Transcript Slide 1

The HeartRescue Project:
State-Wide Strategies to Improve
Cardiac Arrest Survival
NAEMSP
January 13, 2012
Project Overview
Michael Sayre, MD, FACEP, FAHA
Associate Professor
Emergency Medicine, The Ohio State University
Medical Director, HeartRescue Project
An Overlooked Cause of Death
Annual U.S. Deaths
300,000
•
Wide variance in local,
regional, economic and ethnic
survival rates
•
Current data collection
sporadic minimizing ability for
systemic improvement
•
National survival rate is 8%,
no improvement in 30 years
250,000
200,000
150,000
100,000
SCA (1)
Stroke (1)
Lung Cancer (2)
Breast Cancer (2)
AIDS (3)
50,000
0
(1) American Heart Association. Heart Disease and Stroke Statistics –2010 Update.
(2) Jemel A. CA Cancer J Clin. 2003;53:5-26.
(3) U.S. HIV & AIDS Statistic Summary. Avert.org.
Improving SCA Survival
1: Bystander Response
Recognize
SCA
Early
911
Effective
bystander
CPR
Public
access
to AED
2: Pre-hospital Response
Enhanced
dispatch
Enhanced
CPR
Appropriate
defibrillation
therapy
Early
Advanced
Care
3: Hospital Response
Patient
triage to
Resus.
Center of
Excellence
Hypothermia 24/7 Cath
Lab
IC
Ds
Postsurvival
patient
education
& support
HeartRescue
Partner
2nd chain:
Pre-hospital Response
Program Goals
Improved Survival Rates
50% improvement in SCA
survival in program states
• Partner grants
Improved Reporting
Increase and improve
measurement of SCA
nationwide
•Common data set
and registry (CARES)
•SCA national index
Improved National
and Global Impact
Expand nationally and
internationally
•Expand grant program
•SCA Community Playbook
HeartRescue Partners
Center for
Resuscitation
Science
HeartRescue Project Expansion Plan
Fund one state and one country in 2012
Timeline :
1.
2.
3.
4.
5.
6.
Announce program request for applications: Dec 1
LOI deadline: Jan 20
Invite applications: Feb 15
Application deadline: April 5
Partner/Foundation review completed: June 1
Award announced: early June
(to align with the July-June grant cycle for other partners)
During Year One of the Project, Heart Rescue Partners:
• Expanded reach of OHCA data collection to 20%+
population in their states
• Submitted baseline outcome data reports in August 2011
• Developed collaborations with stakeholder organizations
that lead to improvements in overall SCA patient care
(e.g. 911 Dispatch Centers, State EMS offices, Hospital/EMS
connections, Depts. Of Health, CPR Training organizations)
• Established positions within their organizations to take
on the work of the HeartRescue Project, including program
managers, and state data collection coordinators.
• Collaborated as a team to develop best practice
guidelines and programs (e.g. partnership with the CARES
Registry, Resuscitation and Dispatch Academies).
Counties Collecting OCHA Data
As of December 2011
Washington
Minnesota
Pennsylvania
Arizona
Systemic Reasons that OHCA Survival
is stuck in the basement..
Daniel Spaite, MD, FACEP
Professor and Distinguished Chair of
Emergency Medicine
Director of EMS Research
College of Medicine
University of Arizona
Why Survival is Stuck in the Basement
• The answers are simultaneously
profound…and…so simple as to sound (be?)
stupid
– You’ll either be inspired, bored, or incredulous
Why Survival is Stuck in the Basement
• Systemic Reason #1: For decades, responders have
watched so many dead people stay dead…they simply
don’t believe they can make any REAL difference
• Systemic Reason #2: EMS Medical Directors hallucinate
that we can show up once…say something…impress
people…inspire the troops…and…voi la…they’ll pay
attention and change what they do
• Systemic Reason #3: Healthcare (in general) and EMS
systems (specifically) are really good at
implementing…without ACTUALLY implementing
Why Survival is Stuck in the Basement
• Systemic Reason #4: Improving survival is…actually…in
fact...REALLY hard to do
– Systems Engineering:
• “A system is designed to produce the output that it produces”
– In every system…decades of planning, operationalizing,
resourcing, justifying, implementing, administering, and
deploying have given us exactly what we have.
– AND…no matter how good the reasons for change
are…the inertia against true change is monumental.
Corollaries to Systemic Reason #4:
• 4a: It’s really hard to get bystanders to do CPR
•
•
•
•
4b:
4c:
4d:
4e:
It’s really hard to get dispatchers to assist bystander CPR
It’s really hard to do EMS dispatch quickly and accurately
It’s really hard to get EMS systems to collect data
It’s really, really hard to get EMS providers to stop
interrupting chest compressions
• 4f: It’s really hard to do high quality CPR
• 4g: It’s really hard to get hospitals to provide guideline
therapy
• 4h: It’s really hard to overcome all of the regulatory, political,
and operational barriers to regionalization
Why Survival is Stuck in the Basement
• So…these are the systemic…non-profound, obvious,
simpleton reasons for why survival is abysmal
• And now…for the “Jewel”
Single take home jewel that an EMS medical
director can implement in 2012:
• The Jewel: The medical directors have to be
relentless…and resilient…and maniacal…and oblivious
to failure…and impossible to deter…and obsessed with
getting data…and willing to be accused of being a
broken record…and relentless…an relentless…and
relentless!!!
• The Medical Director Jewel in a nutshell:
– “I’m not going away!!!”
RELENTLESSNESS
• An Arizona Example:
– A joint effort between the leaders and medical
directors of the Mesa Fire Department and
Guardian Transport…in partnership with the
State EMS Medical Director.
• Where they were in 2004:
– Overall OHCA Survival:
3.0%
– Witnessed VF Survival:
7.0%
RELENTLESSNESS: What We Did
• A combined local, regional, and statewide effort:
– 2004: Began Utstein-Style data reporting
– 2005: Began EMS MICR & a major bystander COCPR
campaign
– 2006: Added intentional “pit-crew” training for MICR
– 2007: Formal recognition of Cardiac Receiving Centers
– 2008: Approved EMS bypass protocols for regionalization
– 2009: Began CPR quality program
• Scenario-based training
• Monitor-based real-time AV feedback
– 2010: Began Dispatcher-Assisted CPR program
RELENTLESSNESS
SURVIVAL BY YEAR
Overall
Witness VF
2004
3.0%
7.0%
2009
10.2%
31.3%
2011
19.4%
57.9%
THE JEWEL: “I’m not going away!!!
Why Dispatch-Assisted Pre-Arrival CPR
Instructions?
Bentley J. Bobrow, MD
Associate Professor
Emergency Medicine Department
Maricopa Medical Center
Medical Director
Bureau of Emergency Med. Services & Trauma
Arizona Department of Health Services
System of Care
Measurement
Public
EMS
Hospital
Bystander CPR
Great Importance of Bystander CPR
The OR for Bystander CPR was 2.44
(95% CI, 1.69-3.19)
(Sasson et. al. Circulation: Cardiovascular
Quality and Outcomes Nov. 2009.)
The cardiac arrest problem
% Surviving
Arrest
CPR
ROSC
Increased
Bystander
Response &
Improved
CPR Quality
5-8%
Hospital
Discharge
Time
Bystander CPR: Incidence and Type
100%
% Lay
COCPR
80%
77%
60%
40%
44.7%
45% relative increase
28.2%
All Lay
CPR
20%
16%
P = 0.001
0%
2005
2006
SHARE - JAMA 2010; Oct
2007 2008
2009 2010
7265 OHCAs
55.9% received BCPR
25.7% received DA-CPR
30.2% received BCP without DA
Early CPR
Challenges:
• Cardiac arrest is hard to identify
• Rescuers lack confidence to act
• CPR can be technically difficult
• Dispatchers reluctant
2-Question Approach
Dispatch Assisted CPR
Because dispatcher CPR instructions substantially increase the
likelihood of bystander CPR performance and improve survival from
cardiac arrest, ALL dispatchers should be appropriately trained to
provide telephone CPR instructions (Class I, LOE B).
2010 AHA Guidelines for CPR & ECC
You cannot improve what you
can’t measure!
Resuscitation systems should institute
CQI processes to track the incidence and
outcomes from cardiac arrest.
– 2010 AHA Guidelines for CPR & ECC
Date:
Time of Call:
Transfer Call?
Case Number:
Call-taker Name:
Yes
No
Was telephone-assisted CPR needed to process this call?
Were CPR Instructions given?
Is coaching needed with the call-taker?
Time Q/A rater
recognized need
for CPR
Time Calltaker
recognized need
for CPR
Yes
Yes
Yes
Time call-taker
began instructions
No
No
No
Time of first
compression
Breathing
Normally?
Patient
Conscious?
Was caller the
rescuer?
Yes
Yes
Yes No
No Unk
Agonals
reported or
heard?
No Unk Yes No Unk
CPR coached appropriately? (check boxes below)
Assertive?
Rate?
Depth?
Yes
No
Yes
No
Yes
No
Continuous
Coaching?
Yes
No
Unk
Adult?
Child?
Infant?
Time of first
rescue breaths
Was CPR
already in
progress?
Yes No Unk
Was there a
trained rescuer
present?
Yes No Unk
If multiple rescuers
coached to switch?
Yes
No
N/A
What coaching or compliments are needed for the call-taker?
If there was a delay in giving instructions or they were never given, what was the reason?
Caller left the phone
Difficult Access
Unable to get patient to floor
Caller not with patient
DNR (Do Not Resuscitate)
Calltaker not assertive
Language Barrier, if yes language was:
CPR already in progress
Language Line Used
Dangerous Environment
Obvious Death
Didn’t recognize CPR was needed
Unable to calm caller
Other:
CPR DISPATCH ACADEMY
- THE SCIENCE OF CPR
- ROLE OF 9-1-1 PERSONNEL IN THE CHAIN OF
SURVIVAL
- KEY ELEMENTS FOR SAVING LIVES
- SMALL GROUP TRAINING
Single take home jewel that an EMS medical
director can implement in 2012:
Dispatch Assisted CPR 
More Bystander CPR 
More Survivors
The Science Behind
Compression Only “CPR”
Cardiocerebral Resuscitation
Gordon A. Ewy, M.D. FACC, FAHA
Professor of Medicine (Cardiology)
Director University of Arizona Sarver Heart Center
University of Arizona College of Medicine
Tucson, AZ USA
THE UNIVERSITY
OF ARIZONA
Sarver Heart Center
Coronary Perfusion
Pressure (mm Hg)
Survival from VF arrest in our experimental studies was
related to the coronary perfusion pressures
35
30
25
20
15
10
5
0
Not the pH
Not the oxygen content
Coronary perfusion
pressure
Same
in
man
24-hour
Survivors
Resuscitated
But
Expired
Could
Not
Resuscitate
Kern, Ewy, Voorhees, Babbs, Tacker Resuscitation 1988; 16: 241-250
Paradis et al. JAMA 1990; 263:1106
Percent 24-48 Hour Neurologically
Normal Survival
In our swine model of VF OHCA, survival was better
with CO-CPR than no CPR until ACLS
100%
80%
40%
20%
73%
13%
0%
CO-CPR
No CPR
University of Arizona Sarver Heart Center CPR Research Group Circulation 1993;88:1907-1915
Percent 24-48 Hour Neurologically
Normal Survival
Between 1993 and 2002, 6 publications (total of 169 nonparalyzed swine) each reporting no difference in survival between
CO-CPR and “Guidelines” CPR
100%
These publications had no influence on Guidelines
80%
60%
40%
73%
70%
20%
0%
CO-CPR
“Ideal” Std-CPR
University of Arizona Sarver Heart Center CPR Research Group
CO-CPR
equivalent
to “ideal CPR”:
4 sec interruption
of each set of
chest
compressions
for MTM
ventilations
What about
“realistic CPR”:
16 sec interruption
of each set of chest
compressions
for MTM ventilation?
ECG: VF
Coronary
perfusion
pressure
71% compressions 19% ventilations
42% compressions
58% ventilations
Outcomes During Simulated Single Lay Rescuer Scenario of OHCA
from VF
(3 minutes VF, 12 minutes CPR, then ACLS)
24-Hour Neurological
Normal Survival (percent)
100%
80%
P < 0.003
60%
40%
~70%
20%
0%
13%
CC Only CPR
Realistic 2:15 CPR
Kern, Hilwig, Berg, Sanders, Ewy. Circulation 2002; 105: 645-649
Single rescuer performing 30:2 with realistic 16 sec.
interruption of chest compressions for MTM ventilations
160
Cerebral Perfusion
Pressures
5 sec
No Cerebral
Perfusion
mmHg
120
80
40
Coronary Perfusion Pressures
0
Time (sec)
160
Single rescuer performing
continuous chest compressions
5 sec
mmHg
120
Continuous Cerebral Perfusion Pressures
80
40
Coronary Perfusion Pressures
0
Time (sec)
Survival Following Simulated Single Lay Rescuer Scenario of
Primary Cardiac Arrest
(4-6 minutes VF, bystander to 12 min, then ACLS)
24-Hour Neurological
Normal Survival (percent)
100%
P < 0.05
80%
60%
40%
64%
16/25
20%
26%
6/23
0%
CCO CPR
Realistic 30:2 CPR
Ewy GA, Zuercher, M. Hilwig, R.W. et al Circulation 2007;116:2525
Survival to Hospital Discharge
Survival after Bystander CPR for OHCA in Arizona (2005 to 2010)
Compression Only CPR Advocated and Taught
35%
A. All OHCA
B. Witnessed/Shockable
30%
AOR 1.6 (95% CI, 1.08-2.35)
25%
23 years
17.7%
20%
15%
33.7%
30 years
7.6%
10%
5%
0%
P < 0.001
7.8%
Std-CPR
13.3%
COCPR
17.7%
Std-CPR
Bobrow, et al. JAMA 2010:304:1447-1454
COCPR
North Carolina
How to choreograph and execute
high-performance CPR among EMS teams
Brent Myers, M.D., MPH, FACEP
Medical Director, Wake County EMS System
Adjunct Assistant Professor of Emergency
Medicine at UNC School of Medicine
Perfusion.
Plan For Discussion
•
•
•
•
•
Rationale for EMS Providers
On-Scene Resuscitation
Choreography
Check lists
Conclusions
Prehospital Emergency Care 2011;15(1):106
Results (Pre-Feedback)
N = 108
% (25th, 75th)
Scene Correct Rate%
Median: 44.8 (9.54, 59.6)
Mean: 38.49 CI (33.2, 43.78)
Transport Correct Rate%
Median: 11.16 (5.83, 39.32)
Mean: 23.16 CI (18.35, 27.97)
Scene Correct Depth%
Median: 40.94 (15.96, 73.29)
Mean: 45.06 CI (38.76,
51.37)
Transport Correct Depth%
Median: 8.88 (2.62, 49.01)
Mean: 26.37 CI (20.12,
32.63)
55 | MDT Confidential
Results (PostFeedback)
N = 35
% (25th, 75th)
Scene Correct Rate%
Median: 48.16 (14.68, 62.36)
Mean: 43.6 CI (34.61, 52.59)
Transport Correct Rate%
Median: 19.0 (9.52, 60.22)
Mean: 32.78 CI (23.21, 42.33)
Scene Correct Depth%
Median: 75.73 (36.23, 95.07)
Mean: 66.86 CI (56.57,
77.16)
Transport Correct Depth%
Median: 14.0 (4.78, 90.78)
Mean: 42.04 CI (27.98,
56.11)
56 | MDT Confidential
Task Interruptions
•
•
•
•
•
•
•
Airway interventions and IVs
Ventilations
Pulse checks
Rhythm analysis
Defibrillation
Changing compressors
Patient movement
We have limited awareness of task time in
complex processes….so these interruptions
should be engineered and choreographed to
minimize their impact…..
>20 second pause for defibrillation. Appears that a
ventilation was given before the compressions resumed.
Compressions resume 10 seconds after shock delivery.
©2010 Paul R. Hinchey
Pit Crew Model
• Same name…many versions
• CPR
– Maximize compression fraction
– Effective compression(rate/depth)
– Provider fatigue
• Controlled ventilations
• Defib
– Pre-charge @1:45
– Emphasis on Shock/Don’t’ shock
So we went to the simulation lab and now
it’s ALL choreographed….
Need cpr checklist
©2010 Paul R. Hinchey
Take Away
• Choreograph your cardiac arrest
• Focus on priorities
–
–
–
–
Limited interruption
Controlled ventilation
Timely defib
Compressor fatigue
• Continuous reassessment and reengineering
• Research is required to validate compression quality
The Challenges of Implementing
a System of OHCA Care
in a Rural Setting
Lisa Monk MSN, RN, CPHQ
RACE CARS State Project Leader
www.ncruralcenter.org/databank/rural_county_map.php
Population: 9,535,483/ 196 persons/square mile(48, 617)
http://quickfacts.census.gov/qfd/states/37000.html
Challenges:
• Medical Leader
– Increase in survival from OOHCA
• Organized System with a Plan
• Data
• Community
– Recognition and response by lay people
– Increase rates of bystander CPR and AED
use
• EMD
– Decrease dispatch to scene arrival
– Increase dispatch assisted CPR instruction
• EMS Care
–
–
–
–
Response times 5-6 minutes
High Quality CPR and AED
Cooling
Increase ROSC
• Long Response Times
• Lack EMD or advanced 911
• Lack resources
– Training
– Data entry
– “Technology”
• Commitment
• Time
• Economic Issues
Single take home jewel that an EMS medical
director can implement in 2012:
Understanding your community and
leveraging your resources
WILL
save lives!
Travel North Carolina
The Safest Place in the Country to Have a
Cardiac Arrest!
American Medical
Response
*Yellow indicates AMR
agencies working with
partner state and not
included in totals.
Why should EMS medical directors and
senior staff care about the 1% of cases
that are OHCA ?
Edward M. Racht, MD
Chief Medical Officer
American Medical Response
A lot of work for 0.7% of what
18,000 practitioners take care of…
The AMR challenge
• Size
–
–
–
–
•
•
•
•
•
Volume of arrests
Diversity of communities / practices
Wide variation in survival
Many cooks / family recipes
Significant impact of improvement
The art of implementing the science
Communicating science / best practices / successes
Developing sustainable partnerships
“We are more effective as one than we are as many”
The EMS role in resuscitation systems of care
(The importance of the HeartRescue initiative)
• Building a SYSTEM of care for resuscitation impacts other out-ofhospital acute illness and injury management
• It’s important (and nice) to play with smart people
• EMS is the catalyst for evidence-based resuscitation efforts in most
communities
• The science is often much easier than the art
• Data organization and analysis will help us improve care (and
ultimately outcomes)
• It’s important to ignite a passion in the (very-busy-I-have-manyother-things-to-do-and-this-will-never-happen-to-me) community
Most of these patients die anyway, right?
A message from one of our Paramedics
to his partners…
What is the “triple threat” ?
Scott Bourn PhD, RN, EMT-P
Vice-President of Clinical Practices & Research
American Medical Response
Secondary Drivers?
Primary Drivers?
Bystander Response
OUTCOME
Increase
survival in outof-hospital
sudden cardiac
arrest (how
much? By
when?)
Pre-Hospital Response
•
•
•
•
•
Community awareness activities
Early Recognition of Arrest
Bystander CPR Training
Public Access Defibrillation
911 Dispatcher Pre-Arrival Instructions
•
•
•
•
•
•
Establish Sudden Cardiac Arrest Data Collection
Improving Recognition of SCA & initiation of PAIs by 911 call takers
High quality CPR with minimal interruptions (C-A-B)
Establish OHCA System of Care?
Implement quantitative waveform capnography for ET patients
Develop Teamed / Role-Based Resuscitation
•
Optimize cardio-pulmonary function & vital organ perfusion
after ROSC
Transport/transfer to appropriate hospital or CCU with
comprehensive post cardiac arrest treatment system of
care.
Identify and treat advanced ACS & other reversible causes
Control temperature to optimize neurological recovery.
Anticipate, treat, & prevent multi-organ dysfunction. Include
avoiding excessive ventilation and hyperoxia.
•
Hospital Response
•
•
•
•
Survivor Support
•
•
•
•
At discharge refer survivors / families to resources for
physical rehab to cope with brain injury.
Provide honest and specific answers to questions
Provide patient diagnosis specific resources about condition
Share knowledge about what to expect & how to react when
systems are experienced post discharge.
Provide ICD coaching and coping skills
Secondary Drivers
• Community awareness activities
• Early Recognition of Arrest
• Bystander CPR Training
• Public Access Defibrillation
• 911 Dispatcher Pre-Arrival Instructions
• Establish Sudden Cardiac Arrest Data Collection
• Improving Recognition of SCA & initiation of PAIs by 911 call takers
• High quality CPR with minimal interruptions (C-A-B)
• Establish OHCA System of Care?
• Implement quantitative waveform capnography for ET patients
• Develop Teamed / Role-Based Resuscitation
• Optimize cardio-pulmonary function & vital organ perfusion after ROSC
• Transport/transfer to appropriate hospital or CCU with comprehensive post cardiac
arrest treatment system of care.
• Identify and treat advanced ACS & other reversible causes
• Control temperature to optimize neurological recovery.
• Anticipate, treat, & prevent multi-organ dysfunction. Include avoiding excessive
ventilation and hyperoxia.
• At discharge refer survivors / families to resources for physical rehab to cope with
brain injury.
• Provide honest and specific answers to questions
• Provide patient diagnosis specific resources about condition
• Share knowledge about what to expect & how to react when systems are
experienced post discharge.
• Provide ICD coaching and coping skills
Change Concepts & Change Ideas for PDSA Testing
How to measure out-of-hospital cardiac arrest:
what are the options?
Lynn White, MS
National Director of Resuscitation & Accountable Care
American Medical Response
System Complexities
Organizational Relationships
Community Relationships
THANK YOU!
• www.HeartRescueProject.com
• Leave your comment card on your chair.
• Take a Playbook on your way out.