SCA: 25 Steps to Ending Survival Envy

Perhaps you live in a community where the sudden cardiac arrest survival rate is especially modest. Maybe you look with envy at places like Rochester, MN, where, over 13 years, an impressive 46% of those experiencing witnessed ventricular fibrillations ultimately lived to hospital discharge, or in King Co., WA, where the survival rate from cardiac arrest in King County has reached an all-time high of 57%. You might despair that your jurisdiction will never savor such success, even among the witnessed v-fib subset of cardiac arresters most amenable to saving.

Maybe, maybe not. But you can do better than you do now, and one of the architects of King County's success wants to tell you how.

In his book, Resuscitate! How Your Community Can Improve Survival From Sudden Cardiac Arrest, King County EMS Medical Director Mickey Eisenberg, MD, PhD, articulates 25 steps to take that will help communities improve their cardiac arrest survival rates.

"The goal was to give concrete suggestions, rather than nice-sounding platitudes," says Eisenberg, a professor of medicine at the University of Washington. "I figured if I were the manager of an EMS system, I'd want practical suggestions, not abstract theory about why some communities succeed and others don't."

The resulting measures are indeed concrete, but come with an important caveat: Communities can only proceed in the context of their own resources, systems, circumstances and cultures. There are no one-size-fits-all answers or templates by which to apply them, and individual jurisdictions may not be able to achieve everything on the list.

Fortunately, they don't have to. Even one or two motivated leaders attacking one or two challenges, Eisenberg says, can yield an important difference in outcomes.

"Whatever your role in your EMS system," he writes in Chapter 10, "you can take or contribute to some relatively resource-light actions that are likely to raise your community's survival rate for cardiac arrest."

DO NOW

Easiest among those are the first five steps Eisenberg outlines, which can be done immediately and without much difficulty. These are:

1) Establish rapid dispatch--Get the closest EMT vehicles to 9-1-1 calls en route, even as the dispatcher gathers further information.

2) Dispatcher CPR instructions--It's important to give them, but don't stop there. Audit calls and provide feedback. "You have to listen to every cardiac arrest tape--those where instructions were given and those where they weren't," Eisenberg says. "If they weren't given, is there a teaching point to make it possible next time? If they were done, were they done properly? Were there delays you can reduce? Unless you scrutinize the dispatch aspect of the cardiac arrest as well as the run report, you're not doing a complete job."

3) Develop a community cardiac arrest registry--Collect information on all cardiac arrests, but pay special attention to VF cases. How can first shocks be delivered more quickly?

4) Promote public access defibrillation--Seattle/King County has more than 2,200 registered AEDs.

5) Voice-record resuscitation attempts--Newer defibrillators can digitally record voices during resuscitation attempts. This brings calls to life during later review. "It helps explain what's happening," Eisenberg says. "You feel like you're there in the living room, with all the distractions and dogs barking and chaos that occurs. We consider it a vital part of reconstructing. It also helps answer questions about timing, like when CPR began."

DO LOCALLY

The next 10 measures constitute a local action plan. They include:

6--8) Political, administrative and medical leadership--The specifics of these areas differ, but in general, to raise SCA survival, you'll need good leaders. "Unless you have leadership, everything else is a nonstarter," Eisenberg says. "It's like the catalytic agent to make everything else possible. It's a mysterious quality that's difficult to quantitate, but when it's there, amazing things can be achieved." Good leadership in even one of these areas can help get things rolling.

9) Establish tiered response--Consider arming first responders like police with AEDs and training them in CPR.

10) Comprehensive cardiac arrest registry--Expanded from the community version, and including outcomes data.

11) Continuous quality improvement--Data is only as good as what you do with it. Without QI, a registry is just a collection of numbers.

12) Improve EMT, paramedic and dispatcher skills--Time is important, and skills improve with practice.

13) Hypothermia therapy--Now the standard of care for resuscitated VF patients in hospitals, its is being implemented in many EMS systems.

14) Encourage citizen participation--Advisory boards of citizens can help services improve. Teaching CPR is also a form of citizen participation.

15) Prevention programs--Helping spot and control things like hypertension and diabetes now can prevent cardiac arrests later.

DO NATIONALLY

The final 10 steps represent a national action plan. These are:

16) Political leadership--Good ideas require champions, and understanding of political processes.

17) A national lead EMS agency--As recommended by the IOM in 2006.

18) National performance standards--There exist few if any national performance standards for resuscitation.

19) A resuscitation research entity within NIH--A National Institute for Resuscitation Research would allow research across traditional boundaries.

20) Revise human-subjects regulations--Loosen federal research restrictions on exemptions from informed consent.

21) Revise HIPAA--Make hospital outcome data more available to EMS.

22) Redefine cardiac arrest as a reportable disease--The AHA last year released a statement describing the essential features of doing this. "Unless communities know what their performance is," Eisenberg notes, "they will never be able to improve."

23) Guidelines for withholding resuscitation--King County has a potential model for when resuscitation can be compassionately withheld.

24) EMS research centers--As proposed in the National EMS Research Agenda.

25) CPR/AED tax incentives--To help boost community prevalence.

In general, EMS systems are complex, and changing their cultures and operations can be challenging. But improving cardiac arrest survival is possible, Eisenberg says, and worth the work.

"When we improve our management of cardiac arrest," he writes, "we also improve care for every other patient in need of emergency medical care--a group that may include any one of us at some point in our lives."