at public events, and in certain industries. However, this is far from sufficient where community response is concerned.

An electronic community response system, PulsePoint, has been implemented, but due to insufficient education and publicity, is not yet achieving its goals. Not enough people are signing up, nor are they responding. Along those same lines, we’re only in the early stages of documenting the location of all the AEDs in the county. What we really need is for our medical community to move forward with supporting CPR training for staff—a concept not yet universally accepted.

We will continue to deploy our comprehensive bundle of care for patients in cardiac arrest, which we expect to continue to enhance survival rates, even though the population of Whatcom County is growing at a rate of 10% per year.

In 2016, Whatcom County passed a levy to support and help build upon the countywide EMS system. The funds will provide for much-needed new paramedic training, a universal electronic health record, and upgraded professional dispatch, including review of all telephone CPR calls. In addition to other administrative and medical review, we’ve hired a full-time data analyst. We hope to add an administrative educator and community EMS planner in the near future.