A Systematic Approach to EMS

Cardiac Arrest Management

Improves Survival for Out of
Hospital Cardiac Arrest
Angelo Salvucci, MD, FACEP
Contributing Authors

AMR Medicine: Santa Barbara County EMS:

•Lynn White, MS •Jennie Simon, RN
•Les Hugie, EMT-P
Ventura County EMS: •Alexia Armenta, BS
•Chad Panke, EMT-P •Gregory Shinn, BS
•Katy Hadduck, RN
•David Chase, MD
Presenter Disclosure Information

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 Santa Barbara Co.
• 440,000
Ventura Co.
• 5 Hospitals •840,000
• 2 SRCs •8 Hospitals
•3 SRCs
EMS:
•MPDS EMD
•BLS & ALS FD FR
•ALS Ambulance
•ROSC to SRC: TTM & PCI
Presentation Slide Title
New York Times; December 7, 2015

“My fear is that they won’t make much of a

difference. You have this information in
the ether, but there’s no point if people
aren’t doing it to patients.”

Sam Parnia, MD
Director, Resuscitation Research
Stony Brook Hospital
“WHAT”

VS

“HOW”
OHCA Survival 1980-2008

Sasson C et al. Circ Cardiovasc Qual Outcomes 2010;3:63-81

 Disparities

• ROC: 12,000, OHCAs 10 systems

• Overall survival 3.0% - 16.3%, median 8.4%
• VF survival 7.7% - 39.9%, median 22.0%
• Increase from median to max would prevent 15,000 deaths
Nichol: JAMA. 2008;300(12):1423-1431.

Sanders: JAMA. 2008;300(12):1462-1463.

Objective

To determine if a comprehensive
system of education, training,
treatment protocols and quality
improvement would affect survival
of patients in sudden cardiac arrest.
Cardiac Arrest Management (CAM)
System of care:
•Commitment of all participants
•Evidence-based treatment protocols
– 10:1 compression/ventilation w/o pause
– BLS airway preferred
•Targeted, goal-directed education
– 60 minutes didactic
– Teamwork, Positioning, CPR (CC, BMV), ALS, ROSC
•Individual and team training: 120 minutes
– Mandatory minimum proficiency thresholds
– Organized explicit system of rescuer roles
•QI program with process and outcome measures
 Process
• Multidisciplinary Development Committee
• All EMTs and Paramedics in the EMS system were
trained
– Santa Barbara: December 2012
– Ventura County: December 2013
• Cardiac Arrest Registry to Enhance Survival (CARES)
utilized for data management and comparison.
• Patient populations studied:
– All cardiac arrests of presumed cardiac etiology
– Bystander-witnessed cardiac arrest with shockable first
rhythm
Goal

To maximize the number of

cardiac arrest patients that
return home to their families
neurologically intact
Strategies
HOW TO ACHIEVE THE GOAL:
1.Assigned roles
2.Rapid and accurate assessment
3.Adequate work space
4.Continuous high quality chest compressions
5.Airway with synchronized ventilations
6.Prompt defibrillation
7.ALS: Vascular access with medications
8.Resuscitation Management & Teamwork
9.Recognition of ROSC
Back to Basics
 Cornerstones of treatment:
◦ Assessment
◦ Patient Positioning
◦ CPR
 Continuous Chest Compressions
 Airway/Ventilation/Oxygenation
◦ Defibrillation

 Possible, but unproven value:

◦ Intubation
◦ Vascular access (IV/IO)
◦ Pressors (epinephrine)
◦ Antiarrhythmics (lidocaine, amiodarone)
Strategy #4

Continuous High Quality Chest Compressions

• Rate 112/Minute (metronome)

• Depth 2-2.5 Inches
• Full Chest Recoil

o Increases likelihood of successful defibrillation

o Maintains brain viability
Competency-Based Training
Process Measures QI
RESULTS
Cardiac Etiology – All Rhythms
Survival to Hospital Discharge (%)
National CARES Santa Barbara County

p=0.002

2012 2013
Bystander-Witnessed Shockable 1st Rhythm
Survival to Hospital Discharge (%)
National CARES Santa Barbara County

P> 0.05

2012 2013
Cardiac Etiology – All Rhythms
Survival to Hospital Discharge (%)

15.8

Post-
8.1 CAM
Pre-
CAM

2011-12 2013-1Q15
Bystander-Witnessed Shockable 1st Rhythm
Survival to Hospital Discharge (%)

45.0

Post-
CAM
25.9
Pre-
CAM
2011-12 2013-1Q15
Cardiac Etiology – All Rhythms
Survival to Hospital Discharge (%)
National CARES Ventura County
CAM
Bystander-Witnessed Shockable 1st Rhythm
Survival to Hospital Discharge (%)
National CARES Ventura County
CAM
Lessons Learned

• Engage entire system.

• Build interest.
• Insist on consistency.
• Will sell itself.
– Process improvements (organization, CPR)
precede outcome benefits.
• Costs are modest.
Conclusions

• Introduction of an organized Cardiac Arrest

Management (CAM) program resulted in a
significant improvement in survival.
• Simultaneous introduction of entire bundle
of care resulted in more convincing single-
step improvement.
Conclusions

• Emphasis on early, continuous, high-quality

chest compressions with infrequent low-
volume ventilations.
• System to enable that:
– Clear and detailed protocols
– Assigned roles
– EMTs responsible for BLS
– Competency-based individual and team training
– Ongoing active data-driven QI
Survivor Group