Cardiac Arrest Survival in Areas with Black and Hispanic Populations: A Preexisting Issue with Proposed Solutions

The Study 

A recent publication in JAMA Internal Medicine, titled "Cardiac Arrest Survival at Emergency Medical Service Agencies in Catchment Areas With Predominantly Black and Hispanic Populations" by Anezi I. Uzendu et al. (https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2809097), has shed light on a concerning problem. The study reveals that risk-standardized survival rates for out-of-hospital cardiac arrest (OHCA) are notably lower for emergency medical service (EMS) agencies operating in areas primarily inhabited by Black and Hispanic populations compared to those in predominantly White communities.

This cohort study leveraged data from the Cardiac Arrest Registry to Enhance Survival (CARES) and focused on adults who suffered nontraumatic OHCA between January 1, 2015, and December 31, 2019, with data analysis spanning from August 17, 2022, to July 7, 2023. Among the EMS agencies scrutinized, 82 (10.7%) served areas with predominantly Black and Hispanic populations. The median age of OHCA patients was 63.0 years, with 36.1% being women and 63.9% being men. The overall average risk-standardized survival rate (RSSR) stood at 27.5%, with a standard deviation of 3.6%. It is noteworthy that EMS agencies operating in Black and Hispanic catchment areas recorded lower survival rates at 25.8% (SD: 3.6%) compared to those in White catchment areas, where the survival rate reached 27.7% (SD: 3.5%). This difference was statistically significant (P < .001). 

The study's primary aim was to investigate whether emergency medical service (EMS) agencies in Black and Hispanic communities exhibited lower survival rates for out-of-hospital cardiac arrest (OHCA) cases in comparison to their counterparts serving White communities. The findings underscored that among the 764 EMS agencies analyzed, primarily serving Black and Hispanic populations, there were consistently lower survival rates for OHCA patients, particularly concerning hospital admission. Importantly, even after adjusting for various factors, such as EMS response times, EMS termination of resuscitation rates, and first responder rates of initiating cardiopulmonary resuscitation or applying an automated external defibrillator before EMS arrival, the disparities in RSSRs between agencies serving Black and Hispanic catchment areas and those serving White catchment areas persisted, remaining statistically significant. 

Suggested Actions 

Regrettably, none of the findings presented in this study come as a surprise. Setting aside the issue of bias in treating citizens in these communities (which could serve as the subject of another op-ed), I can draw from my own firsthand experiences to propose solutions to raise awareness of OHCA and recommend specific community actions. During my tenure as the Chief Operating Officer of the Richmond Ambulance Authority, we initiated two targeted projects designed to address the challenges identified in this study. Here's an overview: 

Empowering Black Communities 

In alignment with the discoveries made by Uzendu et al., our internal analysis via CARES data and focused bio-surveillance using our First Watch and associated First Pass systems had already indicated poorer outcomes in areas predominantly inhabited by African-American residents within our city. Anecdotally, we had recognized a hesitancy among our call takers to provide pre-arrival, hands-on CPR. Extensive literature research at the time corroborated this observation, revealing a general reluctance to deliver hands-only dispatch CPR and initiate CPR within home environments. 

In response, we launched a program aimed at delivering CPR training to individuals at risk within their communities. The key to success lies in forging partnerships with the local housing authority and actively participating in each new tenant orientation session. Securing a grant from the Philip Morris Foundation, (using the published peer-reviewed research and our data as evidential support) known for its substantial corporate social responsibility initiatives, enabled us to procure a substantial number of AHA Hands-Only CPR kits. The program's fundamental premise for new tenants was simple: 'no CPR, no key'! Additionally, every family received a CPR kit to take home for training additional family members. 

These Hands-Only kits were also bundled into tote bags and distributed as 'Community CPR kits' to youth, athletic groups, and churches following an initial CPR class. Another effective avenue for CPR education and training involved attending every community's National Night Out event (held annually in August), where mass CPR instruction sessions were conducted, and community kits were left behind to foster interest and understanding. 

Empowering Hispanic Communities

Each summer, we established an internship program for a public health intern or a medical school student pursuing a master's degree in public health. One of the theses, conducted by Dr. Michael Rains and his team, focused on the decline in 911 calls originating from the Latino community within our city. An analysis revealed a distinct gap in our coverage map, with fewer calls per capita and in specific areas (amounting to a 25% decrease in utilization) within the concentrated Latino community. 

Further investigations and discussions with our Police Department uncovered a natural reluctance among community members to dial 911. This reluctance stemmed from the fear that alerting the authorities could lead to the involvement of ICE and immigration services, even in the presence of a life-threatening emergency. 

Our initial actions to address this issue included: 

Collaborating with community organizers and local leaders from the League of United Latin American Citizens (LULAC -https://lulac.org/) to establish a Latino EMS citizens youth academy. This initiative targeted bilingual pre-teens who could return to their communities and advocate for the use of 911 in emergencies and encourage confidence in initiating CPR. 

Participation in the existing Police Spanish language youth academy to deliver a CPR training session. 

Training Spanish-speaking staff from both the EMS system and local hospitals as certified CPR instructors. These instructors regularly visited the community, delivering CPR training in local Latino Promotoras-based clinics, where trust was already established, and the knowledge could be passed on. 

Taking Swift Action 

The paper authored by Uzendu et al. is not the first to bring attention to this issue. However, there are straightforward actions that every EMS agency and system can take to foster better relationships, build trust, and encourage prompt action. Data analysis within the system (including collaboration with MPH interns) can identify areas where a reluctance to deliver Telephone CPR (TCPR) and acting on this information can significantly enhance community outcomes and Return of Spontaneous Circulation (ROSC) rates. Your community and its overall health will undoubtedly benefit from these efforts.