Transcript A Systematic Approach to EMS Cardiac Arrest Management

A Systematic Approach to EMS
Cardiac Arrest Management
Improves Survival for Out of
Hospital Cardiac Arrest
Angelo Salvucci, MD, FACEP
Contributing Authors
AMR Medicine:
• Lynn White, MS
Ventura County EMS:
• Chad Panke, EMT-P
• Katy Hadduck, RN
• David Chase, MD
Santa Barbara County EMS:
• Jennie Simon, RN
• Les Hugie, EMT-P
• Alexia Armenta, BS
• Gregory Shinn, BS
Presenter Disclosure Information
FINANCIAL DISCLOSURE:
 None
UNLABELED/UNAPPROVED USES
DISCLOSURE:
 None
Santa Barbara Co.
• 440,000
• 5 Hospitals
• 2 SRCs
EMS:
• MPDS EMD
• BLS & ALS FD FR
• ALS Ambulance
• ROSC to SRC: TTM & PCI
Ventura Co.
• 840,000
• 8 Hospitals
• 3 SRCs
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.
2.
3.
4.
5.
6.
7.
8.
9.
Assigned roles
Rapid and accurate assessment
Adequate work space
Continuous high quality chest compressions
Airway with synchronized ventilations
Prompt defibrillation
ALS: Vascular access with medications
Resuscitation Management & Teamwork
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
8.1
PreCAM
2011-12
PostCAM
2013-1Q15
Bystander-Witnessed Shockable 1st Rhythm
Survival to Hospital Discharge (%)
45.0
25.9
PostCAM
PreCAM
2011-12
2013-1Q15
Cardiac Etiology – All Rhythms
Survival to Hospital Discharge (%)
National CARES
2008
2009
Ventura County
2010
2011
2012
CAM
2013
2014
Bystander-Witnessed Shockable 1st Rhythm
Survival to Hospital Discharge (%)
National CARES
2008
2009
Ventura County
2010
2011
2012
CAM
2013
2014
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 singlestep improvement.
Conclusions
• Emphasis on early, continuous, high-quality
chest compressions with infrequent lowvolume 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