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CDC Heart Disease and Stroke Prevention Annual Grantee Meeting The Role of States in Improving the Chain of Survival

Key Points. Over 4 decades, we have made remarkable scientific progress regarding the epidemiology, pathophysiology and treatment of Out-of-Hospital Cardiac Arrest (OHCA).. Key Points. Over 4 decades, we have made remarkable scientific progress regarding the epidemiology, pathophysiology and treat

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CDC Heart Disease and Stroke Prevention Annual Grantee Meeting The Role of States in Improving the Chain of Survival

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    1. CARES is a CDC funded and AHA endorsed program out of Emory University in Atlanta GA.CARES is a CDC funded and AHA endorsed program out of Emory University in Atlanta GA.

    2. Key Points Over 4 decades, we have made remarkable scientific progress regarding the epidemiology, pathophysiology and treatment of Out-of-Hospital Cardiac Arrest (OHCA).

    3. Key Points Over 4 decades, we have made remarkable scientific progress regarding the epidemiology, pathophysiology and treatment of OHCA None of it has made much difference –rates of resuscitation have not improved in 30 yrs

    4. Key Points Over 4 decades, we have made remarkable scientific progress regarding the epidemiology, pathophysiology and treatment of OHCA. None of it has made much difference –rates of resuscitation have not improved in 30 yrs In OHCA, the battle is won or lost on the scene

    5. Key Points Over 4 decades, we have made remarkable scientific progress regarding the epidemiology, pathophysiology and treatment of OHCA None of it has made much difference –rates of resuscitation have not improved in 30 yrs In OHCA, the battle is won or lost on the scene To optimize a victim’s chances, focus on the chain of survival – do it quickly and well.

    6. Key Points Over 4 decades, we have made remarkable scientific progress regarding the epidemiology, pathophysiology and treatment of OHCA None of it has made much difference –rates of resuscitation have not improved in 30 yrs In OHCA, the battle is won or lost on the scene To optimize a victim’s chances, focus on the chain of survival – do it quickly and well. Use data to drive performance

    7. Prehospital Cardiac Care: Belfast, 1966

    12. American Paramedic Programs 1968-1971 Miami Columbus Los Angeles Portland Seattle

    13. Pre-guideline Era: 1968-1973 Variety of EMS systems Variety of training protocols Mostly single-tiered systems Lots of excitement Little science

    14. First CPR & ECC Guidelines: 1974-1979 Standardized EMT and paramedic curricula 911 systems established Emphasis on value of CPR 30 pages, 41 references

    15. Sixth CPR&ECC Guidelines: 2005-present “Back to the basics” Maximize CPR Less emphasis on medications 4 adult algorithms Continued evidence based Continued international

    16. The “Chain of Survival” Concept introduced by the American Heart Association to try to decrease the number of deaths from cardiac arrests in the community. Each link in the chain depends on the successful initiation and completion of the previous links. EARLY ACCESS – early recognition of SCA and activation of EMS. The community is generally pretty goo at early access and notification. Calling 911. EARLY CPR – early bystander CPR has shown to double or triple the chance of survival EARLY DEFIBRILLATION – when combined with early CPR and administered within five minutes can produce survival rates as high as 49-75%. EARLY ADVANCED CARE – delivered by healthcare workers. ***While we have made great strides in the last two links in the chain and much attention and financial resources have been focused on early defibrillation, despite extensive public health campaigns to increase CPR training, Bystander or Citizen CPR rates remain dismally low. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Circulation, Vol 112, No 24, December 13, 2005. Cummmins RO, Hazinski MF. Cardiopulmonary Resuscitation Techniques and Instruction: When does Evidence Justify Revision?. Ann Emerg Med, Vol 34(6). December 1999. 780-784. Concept introduced by the American Heart Association to try to decrease the number of deaths from cardiac arrests in the community. Each link in the chain depends on the successful initiation and completion of the previous links. EARLY ACCESS – early recognition of SCA and activation of EMS. The community is generally pretty goo at early access and notification. Calling 911. EARLY CPR – early bystander CPR has shown to double or triple the chance of survival EARLY DEFIBRILLATION – when combined with early CPR and administered within five minutes can produce survival rates as high as 49-75%. EARLY ADVANCED CARE – delivered by healthcare workers. ***While we have made great strides in the last two links in the chain and much attention and financial resources have been focused on early defibrillation, despite extensive public health campaigns to increase CPR training, Bystander or Citizen CPR rates remain dismally low. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Circulation, Vol 112, No 24, December 13, 2005. Cummmins RO, Hazinski MF. Cardiopulmonary Resuscitation Techniques and Instruction: When does Evidence Justify Revision?. Ann Emerg Med, Vol 34(6). December 1999. 780-784.

    17. Concept introduced by the American Heart Association to try to decrease the number of deaths from cardiac arrests in the community. Each link in the chain depends on the successful initiation and completion of the previous links. EARLY ACCESS – early recognition of SCA and activation of EMS. The community is generally pretty goo at early access and notification. Calling 911. EARLY CPR – early bystander CPR has shown to double or triple the chance of survival EARLY DEFIBRILLATION – when combined with early CPR and administered within five minutes can produce survival rates as high as 49-75%. EARLY ADVANCED CARE – delivered by healthcare workers. ***While we have made great strides in the last two links in the chain and much attention and financial resources have been focused on early defibrillation, despite extensive public health campaigns to increase CPR training, Bystander or Citizen CPR rates remain dismally low. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Circulation, Vol 112, No 24, December 13, 2005. Cummmins RO, Hazinski MF. Cardiopulmonary Resuscitation Techniques and Instruction: When does Evidence Justify Revision?. Ann Emerg Med, Vol 34(6). December 1999. 780-784. Concept introduced by the American Heart Association to try to decrease the number of deaths from cardiac arrests in the community. Each link in the chain depends on the successful initiation and completion of the previous links. EARLY ACCESS – early recognition of SCA and activation of EMS. The community is generally pretty goo at early access and notification. Calling 911. EARLY CPR – early bystander CPR has shown to double or triple the chance of survival EARLY DEFIBRILLATION – when combined with early CPR and administered within five minutes can produce survival rates as high as 49-75%. EARLY ADVANCED CARE – delivered by healthcare workers. ***While we have made great strides in the last two links in the chain and much attention and financial resources have been focused on early defibrillation, despite extensive public health campaigns to increase CPR training, Bystander or Citizen CPR rates remain dismally low. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Circulation, Vol 112, No 24, December 13, 2005. Cummmins RO, Hazinski MF. Cardiopulmonary Resuscitation Techniques and Instruction: When does Evidence Justify Revision?. Ann Emerg Med, Vol 34(6). December 1999. 780-784.

    18. “Early Access” 9-1-1 Enhanced 9-1-1 Cell phones “Call First – Call Fast” Automatic notification

    19. Concept introduced by the American Heart Association to try to decrease the number of deaths from cardiac arrests in the community. Each link in the chain depends on the successful initiation and completion of the previous links. EARLY ACCESS – early recognition of SCA and activation of EMS. The community is generally pretty goo at early access and notification. Calling 911. EARLY CPR – early bystander CPR has shown to double or triple the chance of survival EARLY DEFIBRILLATION – when combined with early CPR and administered within five minutes can produce survival rates as high as 49-75%. EARLY ADVANCED CARE – delivered by healthcare workers. ***While we have made great strides in the last two links in the chain and much attention and financial resources have been focused on early defibrillation, despite extensive public health campaigns to increase CPR training, Bystander or Citizen CPR rates remain dismally low. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Circulation, Vol 112, No 24, December 13, 2005. Cummmins RO, Hazinski MF. Cardiopulmonary Resuscitation Techniques and Instruction: When does Evidence Justify Revision?. Ann Emerg Med, Vol 34(6). December 1999. 780-784. Concept introduced by the American Heart Association to try to decrease the number of deaths from cardiac arrests in the community. Each link in the chain depends on the successful initiation and completion of the previous links. EARLY ACCESS – early recognition of SCA and activation of EMS. The community is generally pretty goo at early access and notification. Calling 911. EARLY CPR – early bystander CPR has shown to double or triple the chance of survival EARLY DEFIBRILLATION – when combined with early CPR and administered within five minutes can produce survival rates as high as 49-75%. EARLY ADVANCED CARE – delivered by healthcare workers. ***While we have made great strides in the last two links in the chain and much attention and financial resources have been focused on early defibrillation, despite extensive public health campaigns to increase CPR training, Bystander or Citizen CPR rates remain dismally low. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Circulation, Vol 112, No 24, December 13, 2005. Cummmins RO, Hazinski MF. Cardiopulmonary Resuscitation Techniques and Instruction: When does Evidence Justify Revision?. Ann Emerg Med, Vol 34(6). December 1999. 780-784.

    20. 1950’s – Safar and Elam describe mouth-to-mouth ventilation 1960’s – Kouwenhoven notes that forceful chest compressions produce arterial pulses Safar combines the techniques - CPR is born 1966 – First conference on CPR CPR has not been around that long. It wasn’t recognized as a resuscitation technique until the 1960s and the 1st set of ACLS guidelines that we are familiar with weren’t developed until the 1980’s. The major shift has been towards stressing evidence based guidelines which started with the 2000 updates and continued through the 2005. 2005 – Major theme is simplifying CPR (One compression to ventilation ratio). CPR before defibrillation in prolonged arrests. One shock and immediate CPR. CPR has not been around that long. It wasn’t recognized as a resuscitation technique until the 1960s and the 1st set of ACLS guidelines that we are familiar with weren’t developed until the 1980’s. The major shift has been towards stressing evidence based guidelines which started with the 2000 updates and continued through the 2005. 2005 – Major theme is simplifying CPR (One compression to ventilation ratio). CPR before defibrillation in prolonged arrests. One shock and immediate CPR.

    21. Does it make a difference? Delaying CPR for >10 min renders defibrillation ineffective (Valenzuela 1997) Bystander CPR triples the odds of survival and halves the risk of brain death (Herlitz 1994) Early CPR improved survival in 16 of 17 studies (odds ratios ranged from 1.9-11.5) (Cummins 1990) Not only is it effective, there is a measurable difference between the outcomes of patients receiving early vs late CPR. (Early CPR is defined as within 4 minutes from collapse). Considering most EMS systems do not have 4 min arrival times, this stresses the need for bystander CPR even more. ****It is believed that CPR slows the dying process and may keep patients in V fib longer. Studies have shown that patients receiving early CPR are found in V Fib at a greater percentage than those who did not…..thus they also have a higher successful defibrillation rate and survival rate. Valenzuela TD, Roe DJ, Cretin S, Spaite D, Larsen MP. Estimating Effectiveness of Cardiac Arrest Interventions: A logistic Regression of Survival Model. Circulation. Vol 96(10) Nov 18, 1997. pp3308-3313. Herlitz J, Engdahl J, Svensson L, Anquist KA, Young M, Holmberg S. Factors Associated with an increased chance of survival among patients suffering from an out of hospital cardiac arrest in a national perspective in Sweden. American Heart Journal, Vol 149(1), January 2005, p61-66. Cummins RO et al. Improving Survival from Sudden Cardiac Arrest: The “Chain of Survival” Concept. Oct 17, 1990. ***Odds ratio is not a simple ratio of survival. It is calculated as the odds of surviving with bystander CPR (Number discharged alive divided by the number who died) divided by the odds of discharge alive for people who received late CPR (number discharged alive divided by the number who die).Not only is it effective, there is a measurable difference between the outcomes of patients receiving early vs late CPR. (Early CPR is defined as within 4 minutes from collapse). Considering most EMS systems do not have 4 min arrival times, this stresses the need for bystander CPR even more. ****It is believed that CPR slows the dying process and may keep patients in V fib longer. Studies have shown that patients receiving early CPR are found in V Fib at a greater percentage than those who did not…..thus they also have a higher successful defibrillation rate and survival rate. Valenzuela TD, Roe DJ, Cretin S, Spaite D, Larsen MP. Estimating Effectiveness of Cardiac Arrest Interventions: A logistic Regression of Survival Model. Circulation. Vol 96(10) Nov 18, 1997. pp3308-3313. Herlitz J, Engdahl J, Svensson L, Anquist KA, Young M, Holmberg S. Factors Associated with an increased chance of survival among patients suffering from an out of hospital cardiac arrest in a national perspective in Sweden. American Heart Journal, Vol 149(1), January 2005, p61-66. Cummins RO et al. Improving Survival from Sudden Cardiac Arrest: The “Chain of Survival” Concept. Oct 17, 1990. ***Odds ratio is not a simple ratio of survival. It is calculated as the odds of surviving with bystander CPR (Number discharged alive divided by the number who died) divided by the odds of discharge alive for people who received late CPR (number discharged alive divided by the number who die).

    22. If it works, why don’t people do it more often? Despite widespread knowledge of benefit, rates of bystander CPR are abysmally low in most communities The importance of bystander CPR is critical in maintaining an intact chain of survival. Yet despite concerted public health efforts, this widely accessible and inexpensive intervention remains shockingly low. Atlanta – around 15%The importance of bystander CPR is critical in maintaining an intact chain of survival. Yet despite concerted public health efforts, this widely accessible and inexpensive intervention remains shockingly low. Atlanta – around 15%

    23. Why don’t more people do CPR? Too complicated Too costly Too time consuming Too embarrassing Too scary Too icky Too easily forgotten Each successive revision of the guidelines since the trend towards EBM has stressed simplifying CPR for the lay person. 1 in 4 times a rescuer will check for breathing or a pulse, their evaluation will be wrong. This can be deadly for patients who do not have a pulse but the rescuer thinks he/she feels one. - 10% of time rescuers will feel a pulse when one is absent. - 40% of time rescuers will not feel a pulse when one is present. - 12% of time rescuers will say breathing is present when it is not. - 25% of time rescuers will say breathing is absent when it is present. 1) Cummins RO, Hazinski MF. Cardiopulmonary Resuscitation Techniques and Instruction: When does evidence justify Revision? Annals of Emerg Medicine Vol 34(6), December 1999, pp780-784.Each successive revision of the guidelines since the trend towards EBM has stressed simplifying CPR for the lay person. 1 in 4 times a rescuer will check for breathing or a pulse, their evaluation will be wrong. This can be deadly for patients who do not have a pulse but the rescuer thinks he/she feels one. - 10% of time rescuers will feel a pulse when one is absent. - 40% of time rescuers will not feel a pulse when one is present. - 12% of time rescuers will say breathing is present when it is not. - 25% of time rescuers will say breathing is absent when it is present. 1) Cummins RO, Hazinski MF. Cardiopulmonary Resuscitation Techniques and Instruction: When does evidence justify Revision? Annals of Emerg Medicine Vol 34(6), December 1999, pp780-784.

    24. We aren’t training the right people The average victim of OHCA is: Older: 65-73 (M/F) 75% are men 77% of events occur at home Victims often less educated / non professionals But most CPR courses are given to young, well-educated adults In one survey of people trained in CPR, only 7% lived with someone known to have heart disease. The target group should be people living with potential SCA victims 1) Cummins RO et al. Improving Survival from Sudden Cardiac Arrest: The “Chain of Survival” Concept. Oct 17, 1990.In one survey of people trained in CPR, only 7% lived with someone known to have heart disease. The target group should be people living with potential SCA victims 1) Cummins RO et al. Improving Survival from Sudden Cardiac Arrest: The “Chain of Survival” Concept. Oct 17, 1990.

    25. Dispatcher-Assisted CPR First implemented in King County, WA Subsequently replicated in Memphis TN Programs now widespread

    26. Video Self-Instruction (VSI) CPR Training Concept pioneered by Braslow and Brennan Inexpensive & fast (< 30 minutes) More hands-on practice than 4 hour course First validation studies conducted at Emory, 1998 & 1999, but ignored for 6 years VSI produced CPR of comparable quality to that achieved by the AHA’s 4-hour “Heartsaver” course “CPR Anytime” rolled out by AHA in 2005 Initial study involved med students and follow-up study involved population from an African American Church. The video CPR group and the control group (4 hour Heartsaver course) performed comparably when tested by observation and a recording manikin. Important to note that both groups had poor CPR skills but there was no difference among the groups. Todd KH, Heron SL, Thompson M, Dennis R, O’Conner J, Kellermann AL. Simple CPR: a Randomized, Controlled Trial of Video Self Instructional Cardiopulmonary Training in an African American Church Congregation. Annals of Emergency Medicine, Vol 34:6, Dec 1999, pp730-737. 1) Cummins RO, Hazinski MF. Cardiopulmonary Resuscitation Techniques and Instruction: When does evidence justify Revision? Annals of Emerg Medicine Vol 34(6), December 1999, pp780-784. Initial study involved med students and follow-up study involved population from an African American Church. The video CPR group and the control group (4 hour Heartsaver course) performed comparably when tested by observation and a recording manikin. Important to note that both groups had poor CPR skills but there was no difference among the groups. Todd KH, Heron SL, Thompson M, Dennis R, O’Conner J, Kellermann AL. Simple CPR: a Randomized, Controlled Trial of Video Self Instructional Cardiopulmonary Training in an African American Church Congregation. Annals of Emergency Medicine, Vol 34:6, Dec 1999, pp730-737. 1) Cummins RO, Hazinski MF. Cardiopulmonary Resuscitation Techniques and Instruction: When does evidence justify Revision? Annals of Emerg Medicine Vol 34(6), December 1999, pp780-784.

    27. Have a question about CPR?

    28. CPR Truths Any CPR better than no CPR. Doing CPR well is considerably better than doing it poorly.

    29. 2005 ECC Guidelines: CPR is Back! “Push hard, push fast” CPR “density”: Initial defib sequence changed from 3 “stacked” shocks to 1 shock, followed by immediate CPR Provide continuous CPR Minimize pulse checks (once every 5 cycles) Optimize the timing of defibrillation If arrest unwitnessed, or time from collapse to EMS arrival exceeds 4 minutes, perform CPR for 5 cycles (2 minutes) prior to defibrillation

    30. 2005 Guidelines – Resp. Rate 8 - 10 breaths per minute (one breath every 6 – 7 seconds!) Recommend devices to time appropriate rates Early use of a transport ventilator, or switch to a mechanical ventilator Minimize respiratory acidosis and alkalosis

    31. Should lay rescuers even attempt rescue breathing? “Why is it that every time I press on his chest he opens his eyes, and every time I stop to breathe for him he goes back to sleep?”

    32. Cardiocerebral resuscitation (CCR) Also known as “hands-only” CPR Continuous-compression CPR without mouth-to-mouth breathing in adults Time required to deliver breaths detracts from compressions, which perfuse the coronaries Animal models and some human data show improved rates of survival vs. traditional CPR

    33. Concept introduced by the American Heart Association to try to decrease the number of deaths from cardiac arrests in the community. Each link in the chain depends on the successful initiation and completion of the previous links. EARLY ACCESS – early recognition of SCA and activation of EMS. The community is generally pretty goo at early access and notification. Calling 911. EARLY CPR – early bystander CPR has shown to double or triple the chance of survival EARLY DEFIBRILLATION – when combined with early CPR and administered within five minutes can produce survival rates as high as 49-75%. EARLY ADVANCED CARE – delivered by healthcare workers. ***While we have made great strides in the last two links in the chain and much attention and financial resources have been focused on early defibrillation, despite extensive public health campaigns to increase CPR training, Bystander or Citizen CPR rates remain dismally low. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Circulation, Vol 112, No 24, December 13, 2005. Cummmins RO, Hazinski MF. Cardiopulmonary Resuscitation Techniques and Instruction: When does Evidence Justify Revision?. Ann Emerg Med, Vol 34(6). December 1999. 780-784. Concept introduced by the American Heart Association to try to decrease the number of deaths from cardiac arrests in the community. Each link in the chain depends on the successful initiation and completion of the previous links. EARLY ACCESS – early recognition of SCA and activation of EMS. The community is generally pretty goo at early access and notification. Calling 911. EARLY CPR – early bystander CPR has shown to double or triple the chance of survival EARLY DEFIBRILLATION – when combined with early CPR and administered within five minutes can produce survival rates as high as 49-75%. EARLY ADVANCED CARE – delivered by healthcare workers. ***While we have made great strides in the last two links in the chain and much attention and financial resources have been focused on early defibrillation, despite extensive public health campaigns to increase CPR training, Bystander or Citizen CPR rates remain dismally low. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Circulation, Vol 112, No 24, December 13, 2005. Cummmins RO, Hazinski MF. Cardiopulmonary Resuscitation Techniques and Instruction: When does Evidence Justify Revision?. Ann Emerg Med, Vol 34(6). December 1999. 780-784.

    35. So what have we learned in the past 40 years?

    36. Pathophysiology Most victims have underlying coronary artery disease Most have symptoms before collapse The incidence of VF is steadily declining

    38. Patient Characteristics Associated with Survival Witnessed collapse Public location Rhythm VF or VT Few/no co-morbid conditions Socioeconomic status

    39. Program Characteristics Associated with Survival Tiered EMS systems Bystander CPR Fast EMS response times Public access defibrillation Quality EMS care (?) Medical control(?)

    40. Time Matters 1,000 witnessed cardiac arrests, 1976-78 Time to CPR <4 min and time to definitive care <8 min: 43% survival Time to CPR >8 min and time to definitive care >8 min: 3% survival

    41. OHCA is a Prehospital Disease For every minute that defibrillation is delayed, the chances of surviving sudden cardiac arrest (SCA) are reduced by approximately 10%. Survival chances drop particularly fast in the first five minutes. Since rapid time to defibrillation is so critical, expanding the number of early defibrillator responders offers SCA patients a real chance to survive an otherwise lethal event. In fact, by extending defibrillation skill using AEDs to more responders, survival rates have increased dramatically in some settings; e.g.: 40% survival-to-hospital-discharge (neurologically intact) in Rochester, MN with police first responders (White RD. Resuscitation 1998). 70% survival-to-hospital-discharge in Nevada casinos (Valenzuela TD Acad Emerg Med 1998). 80% survival-to-discharge in the Chicago Airport System, compared to a 3.5% save rate in Chicago with a paramedic response (USA Today, December 28, 1999). For every minute that defibrillation is delayed, the chances of surviving sudden cardiac arrest (SCA) are reduced by approximately 10%. Survival chances drop particularly fast in the first five minutes. Since rapid time to defibrillation is so critical, expanding the number of early defibrillator responders offers SCA patients a real chance to survive an otherwise lethal event. In fact, by extending defibrillation skill using AEDs to more responders, survival rates have increased dramatically in some settings; e.g.: 40% survival-to-hospital-discharge (neurologically intact) in Rochester, MN with police first responders (White RD. Resuscitation 1998). 70% survival-to-hospital-discharge in Nevada casinos (Valenzuela TD Acad Emerg Med 1998). 80% survival-to-discharge in the Chicago Airport System, compared to a 3.5% save rate in Chicago with a paramedic response (USA Today, December 28, 1999).

    42. Have Survival Rates Improved? Over the past 30 years, aggregate rates of survival (all rhythms) to discharge have been remarkably consistent – about 7.5 – 8.0% Huge city-by-city variability exists

    43. Community Rates Vary Widely 23 year survey, 35 communities, 35,000 OHCA events, 62 million person-years of observation All-rhythm survival: 1.8% to 21.8% (average: 8.4%) VF survival: 3.3% to 40.5% (average: 17.7%)

    44. More recently data was published in JAMA from ROC cardiac arrest registry. ROC is a large 100 million plus dollar clinical trial consisting of sites across the US and Canada). Looking at a years worth of data, they found that there were significant disparities in survival outcomes ranging anywhere from 8-40% for those patients with a first arrest rhythm of vifb. They also found that only about 1/3 of the time bystanders are performing CPR. Even though these sites covered large geographic regions, considering they were selected based on a rigorous, competitive process of high performing EMS systems – the findings are surprising. The authors conclude: “In this study involving 10 geographic regions in North American, there were significant and important regional differences in out of hospital cardiac arrest incidence and outcomes”. More recently data was published in JAMA from ROC cardiac arrest registry. ROC is a large 100 million plus dollar clinical trial consisting of sites across the US and Canada). Looking at a years worth of data, they found that there were significant disparities in survival outcomes ranging anywhere from 8-40% for those patients with a first arrest rhythm of vifb. They also found that only about 1/3 of the time bystanders are performing CPR. Even though these sites covered large geographic regions, considering they were selected based on a rigorous, competitive process of high performing EMS systems – the findings are surprising. The authors conclude: “In this study involving 10 geographic regions in North American, there were significant and important regional differences in out of hospital cardiac arrest incidence and outcomes”.

    45. Can we do better?

    46. Domino’s vs. EMS Hungry? 30 minutes call-to door guaranteed. Customer input for QI Cost: $9.95 (plus tip) Cardiac Arrest? Call-to-door time rarely tracked No performance metrics, no QI Cost: Priceless

    47. “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.” - Bob Davis, “Six Minutes to Live” USA Today, 2003

    48. You can’t manage what you can’t measure!

    49. Institute of Medicine Report on EMS “What is missing is a standard set of measures that can be used to assess the performance of the emergency and trauma care system within each community, as well as the ability to benchmark that performance against statewide and national performance metrics.”

    51. CARES Allows communities to determine OHCA outcomes & identify high risk groups and neighborhoods Enables clinical benchmarking to identify opportunities for improvement and track the diffusion of new therapies Promotes accountability to improve the quality and impact of prehospital care

    53. Cardiac Arrest is a leading cause of death More deaths result from SCD than AIDS, breast cancer and lung cancer combined The CDC was interested in looking at cardiac arrest due to the significant burden of disease. It is estimated that anywhere from 250-400,000 people die of cardiac arrest ever year – which as you can see here is more people than aids, breast cancer and lung cancer combined. Of course the number of deaths related to SCD are estimates at best because currently there is no uniform national data collection system nationally. The CDC was interested in looking at cardiac arrest due to the significant burden of disease. It is estimated that anywhere from 250-400,000 people die of cardiac arrest ever year – which as you can see here is more people than aids, breast cancer and lung cancer combined. Of course the number of deaths related to SCD are estimates at best because currently there is no uniform national data collection system nationally.

    54. The next logical question to ask is what is causing this variation in survival. One factor could be of course the way the data is being collected – different data elements, different definitions, etc. However, more likely this has to due with both the professional and community level response to cardiac arrest. Successful resuscitation depends on rapid performance of four critical actions: early access to 911, rapid provision of cardiopulmonary resuscitation (CPR), immediate defibrillation of pts found in a shockable rhythm, and prompt access to definitive care. These elements are known to be so important that AHA has coined it as ‘the chain of survival’. And it is the range in timeliness and quality of the links in the chain of survival that create the wide variation in survival rates. The next logical question to ask is what is causing this variation in survival. One factor could be of course the way the data is being collected – different data elements, different definitions, etc. However, more likely this has to due with both the professional and community level response to cardiac arrest. Successful resuscitation depends on rapid performance of four critical actions: early access to 911, rapid provision of cardiopulmonary resuscitation (CPR), immediate defibrillation of pts found in a shockable rhythm, and prompt access to definitive care. These elements are known to be so important that AHA has coined it as ‘the chain of survival’. And it is the range in timeliness and quality of the links in the chain of survival that create the wide variation in survival rates.

    55. So all of this has really been supporting the need for a national registry and this is where CARES comes in to play. Data collection into a registry at the regional, state, or national level enables providers or EMS systems to benchmark their outcomes and results with other communities. Collecting data into a registry allows for the identification of strengths and weaknesses to improve the system of care. So all of this has really been supporting the need for a national registry and this is where CARES comes in to play. Data collection into a registry at the regional, state, or national level enables providers or EMS systems to benchmark their outcomes and results with other communities. Collecting data into a registry allows for the identification of strengths and weaknesses to improve the system of care.

    59. Since hospital outcomes are critical in determining survival from out of hospital cardiac arrest, CARES asks for voluntary participation from every hospital where an EMS agency transports cardiac arrest patients. A CARES contact is identified at each participating hospital who is responsible for entering outcomes for pts transported to their hospital. A CARES event is initiated by EMS personnel. When it is indicated on an EMS dataset that the arrest is of ‘presumed cardiac etiology’, resuscitation is attempted by EMS, and there is ongoing resuscitation in the ED, the CARES software generates a generic email to the hospital contact at the receiving facility saying a pt has been transported to their facility. When it is convenient for the hospital contact – perhaps once every two weeks or a month (depending on the call volume) the hospital contact can log-in and complete the outcomes for pending pts. The hospital dataset consists of 4 simple questions and only takes a few minutes to complete. Once a CARES event is complete the record is scrubbed of all pt identifiers. We do ask that the CARES data use agreement is signed by a supervisor at each hospital to ensure confidentiality of data exchange.Since hospital outcomes are critical in determining survival from out of hospital cardiac arrest, CARES asks for voluntary participation from every hospital where an EMS agency transports cardiac arrest patients. A CARES contact is identified at each participating hospital who is responsible for entering outcomes for pts transported to their hospital. A CARES event is initiated by EMS personnel. When it is indicated on an EMS dataset that the arrest is of ‘presumed cardiac etiology’, resuscitation is attempted by EMS, and there is ongoing resuscitation in the ED, the CARES software generates a generic email to the hospital contact at the receiving facility saying a pt has been transported to their facility. When it is convenient for the hospital contact – perhaps once every two weeks or a month (depending on the call volume) the hospital contact can log-in and complete the outcomes for pending pts. The hospital dataset consists of 4 simple questions and only takes a few minutes to complete. Once a CARES event is complete the record is scrubbed of all pt identifiers. We do ask that the CARES data use agreement is signed by a supervisor at each hospital to ensure confidentiality of data exchange.

    60. Since hospital outcomes are critical in determining survival from out of hospital cardiac arrest, CARES asks for voluntary participation from every hospital where an EMS agency transports cardiac arrest patients. A CARES contact is identified at each participating hospital who is responsible for entering outcomes for pts transported to their hospital. A CARES event is initiated by EMS personnel. When it is indicated on an EMS dataset that the arrest is of ‘presumed cardiac etiology’, resuscitation is attempted by EMS, and there is ongoing resuscitation in the ED, the CARES software generates a generic email to the hospital contact at the receiving facility saying a pt has been transported to their facility. When it is convenient for the hospital contact – perhaps once every two weeks or a month (depending on the call volume) the hospital contact can log-in and complete the outcomes for pending pts. The hospital dataset consists of 4 simple questions and only takes a few minutes to complete. Once a CARES event is complete the record is scrubbed of all pt identifiers. We do ask that the CARES data use agreement is signed by a supervisor at each hospital to ensure confidentiality of data exchange.Since hospital outcomes are critical in determining survival from out of hospital cardiac arrest, CARES asks for voluntary participation from every hospital where an EMS agency transports cardiac arrest patients. A CARES contact is identified at each participating hospital who is responsible for entering outcomes for pts transported to their hospital. A CARES event is initiated by EMS personnel. When it is indicated on an EMS dataset that the arrest is of ‘presumed cardiac etiology’, resuscitation is attempted by EMS, and there is ongoing resuscitation in the ED, the CARES software generates a generic email to the hospital contact at the receiving facility saying a pt has been transported to their facility. When it is convenient for the hospital contact – perhaps once every two weeks or a month (depending on the call volume) the hospital contact can log-in and complete the outcomes for pending pts. The hospital dataset consists of 4 simple questions and only takes a few minutes to complete. Once a CARES event is complete the record is scrubbed of all pt identifiers. We do ask that the CARES data use agreement is signed by a supervisor at each hospital to ensure confidentiality of data exchange.

    68. In OHCA, lives are saved or lost in the field We have learned a great deal about OHCA, but we have failed to translate this knowledge into better treatment & outcomes Widespread disparities persist We need to refocus on the “chain of survival” Use data to drive performance!

    69. Acknowledgements Arthur Kellermann, MD, MPH Assistant Dean and Professor of Emergency Medicine and Health Policy Emory University School of Medicine Mickey Eisenberg, MD, PhD Professor of Medicine University of Washington School of Medicine

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