Bundles of Care as a Formula for Resuscitation Success

The dog barking at 2 a.m. awakens Ben’s brother. Does he have to go outside to “do his business”? Ben’s brother didn’t think so because the dog’s bark was different–panicked.

So, he went into his brother’s room to check on him and found him making terrible noises.

Ben was just 22-years-old and seemed fine when they watched the Stanley Cup playoffs together only one hour earlier. But now he was blue and taking what sounded like his last gasps.

Ben’s mom, a nurse, calls 9-1-1 and starts CPR. Fire department first responders arrive within eight minutes and attempt to shock Ben back to life with an automated external defibrillator (AED); to no avail. Ben was still in cardiac arrest.

Five minutes later, Allina Health EMS arrives with an ALS crew and the tools needed to perform CPR according to a new a initiative called Take Heart America.

They immediately start their protocol. Within 20 minutes, Ben has a pulse and is rushed off to Mercy Medical Center for additional advanced care including therapeutic hypothermia.

This incident occurred in 2007, and at the time, Ben was the youngest patient ever treated with hypothermia for cardiac arrest.

This article focuses on the critical role of first responders and advanced cardiac life support personnel in the treatment of out-of-hospital cardiac arrest. It will illustrate how the Take Heart America bundle of care approach has helped to transform the landscape of care for sudden cardiac arrest across the country.

Ten years after Ben was successfully resuscitated, the bundle of care has continued to develop. Its implementation contributes to the fact that Minnesota has the best resuscitation outcomes of any state in the nation.

A Moving Target

For decades, we’ve essentially prescribed to a moving target of guidelines and an attempt of standardization of approaches to breathe life and essential circulation back into the lifeless bodies of cardiac arrest patients.

In 2005, the American Heart Association published yet another set of guidelines that refocused our attention on new ways to enhance circulation during CPR. This time, there was less emphasis on ventilation. The Take Heart America program was started at that time, with the intent to simultaneously implement the most highly recommended of these guidelines.

As the pace has quickened in this era of advanced scientific technology and modern research methods, dissemination of current best practices and science updates are proven grounds for improved rates of return of spontaneous circulation (ROSC). But, more importantly, there’s been an increase in neurologically intact survivors that can return to life as usual with minimal modification.

It’s important to recognize that guidelines are guidelines, and protocols are protocols, with both designed for improvement of patient outcomes, and each should be modified as new and compelling evidence emerges.

It should also be noted that these respected guidelines are roadmaps; they’re based on the science that was determined to be relevant at a time prior to publication, but they aren’t hard and fast rules and regulations.

The reality is, in the synergetic approach to the relay race of cardiac arrest management, there are sometimes handoffs that aren’t successfully relayed to other members of the lifesaving team.

Cardiac arrest survival, whether a chain of survival or relay race, begins with the bystander and ends with follow-up care given to a patient who’s experienced a successful outcome.

Take Heart America, a sudden cardiac arrest initiative program, works to implement, reinforce and sustain key advances in resuscitation science. Its mission is to bring the science and education related to cardiac arrest that we know works into a practice and create a culture that’s put into play each time a premature death related to cardiac arrest occurs.

Take Heart America subscribes to the philosophy that resuscitation starts with a concept of bundles of care, which are based on current scientific best practices and deployed to assist cardiac arrest patients. The bundles can be thought of as steps in the process that begin at the time the patient experiences sudden cardiac arrest.

1. Rapid Response

Efforts to decrease the time between when a dispatcher receives a 9-1-1 call for help to the arrival-on-scene and start of CPR by first responders, save lives. The chance of survival is reduced by 10% with every minute that passes without CPR.1 First responders may include volunteers, police, firefighters and EMS personnel with a variety of skill sets and licensing levels.

Every EMS system should, through quality improvement processes, assess their emergency first responder on-scene time intervals and time-to-patient interval to ensure it’s as short as possible.

Systems should then implement process improvement measures to close areas identified in their gap analysis related to cardiac arrest management.

2. Start CPR Immediately

If you’re still doing the “quick look” and the deferential diagnosis analysis, stop that practice and just have your crews just start CPR. Don’t wait on the skills of the advanced provider. Patients without a pulse means hands-on CPR, and that should be the focus.

Knowing what we know now, it’s difficult for me to think back and remember how many times my crews looked to the advanced provider and then focused on advanced procedures like intubation, thinking that the advanced paramedic skills were the key to patient survival.

Of course, advanced skills are critical for a positive outcome, but it’s a balance; and it’s the basics that make the difference in achieving high-perfusion CPR with positive outcomes.

When first responders arrive on scene and confirm a cardiac arrest, CPR should be continued if lay rescuer CPR was initiated, or started immediately if it wasn’t. Every minute without CPR reduces the chances of surviving by up to 10%.

Defibrillation capabilities, such as use of an AED should be used in conjunction with high-quality CPR.2,3

3. High-Quality CPR

Let’s call it what it really should be called: high-perfusion CPR.

With the progression of evidence-based approaches to higher quality CPR comes higher levels of perfusion.

By now you’ve probably heard of active compression/decompression CPR and an impedance threshold device. This scientifically proven method of improving the approach to CPR is making a difference in neurologically intact survivors of cardiac arrest.

For manual closed-chest CPR to be effective, it needs to be delivered correctly. We know that CPR only yields 20—40% efficiency of normal cardiac output.4

The compression rate is 100—110 per minute (not slower, not faster), a depth of two inches in adults and 1.5 inches in infants, and the chest must fully recoil after each compression. First responders use a compression:ventilation ratio of 30:2, a two-handed facemask technique, bag-valve ventilation with a tidal volume of 500—600 cc, and delivery of each breath should be given over < 1 second, until more advanced forms of airway management are placed. Chest compressions shouldn’t be stopped for airway management and rescuers should rotate no less than every minute two minutes, with minimal interruptions. Each of these recommendations is closely linked to increased survival with good brain function.5—15

When an advanced airway is placed, the compression to ventilation ratio is changed to 10:1, with asynchronous ventilations.

Moving from the above high-quality CPR to high-perfusion CPR is accomplished using intrathoracic pressure regulation (IPR) and active compression/decompression CPR.

The body continually regulates the circulation of blood by using positive and negative pressures inside the thoracic cavity to maintain equilibrium. By regulating pressures inside the chest, our body regulates the interactions that occur between three critical body systems: the respiratory, circulatory and nervous systems.

Conventional CPR’s driving force is active positive pressure (i.e., pushing) with little balance with regard to the negative (i.e., pulling). As the chest wall begins to recoil, air rushes in through an open airway and wipes out much of the vacuum (i.e., negative pressure) that’s critical for returning blood to the heart.

IPR enhances negative intrathoracic pressure to treat patients in states of low blood flow. Enhancing the vacuum in the chest helps to increase pre-load, cardiac output and blood pressure. IPR lowers intracranial pressure by influencing the fluid-filled venous sinuses that run along the spinal column that allow us to transmit pressure in the chest to the head.

Think about it; have you ever had a bear hug delivered by someone and felt the increased pressure in your head? That’s an example of chest pressure being transmitted to the head.

So, how can we harness this regulation of pressure that will give us a better balance to mimic the body’s physiology to restore adequate blood flow in a cardiac arrest event?

The answer is two-fold: 1) an impedance threshold device (ITD) and 2) a device allowing for the delivery of active compression/decompression CPR.

An ITD is an adjunct that lowers intrathoracic pressure during the chest recoil phase of CPR, drawing more blood back into the heart and lowering intracranial pressures. When an ITD is used in conjunction with high-quality CPR, it contributes to the increase in survival with good brain function.16—21 Without high-quality CPR, the benefits of the ITD can’t be assured.22

Using an ITD in combination with an active compression/decompression CPR device provides 2—3 times more blood flow to the heart and the brain vs. traditional manual CPR.23

This device combination has been shown to increase the likelihood of survival by 50% when compared with conventional manual CPR.16—19

The combination can be used by first responders (police and fire), and BLS and ALS EMS personnel.

When performing CPR with this device combination, it can be performed with a 30:2 or 10:1 compression to ventilation ratio. An ITD has a timing light that flashes 10 times per minute to guide the ventilation rate during ALS. It’s been shown that training is needed to teach the proper technique when using this device combination.19

4. First Responder Rapid AED Use

For more than 30 years, the public has been witness to the technology of AEDs, which we know are a critical element in the chain of survival.

Approximately 30% of patients in cardiac arrest present with an initial rhythm of ventricular fibrillation (v fib), which can be treated with a defibrillator. Today these devices are as common as a fire extinguisher in public buildings, and many cities have instituted building codes to mandate AED placement.

Combined with the American Heart Association’s inclusion of AED education in their BLS courses and you might be surprised that despite how far we’ve seemingly come, fewer than 5% of the lay rescuers use AEDs. The primary reason for this is the public’s fear of doing something wrong or that they lacked recent training.24—28

AEDs should be used as soon as possible when there are adequate personnel on scene and efforts are made to perform chest compressions without interruption by one rescuer as the second rescuer positions and uses the AED.29—32

EMS agencies and other public safety entities need to make sure that they don’t view public-access defibrillation programs as just a checkbox to officially register devices in their community. It’s crucial for us to actively promote their use, including providing assistance with implementation and voicing to the public that AEDs are one of the most important links in the chain of cardiac arrest survival.

5. CPR Feedback Tools

High-quality CPR is difficult to perform without real-time guidance.33 Feedback tools that assist help providers deliver the proper rate, depth, and recoil of high-quality CPR are readily available. These devices are often linked to defibrillators, and have been shown to improve CPR quality as it relates to consistency.

We know that high-quality CPR is closely associated with better survival rates.34 Feedback devices are of value in training first responder crews during education sessions and affords the rescuer to make real-time adjustments to CPR performance.

Research on the survival advantages of CPR feedback devices is still in its infancy, and the verdict is still out on these devices. The Resuscitation Outcome Consortium found no survival advantages from feedback devices in out-of-hospital cardiac arrest. However, as we’re aware, results can evolve as the feedback devices see more widespread use and a larger but more specific protocol is developed in the research. Anecdotally, it makes perfect sense that if first responders are educated on feedback devices that alert them to improve performance and the same tool is used during an actual cardiac arrest, we should begin to see improvement.35,36 So much so that the 2015 AHA Guidelines and Emergency Cardiovascular Care recommends the use of these devices for training.37

6. Data Collection

Data, it’s just numbers. We collect them to see what exactly? Yes, we want to know how well a provider is preforming their clinical skills. But the data yields much more than that.

Performance data tells you how your system is doing as a whole, and identifies where there may be gaps in your ability to improve cardiac arrest outcomes.

Could utilizing a crew resource management concept like “pit crew CPR” help in outcome? Could the use of the devices and practices talked about in this article assist you in increasing the number of neurologically intact patients discharged after a cardiac arrest?

Looking at your current performance data will enable you to move forward and identify next steps in improving your systems approach in addressing minimal or marginal ROSC rates.

It’s best to start looking at data that reflects what we really want to achieve, not just a pulse upon arrival at your local ED. Data elements for review by first responder medical directors and agency leaders that can assist a first responder agency in this quest include:

  • Data collected on all cases related from 9-1-1 call to dispatch;
  • Pre-arrival instructions from 9-1-1 operators;
  • Multiple subsequent clinical and operational actions taken by the care providers including time from dispatch to the scene;
  • Time from 9-1-1 call to start of CPR;
  • Time to AED placement and use;
  • Duration and quality of CPR performed;
  • Number of personnel on scene; and
  • Method of airway management, the use of the ITD and the use of other CPR adjuncts.

7. Base Hospital Communication

In addition to proactive medical direction both on-line and off-line, recent advances in cellphone app technology and the advent of telemedicine allows first responders and EMS personnel to communicate rapidly with base hospital physicians, cardiologists, cath lab personnel and support staff.

This rapid communication ensures early medical oversight resulting in improved care on scene, as well as facilitating more timely plans for efficient on-scene management and transport to an appropriate cardiac receiving center.


Ultimately, in communities that have embraced the Take Heart America program, there’s a switch that’s flipped: we now expect a ROSC in every patient we code, and when that doesn’t happen we’re very disappointed and we try to understand why.

Take Heart America believes that resuscitation is a true specialty, one that requires a carefully calculated and well-practiced approach so that resuscitative measures are delivered rapidly, involving the community in a maximum-effort approach with early citizen responder alerting, response and delivery of chest compressions and AED application and use.

It’s critical that citizen response be followed by first responder, BLS and ALS care that’s delivered in a systematic manner using the bundles of care presented in this article.

Deviation and inconsistency in care delivery are not options. The human body and its vital organs need, and deserve, the consistent, uninterrupted flow of precious circulation. Our efforts must never forget, or neglect, that!


1. Neukamm J, Grasner JT, Schewe JC, et al. The impact of response time reliability on CPR incidence and resuscitation success: A benchmark study from the German Resuscitation Registry. Crit Care. 2011;15(6):R282.

2. Valenzuela TD, Roe DJ, Cretin S, et al. Estimating effectiveness of cardiac arrest interventions: A logistic regression survival model. Circulation. 1997;96(10):3308—3313.

3. Caffrey S. Feasibility of public access to defibrillation. Curr Opin Crit Care. 2002;8(3):195—198.

4. Sayre MR, Koster RW, Botha M, et al. Part 5: Adult basic life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with treatment recommendations. Circulation. 2010;122(16 Suppl 2):S298—S324.

5. Kern KB, Hilwig RW, Berg RA, et al. Importance of continuous chest compressions during cardiopulmonary resuscitation: Improved outcome during a simulated single lay-rescuer scenario. Circulation. 2002;105(5):645—649.

6. Bobrow BJ, Clark LL, Ewy GA, et al. Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest. JAMA. 2008;299(10):1158—1165.

7. Aufderheide TP, Pirrallo RG, Yannopoulos D, et al. Incomplete chest wall decompression: A clinical evaluation of CPR performance by EMS personnel and assessment of alternative manual chest compression-decompression techniques. Resuscitation. 2005;64(3):353—362.

8. Yannopoulos D, McKnite S, Aufderheide TP, et al. Effects of incomplete chest wall decompression during cardiopulmonary resuscitation on coronary and cerebral perfusion pressures in a porcine model of cardiac arrest. Resuscitation. 2005;64(3):363—372.

9. Sanders AB, Kern KB, Berg RA, et al. Survival and neurologic outcome after cardiopulmonary resuscitation with four different chest compression-ventilation ratios. Ann Emerg Med. 2002;40(6):553—562.

10. Dorph E, Wik L, Stromme TA, et al. Oxygen delivery and return of spontaneous circulation with ventilation:compression ratio 2:30 versus chest compressions only CPR in pigs. Resuscitation. 2004;60(3):309—318.

11. Dorph E, Wik L, Stromme TA, et al. Quality of CPR with three different ventilation:compression ratios. Resuscitation. 2003;58(2):193—201.

12. Fenici P, Idris AH, Lurie KG, et al. What is the optimal chest compression-ventilation ratio? Curr Opin Crit Care. 2005;11(3):204—211.

13. Sayre MR, Cantrell SA, White LJ, et al. Impact of the 2005 American Heart Association cardiopulmonary resuscitation and emergency cardiovascular care guidelines on out-of-hospital cardiac arrest survival. Prehosp Emerg Care. 2009;13(4):469—477.

14. Olasveengen TM, Vik E, Kuzovlev A, et al. Effect of implementation of new resuscitation guidelines on quality of cardiopulmonary resuscitation and survival. Resuscitation. 2009;80(4):407—411.

15. Aufderheide TP, Lurie KG. Death by hyperventilation: A common and life-threatening problem during cardiopulmonary resuscitation. Crit Care Med. 2004;32(9 Suppl):S345—S351.

16. Sugiyama A, Duval S, Nakamura Y, et al. Impedance threshold device combined with high-quality cardiopulmonary resuscitation improves survival with favorable neurological function after witnessed out-of-hospital cardiac arrest. Circ J. 2016;80(10):2124—2132.

17. Lick CJ, Aufderheide TP, Niskanen RA, et al. Take Heart America: A comprehensive, community-wide, systems-based approach to the treatment of cardiac arrest. Crit Care Med. 2010;39(1):26—33.

18. Aufderheide TP, Yannopoulos D, Lick CJ, et al. Implementing the 2005 American Heart Association Guidelines improves outcomes after out-of-hospital cardiac arrest. Heart Rhythm Journal. 2010;7(10):1357—1362.

19. Aufderheide TP, Frascone RJ, Wayne MA, et al. Standard cardiopulmonary resuscitation versus active compression-decompression cardiopulmonary resuscitation with augmentation of negative intrathoracic pressure for out-of-hospital cardiac arrest: A randomised trial. Lancet. 2011;377(9762):301—311.

20. Thigpen K, Davis SP, Basol R, et al. Implementing the 2005 American Heart Association Guidelines including use of the impedance threshold device improves hospital discharge rates after in-
hospital cardiac arrest. Respiratory Care. 2010;55(8):1014—1019.

21. Sporer K, Jacobs M, Derevin L, et al. Continuous quality improvement efforts increase survival with favorable neurologic outcome after out-of-hospital cardiac arrest. Prehosp Emerg Care. 2017;21(1):1—6.

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

23. Aufderheide TP, Lurie KG. Vital organ blood flow with the impedance threshold device. Crit Care Med. 2006;34(12 Suppl):S466—S473.

24. National efforts to raise public awareness about sudden cardiac arrest. [Meeting/hearing.] National Academy of Medicine meeting: Seattle, June 16, 2014.

25. Heidenreich JW, Bonner A, Sanders AB. Rescuer fatigue in the elderly: Standard vs. hands-only CPR. J Emerg Med. 2012;42(1):88—92.

26. Bottiger BW, Van Aken H. Kids save lives: Training school children in cardiopulmonary resuscitation worldwide is now endorsed by the World Health Organization (WHO). Resuscitation. 2015;94:A5—7.

27. Neset A, Birkenes TS, Furunes T, et al. A randomized trial on elderly laypersons’ CPR performance in a realistic cardiac arrest simulation. Acta Anaesthesiol Scand. 2012;56(1):124—131.

28. Blewer AL, Leary M, Decker CS, et al. Cardiopulmonary resuscitation training of family members before hospital discharge using video self-instruction: A feasibility trial. J Hosp Med. 2011;6(7):428—432.

29. Eftestol T, Sunde K, Steen PA. Effects of interrupting precordial compressions on the calculated probability of defibrillation success during out-of-hospital cardiac arrest. Circulation. 2002;105(19):2270—2273.

30. Edelson DP, Abella BS, Kramer-Johansen J, et al. Effects of compression depth and pre-shock pauses predict defibrillation failure during cardiac arrest. Resuscitation. 2006;71(2):137—145.

31. Yu T, Weil MH, Tang W, et al. Adverse outcomes of interrupted precordial compression during automated defibrillation. Circulation. 2002;106(3):368—372.

32. Gundersen K, Kvaloy JT, Kramer-Johansen J, et al. Development of the probability of return of spontaneous circulation in intervals without chest compressions during out-of-hospital cardiac arrest: An observational study. BMC Med. 2009;7:6.

33. Handley AJ, Handley SA. Improving CPR performance using an audible feedback system suitable for incorporation into an automated external defibrillator. Resuscitation. 2003;57(1):57—62.

34. Kirkbright S, Finn J, Tohira H, et al. Audiovisual feedback device use by health care professionals during CPR: A systematic review and meta-analysis of randomised and non-randomised trials. Resuscitation. 2014;85(4):460—471.

35. Hostler D, Everson-Stewart S, Rea TD, et al. Effect of real-time feedback during cardiopulmonary resuscitation outside hospital: Prospective, cluster-randomised trial. BMJ. 2011;342:d512

36. Kirkbright S, Finn J, Tohira H, et al. Audiovisual feedback device use by health care professionals during CPR: A systematic review and meta-analysis of randomized and non-randomized trials. Resuscitation. 2014;85(4):460—471.

37. Bhanji F, Donoghue AJ, Wolff MS, et al. Part 14: Education: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132(18 Suppl 2):S561—S573.

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