members of the columbus division of fire teach hands-only ......unadjusted survival outcomes by who...

2017 Annual Report

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MembersoftheColumbusDivisionofFireteachHands-OnlyCPRoutsideofNationwideStadiumduringEMSWeek.PhotocourtesyoftheColumbusDivisionofFire;Photocredit:JamesMiller.

CARESAnnualReport2017|3

Contents§ Introduction 5

§ WhyCARESMatters:AStoryofSurvivalfromOHCA 6

§ TheCardiacArrestRegistrytoEnhanceSurvival(CARES) 9

§ CARESinAction 12

§ ExecutiveSummary 15

§ Incidence&Demographics 16

§ ChainofSurvival 21

§ SurvivalOutcomes 26

§ 2017ResearchHighlights 34

§ ListofAbbreviations&Definitions 36

§ References 36

§ TheCARESGroup 38

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ListofFigures

Figure1.MapofCARESparticipants. 9

Figure2.AgedistributionofOHCAevents. 16

Figure3.Etiologyofarrestforadults. 17

Figure4.Etiologyofarrestforpediatricpatients. 17

Figure5.Etiologyofarrestbyagegroup. 17

Figure6.Locationofarrest. 18

Figure7.Percentageofeventsthatarebystanderwitnessed,receivebystanderCPR,andsurvivetohospitaldischargebyarrestlocation. 18

Figure8.Arrestwitnessstatus. 19

Figure9.Presentingarrestrhythmbyarrestwitnessstatus. 19

Figure10.DistributionofFirstResponderandEMSresponsetimes(timeintervalfrom911calltoarrivalonscene). 21

Figure11.SurvivalratebyEMSresponsetimeandarrestwitnessstatus. 22

Figure12.SurvivalratebyEMSresponsetimeandarrestwitnessstatus,amongpatientswhoreceivedbystanderCPR. 22

Figure13.BystanderCPRprovisionbyarrestwitnessstatus. 24

Figure14.UnadjustedsurvivaloutcomesafterbystanderCPR. 24

Figure15.Unadjustedsurvivaloutcomesbywhoperformedfirstdefibrillationinthepopulationwithashockablepresentingrhythm. 25

Figure16.Unadjustedpre-hospitalandin-hospitalOHCApatientoutcomes. 26

Figure17.Unadjustedsurvivaloutcomesbyarrestetiology. 27

Figure18.Unadjustedsurvivaloutcomesbypresentingarrestrhythm. 27

Figure19.Unadjustedsurvivaloutcomesbyarrestwitnessstatus. 27

Figure20.2017CARESNon-TraumaticEtiologyUtsteinSurvivalReport. 28

Figure21.2017CARESNon-TraumaticEtiologyHospitalSurvivalReport. 31

Figure22.Variabilityinoverallsurvivalrates,amongEMSagencieswith≥150CAREScasesin2017. 32

Figure23.VariabilityinUtsteinsurvivalrates,amongEMSagencieswith≥150CAREScasesin2017. 32

Figure24.VariabilityinbystanderCPRrates,amongEMSagencieswith≥150CAREScasesin2017. 32

ListofTables

Table1.CARESinclusioncriteria. 10

Table2.CARESexclusioncriteria. 10

Table3.CerebralPerformanceCategory(CPC)scores. 26

Table4.CARESHealthyPeopleMetrics,2017. 33


IntroductionOut-of-hospitalcardiacarrest(OHCA)isasignificantpublichealthissueandleadingcauseofdeathintheUnitedStates.Morethan200,000patientseachyearwillhaveresuscitationattemptedafteranout-of-hospitalcardiacarrest,butonly10%willsurvivetohospitaldischarge.Cardiacarrestresuscitationisanimportantmeasureofacommunity’semergencyresponsereadiness.Successfulresuscitationrequiresinvolvementbyarangeofindividualsincludingbystanders,emergencymedicaldispatchers,firstresponders,paramedics,andhospitalproviders.Measurementiskeytoimprovingqualityofcareandpatientoutcomes.In2015,theInstituteofMedicinereleased“StrategiestoImproveCardiacArrestSurvival:ATimetoAct,”whichrecommendedtheestablishmentofanationalcardiacarrestregistrytomonitorperformanceintermsofbothsuccessandfailure,identifyproblems,andtrackprogress1.

TheCardiacArrestRegistrytoEnhanceSurvival(CARES)allowscommunitiestobenchmarktheirperformancewithlocal,state,ornationalmetricstobetteridentifyopportunitiestoimprovetheirOHCAcare.CARESoffersacomprehensiveunderstandingofwherearrestsareoccurring,whetherbystandersareprovidinginterventionpriortoEMSarrival,EMSandhospitalperformance,andpatientoutcomes.Thisinturnprovidesthedatanecessarytomakeinformeddecisionsandallocatelimitedresourcesformaximalcommunitybenefit.Bycreatinganeasy-to-useandflexiblesystemtocollectOHCAdataandformingacommunitytosharebestpractices,CAREShastransformedthewayEMSagenciesaretreatingcardiacarrest.Participatingagenciesareabletomakedecisionsintheircommunitybasedonreal-timefeedbackandanalysis,inordertoincreasesurvival.

WesincerelyappreciatethemembersoftheEMSandhospitalCAREScommunities,aswellasthesponsors(AmericanRedCross,AmericanHeartAssociation,TheHeartRescueProject,Physio-Control)whosupportourmissiontosavelivesandimprovepatientcare.Wearepleasedtopresentthe2017AnnualReport.

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WhyCARESMatters:AStoryofSurvivalfromOHCAAtCARES,wefocusonsystemizeddatacollectiontomeasureandbenchmarkout-of-hospitalcardiacarrestoutcomestoimprovecareandsurvival.Thedataarecrucialinhelpingcreatemorehumanstorieslikethisone.RickandJenniferChapfromOrlando,Florida,sharetheirinspiringstoryofsurvivalandputthehumanfaceonourmission.Theirstoryillustratestheimportanceofeachlinkinthe“ChainofSurvival”–earlyrecognitionandaccesstocare,earlyCPR,earlydefibrillation,rapiddeliveryofEMScare,andearlypost-resuscitativecare.

APerfect(or“Purrfect”)ChainofSurvivalTheChainofSurvivalhasfiveparts.But,Rick’schainhada6thlink,theChapfamily’sbelovedcatBuddy.

It’sFebruary27,2012andatypicalMondaymorning.RickandJenniferChapworkfromtheirhomeinOrlando.Rickisinthekitchengettingcoffee,andJenniferisinherhomeofficewithBuddy.She’sonaconferencecallwithaclient,sothedoorisclosed.SuddenlyBuddybeginsmeowing,jumpingandscratchingunusuallytogetJennifer’sattention.Fortunately,hedoes.

JenniferpicksupBuddyandtakeshimoutoftheroomonlytofindthesourceofBuddy’sconcern.Rickiscollapsedonthekitchenfloor,unresponsiveandgaspingforairasifinaseizure.

Phonestillinhand,Jenniferimmediatelydials911,openingalife-linetodispatcherKevinSealeyoftheOrlandoFireDepartment.Kevinisdiagnostician,communicator,coachandwillbecomeJennifer’shero.Theyinstantlybecomeateam.Kevinworksquicklytogetthefactsandhelpontheway.Jenniferdoesn’tknowityet,butRickisinsuddencardiacarrest.Hisheartisnotbeating.Heisnotbreathing.Heisclinicallydead.

“I’mlosinghim,I’mlosinghim!”Jenniferyells.Andtoherhorror,Ricktakeshisfinalagonizingbreathinherarms.Asfearturnstodread,sherealizesRickneedsCPR.KevinimmediatelytellsJenniferwhattodo,wheretopress,howdeeptopressandhowfasttopress.And,hesaysonemorethingthatshewillneverforget,“Youneedtobepreparedtodo600compressions.”

JennifertakesadeepbreathandbeginstopushhardandfastinthecenterofRick’schesttothebeatofBeeGees“Stayin’Alive”—asurrealisticmusicaltripthroughtime,whentimeisallthatmatters.

Shepushesandpushesuntilherbodyalmostabandonsherwill,losingcountafter300compressions.Throughout,KevinisontheotherendofthelinecalmlyempoweringJennifertokeepgoing.Forwhatseemedlikeforeverbutwasonlyminutes,JenniferwasRick’sheartbeat,helpingtobuyprecioustimeuntilEMScouldgettheretorestorelife.Atthebrinkofexhaustion,thesix-mancrewofOFDStation6,shiftBledbyLt.TrentJohnstonarrives.EMStakesoverinperfectharmony,eachperformingafocusedandspecifictasktohelpsaveRick.

Jenniferbacksawayasifinafarawaydream-state,hereyesnotcomprehendingwhatsheisseeing.Rickisblue.TheycontinueCPRandquicklyplacetheirAEDpads.Itisasifsheiswatchingamovie,butthisisfarfrommakebelieve.Thisishorriblyreal.Jenniferhears,“Clear!”Silence.Thenmiraculously,“Wegotaheartbeat.”Rickisalive.

Stillunconscious,pulselessandnotbreathing,Rickisintubatedandwhiskedaway.OFDfire-basedtransportprovidescontinuityofcareallthewaytoOrlandoRegionalMedicalCenter(ORMC),alevel1traumahospital.

AttheORMCEmergencyDepartment,Rickisattendedbya20+personteamallfocusedonsavinghislife.Jenniferistoldheisincriticalconditionandthenext24hoursarecrucial.RickisputintotherapeutichypothermiatoprotecthisbrainandmovedtotheICU.Hereceivesamazingadvancedmedicalcarefromanincredibleandcompassionateteamofdoctors,nursesandsupportstaff.AndJenniferreceivessupportfromhospitalclergy,familyandfriends.Thewaitisalmostunbearable,butthemedicalteamishopeful.

Onday3Rickiswarmed,andonday4heisawakeandextubated.AndJennifergetsherfirstkiss!RickhassurvivedOHCAandisoneofthelessthan10%whosurvive.Astentinhisleftanteriordescendingartery,11daysinthehospitalandayearofcardiacrehab,Rickisalivetosharehissideofthestory.


LifeAfterOHCA—TheChainofSurvivalGoesFullCircleUndoubtedlysuddencardiacarrest(SCA)haschangedbothRickandJennifer.Onthatfatefulmorning,theywerecompletelyunawareofSCAandthatitcanhappentoaseeminglyhealthyperson.ThankfullyRicksurvived.Butastheynowknow,9outof10OHCAvictimsdonotsurviveandwillnevercomehome.Theimpactontheirfamiliesisdevastating.

ForRick,itallcamedowntoa“purrfect”chainofsurvivalstartingwithonehero,acatnamedBuddy.TodaytheChapsaredrivenbyamissiontohelpsavemorelivesfromSCAinwhateverwaytheycan.

• WithinmonthsofRick’sSCA,theChapssharedtheirstoryatanOrlandoCityCouncilmeetingtothankandadvocatefortheOrlandoFireDepartment.Thishelpedinspirethecity’s“TakeHeartOrlando”program,whichhasthegoaloftrainingeveryOrlandocitizeninCPR.Theprogramisnowinits5thyearandtheChapsvolunteerasCPRinstructors.

• TheyfoundedBuddyCPRtoencourageeveryoneto“learnCPRwithabuddy”sincemostsuddencardiacarrestshappenathome.Youneedabuddy—there’snosuchthingasdo-it-yourselfCPR.

• TheyarevolunteersandadvisorswithSuddenCardiacArrestFoundationwheretheyusetheirmarketingexperiencetoconductnationalpublicawarenessandmessagingstudies,andcreateda“TogetherWeCanSaveMoreLives”PSAvideo.

• AndtheyparticipateinTelephoneCPRworkshops,sharingthecaller’sperspectivewithEMSproviders.

TheChapsarefilledwithincomprehensiblegratitudeandarethankfultoliveinacommunitythatrecognizestheimportanceofacompletesystemofcareforOHCAfromhighlytrainedEMS,toCPRprograms,tohospitalswithadvancedpostcardiacarrestcare.Andbecauseofthis,they’reableto“makememoriesthatmaynothavebeen.”

RickislivingproofthatCPRandanintegratedsystemofcareworks.

RickChap,SCAsurvivor,JenniferChapTCPRlayrescuer,andBuddytheherocat,whoalertedJenniferthatRickwasincardiacarrest.SeatedinOrlandoFireDepartment’sTower6,whichwasonsceneforRick’scodesaveon2/27/12.(PhotobyDanBeckmann)

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FirefighterparamedicsfromTualatinValleyFire&RescueinOregonparticipateinatrainingexerciseontheprovisionofpost-resuscitativecare.PhotocourtesyofTualatinValleyFire&Rescue.


TheCardiacArrestRegistrytoEnhanceSurvival(CARES)In2004,theCentersforDiseaseControlandPrevention(CDC)establishedtheCardiacArrestRegistrytoEnhanceSurvival(CARES)incollaborationwiththeDepartmentofEmergencyMedicineattheEmoryUniversitySchoolofMedicine.CARESwasdevelopedtohelpcommunitiesdeterminestandardoutcomemeasuresforout-of-hospitalcardiacarrest(OHCA),bylinkingthethreesourcesofinformationthatdefinethecontinuumofemergencycardiaccare:911dispatchcenters,emergencymedicalservices(EMS)providers,andreceivinghospitals.ParticipatingEMSsystemscancomparetheirperformancetode-identifiedaggregatestatistics,allowingforlongitudinalbenchmarkingcapabilityatthelocal,regional,andnationallevel.

CARESbegandatacollectioninAtlanta,withnearly1,500casescapturedin2006.Atpresent,theregistrynowcapturesthatsamenumberofrecordsweekly.Theprogramhasexpandedtoinclude23state-basedregistries(Alaska,California,Delaware,Florida,Georgia,Hawaii,Illinois,Maine,Maryland,Michigan,Minnesota,Mississippi,Montana,Nebraska,NewHampshire,NorthCarolina,NorthDakota,Ohio,Oregon,Pennsylvania,SouthCarolina,Vermont,andWashington)andtheDistrictofColumbia,withmorethan60communitysitesin19additionalstates.CARESrepresentsacatchmentareaofalmost115millionpeopleorapproximatelyone-thirdoftheUSpopulation.Todate,theregistryhascapturedover350,000records,withmorethan1,400EMSagenciesandover1,900hospitalsparticipatingnationwide.

Figure1.Mapof2018CARESparticipants.

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CaseDefinitionCAREScapturesdataonallnon-traumaticout-of-hospitalcardiacarrestswhereresuscitationisattemptedbya911Responder(CPRand/ordefibrillation).ThisalsoincludespatientsthatreceiveanAEDshockbyabystanderpriortothearrivalof911Responders.Inclusionandexclusioncriteriaaredescribedbelow(Tables1and2).

Table1.CARESinclusioncriteria(allofthefollowing)

• Patientsofallageswhoexperienceanon-traumatic,out-of-hospitalcardiacarrest.

• Patientswhoarepulselessonarrivalof911Responder;OR• Patientswhobecomepulselessinthepresenceof911Responder;OR• PatientswhohaveapulseonarrivalofEMS,whereasuccessfulattemptatdefibrillationwasundertakenbyabystanderpriorto

arrivalof911Responder.

Table2.CARESexclusioncriteria(anyofthefollowing)

• Unworked/untreatedcardiacarrests,toincludecodesthatareterminatedimmediatelyuponarrivalofEMSbecausethepatientisnotaviablecandidateforresuscitationdueto:o Injuriesincompatiblewithlife.o Thepresenceofrigormortisorlividity.

o Signsofdecomposition.o PresenceofavalidDNR.

• PrivateEMStransportthatdidnotinvolve911dispatch.

• Cardiacarrestofclearandobvioustraumaticetiology.

• Bystandersuspectedcardiacarrest,whereROSCwasachievedwithouttheneedfordefibrillationor911ResponderCPR.

DataCollection&ElementsDatacollectionwithinCARESisbasedontheUtstein-styledefinitions–astandardizedtemplateofuniformreportingguidelinesforclinicalvariablesandpatientoutcomesthatwasdevelopedbyinternationalresuscitationexperts2,3.

TheCARESweb-basedsoftware(https://mycares.net),linksthreesourcestodescribeeachOHCAevent:1)911callcenterdata,2)EMSdata,and3)hospitaldata.Datacanbesubmittedintwoways:usingadata-entryformontheCARESwebsite,orviadailyuploadfromanagency’selectronicpatient-carerecord(ePCR)system.AccesstotheCARESwebsiteisrestrictedtoauthorizedusers,whoareprohibitedfromviewingdatafromanotheragencyorhospital.

DataelementscollectedfromEMSprovidersincludedemographics(i.e.name,age,dateofbirth,incidentaddress,sex,andrace/ethnicity),arrestcircumstances(i.e.locationtypeofarrest,witnessstatus,andpresumedetiology),andresuscitation-specificdata(i.e.informationregardingbystanderCPRinitiationand/orAEDapplication,defibrillation,initialarrestrhythm,returnofspontaneouscirculation[ROSC],fieldhypothermia,andpre-hospitalsurvivalstatus).

EMSprovidersarealsoabletoenteranumberofoptionalelements,whichfurtherdetailarrestinterventions(i.e.usageofmechanicalCPRdevice,ITD,12Lead,automatedCPRfeedbackdevice,andadvancedairway;administrationofdrugs;anddiagnosisofSTEMI).TheCARESformincludesanumberofoptionaltimeelements,includingestimatedtimeofarrest,defibrillatoryshock,andinitialCPR.Supplementaldataelementscollectedfromthe911callcentersincludethetimethateach911callwasreceived,thetimeofdispatchforbothfirstresponderandEMSproviders,andarrivaltimeatthescene.

Dataelementscollectedfromreceivinghospitalsincludeemergencydepartmentoutcome,provisionoftherapeutichypothermia,hospitaloutcome,dischargelocation,andneurologicaloutcomeatdischarge(usingtheCerebralPerformanceCategories[CPC]Scale).Receivingfacilitiesmayalsocompleteoptionalelementsoutlininghospitalprocedures,includingcoronaryangiography,CABG,andstentorICDplacement.

TheCARESdatasetisgeocodedonanannualbasis,andlinkedtoanumberofcensus-tractlevelvariablesincluding:medianhouseholdincome,medianage,race,unemploymentrate,averagehouseholdsize,populationdensity,andeducationalattainment.


ReportingCapabilityTheCARESsoftwareincludesfunctionalitytoautomatedataanalysisforparticipatingEMSagencies.Thereportsinclude911responseintervals,deliveryratesofcriticalinterventions(i.e.bystanderCPR,dispatcherCPR,publicaccessdefibrillation[PAD]),andcommunityratesofsurvivalusingtheUtsteintemplate.AnEMSagencyhascontinuousaccesstotheirdataandcangeneratereportsbydaterangeattheirconvenience.ThesoftwareisalsocapableofaggregatereportingsuchthatCARESstaffcangeneratecustomreportsforbenchmarkingandsurveillancepurposes.Inaddition,hospitalshaveaccesstofacility-specificreports,allowinguserstoviewpre-hospitalandin-hospitalcharacteristicsoftheirpatientpopulationwithbenchmarkingcapability.Arobustqueryfeaturealsoallowsagenciesandhospitalstocreatecustomizedsearchesoftheirdata.ThesesearchresultscanbeeasilyexportedtoMicrosoftExcelforfurtheranalysis.DataValidationTheCARESqualityassuranceprocessisoneofthestrengthsoftheregistry,asanumberofmeasuresaretakentoensuretheintegrityandaccuracyofthedata.ThesemeasuresincludestandardizedtrainingofallCARESusers,built-insoftwarelogic,anauditalgorithmensuringconsistentdatavalidationacrosstheregistry,andabi-annualassessmentofpopulationcoverageandcaseascertainment.

Training,Education,andSupport

Training,education,andongoingtechnicalandoperationssupportarekeycomponentsofCARESthatcontributetotheregistry’ssuccessandenhancetheexperienceforparticipatingsites.Duringtheenrollmentprocess,EMSandhospitalusersreceiveextensivetrainingfromCARESstaffonthedataelements,datacollectionprocess,andfeaturesoftheCARESwebsite.Thistrainingincludesaone-on-onesessionwithaCARESProgramorStateCoordinatorpriortobeinggrantedaccesstothesoftware.EMSandhospitalusersarealsoprovidedwithnumerousresources,includingadetailedCARESdatadictionaryandaCARESuserguide.Onceacommunityhasbeenparticipatingintheregistryforanextendedperiodoftime,CARESprovidesongoingsupportintheformofansweringquestionsasneeded,providingupdatedtrainingdocuments,andrespondingtoindividualreportingrequests.

SoftwareLogicandAuditing

Inordertoprovideconsistentdatavalidationacrosstheregistry,eachCARESrecordisreviewedforcompletenessandaccuracythroughanautomatedauditalgorithm.Oncetherecordisprocessedbythealgorithm,dataentryerrorsareflaggedforreviewbyEMSandhospitalusers(asappropriate)andCARESstaff.Logicanderrormessagesarealsoincorporatedintothedata-entryformtominimizethenumberofincompletefieldsandimplausibleanswerchoicesduringthedataentryprocess.Finally,aggregatedataisanalyzedonaregularbasistoidentifyagency-specificanomalies.CARESstaffutilizesite-by-sitecomparisontoolstodetectoutliersandcompareeachagency’sdatawiththenationalaverage.

CaseAscertainment

EachEMSagencyisaskedtoconfirmtheirnon-traumaticcallvolumetoensurecaptureofallarrestsinadefinedgeographicarea.ThevolumeofOHCApermonthiscomparedwithhistoricmonthlyvolumesbyCARESstaff;whenasubstantialdropinthenumberofeventsoccurs,theEMScontactisnotifiedtodetermineifthevariationwasrealortheresultofalaginthedata-entryprocess.Inaddition,CARESconductsabi-annualassessmentofpopulationcoverageandcaseascertainment.CARESstaffandStateCoordinatorsprovideeachEMSagency’sgeographiccoverage,censuspopulation,andstartdateviaastandardizedtemplate.Thisinformationisthenlinkedwithrecordvolumetoidentifyoutliersacrosstheentireregistry.Intheeventthatanoutlierisfound,CARESstaffortheStateCoordinatorworkscloselywiththeEMSagencytoidentifyanyissuesinthedatacollectionprocessandresolveasneeded.

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CARESinActionSaveMiHeartinMichiganByTeriShields,MichiganCARESCoordinator

In2014,MichiganpartneredwithCARESasastatewideefforttoreportdataonout-of-hospitalcardiacarrest.ThesameyearSaveMiHeart1,anon-profitinitiative,wasformedtounitethecommunity,dispatch,firstresponders,EMSandhospitalsystemstoimprovecardiacarrestsurvival.Currently,theCARESregistrycoversapproximately7.9millionofthetotal9.9millionMichiganresidents.In2017,therewere136MichiganEMSagenciesand110hospitalsactivelyenteringdataintoCARES.Thegoalistohavetheentirestatecoveredby2020.

CAREShasprovidedvaluabledatatoidentifyareasforimprovement.Recognizingcardiacarrestimmediatelyandactingquicklyhasbeenshowntohavethegreatestimpactonsurvival.SaveMiHeartaimstoincreasecommunityawarenessandeducationofsuddencardiacarrestandincreasebystandercompression-onlyCPRandAEDuserates.ThebystanderCPRrateinMichiganhasstayedbetween36%and40%overthepast4years.ThepercentageofcardiacarrestpatientswhohadanAEDappliedpriortoEMSarrivalwas32%in2014and34.7%in2017.Acurrentproject,HandsontheHeartofDetroit,focusesonpopulationslocatedinneighborhoodswithhighincidenceofcardiacarrestandlowratesofbystanderresponse.Programssuchasthisworkingtogetherwithcommunity,faith-basedandschoolorganizationswillhelpcreatemeasurablechangeinimprovingsurvival.SaveMiHearthascollaboratedwiththeUniversityofMichiganathleticsprogramtoprovideCPRandAEDtrainingduringfootballpregametailgatingandalsoshowsaPSAvideo2inthestadiumtoover100,000spectators.Thefunyeteducationalvideohasgainedpopularityandhasbeenshownatothersportingeventsthroughouttheyear.

CAREShasallowedMichigancommunities,whichrangefromremoteruraltosuburbanandurbanpopulations,toaddressareasforimprovementbyprovidingauser-friendlytooltomeasureperformanceandprovidemeaningfulfeedbacktocontinuallyimprovetheirsystemofcare.SaveMiHeartworkswithEMSagenciestorecognizeandreunitesurvivorswiththeirrescuers.BystanderinterventionalongwithanexcellentsystemofcareoftenmeansthedifferencebetweenalifeSAVEDandonelost.UtilizingCARESasastrategytoaccomplishthemissionofSaveMiHearttodoublesurvivalinourstateby2020hasalreadyhelpedsaveadditionallives.

IncidentCommandforCardiacArrestinChicagoByDr.JosephWeber,EMSMedicalDirector,ChicagoFireDepartment

Untilrecently,Chicagohasbeenknownasacitywithoneofthelowestpublishedcardiacarrestsurvivalratesandtherefore,aplaceyoudidnotwanttohaveacardiacarrest.Butin2011,theChicagoEMSSystemandtheChicagoFireDepartment(CFD)decidedtotakeonout-of-hospitalcardiacarrest.ThisnewqualityassuranceinitiativestartedwithafocusonCFDandtheirEMSresponsetocardiacarrest.Thedepartmentcreatednewprotocolsthatfocusedonhighqualityonsceneresuscitationwithteam-basedcare.However,inanEMSsystemthesizeofChicagowithmorethan1,500paramedicsand3,000EMTs,protocolchangeisnoteasilyachieved.TheCFDsimulationtrainingcenterwascentraltotheirsuccess.Theytookontheherculeantaskofputtingalloftheirprovidersthroughahands-onsimulationbasedcourseintheirnewapproachtocardiacarrest,termed“IncidentCommandforCardiacArrest”.Thetrainingcontinuestodayforallnewprovidersaswellasrefreshercoursesforthosewhohavepreviouslycompletedthetraining.

Withtheirnewprotocolsonthestreets,CFDneededdatatoseeiftheirinitiativeswereimprovingsurvival.In2013,theyjoinedamulti-institutionalcollaborativegroupfromthestateofIllinois,IllinoisHeartRescue,thatappliedforandwasawardedtheMedtronicFoundationHeartRescueGrant.Aspartofthisgrant,CFDbeganusingtheCARESRegistrytocollectoutcomedataonalloftheircardiacarrestpatients.InSeptemberof2013,thefirstdatareportsfromtheCARES

1https://www.savemiheart.org/about2https://www.youtube.com/watch?v=QLyxKFSwX5M


registryshowedthattheireffortsthusfarhadalreadymadesignificantimprovementsincardiacarrestsurvivalratesintheCityofChicagoandtheir2013-2016datashowamorethanfour-foldincreaseinsurvivaloverpreviouslypublishedrates.

CARESregistrydataandcollaborationwithIllinoisHeartRescuealsohelpedidentifyotherareasforout-of-hospitalcardiacarrestqualityimprovement.NewdispatchCPRprotocolsandtrainingwereinitiated,aswellasamoreformalizedqualityassurancecallreviewprocess.BystanderCPRtraininginitiativeswereledbytheIllinoisHeartRescueCommunitySphere,whichfocusedeffortsonmedicallyunderservedareasofthecitywithahighincidenceofcardiacarrest.BothoftheseinitiativeshaveledtoamorethandoublingofbystanderCPRratesinChicago.Finally,newEMSprotocolsweredevelopedrequiringthatresuscitatedcardiacarrestpatientsbetransportedonlytohospitalsabletoperform24/7percutaneouscoronaryintervention(PCI)andtargetedtemperaturemanagement(TTM).HospitalbasedCARESdataisadditionallyusedtogivefeedbacktothesehospitalsonthequalityofcaretheydelivertothesepatients.

Chicagohasmadegreatstridesintheirapproachtocardiacarrestoverthepastseveralyears.TheirbasicapproachanduseofCARESdatatomeasureandimproveisnowanexampleforcommunitiesofanysize,thatimprovingcardiacarrestsurvivalispossibleanywhere.

CriteriaBasedDispatchinAnchorageByDr.MikeLevy,EMSMedicalDirector,AnchorageFireDepartment

ImagineyouworkasaTelecommunicator(akaDispatcher)atyourlocalpublicsafetyaccesspoint(PSAP)takingcallsforthefire-basedEMSsystem.Itisaprettybusyplacethatprocesses80,000callsforserviceinayearthatmayincludeEMS,Fireandrequestsfromotheragenciesforhelp.Thecallerscouldbereportingthesmellofsmokeinastructure,apsychologicalemergency,agunshotwound,aheartattack...thepotentialisalmostendless.Asanaddedtwist,thecallerswillcoveranimmensegamutofcommunicationskillsandprimarylanguages.Anchorage,AlaskaisbysomeaccountsthemostdiversecityintheUS3.Thelocalschooldistrictreportsthatthereare99languagesbesidesEnglishspokenbyitsstudentbody.Thosewhocallmay,ofcourse,beveryemotionalinresponsetotheincident.Howdoemergencytelecommunicatorsrapidlyprocesscallstoidentifyalife-threateningemergency?

AnchorageFireDepartmentusesasystemcalledCriteriaBasedDispatch(CBD)whichwasdevelopedatKingCountyEMS.Oncebasiclocationinformationisobtained,thedispatchersasktwokeyquestionsonallcalls:

1) “Isthepersonawakeandalert?”2) “Is(s)hebreathingnormally?”

Iftheanswertothosequestionsis“no”thenthedispatchertellsthemtostartCPRandgivesinstructions.Thisistheso-called“No-No-Go”methodthatwaspioneeredinSeattle/KingCounty.ThismethodislikelythefastestmeansofinitiatingCPRwithlayrescuersandhasresultedinsignificantimprovementinthetimetofirstCPRaswellasthenumberoftimesthatCPRisperformedintheAnchoragesystem.UsingtheCARESDispatcherAssistedCPRmodule,AnchorageFDwasabletotracknumeroustimeintervalsaswellasmonitorbarriersencounteredbythedispatcher.AfterimplementingCBDinthespringof2014(andusingtheCARESDispatcherModulewhenitbecameavailableinlate2015),thetablebelowshowshowAnchorageFDhasbeenabletofarexceedthenationalstandardsinTelephoneCPR4.

CallreceipttoCPRrecognition

Callreceipttofirstcompression

NationalStandard:HighPerformance 60seconds 120secondsNationalStandard:Minimum 120seconds 180seconds

AnchorageFD2016 44seconds 100secondsAnchorageFD2017 52seconds 111seconds

3https://www.cnn.com/2015/06/12/us/most-diverse-place-in-america/index.html.4http://cpr.heart.org/idc/groups/heart-public/@wcm/@ecc/documents/downloadable/ucm_493303.pdf

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CBDisuniqueinthatthedispatchersareencouragedtousetheirverbalandexperientialdispatchskillstoquicklygettotherightanswer.Forexample,ifthecallerisunabletodetermineifthepersonisbreathingnormally,thissystemencouragesthedispatchertohavethecallermovethephonetothepatient.Manytimes,thisallowsthedispatchertoidentifytheineffectivebreathingpatternofcardiacarrestknownasagonalrespirationsandwiththatinformationtheyimmediatelyhavethecallerstartCPR.Thisisonlyeffectiveindispatchcentersthathavebeentrainedandinwhichthedispatchersaregiventhelatitudetodrawtheseconclusions.Inotherwords,somesystemsareveryrigidanddonotallowanyvariationsfromasetalgorithm.

WiththeCARESDispatcherAssistedCPRModule,theAnchorageFireDepartmenthasfoundthatwhenthetelecommunicators/dispatchersaretrainedinCBDANDenabledtoaddflexibilitytothecalltakingANDrewardedwithfeedbackonthecardiacarrest“saves”,wesawsignificantimprovementsinourtimetofirstcompressionsandfrequencyofCPRbeingperformedpriortoEMSarrival.Thisprocessis“easybutnotsimple”asitoftenrequiresconfrontinganestablisheddispatchculturebutithaspaidimmensedividendsforAnchorageFDandthecommunityitserves.

HiltonHeadIslandFireRescue’sFlightPlanforSurvivalByBattalionChiefofEMSTomBouthillet,HiltonHeadIslandFireRescue

HiltonHeadIslandFireRescuejoinedtheCardiacArrestRegistrytoEnhanceSurvival(CARES)in2010.Atthetime,theyhadnoideahowtheywereperformingwithsuddencardiacarrest.

“Wefeltsomeanxietybecausewedidn’tknowwhatthedatawouldshow,”saysBattalionChiefofEMSTomBouthillet.“Butwealsoknewthatweneededthedatatomoveforward.”TheturningpointwastheMiracleontheHudsonwhenCapt.Chesley“Sully”Sullenbergerandhiscrewsaved150passengersaboardUSAirwaysFlight1549.“Theeventcapturedtheimaginationofthenation,”saysBouthillet.“Ifeltinstinctivelythatifwecoulddevelopaparalleltocardiacarrestsurvivalthatitwouldinspirethedecisionmakerstomoveforward.”Bouthillet,alinefirefighter/paramedicatthetime,presentedaplantosave150livesfromout-of-hospitalcardiacarresttotheseniorstaff,inspiringtheorganizationtotakeaction.

Overtheyears,HiltonHeadIslandFireRescueimplementedmanysystemimprovementsforsuddencardiacarrest,startingwithamorerobustinitialassignmentincludinganambulance,twofireengines,andabattalionchief.Insteadofsending4or5peopletoacardiacarrest,theynowsend7to11.AllpersonnelweretrainedinPitCrewCPRanddispatchersreceivedadditionaltraininginTelecommunicatorCPR.Theydevelopedachecklistforon-scenecareincludingpost-resuscitationcare.TheystartedhavingmeetingswithHiltonHeadHospital.Feedbackwasprovidedtocrewsafteraresuscitationattempt.Itwasacompletechangeofcultureandthestaffrosetotheoccasion.

Thereweresomebumpsalongtheway.“Wewonanationalawardin2012,butourperformanceslumpedin2013and2014.Ittaughtusthatexcellencerequiressustainedeffortovertime.It’salwaysaworkinprogress.”Afterre-trainingtheentiredepartmentinSeattle’sHighPerformanceCPRtheyclawedtheirwaybacktosuccess.“Iwantedtoprovethat2012wasn’tafluke,”saysBouthillet.HiltonHeadIslandFireRescuehadtheirbestyeareverin2017,when11of16witnessedVF/VTpatientssurvivedtohospitaldischargewithaCPCscoreof1or2–asurvivalrateof68%forthisgroupofpatients.Inanefforttoengagewithandacknowledgethecommunity,HiltonHeadFireRescuekeepsincontactwiththeircardiacarrestsurvivorsandthecitizenswhoperformbystanderCPRordeploypubliclyavailableAEDs.

BouthilletcreditstheCARESregistryforarminghisorganizationwithknowledge.“It’slikeDemingsaid,withoutdatayou’rejustanotherpersonwithanopinion.”ThisyearHiltonHeadIslandFireRescuehungadiagramofaBoeing737with150seatsinthelobbyoftheirmainbuildingtohelpmeasuretheirprogress.“We’remakingapubliccommitmenttoourcitizensandvisitorstosave150livesandwe’rerightontrack.”


76,215non-traumatic,workedOHCAsreportedtoCARESin2017

28.1%ofpatientssurvivedtohospitaladmission

45.2%ofadmittedpatientsreceivedhypothermiacare

10.4%ofpatientssurvivedtohospitaldischarge

80.4%ofdischargedpatientshadapositiveneurologicaloutcome(CPC1or2)

MedianEMSresponsetime:7.3minutes

31.8%ofpatientsachievedsustainedROSCinthefield

11.4%ofpatientswhoarrestedinpublichadabystanderappliedAED

38.2%ofpatientsreceivedbystanderCPR

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Incidence&Demographics2017DatasetandIncidenceofOHCAEventsThisreportdescribesCARESdatafromthemostrecentcalendaryear,January1toDecember31,2017.CARESrequiresthatanEMSAgencyenteratleastonecompletecalendaryearofdataandmeetapatientlosttofollow-upthresholdoflessthan1%tobeincludedintheAnnualNationalReport.TheCARES2017NationalReportscanbeviewedat:https://mycares.net/sitepages/reports2017.jsp.

Descriptivestatisticsinthisreportarepresentedasfrequenciesorproportionsforcategoricalvariables,andmedianandinterquartilerangesforcontinuousvariables.Comparisonofproportionswereconductedusingthechi-squaretest.

The2017datasetincludes1,156EMSAgenciesand1,304Hospitals,andrepresentsapopulationof102.6million,approximately32%oftheU.S.population.In2017,76,215OHCAeventswerereportedtoCARES.Thecrudeincidenceofnon-traumatic,workedarrestswas74.3per100,000,higherthantherateof68.9per100,000observedin2016.Using2017censusdatatoextrapolatetotheU.S.population4,CARESestimatesthattherewereapproximately242,000EMS-treated,non-traumaticOHCAsintheUnitedStateslastyear.

DemographicsIn2017,CARESpatientswerepredominatelymale(62.0%).OfthereportedOHCAevents,97.2%(n=74,058)wereadultsand2.8%(n=2,113)werechildren,18yearsandyounger.ThemedianageofOHCApatientswas64.0years(mean:62.0;SD:19.5).Theagedistributionvariedsignificantlyacrossthesexes(Figure2),withfemaleshavingahighermedianageofarrest(66.0vs.63.0years,p<.0001).

Figure2.AgedistributionofOHCAevents.


EtiologyInalignmentwiththemostrecentILCORguidelines3,CARESrequiresthatallEMS-treated,non-traumaticcardiacarrestsbeenteredintotheregistry.Theetiologyofarrestisidentifiedbyfieldprovidersandrecordedinthepatientcarerecord.PertheUsteinguidelines,anarrestispresumedtobeofcardiacetiologyunlessitisclearlydocumentedotherwise.

In2017,82.7%ofadult(>18yearsofage)OHCAswerepresumedtobeofacardiaccause.OthercausesofadultOHCAwere:respiratory/asphyxia(9.1%),drugoverdose(6.1%),exsanguination/hemorrhage(0.7%),drowning/submersion(0.5%),andothermedical(0.9%)(Figure3).

Theetiologyofarrestforpediatricpatients(≤18yearsofage)differedsubstantiallyfromthatofadults.In2017,43.5%ofpediatricarrestswerepresumedtobeofacardiacetiology.OthercausesofpediatricOHCAwere:respiratory/asphyxia(34.9%),drowning/submersion(7.8%),SIDS/SUID(7.5%),drugoverdose(2.7%),andothermedical(3.6%)(Figure4).

Figure3.Etiologyofarrestforadults.

Figure4.Etiologyofarrestforpediatricpatients.

Figure5furtherhighlightstherelationshipbetweenarrestetiologyandpatientage.Presumedcardiaccausewasthemostpredominantetiologyforallagegroups,withtheproportionofarrestsattributabletothiscauseincreasingwithpatientage.However,pediatricpatientsweremuchmorelikelythanadultstoexperienceanarrestduetorespiratorycause.Drugoverdoseaccountedfor39%ofarrestsinthe19-34agegroupand17%ofarrestsinthe35-49agegroup,whichisconcerningduetothecurrentopioidepidemicintheUnitedStates.

Figure5.Etiologyofarrestbyagegroup.

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LocationofArrestThemostcommonplaceforanOHCAtooccurisinaresidentialsetting,with69.9%ofeventsoccurringinahome.Othercommonarrestlocationswerenursinghome(11.4%),publicorcommercialbuilding(7.2%),streetorhighway(5.4%),andhealthcarefacility(3.5%)(Figure6).

ThelocationofanOHCAishighlycorrelatedwithbystanderinterventionandpatientoutcome.Incomparisontoresidentialarrests,patientswhoarrestedinapublicsettingwerefarmorelikelytohaveabystanderwitnessedeventandreceivebystanderCPRpriortoEMSarrival(Figure7).Patientoutcomeswerealsosignificantlydifferentacrossincidentlocations,withpublicarrestshavinganearly2.5-foldrateofsurvivaltohospitaldischargecomparedtoresidentialarrests(21.5%vs8.7%,respectively;p<.0001).

Figure6.Locationofarrest.

Figure7.Percentageofeventsthatarebystanderwitnessed,receivebystanderCPR,andsurvivetohospitaldischargebyarrestlocation.


WitnessStatusArrestwitnessstatushassignificantimplicationsforpatientoutcomes,aswitnessedarrestshavemoreopportunityforbystanderinterventionandearlydeliveryofcare.

Approximatelyhalfofarrestswereunwitnessed(51.1%),while36.6%werebystanderwitnessedand12.3%werewitnessedbya911Responder(Figure8).Patientswithabystanderwitnessedarrestweremorethan3timesaslikelytosurvivetheireventcomparedwithunwitnessedarrests(16.0%vs4.6%,respectively;p<.0001),whilepatientswitha911Responderwitnessedarrestwerenearly4timesaslikelytosurvivecomparedwithunwitnessedarrests(18.1%vs4.6%,respectively;p<.0001).

Figure8.Arrestwitnessstatus.

InitialRhythmWhenthecardiacrhythmisfirstmonitoredafterOHCA,apatientmaypresentinashockablerhythm(ventricularfibrillationorventriculartachycardia)ornon-shockablerhythm(asystoleoridioventricular/pulselesselectricalactivity(PEA)).Treatmentandprognosisdependonpresentingrhythm,withbettersurvivalafterOHCAamongpatientswithashockablerhythm(29.1%vs.6.2%,p<.0001).

18.4%ofpatientspresentedwithaninitialshockablerhythmofventricularfibrillation(VF)orventriculartachycardia(VT),while81.6%ofpatientspresentedinanunshockablerhythm,withasystolebeingthemostcommon(50.2%).Presentingrhythmdifferedmarkedlybyarrestwitnessstatus,withbystanderwitnessedpatientsbeingmuchmorelikelytopresentinashockablerhythmthanunwitnessedpatients(30.1%vs10.0%,respectively;p<.0001)(Figure9).

Figure9.Presentingarrestrhythmbyarrestwitnessstatus.

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Earlyaccesstocare

EarlyCPR

Earlydefibrillation

RapiddeliveryofEMScare


ChainofSurvivalThechainofsurvivalreferstoaseriesofactionsintendedtomaximizethechancesofsurvivalfollowingcardiacarrest.Thefivelinksinthechainofsurvivalareearlyaccesstocare,earlyCPR,earlydefibrillation,rapiddeliveryofEMScare,andearlypost-resuscitativecare.ForeveryminuteofcardiacarrestwithoutCPRordefibrillation,apatient’schanceofsurvivalfallsby7-10%5.ThismeansthatthecommunityandbystanderresponseareintegraltosurvivalfromOHCA.EarlyAccesstoCareThefirststepinthechainofsurvivalisrecognitionofcardiacarrestandactivationoftheemergencyresponsesystembycalling911.Thenextcrucialtimeperiodistheintervalbetweencallreceiptatthedispatchcentertoarrivalonscene,or“responsetime”.ThedistributionofFirstResponderandEMSresponsetimesarepresentedinFigure10.

ResponseandtreatmenttimesaresupplementalelementsinCARES;however,participantsareencouragedtomeasureresponsetimesinordertoidentifylocalopportunitiesforimprovement.Recordswithmissingresponsetimes(21.3%)aswellasthosethatwerewitnessedbya911Responder(12.3%),havebeenexcludedfromresponsetimeanalyses.

In2017,medianresponsetimebyFirstResponderswas6.2minutes(IQR:4.8-8.6minutes)andmedianresponsetimebyEMSwas7.3minutes(IQR:5.4-10.1minutes).FirstRespondersarrivedonscenein≤5minutesfor31.2%ofarrests,whileEMSarrivedonscenein≤9minutesfor67.6%ofarrests.

Figure10.DistributionofFirstResponderandEMSresponsetimes(timeintervalfrom911calltoarrivalonscene).

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Figure11isabivariateanalysisofsurvivalratebyEMSresponsetime(measuredfromcallreceiptatdispatchcentertoarrivaloftheambulanceatthescene)forallOHCApatientsaswellasthreesubsets:bystanderwitnessed,bystanderwitnessedVF/VT(Utstein),andunwitnessed.PatientswithawitnessedVF/VTarrestexperiencedasignificantdecreaseinsurvivalwithincreasingEMSresponsetime.Incontrast,responsetimehadlittleeffectonsurvivalamongunwitnessedarrests.

Figure11.SurvivalratebyEMSresponsetimeandarrestwitnessstatus.Figure12illustratestheinterdependencebetweenthelinksinthechainofsurvival,byhighlightinghowrapid911responseandbystanderCPR(bCPR)workintandemtoimprovepatientsurvival.BystanderCPRhelpsprovidecriticalandtimelyinterventionwhile911vehiclesareintransittothescene.BycomparingthesamepatientsubgroupsinFigure11andFigure12,onecanseehowsurvivaliselevatedwhenbystanderCPRisperformed.

Figure12.SurvivalratebyEMSresponsetimeandarrestwitnessstatus,amongpatientswhoreceivedbystanderCPR.


AtelecommunicatorattheCombinedCommunicationCenterinSpokane,Washingtonrespondsto911callsandprovidesdispatchfor15localfiredepartments.PhotocourtesyofSpokaneFireDepartment.

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EarlyCPROneofthecriticalinterventionstoachievingsuccessfulresuscitationisearlyCPR.IfCPRisstartedbeforeanambulancearrives,thepatient’schancesofsurvivaldramaticallyincrease.In2017,bystanderCPRwasinitiatedon38.2%ofCARESpatients.Ofnote,CARESexcludes911ResponderwitnessedeventsaswellasthosethatoccurredinanursinghomeorhealthcarefacilityfromourbystanderCPRrate,asthesearescenarioswherewewouldexpectCPRtobeperformedbyatrainedmedicalprovider.

BystanderCPRprovisionwasstronglycorrelatedwitharrestwitnessstatus(Figure13).BystanderCPRwasinitiatedafter46.9%ofbystanderwitnessedevents,comparedwith31.7%ofunwitnessedevents(p<.0001).

Figure13.BystanderCPRprovisionbyarrestwitnessstatus.Returnofspontaneouscirculation(ROSC)inthefield,survivaltohospitaladmission,andsurvivaltohospitaldischargewereallstronglyassociatedwithreceiptofbystanderCPR(Figure14).ThesurvivaltodischargerateforpatientsreceivingbystanderCPR(13.7%)wassignificantly(p<.0001)higherthanthatofpatientswhodidnotreceivebystanderCPR(7.5%).

Figure14.UnadjustedsurvivaloutcomesafterbystanderCPR.


EarlyDefibrillationMorethan15%ofOHCAsoccurinapubliclocation;therefore,publicaccessAEDsandcommunitytraininghavealargeroletoplayinearlydefibrillation.However,thenumberofpatientswhohaveanAEDappliedbyabystanderremainslow,occurringafteronly11.4%ofpublicarrests.

In2017,30.3%(n=23,100)ofCARESpatientsweredefibrillatedinthefield.Theproportionofpatientsfirstdefibrillatedbyabystanderwas5.2%,whereas19.0%and75.8%werefirstdefibrillatedbyaFirstResponderorEMSpersonnel,respectively.

Reducingdelaystodefibrillationleadstobetteroutcomesforpatientsinashockablerhythm.Unadjustedoutcomesforthissubsetofpatientsvaryaccordingtowhoperformedthefirstdefibrillation(Figure15).TheproportionofOHCApatientssurvivingtohospitaldischargewhenfirstdefibrillatedbyabystanderwithanAEDwas49%,comparedwith28%ofpatientsfirstshockedbyFirstRespondersand27%ofpatientsfirstshockedbyrespondingEMSpersonnel.

Figure15.Unadjustedsurvivaloutcomesbywhoperformedfirstdefibrillationinthepopulationwithashockablepresentingrhythm.

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SurvivalOutcomesPatientOutcomesOnthebasisoflocalEMSagencyprotocols,35.7%ofpatientswerepronouncedonsceneafterresuscitativeeffortswereterminatedinthepre-hospitalsetting,asincreasefromthelastseveralyears(30.3%in2015and32.4%in2016).Asuccessfulattemptatresuscitationinthefieldisoftendefinedbyapatient’sreturnofspontaneouscirculation(ROSC).In2017,sustainedROSC(20consecutiveminutesofROSC,orpresentattransferofcaretoareceivinghospital)wasachievedby31.8%ofCARESpatients(Figure16).

Therateofsurvivaltohospitaladmissionwas28.1%(EDoutcomemissingfor157cases;0.2%),andtherateofsurvivaltohospitaldischargewas10.4%(hospitaloutcomemissingfor173cases;0.2%).Amajorityofpatientswhoweredischargedalivehadaneurologicallyfavorableoutcome,aCerebralPerformanceCategory(CPC)scoreof1or2(Table3).

Figure16.Unadjustedpre-hospitalandin-hospitalOHCApatientoutcomes.Table3.CerebralPerformanceCategory(CPC)scores

CPCScore Description

CPC1 GoodCerebralPerformanceConscious,alert,abletoworkandleadanormallife.

CPC2ModerateCerebralDisabilityConsciousandabletofunctionindependently(dress,travel,preparefood),butmayhavehemiplegia,seizures,orpermanentmemoryormentalchanges.

CPC3SevereCerebralDisabilityConscious,dependentonothersfordailysupportbecauseofimpairedbrainfunction(inaninstitutionorathomewithexceptionalfamilyeffort).

CPC4Coma,VegetativeStateNotconscious.Unawareofsurroundings,nocognition.Noverbalorpsychologicalinteractionswithenvironment.

CPC5 Death


Figure18.Unadjustedsurvivaloutcomesbypresentingarrestrhythm.

ArrestCharacteristicsandOutcomesSurvivaloutcomesdifferedmarkedlyacrossetiology,presentingrhythm,andwitnessstatuscategories.

Patientswithanarrestofpresumedcardiacetiologyhadanunadjustedsurvivalratetohospitaldischargeof9.8%.Survivalamongpatientswithanarrestcausedbyarespiratorymechanismordrowningwasslightlyhigher(12.3and12.7%,respectively),whereaspatientswithanoverdose-relatedarresthadasurvivalrateof16.1%.Survivalwaslowestamongpatientswithanarrestduetoexsanguinationorhemorrhage(4.0%)(Figure17).

Figure17.Unadjustedsurvivaloutcomesbyarrestetiology.Patientsthatpresentwithaninitialshockablerhythmofventricularfibrillation(VF)orventriculartachycardia(VT)haveamuchhigherchanceofsurvivalthanpatientswhopresentwithanon-shockablerhythmsuchasasystoleorpulselesselectricalactivity(PEA)(Figure18).Patientswhopresentedinashockablerhythmhadasurvivaltohospitaladmissionrateof48.5%,comparedwith34.8%forthoseinPEAand16.7%forthoseinasystole.Similarly,patientspresentinginashockablerhythmhadagreaterchanceofbeingdischargedalive(29.1%),comparedwith10.1%ofpatientspresentinginPEAand2.4%ofpatientsinasystole.Arrestwitnessstatusalsohasasignificantimpactonpatientoutcomes,aswitnessedarrestshavemoreopportunityforbystanderinterventionandearlydeliveryofcare.OHCApatientswitha911Responderwitnessedarresthadthehighestchanceofsurvivaltohospitaldischarge(18.1%),followedcloselybythosewithabystanderwitnessedarrest(16.0%).Incontrast,unwitnessedeventshadasurvivalrateof4.6%(Figure19).

Figure19.Unadjustedsurvivaloutcomesbyarrestwitnessstatus.

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UtsteinSurvivalTheUtsteintemplatewasdevelopedbyinternationalresuscitationexpertstopromoteuniformreportingguidelinesforclinicalvariablesandpatientoutcomes2,3.TheseguidelinesdefinecoredatafieldstoensureconsistencyinterminologyandmakerecommendationsonthedataelementstoberecordedforeachOHCAevent.

PatientswhohaveabystanderwitnessedOHCAandpresentinashockablerhythmarethemostlikelytosurvivetheirarrest,andarereferredtoasthe“Utstein”subgroup.Thissubsetofarrestsisanimportantmeasureofsystemefficacy,allowingforcomparisonofpatientoutcomesbetweensystemsandtimeperiods,despitethewidevariationofcardiacarrestcircumstancesandpatientcharacteristics.

Figure20showstheNationalCARESUtsteinSurvivalReportfor2017.Thisreportstratifiesarrestsbywitnessstatusandpresentingrhythm.In2017,thesurvivaltohospitaldischargeratefortheUtsteinsubgroupwas32.6%.Utsteinbystanderpatients(arrestwitnessedbyabystander,presentedinashockablerhythm,andreceivedsomebystanderintervention[CPRand/orAEDapplication])hadasurvivalrateof36.5%.

Figure20.2017CARESNon-TraumaticEtiologyUtsteinSurvivalReport.


Figure20.2017CARESNon-TraumaticEtiologyUtsteinSurvivalReport.

30

PrehospitalandhospitalteamstransferapatientsafelytoChildren'sNationalHealthSysteminWashington,DC.PhotocourtesyofChildren’sNationalHealthSystem.


HospitalSurvivalNewtoCARESthisyear,theHospitalSurvivalReportallowsreceivingcenterstoviewsummarymetricsfortheirpatientpopulation.Thereportfollowsaflowdiagramformat,categorizingarrestsbysustainedROSCinthefield,initialrhythm,andpatientoutcome,andalsoallowsforfilteringofpatientsbywhethertheyweretransportedbyEMSortransferredfromanotheracutecarefacility.Figure21showstheNationalCARESHospitalSurvivalReportfor2017.

Amongallpatientstransportedtoahospital,thesurvivaltoadmissionratewas43.7%andthesurvivaltodischargeratewas16.2%.SurvivaltohospitaldischargewassubstantiallyhigheramongthosewhoachievedsustainedROSCinthefield(30.5%)comparedwiththosewhodidnot(2.5%),andamongthosewhoweretransferredfromanotherfacility(46.0%)comparedwithpatientswhoweretransporteddirectlybyEMS(14.7%).

Figure21.2017CARESNon-TraumaticEtiologyHospitalSurvivalReport.

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RegionalVariationinOHCAOutcomesThereismarkedregionalvariationinOHCApatientoutcomesandbystanderinterventionrates.ThediversityofCAREScommunitiesallowsforcomparisonofsystemperformanceandoutcomemetrics.Thefiguresbelowcompareoverallsurvivalrates(Figure22),Utsteinsurvivalrates(Figure23),andbystanderCPRrates(Figure24)amongthe125EMSagencieswith≥150CAREScasesin2017.Thesefigureshighlightthesignificantvariabilityamongparticipatingagencies(ranges:overallsurvival2.9-21.1%(7-folddifferenceinsurvival);Utsteinsurvival0-76.5%;bystanderCPR6.3-81.3%(12-folddifferenceinbystanderCPR).Thebarsineachfigurerepresentcommunitieswithanunderlyingpatientpopulationrangingfrom100,000toover2million.Thereddottedlinedenotesthenationalaverageforbenchmarkingpurposes(overallsurvival:10.4%;Utsteinsurvival:32.6%;bystanderCPR38.2%).

Figure22.Variabilityinoverallsurvivalrates,amongEMSagencieswith≥150CAREScasesin2017.

Figure23.VariabilityinUtsteinsurvivalrates,amongEMSagencieswith≥150CAREScasesin2017.

Figure24.VariabilityinbystanderCPRrates,amongEMSagencieswith≥150CAREScasesin2017.


HealthyPeople2020Everydecade,theHealthyPeopleinitiativedevelopsasetofobjectivestoimprovethehealthofallAmericans.Thetopicof“Preparedness”wasaddedtothe2020objectives,withthegoalofstrengtheningandsustainingcommunities’abilitiestoprevent,protectagainst,mitigatetheeffectsof,respondto,andrecoverfromincidentswithnegativehealtheffects6.Communityresilience,theabilityofacommunitytouseitsassetstostrengthenpublichealthandhealthcaresystems,isacornerstoneofpreparedness.CARESispartneringwithHealthyPeople2020tofocusonandpromotebystanderresponse,withthegoalofincreasingtheratesof:

• BystanderCPRforallnon-traumaticcardiacarrests.• BystanderAEDusefornon-traumaticcardiacarrestsoccurringinpubliclocations.• Survivaltohospitaldischargeforpatientswhoreceivebystanderintervention(throughCPRand/orAED

application).• SurvivaltohospitaldischargeforUtsteinbystanderpatients(thosewithabystanderwitnessednon-traumatic

cardiacarrestthatpresentinashockablerhythmandreceivebystanderinterventionthroughCPRand/orAEDapplication).

CARESisutilizingthestable2015cohort,comprisedofthemorethan500EMSagenciesthatparticipatedintheregistryin2015andserveapopulationofapproximately85million,totrackthesemetricslongitudinallyovera5-yearperiod(2015through2019).Theunadjusted2017ratesforthiscohortarelistedinTable4.

Table4.CARESHealthyPeopleMetrics,2017

BystanderCPR 38.8%

BystanderAEDuseinpubliclocations 11.7%

SurvivaltodischargeamongpatientswhoreceivedbystanderCPRand/orAEDapplication 14.0%

SurvivaltodischargeamongUtsteinbystanderpatients 37.8%

34

2017ResearchHighlights

Peer-ReviewedPublications• ShahM,BartramC,IrwinK,VellanoK,McNallyB,

GallagherT,SworR.EvaluatingDispatch-AssistedCPRUsingtheCARESRegistry.PrehospitalEmergencyCare.Dec8:1-7.

• FordyceCB,HansenCM,KragholmK,DupreME,JollisJG,RoettigML,BeckerLB,HansenSM,HinoharaTT,CorbettCC,MonkL,NelsonRD,PearsonDA,TysonC,vanDiepenS,AndersonML,McNallyB,GrangerCB.AssociationofPublicHealthInitiativesWithOutcomesforOut-of-HospitalCardiacArrestatHomeandinPublicLocations.JAMACardiology.2(11):1226-1235.

• HansenML,LinA,ErikssonC,DayaM,McNallyB,FuR,YanezD,ZiveD,NewgardC,CARESsurveillancegroup.Acomparisonofpediatricairwaymanagementtechniquesduringout-of-hospitalcardiacarrestusingtheCARESdatabase.Resuscitation.120:51-56.

• vanDiepenS,GirotraS,AbellaBS,BeckerLB,BobrowBJ,ChanPS,FahrenbruchC,GrangerCB,JollisJG,McNallyB,WhiteL,YannopoulosD,ReaTD.Multistate5-YearInitiativetoImproveCareforOut-of-HospitalCardiacArrest:PrimaryResultsFromtheHeartRescueProject.JournaloftheAmericanHeartAssociation.22;6(9).

• KragholmK,MaltaHansenC,DupreME,XianY,StraussB,TysonC,MonkL,CorbettC,FordyceCB,PearsonDA,FosbølEL,JollisJG,AbellaBS,McNallyB,GrangerCB.DirectTransporttoaPercutaneousCardiacInterventionCenterandOutcomesinPatientsWithOut-of-HospitalCardiacArrest.Circulation:CardiovascularQualityOutcomes.10(6).

• TobinJM,RamosWD,PuY,WernickiPG,QuanL,RossanoJW.BystanderCPRisassociatedwithimprovedneurologicallyfavourablesurvivalincardiacarrestfollowingdrowning.Resuscitation.115:39-43.

• MaderTJ,WestaferLM,NathansonBH,VillarroelN,CouteRA,McNallyBF.TargetedTemperatureManagementEffectivenessintheElderly:InsightsfromaLargeRegistry.TherapeuticHypothermiaTemperatureManagement.7(4):222-230.

• AdabagS,HodgsonL,GarciaS,AnandV,FrasconeR,ConteratoM,LickC,WesleyK,MahoneyB,YannopoulosD.Outcomesofsuddencardiacarrestinastate-wideintegratedresuscitationprogram:ResultsfromtheMinnesotaResuscitationConsortium.Resuscitation.110:95-100.

• NaimMY,BurkeRV,McNallyBF,SongL,GriffisHM,BergRA,VellanoK,MarkensonD,BradleyRN,RossanoJW.AssociationofBystanderCardiopulmonaryResuscitationWithOverallandNeurologicallyFavorableSurvivalAfterPediatricOut-of-HospitalCardiacArrestintheUnitedStates:AReportFromtheCardiacArrestRegistrytoEnhanceSurvivalSurveillanceRegistry.JAMAPediatrics.171(2):133-141.

• HubbleMW,TysonC.ImpactofEarlyVasopressorAdministrationonNeurologicalOutcomesafterProlongedOut-of-HospitalCardiacArrest.PrehospitalDisasterMedicine.32(3):297-304.


Abstracts• ShahM,BartramC,IrwinK,McNallyB,GallagherT,

VellanoK,SworR.EvaluatingTheProvisionAndOutcomeOfDispatch-AssistedCardiopulmonaryResuscitationUsingTheCardiacArrestRegistryToEnhanceSurvival(CARES).NationalAssociationofEMSPhysiciansAnnualMeeting;2017January21-26;NewOrleans,LA.

• ShahM,BartramC,IrwinK,McNallyB,GallagherT,VellanoK,SworR.BarriersToDispatch-AssistedCardiopulmonaryResuscitationInstruction.NationalAssociationofEMSPhysiciansAnnualMeeting;2017January21-26;NewOrleans,LA.

• HansenS,HansenCM,FordyceC,DupreM,MonkL,TysonC,JollisJ,GrangerC,andtheCARESSurveillanceGroup.EarlyDefibrillationbyFirst-RespondersinRelationtoFireStations:OptimalBenefitAccordingtoLocation.AmericanCollegeofCardiology66thAnnualScientificSession;2017March17-19;Washington,DC.

• NaimMY,GriffisHM,BurkeRV,McNallyBF,SongL,BergRA,NadkarniVM,VellanoK,BradleyRN,MarkensonD,RossanoJW.Race/EthnicityandSocioeconomicFactorsareAssociatedWithBystanderCPRinPediatricOutofHospitalCardiacArrest:AStudyFromtheCardiacArrestRegistrytoEnhanceSurvival(CARES).AmericanHeartAssociationResuscitationScienceSymposium,DickinsonW.RichardsMemorialLecture;2017November11-13;Anaheim,CA.

• AndersenLW,HolmbergMJ,GranfeldtA,LøfgrenB,VellanoK,McNallyBF,SiegerinkB,KurthT,DonninoMW,theCARESSurveillanceGroup.NeighborhoodCharacteristics,BystanderAutomatedExternalDefibrillatorUse,andPatientOutcomesinPublicOut-of-HospitalCardiacArrest.AmericanHeartAssociationResuscitationScienceSymposium;2017November11-13;Anaheim,CA.

• BalianS,BucklerDG,BhardwajA,AbellaBS.PostAdmissionVariabilityinOHCASurvivalOutcomesinPennsylvania.AmericanHeartAssociationResuscitationScienceSymposium;2017November11-13;Anaheim,CA.

• BucklerDG,GrossestreuerAV,KarpDN,BalianS,CarrBG,WiebeDJ,AbellaBS.AssociationofDemographicandGeospatialFactorsWiththeProvisionofBystanderCPRFollowingOut-of-HospitalCardiacArrest.AmericanHeartAssociationResuscitationScienceSymposium;2017November11-13;Anaheim,CA.

• GrossestreuerAV,CarrBG,BucklerDG,KarpDN,AbellaBS,DonninoMW,GaieskiDF,WiebeDJ.CardiacArrestRiskStandardizationinPennsylvaniaUsingAdministrativeDataComparedtoRegistryData.AmericanHeartAssociationResuscitationScienceSymposium;2017November11-13;Anaheim,CA.

36

ListofAbbreviations&Definitions

AED AutomatedExternalDefibrillator

CARES CardiacArrestRegistrytoEnhanceSurvival

CPC CerebralPerformanceCategory

CPR CardiopulmonaryResuscitation

DNR DoNotResuscitate

ED EmergencyDepartment

EMS EmergencyMedicalServices

OHCA Out-Of-HospitalCardiacArrest

PEA PulselessElectricalActivity

ROSC ReturnofSpontaneousCirculation

SIDS/SUID Suddeninfantdeathsyndrome/Suddenunexpectedinfantdeath

VF VentricularFibrillation

VT VentricularTachycardia

References

1.GrahamR,McCoyMA,SchultzAM.Strategiestoimprovecardiacarrestsurvival:ATimetoAct.InstituteofMedicine.2015.2.CumminsRO,ChamberlainDA,AbramsonNS,AllenM,BaskettPJ,BeckerL,BossaertL,DeloozHH,DickWF,EisenbergMS,EvansTR,Holmberg,KerberR,MullieA,OrnatoJP,SandoeE,SkulbergA,Tunstall-PedoeH,SwansonR,ThiesWH.Recommendedguidelinesforuniformreportingofdatafromout-of-hospitalcardiacarrest:TheUtsteinstyle.AstatementforhealthprofessionalsfromaTaskForceoftheAmericanHeartAssociation,theEuropeanResuscitationCouncil,theHeartandStrokeFoundationofCanada,andtheAustralianResuscitationCouncil.Circulation.1991;84:960-975.3.PerkinsGD,JacobsIG,NadkarniVM,BergRA,BhanjiF,BiarentD,BossaertLLetal.CardiacArrestandCardiopulmonaryResuscitationOutcomeReports:UpdateoftheUtsteinResuscitationRegistryTemplatesforOut-of-HospitalCardiacArrest:AStatementforHealthcareProfessionalsFromaTaskForceoftheInternationalLiaisonCommitteeonResuscitation(AmericanHeartAssociation,EuropeanResuscitationCouncil,AustralianandNewZealandCouncilonResuscitation,HeartandStrokeFoundationofCanada,InterAmericanHeartFoundation,ResuscitationCouncilofSouthernAfrica,ResuscitationCouncilofAsia);andtheAmericanHeartAssociationEmergencyCardiovascularCareCommitteeandtheCouncilonCardiopulmonary,CriticalCare,PerioperativeandResuscitation.Resuscitation.2015;96:328-340.4.AnnualEstimatesoftheResidentPopulation:April1,2010toJuly1,2017Source:U.S.CensusBureau,PopulationDivision

5.LarsenMP,EisenbergMS,CumminsRO,HallstromAP.Predictingsurvivalfromout-of-hospitalcardiacarrest:agraphicmodel.AnnEmergMed.1993;22:1652–1658.

6.OfficeofDiseasePreventionandHealthPromotion.HealthyPeople2020TopicsandObjectives:Preparedness.Retrievedfromhttps://www.healthypeople.gov/2020/topics-objectives/topic/preparedness.


AParamedicsPluscrewrespondstoanout-of-hospitalcardiacarrestinSiouxFalls,SouthDakota.PhotocourtesyofSiouxFallsRegionalEmergencyMedicalServicesAuthority(REMSA);Photocredit:MatthewGruchow.

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TheCARESGroup

Dr.BryanMcNallyExecutiveDirector

AllisonCrouchDirectorofOperations&StrategicPlanning

MonicaRajdevDirectorofStatePrograms&DataIntegration

KimberlyVellanoDirectorofDataManagement&SoftwareDevelopment

TiaraSinkfieldAssociateDirector

StephanieGranadaProgramAssociate

JulieMayoProgramAssociate

AmericanMedicalResponseRobynHughesLynnWhite

CaliforniaJoanneChapman

DelawareMichelleJohnson

IllinoisTeriCampbellClausJohnsen

MaineClaireDufortTimNangle

MarylandMelanieGertner

MichiganTeriShields

MinnesotaLucindaHodgson

MississippiDeeHoward

MontanaShariGrahamJanetTrethewey

NebraskaBeckaNeumiller

NorthCarolinaLisaMonkClarkTyson

NorthDakotaDanielleSchochShilaThorsonOhio

MikeSnyder

PennsylvaniaKimbraShoop

SouthCarolinaDianneDavisBethMorgan

UtahChrisStratford

VermontSarahLamb

Washington,Oregon,AlaskaJennyShin

Staff

StateCoordinators


CharleneCobbNationalAssociationofEmergencyMedicalTechnicians(NAEMT),Clinton,MS

DrewDawsonFormerDirectorofEMS,NationalHighwayTrafficSafetyAdministration(NHTSA)

Dr.AlexIsakovEmoryUniversity,Atlanta,GA

Dr.DougKupasNationalAssociationforStateEMSOfficials(NASEMSO);PennsylvaniaDepartmentofHealth

RobertMerrittCentersforDiseaseControlandPrevention,Atlanta,GA

DalePearsonWhitterviewGroup

ChiefJohnSinclairInternationalAssociationofFireChiefs(IAFC),Fairfax,VA

Dr.DavidSlatteryNationalAssociationofEMSPhysicians(NAEMSP);LasVegasFireDepartment/UniversityofNV

Dr.BenBobrowUniversityofAZ/AZStateDept.ofHealth

Dr.SophiaDyerBostonMedicalCenter/BostonEMS/Fire/Police

TimHakamakiPulsara

LucindaHodgsonUniversityofMinnesota

Dr.DouglasKupasNationalAssociationforStateEMSOfficials(NASEMSO);PennsylvaniaDepartmentofHealth

BobNiskanenResurgentBiomedicalConsulting

Dr.JosephRossanoChildren'sHospitalofPhiladelphia

Dr.AngeloSalvucciVenturaCounty,CAEMSAdvisoryAgency

Dr.SangDoShinSeoulNationalUniversityCollegeofMedicine,Seoul,SouthKorea

Dr.RobertSworWilliamBeaumontHospital,RoyalOak,Michigan

Dr.HideharuTanakaKokushikanUniversity,Tokyo,Japan

Dr.JosephWeberEMSSystem-CookCountyHealth&HospitalsSystem

LynnWhiteAmericanMedicalResponse,Columbus,Ohio

OversightBoard

AdvisoryCommittee

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https://mycares.netcares@emory.eduTheCardiacArrestRegistrytoEnhanceSurvival(CARES)WoodruffHealthSciencesCenterMailstop1599/001/1BQ1599CliftonRoadNEAtlanta,Georgia30322

members of the columbus division of fire teach hands-only ......unadjusted survival outcomes by who...

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