Improving survival for ‘out of hospital’ cardiac arrest
Cardiac arrest occurs suddenly and often without warning. The opportunity to change the outcome for the patient lies in the actions taken in the first few minutes after collapse. CPR, defibrillation and advanced life support can save lives. Survival from Out of Hospital Cardiac Arrest (OHCA) is regarded as a key marker for the clinical quality of any Emergency Medical Service (EMS). In many countries, including Australia, Fire Fighting personnel support Paramedics to deliver basic life support in time critical situations.
Improvement in survival from OHCA requires a system wide and team based approach from those involved in the delivery of care. This paper is based on an observational study of different EMS systems in the US and personal experience in Victoria Melbourne, where EMS providers have worked together to achieve measurable improvements in survival from OHCA in their communities. They all demonstrate continuous improvement through analysis of their system then structured deliberate changes to their call taking, their training their performance and the system of care for those experiencing OHCA.
The chain of survival describes the key actions that ensure the delivery of care known to give patients the greatest opportunity for survival. There are many factors that contribute to the outcome for each individual, some of these such as age, co morbidities and event factors are out of the control of those providing EMS. The chain of survival with its 5 links of early access, early CPR, early defibrillation, early ALS, and early post resuscitative care highlight the critical factors that are essential for any system to deliver a comprehensive system of care.
It is easy to look at the chain and conceptually understand what needs to be done each step of the way. The difficulty is often linking the steps and supporting each other to work together. The outcome for each patient is linked back to the individual performance of those undertaking each component of care. To achieve the best outcomes in OHCA the organisations that deliver each link in your system must be accountable for the role they play and be committed to work together. Success lies not just in achieving each link within your system of care, but will come from leadership and a culture of excellence. Accountability, quality training and measuring performance in each organisation will drive any organisational change that will improve the system.
Well performing EMS systems around the world are achieving survival rates for unwitnessed OHCA (shockable rhythms) upwards of 60% yet in other locations survival is as less than 10%. How do we know this? Because the first step to improving something is to measure it. Internationally the Utstein template is used to measure and report on OHCA survival. We know that OHCA is a time critical event, therefore measuring the time it takes to respond, to arrive, to provide CPR, to apply the defibrillator etc. will give you a baseline for benchmarking with best practice and will give you a starting point from which you can apply an intervention and measure the difference. Data and measuring performance are key to any improvement in outcomes. Ongoing data capturing will guide system changes and support quality improvement. Training/identifying your own systems and then challenging the system to get better if there are weaknesses in the link is where the real success lies.
There are many differences in EMS systems and communities around the world and driving change can be complex. Those systems that were performing well and who continued to drive performance improvement were those who had leadership which transformed the culture in the organisation. Leadership is crucial to any culture of excellence. The underpinning desire to save a life and do whatever it takes to be the best at saving the life. In those systems where OHCA was considered a survivable event each component of the system linked together and each group within the system was driven to do their part the best. Whether it was the 74% of bystanders doing CPR, or the call taker recognising cardiac arrest and instructing CPR over the phone or the EMS personnel doing CPR, they all believed that could contribute to saving the person’s life. What contributes to outcomes for patients is the actual performance of the call taking staff, the fire personnel, and the paramedics.
For the call taking staff and those performing the resuscitation successful resuscitation will not just come through following a guideline or protocol, but through measuring how you perform, comparing this with what the best looks like, then practicing and continuing to improve your performance.
One of the most valuable tools for improvement is to use objective measured feedback on your performance, compare this to where the current world’s best practice is and then train/practice to strive to be the best. When staff do perform well, feedback and recognition of a job well done are simple measures that drive a culture of ensuring everyone feels part of the team and is accountable for the outcome.
As an organisation in order to be the best you need to believe that OHCA (from shockable rhythm) is a survivable event, this comes from a strong belief in their system, their teams, along with being competitively driven to continue to improve. The only way to improve is to practice what you do.
Dispatcher Aided CPR
The culture of belief needs to start with call takers. A system that includes Dispatcher Aided Resuscitation Training (DART) sets up the system for success from the start. Early CPR (within the first few minutes) is impossible for any EMS agency to provide no matter how good their response times, therefore recognising the cardiac arrest, dispatching an EMS response and instructing someone to perform CPR is crucial to patient outcomes. Recognising cardiac arrest can be quite challenging for the call taker. Coaching, supportive training and ongoing feedback are essential. It’s not just about telling someone to do CPR, but it’s about taking control of a stressful situation over the phone and instructing them (sometimes quite aggressively) to start CPR. Most call centres instruct compression only CPR which is endorsed by the International Liaison Committee on Resuscitation.
CPR and Defibrillation
High quality chest compressions with minimal interruptions and early rapid defibrillation underpin successful resuscitation. Different organisations have tried varying the ratio of ventilations and compressions in their CPR as well as interposing the ventilations and compressions to reduce the time off the chest, however recent published data and has demonstrated no difference in long term outcome. What does make a difference is the quality of performance by the rescuers.
Quality training with immediate feedback allows the rescuer to modify their practice immediately to improve performance. Over time, access to quality equipment and regular training with objective feedback allows the rescuer to refine and improve their performance. There are plenty of devices and manikins to aid quality training as well as devices that provide real time live feedback on compression performance during cardiac arrest. Real time feedback both in regular training and in the operational setting have led to improved performance.
Defibrillation is the 3rd link in the chain of survival. The availability of Automatic External Defibrillators (AEDs) all over the community over the last 10 years now brings this part of the resuscitation into the public domain. Call takers standard questioning is to ask whether there is an AED nearby for all cardiac arrest events. The challenge is not so much how many AEDs you have in your community, but rather how do you integrate their deployment to the patient who needs one? Some systems have integrated this into an AED registry linked with their dispatch system, others make them available on an app where a trained responder (off duty) can be notified if they are within a few hundred meters of a cardiac arrest, to assist with CPR and defibrillation. The system will allow the trained bystander to be notified where the closest AED is available and where to take it to the patient in need. Integrated technology is really challenging the way we engage with our community to drive improvement and that all important response to someone in cardiac arrest.
There is no single magic easy fix to improving survival from OHCA. There are many variables and multiple organisations that are accountable for each component that needs to happen for the patient to survive an OHCA. Frequent training, measuring performance and feedback drove ongoing practice and training to get better.
As a wise person (Dr Michael Sayre) once told me “It takes a system to save a life”. The science behind improving survival from OHCA is not difficult, but it’s not simple. This is an opportunity for you to take a look at the organisation you work in, and think about what you can do from the ground up better to improve the outcome for the people in your community.
For more information, go to www.resuscitationacademy.org