A Template for Boosting Cardiac Saves

     There are no simple solutions for improving a community's cardiac arrest save rates, and those numbers can have implications beyond just 9-1-1 and EMS. But when a city's efforts are described as a national template for improving the care of these victims, it's worth a look at what they're doing.

     That's the way USA Today described Atlanta late in 2007. In the roughly two years preceding that story, survival rates for SCA victims in Georgia's capital region went from less than 3% to around 15%—well above the average national rate (6%–10%) calculated by the newspaper for major U.S. cities. A lot went into that increase, and that's the primary lesson to elicit: It takes the proverbial village to help someone in v-fib.

     "It involves all elements of the community," says Atlanta Fire Rescue medical director Jim Augustine, MD, FACEP, who has now moved on to Washington, DC, but is remaining in his Atlanta capacity until a replacement is found. "We had the public well represented—the American Heart Association coordinated a lot of that. They ran programs to teach CPR. They were involved in the cardiac arrest registry program. They broadened that program to include patients with acute MI, and they involved the medical, EMS and cardiology communities. Lead politicians and businesspeople also got involved. For cardiovascular events, that kind of support from across the community results in all kinds of benefits."

     The registry represents a major component of the efforts of Atlanta and a number of other top cities. CARES (the Cardiac Arrest Registry to Enhance Survival) is a database, sponsored by the AHA, CDC and Emory University School of Medicine, to record incidents of prehospital cardiac arrest and link them with outcome data, thus allowing participants to see how many they're saving, and trying to save, versus other communities.

     Before CARES, little of this kind of tracking was done in Atlanta. USA Today noted this in 2003, when it ranked the 50 largest U.S. cities by their cardiac arrest survival rates. A dozen earned "first-tier" status, meaning they specifically tracked the number of v-fib patients ultimately discharged from hospitals with good function. Thirteen more were "second-tier," using less-precise measures. The rest were "third-tier": They didn't know, were studying the issue or just refused to say. Atlanta was in the last group.

     Unhappy with that showing, Mayor Shirley Franklin helped kick-start some changes. Beyond the CARES enrollment, more patients started going straight to dedicated heart centers. AEDs were positioned in likely places of need. There were concentrated efforts to increase bystander CPR rates, including more prearrival dispatch instructions. Franklin even ordered her around 8,000 city employees to be trained in CPR. Overall, the bystander rate jumped from 7% when CARES was launched in 2004 to 17% by late 2007—not Seattle-type numbers, but a considerable improvement.

     That should be celebrated, as should ongoing efforts, in CARES cities and beyond, to salvage more of cardiac arrest's most salvageable victims. Steps like Atlanta took may well help boost save rates. But there's a context to these numbers that's often unrecognized, and that participants in emergency care systems should note. It involves the question of who's going into SCA in the first place.

     "Viable patients aren't generally going into cardiac arrest," Augustine notes. "People at risk for cardiac events often have significant underlying medical problems. And when they arrest, they go into an asystole, and are sometimes dead for a while before they're resuscitated. So if you're running really high resuscitation rates, you should be asking, is your community doing enough primary care? Do people have access to cardiology? Why is your population so at risk for having sudden v-fib or v-tach arrests that can be resuscitated?"

     Consider it this way: Years ago, a 50-year-old man in v-fib, treated quickly enough, could be shocked back into normal rhythm, sometimes repeatedly. This was a sort of low-hanging fruit. That same man today, conversely, might instead seek early treatment—get stented, put on beta blockers and aspirin. The most at-risk have defibrillators implanted. So they don't present for help in cardiac arrest, but rather after their defibrillators fire.

     "In the past," Augustine says, "those people would have been cardiac arrests, many of them amenable to saves. Now they just walk into emergency departments. And that's why our resuscitation rates are low: Because generally, the people having cardiac arrest events are at the end of a long trail, and aren't very amenable to resuscitation. There's a fairly small population now of people who would have a v-fib/v-tach arrest and even be good candidates for prehospital resuscitation. And that's a success story."

     Find CARES at https://mycares.net.