Transcript C.A.R.E.S.

C.A.R.E.S.
Cardiac Arrest Registry to Enhance Survival
City of Austin-Travis County EMS System
Grand Rounds
February 19, 2008
Bryan McNally, MD, MPH
Assistant Professor of Emergency Medicine
Associate Medical Director Emory Flight
Emory University School of Medicine
CARES Grand Rounds
The Present – where we are now
The Future – where we are going
EMS in Georgia
Discussion
Out of Hospital Cardiac Arrest (OHCA)
Is the sudden, unexpected natural death from a
cardiac cause a short time (generally < 1 hour)
after the onset of symptoms (if present) in a
person without any previous condition that would
seem fatal.
Gillum and colleagues have defined SCD as any
cardiac death occurring outside the hospital or
taking place in the emergency department.
SCD Etiology
Utstein Inclusion/Exclusion Criteria
Utstein Criteria
Two Database Formats
 Registry – focuses on continuous quality
improvement.
 Research report – examines specific
interventions and outcomes
Benefits of Data Collection
 Uniform collection and tracking of data
facilitates better continuous quality
improvement within communities.
 Enables comparisons across the systems
for clinical benchmarking to identify
opportunities for improvement.
Why Develop an OHCA Registry?
Burden of disease is high
Most time critical EMS condition
Community variability in measuring OHCA
Community variability in survival OHCA
Variability in system configuration
Patient demographics
NEMSIS
Burden of Disease is High.
Most Time Criticial EMS Condition
100
80
60
Survival reduced by ~7-10%
each minute defibrillation
delayed
Survival Rate
(percent)
40
20
0
5
10
15
20
Time to Defibrillation
(minutes)
25
Most Time Critical EMS Condition
Community Variability in Measuring
OHCA Survival
Community Variability in Survival
Rate
ALL RHYTHMS DISCHARGE RATE 2-25%
VF DISCHARGE RATE 3-33%
Variability in System Configuration
Patient demographics
Age
Gender
Race
Vulnerable populations?
Is there biological disparity in survival?
NEMSIS
Future language to be spoken
“Many Lives are Lost Across USA
Because Emergency Services Fail.”
(USA TODAY, 2003, Robert Davis).
Surveyed the Country’s 50 largest cities.
38 of the 50 either could not, or would not, report
their communities cardiac arrest survival.
Article series revealed the major reasons why
EMS in most cities save few people.
USA TODAY, 2003, Robert Davis
“Most cities don’t measure their performance
effectively, if at all. They don’t know how
many lives they are losing, so they can’t
determine ways to increase survival rates.”
Need for Registry
Data collection into a registry at the regional,
state or national level enables EMS systems to
collect data in a standardized NEMSIS compliant
fashion.
Strengths and weaknesses in a community can
be identified when comparison with the
benchmarked dataset is made.
Future performance measures need to based on
compliance with evidence based guidelines.
IOM Report on Emergency Services
“What is missing is a standard
set of measures that can be
used to assess the performance
of the full emergency and
trauma care system within each
community, as well as the ability
to benchmark that performance
against statewide and national
performance metrics.”
IOM Report on Emergency Services
“While a full-blown data collection and
performance measurement and reporting
system is the desired ultimate outcome,
the committee believes a handful of key
indicators of regional system performance
should be collected and promulgated as
soon as possible.”
Cardiac arrest, pediatric respiratory arrest,
blunt trauma with shock.
CARES Program Overview
Identify and collect pre-hospital cardiac arrest
events to improve survival outcomes.
Establish a method for uniform consolidation of
EMS, 911, and hospital information.
Generate reports of response intervals and
patient outcomes for involved agencies in useful
format.
Allow participating agencies to confidentially
benchmark performance.
The THREE SILOS OF DATA
Importance of Data Elements and Linkage to CARES
CARES NETWORK
CARES Program Database
Sansio
– Mainframe housed in Duluth, MN
Internet database system
– https://mycares.net
– HIPAA compliant security
Unifies EMS, 911, and Hospital
data
– Any EMS system throughout US
EMS Component
Collection methods
– Direct entry online
– Integration of CARES data fields
onto EMS tablet/laptop software
– Scanned CARES form
Query to ensure capture of data
– Manual or through PCR
documentation systems
EMS initiates event and signals
other two components
– Generates email to Hospital
component
– Matches event with daily 911
import
911 CAD Component
Call number on CARES form identifies
Computer-Aided Dispatch (CAD) record.
Times are forwarded to database daily using
auto-extraction tool.
Unmatched CAD times are identified and
matched manually.
– Likely matches ranked based on Date, Time, and
Address.
– Matches confirmed by EMS agency liaison
Hospital Component
Hospital follow-up only required on patients
where outcome is ‘ongoing resuscitation’
Hospital contacts set up through CARES
administrator.
EMS CARES data triggers an email to primary
hospital contact requesting hospital outcome.
When all three data components form a
complete record of the event, the data is deidentified of unique patient identifiers (name and
DOB).
Reporting Features
Bystander intervention / community statistics
– AED/CPR use
– Gender, age (mean and range), and location type
EMS and First Responder Response time intervals
– 911 to arrival
– 911 to dispatch
– Dispatch to arrival
Utstein flow diagram
– Survival to discharge
– Neurological status (CPC)
Call volume
– Total volume for agency as a function of time.
– Hospital Destination
CARES
Ultimate goal of CARES will be to help
local EMS administrators and medical
directors identify:
– Who is affected.
– When and where cardiac arrests occur
– Which elements of the system are functioning
well and those that are not.
– How changes can be made to improve
cardiac arrest outcomes.
Obstacles in Data Collection
Ownership of Data – need for data use
agreement.
Data Security – need for HIPAA compliance,
internet firewall, and encryption of data.
Confidentiality – need for data use agreement.
Fragmented System – lack of linkage with 3 silos
of data; need to automate data collection
process to bring together 3 separate datasets
CARES
Created a model cardiac arrest registry capable
of identifying and tracking all cases in a defined
geographic area.
Year One -- Fulton County, Georgia.
Year Two -- Multi-County Area of metropolitan
Atlanta, Georgia.
Year Three – Began National Expansion.
Ultimate goal is to be universally applicable to
EMS operations nationwide.
Gender Demographics
Null
0.42%
Female
39.46%
Male
60.12%
Age Demographics
1000
900
800
700
600
500
400
300
200
100
0
0-19
20-29 30-39
40-49 50-59 60-69
70-79
80+
Null
Ethnicity Demographics
Asian
3%
Black/AfricanAmerican
26%
Unknown
28%
Native
Hawaiian/
Pacific
2%
Hispanic/Latino
5%
AmericanIndian/Alaskan
1%
White
35%
Location Type
Total
Home/Residence
Percentage
2948
65.25%
Public Building
272
6.02%
Street/Hwy
209
4.63%
Nursing Home/Assisted Living Center
618
13.68%
Residence/Institution
59
1.31%
Physician Office/Medical Clinic
84
1.86%
Educational Institution
14
0.31%
Hospital
12
0.27%
Recreation/Sport Facility
59
1.31%
Industry
36
0.80%
Jail
14
0.31%
166
3.67%
23
0.51%
4
0.09%
4518
100.00%
Other
Airport
Null
Total:
Resuscitation Outcome Consortium
CARES – 3 Applications
Grady EMS – intervention and assessment.
Restarting Atlanta Hearts Program – focus
on identified weak links in chain of survival.
Geomapping and AED Registry Application
Grady EMS Sample Reports
Change in system dispatch process
Before and after metrics - 6 months
Date provided to illustrate comparison
0 Survivors
5 Survivors
Racing the Clock
to
Restart Atlanta’s Hearts
Recommendations
Recommendation 1
– Improve public recognition of signs of heart
attack and prompt 911 calls
Recommendation 2
– Improve bystander CPR rates
Recommendation 3
– Decrease time to defibrillation through strategic
placement of AEDs
Geocoded CARES Data
Geocoded CARES Data
Targeted AED Placement
Targeted Bystander Training
What’s next?
Future Considerations
Expansion
Hypothermia
AED Registry
Mapping
Agency classification – “not all apples are the
same”
Longitudinal surveillance tool to measure
survival locally, regionally, statewide, nationally.
Code summary data integration
List-Serve