Immediate Action Plan to Improve Community Cardiac Arrest Survival
Following are 5 steps that can lead to dramatic and immediate improvement: Rapid dispatch, aggressive telephone CPR, cardiac arrest registry, community AED programs, voice record all resuscitations.
| Immediate Steps | Difficulty of Implementation |
| Establish a rapid dispatch program | Easy |
| Establish an aggressive telephone CPR program | Easy |
| Establish a cardiac arrest registry | Moderate |
| Establish a community AED program | Moderate |
| Voice record all cardiac resuscitations | Easy |
Table: Immediate steps to improve cardiac arrests survival
1. Establish a rapid dispatch program so the closest EMT staffed vehicle (or police car) starts to roll within seconds of the call while additional information is being obtained. Key words spoken by the caller indicate a critical situation and the dispatcher can send the unit(s) and then update the unit(s) with additional information. Often the EMT vehicle may be sent “rapidly” and while it is in route additional information makes it evident that paramedics are needed as well. But at least valuable seconds are saved so the EMT vehicle can arrive as quickly as humanly possible. EMTs can after all perform CPR and deliver a shock using an AED. Some dispatch protocols are too rigid and require full information before vehicles can be sent. This may be acceptable for the majority of calls, but for critical events speed is of the essence and protocols must be short circuited. In our community we train dispatchers to use rapid dispatch when they hear keys words such as breathing difficulty, unconscious, collapsed, heart attack, or whenever the story sounds critical. Dispatch centers must be flexible enough to allow dispatchers to use common sense and short cut the protocols when necessary.
2. Establish an aggressive dispatcher assisted telephone CPR program. Most dispatch centers claim to have telephone CPR protocols in place but in practice they don’t offer instructions very often. Frankly it is difficult and stressful for dispatchers to insure telephone CPR. Far easier is to merely reassure the caller that help is on the way. But a dispatch center whose culture is to aggressively offer and instruct callers in telephone CPR is a center that is an intimate partner in the chain of survival. This culture can only occur if someone has the responsibility to teach the program and monitor it and watch it like a hawk. Someone has to listen and record information from all the cardiac arrest calls and feed this information back to the individuals and entire staff. An obvious ingredient to successful telephone CPR is training and continuing education. Dispatchers in King County receive 40-hours of initial training on emergency medical dispatching and then are required to complete 8 hours of continuing education annually. Special emphasis is placed on cardiac arrest recognition and delivery of CPR instructions. Dispatchers learn the significance of agonal respirations and how to recognize it. They must offer instructions in the face of agonal respirations since these patients have the highest potential of being successfully resuscitated. When telephone CPR is not offered, why wasn’t it? This would likely require a half-time person (for a community of one million). The data collection form we use for a review of all cardiac arrest calls is found in the appendix.
The director of the dispatch center has to do what is necessary with training and motivation to insure that 50% of the cardiac arrests in the community have dispatcher assisted CPR instructions. This is not an unrealistic target. Like any other culture change it requires someone who takes charge and has the authority and then sets in place the training and expectation and ongoing audit to see that it happens. Once dispatcher realize how vital they are to successful resuscitations and once they see concrete evidence of success they will become the loudest advocates.
3. Establish a cardiac arrest registry. This would likely require a half-time person to gather the data and obtain follow up information from hospitals. It also requires access to all electronic information from arrests in which automated external defibrillators were used. The data collection form for the King County EMS registry is found in the appendix. Combined with the Telephone CPR position there are enough tasks for one full time position – assuming a population of approximately one million. A registry assumes that the EMTs and paramedics are collecting the correct information. An ideal data report form for cardiac arrests is shown in the appendix. This form can be completed electronically or on paper. If the paper version is used one copy is left with the receiving hospital. Electronic versions can be free standing or web based. Some communities use a mixture of paper and electronic reporting. Though the registry should collect information on all cardiac arrests in which care is provided emphasis should be on arrests where VF is the presenting rhythm. The QI person must dissect every VF cardiac arrest and ask how the shock could have been provided quicker. Implicit in a cardiac arrest registry is the assumption that time intervals will be measured accurately. It does no good to fudge on times solely to look good. The most important time intervals are time from collapse to start of CPR and time from collapse to defibrillation. I personally think the down time (time from collapse to calling 911) can be estimated in most instances. If this is not possible the clock should start ticking when the primary alarm center picks up the call. For instances of bystander CPR the onset can arbitrarily be defined as half of the response time. AEDs should be synchronized daily with the alarm center.
A registry without access to hospital information is next to useless. Hospital information is vital to determine if the patient was discharged and to determine the cause of the cardiac arrest. In the HIPAA era hospitals are concerned about releasing patient information to EMS agencies. Yet many states allow this information to be provided as part of EMS medical QI activities. For example, in Washington State this access to information is legally defined.
WA State RCW 70.02.050 -- Disclosure without patient's authorization.
(1) A health care provider may disclose health care information about a patient without the patient's authorization to the extent a recipient needs to know the information, if the disclosure is:
- To any other person who requires health care information for health care education, or to provide planning, quality assurance, peer review, or administrative, legal, financial, or actuarial services to the health care provider;...
4. Establish a community AED program: The concept of public access defibrillation attempts to use community AEDs as part of the resuscitation chain. The PAD (Public Access Defibrillation) Trial was a multicenter trial that demonstrated that sites with AEDs on the premises and staff trained in their use had higher survival rates from VF compared to comparable site with no AEDs (the latter sites relied on the fire department of EMS agency to bring the AED to the scene).(2) AEDs in casinos (3) and airplanes(4) also save lives.
There is an active community AED program in Seattle and King County with over 2000 AEDs registered with the EMS agency as of 2007. Sites with AEDs include the airport, health clubs, jails, community centers, senior centers, shopping malls, office buildings and every other imaginable public place one can think of. The experience of this community effort was reported in Circulation in 2004. Of 50 cardiac arrests over a four-year period (1999-2002) there were 25 survivors. During this time period approximately 500 AEDs had been placed in the community and registered with the EMS program. Over 4000 individuals were trained in AED operation. Among the 50 arrests 42 (84%) were in VF. Thus considering only the VF cases the survival was 25 of 42 or an impressive 60%. The strategy of public AEDs has merit but ones enthusiasm must be tempered by the modest number of cardiac arrests in public locations. Only 15% of all cardiac arrests occur in public setting (approximately 150 of 1000 arrests a year in King County). Since the study was reported the percent of arrests with public AEDs at the scene is up to 4% (representing about 40 arrests a year or 27% of all events in public locations) and the survival remains very high. Though the absolute number is small, still these are great saves. Usually they occur in active people out in the community. And since most collapses in public are witnessed CPR is frequently started quickly. The fact that these arrests have everything going for them - witnessed, VF, rapid CPR, rapid defibrillation, probably less co-morbidity - explains the remarkable survival rate.
Residential centers offer great potential for PAD programs. EMS agencies could provide free training and offer to register the AED with the local dispatch center as incentives. The agency could offer advice on where to place the AED in the facility. Communities or apartments or condominiums could establish an AED security system. In such a system the AED would be placed in a locked box (with all the residents knowing the combination) in a central and accessible location. This location would be registered with the dispatch center and if an arrest occurred in that apartment or condominium someone at the scene would be instructed to get the AED.
Existing computer aided dispatch programs allow dispatch centers to identify AEDs on location (assuming they are registered with the center) as well as those in close proximity. AEDs in the community have the potential to save lives. The challenge is to maximize this potential.
5. Voice record all cardiac resuscitations. Virtually all defibrillators and automated external defibrillators have a digital recording option or attachment. Nothing will get the attention of EMTs and paramedics faster than the fact that the event is being recorded and someone is listening and abstracting information following the event. This someone should be the medical director (for small communities this can easily be done but in large communities this role would likely be delegated, perhaps to the cardiac registry QI person).
Though some EMTs and paramedics may think the information will be used for disciplinary purposes, the goal of the recording is simply to accurately reconstruct the actual events of the resuscitation. Listening to a voice recording and simultaneously seeing the patient’s cardiac rhythm make the event vivid. I have listened to hundreds of recordings and feel as though I am virtually at the scene. You can tell when the AED is attached, when respirations are given, piece together the sequence and timing of events and why delays may have occurred (the dog was growling at the EMT, the patient had to be moved from the bathroom to the hallway, the tank ran out of oxygen, etc). Even though all defibrillators and all AEDs offer a post-event digital readout of the rhythm with timing of shocks, nothing can beat a voice recording of the event. The only thing better might be a video recording of the event, not unlike police cams, and some have suggested this. I find the suggestion problematic for several reasons. Such recording would be overly intrusive, not to mention logistically challenging. It would also be a violation of privacy and only a matter of time before resuscitation videos began appearing on YouTube. But most importantly videos are frankly not needed. The voice recording allows an adequate reconstruction of events.
The voice and ECG recording provides the raw data that allow for a reconstruction of the event. If the medical director summarized and fed this information back to the EMTs and paramedics, I guarantee that resuscitations would become as good as they can be. In King County we have analyzed thousands of voice and ECG recordings and have never used them for any disciplinary action. Since the tapes are part of our formal registry and QI program they are protected from public disclosure. (See Data Collection Forms)
The above 5 steps will lead to an increase in cardiac arrest survival -- not guaranteed but likely. They are quick fixes, easily accomplished, and likely to achieve positive results within a year. Most importantly they require minimal resources -- perhaps a full time equivalent program manager or quality improvement person. The steps also require support, buy-in and ongoing commitment by the dispatch director, the EMS administrative director, and the medical director.