Ten Programs

A registry measures all aspects of the resuscitation care and can act as a benchmark for the entire EMS system.

Seattle’s Resuscitation Academy mantra – measure, improve, measure, improve – lies at the heart of the need for a registry.

“A cardiac arrest registry is the essence of measurement”.  The registry measures not only if a patient lives or dies but whether bystander

CPR was performed and also whether telephone CPR instructions were provided; the quality of the CPR; if there were unacceptable pauses in CPR; if the airway management was successful.  Data from every case should be collected and incorporated in a database or registry to use as an internal measurement tool.

Determining the presence of cardiac arrest and providing T-CPR can be difficult and stressful for dispatchers, the first link in the chain of survival. A take-charge attitude that moves ahead with CPR instructions, when there is a reasonable likelihood that cardiac arrest is present, is needed for success. But to achieve that success a T-CPR program requires training with continuing education.

In Seattle’s King County “every call is a cardiac arrest until proven otherwise”.  Dispatchers are primed to always ask two questions (unless the caller is the patient): is the patient conscious? Is the patient breathing normally?”  If the answer to both is no, the dispatcher immediately begins CPR instructions to the caller. Used as a teaching aid – No, No, then Go – prompts immediate action.

Once dispatchers understand how vital they are to the chain of survival and see concrete evidence of their success, they become staunch advocates of T-CPR.

The quality of CPR is an equally important predictor of survival as the time it takes to begin CPR following a collapse. High performance CPR is a quality team performance sometimes called the “dance of resuscitation”, “the CPR ballet”, or “pitstop approach to CPR”.

Like professional race car pit crews, each team member knows exactly what to do and does it with the minimal waste of time and effort.

Ongoing Quality Improvement (QI) programs should provide performance feedback to involved personnel after every cardiac arrest; digital downloads from defibrillators showing CPR percentage and quality allows for QI and team feedback.  Performance goals include: chest compressions given >90% of the available time; Rate 100-120 compressions per minute; depth (if measurable) 5 cm’ full recoil on the upstroke; pre-charging defibrillator prior to rhythm assessment’ CPR immediate aftershock; no pause in CPR greater than 10 seconds’ intubation and IV start without stopping CPR and hold cardiac arrest training drills monthly

Rapid dispatch can add 5-10 percent to a community’s survival rate without additional staffing or resources.  Speed is of the essence in a life or death situation, and in those cases protocols must be short circuited.  The first mention of a critical symptom mandates rapid dispatch, which requires the closest vehicle to be dispatched within seconds, even while additional information is being gathered from the caller. If it is immediately clear that more resources are needed more vehicles can be sent. Performance goals include regular review of adherence to protocols; determination of need for rapid dispatch within 30 seconds or less; regular feedback to dispatchers and frequent training on all caller interviews.

In Seattle and King County, USA, every cardiac arrest has a digital record created in part by a defibrillator.  The record includes second-by-second information about cardiac rhythm and CPR, synchronized with a digital voice recording.  Voice recordings combined with the

patient’s cardiac rhythm creates a vivid image where sequence and timing of events become clear and the reason for delays can be deduced (e.g. the dog was growling at the EMT, the patient was moved from the bathroom, the oxygen tank ran out etc).

Post-event digital readout of compressions, ventilations, heart rhythm, and timing of shocks is clearly useful, but nothing beats a voice recording.  Recommended performance goals include: collecting and reviewing defibrillator data and voice recordings for cardiac arrests; documenting verbalization of event details, interventions and CPR metrics, and timely feedback to EMS.

While public safety officers or other first-responders with CPR skills and AED training have the potential to increase survival rates from cardiac arrest, their role has been modest and inconsistent.  In communities embracing police defibrillation, there have been dramatic

improvements in survival, most notably in Rochester, Minnesota.  There are many issues in a police defibrillation program involving leadership support and buy-in from the rank and file, support from fire department and/or EMS agency, initial and ongoing training

costs, cost of AEDs, supervision, QI, and integration with EMS dispatching.  Police must be dispatched simultaneously with the first responding EMS agency, perhaps the most challenging issue. Our goal is for police to be dispatched only for true cardiac arrest events. How to send police quickly, but not over send, is a challenge we continue to work on.

The past five years has seen introduction of numerous pilot programs using smart technology designed to alert volunteer

responders to a nearby cardiac arrest and/ or identify the location of the nearest AED. The programs mean there is potential for

a volunteer to arrive at the scene ahead of EMS thereby increasing the probability of a successful outcome.  Some examples of immediate response programs: • Register publicly-accessible AEDs with the EMS system and dispatch centre and when possible notify the caller of a nearby AED. • Using a smart phone app, volunteers register on a cardiac arrest notification alert system. When EMS is dispatched, the app notifies nearby volunteers and can display the location of nearby AEDs. • Volunteers agree to have an AED with them most times, and are notified when EMS is dispatched to a cardiac arrest.

A population universally trained in CPR has the potential to double survival rates but how to bring this about is a challenge.

Mandatory training in CPR/AED has been part of the school curriculum in Norway for many years, in Denmark for 10 years and in the US CPR/AED training for high school students is mandatory in 27 states. We need to work toward all adults being trained in CPR and awareness of AEDs and how to use them. Performance goals are to train 100% of high school students in CPR prior to graduation and 100% of public employees.

An annual EMS performance report is the best way to declare accountability to the community. Sharing such important information including cardiac arrest data, is a way of being accountable and can be used to promote the organisation if results are positive, or

alternatively used to motivate stakeholders including community leaders and politicians to invest in efforts to improve.

Performance goals including publishing annual reports internally or externally including major metrics for cardiac arrest patients, response factors, program features.

Creating and nurturing a culture of excellence is perhaps the most difficult step. It involves an implicit awareness perceived by most or all members of the organisation that high expectations and high performance define the standard of care. It requires leadership with a determined vision.  A culture of excellence, hard though it may be to define or measure, is probably a key factor separating great systems from those that are merely satisfactory. When EMS providers recognize the presence of sincere, mission-driven leadership, as opposed to lip service, they respond to the positive culture and contribute to it as well.

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