CCC-CPR; ECG Transmission

Continuous-Chest-Compression CPR
Kellum MJ, Kennedy KW, Ewy GA. Cardiocerebral resuscitation improves survival of patients with out-of-hospital cardiac arrest. Am J Med 119(4):335-40, Apr 2006.

Abstract: In an attempt to improve survival rates, the emergency medical service directors in two rural Wisconsin counties initiated a new protocol for the prehospital management of adult cardiac arrest victims. The results observed after implementation of this protocol are presented and compared with those observed during a three-year period that preceded initiation of the project. Methods-The protocol, based upon the principles of cardiocerebral resuscitation, was significantly different from the standard CPR protocol. A major objective was to minimize interruptions of chest compressions. Each defibrillation, including the first, was preceded by 200 uninterrupted chest compressions. Single shocks, rather than stacked shocks, were utilized. Post-shock rhythm and pulse checks were eliminated, and chest compressions were resumed immediately after a shock was delivered. Initial airway management was limited to an oral pharyngeal device and supplemental oxygen. If the arrest was witnessed, assisted ventilations and intubation were delayed until either a return of spontaneous circulation or until three series of "compressions + analysis +/- shock" were completed. Results-In the three years preceding the change in protocol, during which standard CPR was utilized, there were 92 witnessed out-of-hospital adult cardiac arrests with initially shockable rhythms. Eighteen patients survived, and 14 of 92 (15%) were neurologically intact. After implementation of the new protocol in early 2004, there were 33 witnessed out-of-hospital adult cardiac arrests with initially shockable rhythms. Nineteen patients survived, and 16 of 33 (48%) were neurologically normal. Differences in both total and neurologically normal survival are significant (chi-squared=0.001). Conclusion-Instituting the new cardiocerebral resuscitation protocol for managing prehospital cardiac arrests improved survival of adult patients with witnessed cardiac arrests and initially shockable rhythms.

Comment: Now that we've all begun to adapt to the 2005 American Heart Association CPR Guidelines, here is evidence that continuous-chest-compression CPR (CCC-CPR) has the promise to further improve outcomes. Dr. Ewy has written about this before (Cardiocerebral resuscitation: The new cardiopulmonary resuscitation. Circulation 111(16): 2,134-42, Apr 26, 2005), presenting data showing that in a pig model, CCC-CPR resulted in the same outcomes as perfectly performed traditional CPR-and both outcomes were much better than those of the no-CPR group. When one takes into consideration the frequent interruptions in CPR (e.g., for intubation, AED placement) and the real-world time required to deliver two breaths, CCC-CPR may be superior. And its greatest benefit may be in layperson CPR, where only 15% are willing to perform mouth-to-mouth breathing.

In this study, CCC-CPR appeared to be superior to standard CPR. However, many of the suggested changes are part of the 2005 guidelines, such as minimizing interruptions, decreasing the number of ventilations and eliminating the stacked shocks and post-shock rhythm/pulse checks, so it is not clear that CCC-CPR would still be better. It holds great promise for layperson CPR, to increase bystander CPR rates and effectiveness. Further research is needed.

ECG Transmissions to EDs & Coronary Intervention Times
Vaught C, Young DR, Bell SJ, et al. The failure of years of experience with electrocardiographic transmission from paramedics to the hospital emergency department to reduce the delay from door to primary coronary intervention below the 90-minute threshold during acute myocardial infarction. J Electrocardiol 39(2):136-41, Apr 2006.

Abstract: To minimize delays in time to reperfusion in an urban-rural North Carolina county, Guilford County EMS and the Moses Cone Hospital collaborated to implement transmission of EMS electrocardiographs (ECGs) to the emergency department. The study population included 92 patients who were transported by EMS and received primary coronary intervention during the second, third and fourth years after initiation of this intervention in 1993. Results-The median time from symptom onset to the initial ECG was 77 minutes. There was an additional 23 minutes between the availability of this ECG and the arrival of the patient at the emergency department. In the first year of the intervention, the time from hospital arrival to percutaneous coronary intervention was 80 minutes. In years 2-4, it was 93, 85 and 94 minutes, respectively. In 2003, 10 years after the intervention, the time from hospital arrival to percutaneous coronary intervention was 113 minutes. Conclusion-Initial gains in the time from hospital arrival to percutaneous coronary intervention, attributed to acquisition of the ECG in the prehospital setting, were not sustained over 10 years.

Comment: This study illustrates an important issue in EMS. It is not the device, drug or certification that's important, but the entire system's process of care. That shiny new AED on the golf course clubhouse wall is only useful as part of a system of prompt recognition of cardiac arrest, efficient communication, rapid response by trained personnel, CPR and defibrillation teamwork, and an ongoing commitment to training and oversight. Here, it appears that the studied acute-MI system, after the initial enthusiasm surrounding getting a new tool, saw the energy wane and reverted to the same old processes of care. This demonstrates the role and value of an active quality improvement system. The authors have raised an issue we all face. It would be nice to see them reevaluate their procedures, improve care and publish the new results.

Ramifications of the 8-Minute Standard
Price L. Treating the clock and not the patient: Ambulance response times and risk. Qual Saf Health Care 15(2):127-30, Apr 2006.

Abstract: In a qualitative study of paramedics' attitudes to prehospital thrombolysis (PHT), the government target that emergency calls should receive a response within eight minutes emerged as a key factor influencing attitudes toward staff morale and the job as a whole. A study was undertaken to examine paramedics' accounts of the effects of attempts to meet the eight-minute target on patient care and their own health and safety. Methods-In-depth semi-structured interviews were conducted with a purposive sample of 20 experienced paramedics (16 men), mostly aged 30-50 years, with a mean length of service of 19 years. The paramedics were encouraged to raise issues they considered salient. The interviews were analyzed according to the constant comparative method. Results-The paramedics argued that response-time targets are inadequate as a performance indicator. They dominate ambulance service culture and practice at the expense of other quality indicators and are vulnerable to "fiddling." The targets can conflict with other quality indicators, such as timely administration of PHT and rapid transport of patients to hospitals. The strategies introduced to meet the targets can be detrimental to patient care and have adverse effects on the health, safety, well-being and morale of paramedics. Conclusions-The results of this study suggest that the eight-minute response time is not evidence-based and is putting patients and ambulance crews at risk. There is a need for less-simplistic quality indicators which recognize that there are many stages between a patient's call for help and safe arrival at a hospital.

Comment: This report from the United Kingdom is very applicable to U.S. practice as well. Many, if not most, EMS systems use the eight-minute standard (or something similar) as a key-and sometimes their only-quality indicator. There are many reasons for this. Response times are easily measured, can be compared and benchmarked (though not very accurately, since many different definitions are used) and are easily understood by policymakers. But except for ventricular fibrillation (where eight minutes is too long), they mean very little.

Much research has been done recently to define what helps (or may harm) patients, and we need more. EMS systems should focus their quality improvement efforts on meaningful assessments of prompt response, accurate assessment, proper treatment and correct transport destination-and deemphasize the old eight-minute standard.