We believe these programs will lead to an increase in cardiac arrest survival in your community. Each section gives a summary along with real-world case studies of the program in action. As the Resuscitation Academy says, “If you’ve seen one EMS system, you’ve seen one EMS system.” Leaders from around the globe are proving that no matter where you live, improvement is possible.
Ten Programs with Case Studies
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.
Ambulance Victoria – Data Collection: A database to identify at-risk individuals for cardiac arrest in young people
Denmark – Data Collection: Tripling survival from OHCA in Denmark
Global Resuscitation Alliance – Data Collection: Steady increase in survival: 50% improvement is possible.
Japan – Data Collection: Tripling of survival in Japan over 10 years
Leading EMS Systems – Data Collection: Impressive increases in survival – Denmark, Seattle, and Seoul
Maryland, United States – Data Collection: Statewide implementation of CARES in Maryland
Mexico City, Mexico – Data Collection: Data collection drives improvement in Querétaro, Mexico
Norway – Data Collection: How to resuscitate a cardiac arrest registry
Norway – Data Collection: Saving 200 more lives from OHCA in Norway
Seattle, WA, United States – OHCA Feedback Program: Seattle Medic One uses data to create culture of excellence
Victoria, Australia – Data Collection: Measuring the quality of life of OHCA survivors after discharge from hospital
Victoria, Australia – Data Collection: Using OHCA registry data to inform and monitor operational initiatives and government funding decisions
Wales, United Kingdom – Data Collection: OHCA registry for Wales
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.
American Heart Association – T-CPR: Telephone CPR (T-CPR) program recommendations and performance measures
Arizona, United States – T-CPR: Telephone CPR increases bystander CPR from 44% to 62%
Resuscitation Academy – T-CPR: Telephone CPR pilot program improves dispatcher performance
Seoul, South Korea – Video-assisted CPR: Video-assisted CPR experience in Seoul, South Korea
Seoul, South Korea: Increasing survival rates through dispatcher-assisted CPR
Singapore – T-CPR: Dispatcher-assisted CPR, Singapore Civil Defense Force
Taipei City, Taiwan – Culture of Excellence: Taipei City EMS total quality management initiatives significantly improve OHCA survival
St. John, Western Australia: Working to strengthen T-CPR and AED programs
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.
Alaska, United States – HP-CPR: Accessing, Analyzing and using CPR data in Alaska
Ambulance Victoria, Australia – HP-CPR: High-Performance CPR: The development and implementation of a statewide, multi-agency model in Victoria, Australia
Hawaii, United States – Survival to Discharge: EMS agency collaborates with hospital to improve HP-CPR
King County, Seattle, WA, United States – HP-CPR: Improve EMS CPR with high-performance CPR
King County, Seattle, WA, United States: Cardiac Arrest Case Reviews – A culture of quality improvement
London Ambulance, United Kingdom – HP-CPR: Out-of-hospital pediatric cardiac arrest checklist
New York City, NY, United States – HP-CPR: Tripling OHCA survival in NYC
St. John Ambulance, Western Australia – HP-CPR: Considering human factors in team performance in the design and implementation of an HP-CPR model
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.
Hilton Head, SC, USA – Rapid Dispatch: Rapid dispatch for sudden cardiac arrest
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.
King County, Seattle, WA, United States: A process and tool for providing feedback following a resuscitation
Utah, United States – Measure Professional Resuscitation Using Defibrillator Voice Recording: Promoting legislation for use of audio recording devices within Utah EMS agencies
Program 6: Begin an AED Program for First Responders, Including Police Officers, Guards, and Other Security Personnel
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.
Belgium – AEDs for First Responders: Improving survival by empowering the first responder in Belgium
King County, Seattle, WA, United States – AEDs for First Responders: Police defibrillation in King County, Washington
Melbourne, Australia – AEDs for First Responders: EMS partners with fire brigades to improve survival in Melbourne
Taiwan – AED Program: Comprehensive and prospective national AED deployment policy in Taiwan
Program 7: Use Smart Technologies to Extend CPR and Public Access Defibrillation Programs to Notify Volunteer Bystanders Who Can Respond to Nearby Arrest to Provide Early CPR and Defibrillation
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.
Australia AV – PAD: Increasing utilization of PADs in Victoria, Australia
Japan – Innovative EMS Helmet: Interactive Command Control System and EMS Helmet in Japan
Singapore – Singapore’s multi-faceted approach to improve OHCA outcomes
Singapore – The myResponder App: Crowdsourcing first responders for CPR and AEDs in Singapore
St. John Ambulance, New Zealand – Smart Tech: Crowdsource CPR with GoodSam in New Zealand
United States – Smart Tech: Verified first responder pilot program in the USA
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.
Australia – Community Training: How patient relationship and medical training affect outcomes in Victoria, Australia
British Heart Foundation, United Kingdom – Community Training: Call Push Rescue Program
China – PAD: PAD program trains 150,000 laypeople, places 1,500 AEDS
China – The WeCan CPR Training Program in China
Columbia University, NY, United States – Community Training: Program to reduce post-event stress for bystanders
The European Restart a Heart Day goes global
Hilton Head, SC, United States – Bystander CPR: Recognition program for bystanders who provide CPR
Indonesia – Community Training: CPR and AED for laypersons initiative in places of worship
Japan – Community Training: Simulation training for teachers responding to arrests in schools
King County, Seattle, WA, United States – Community AED & CPR: PAD awareness and registration campaign
Korea – Community Training: Improving bystander training to maximize effects of T-CPR
Michigan, United States – Several Activities: Improving bystander response in Michigan
Oregon, United States – Community Training: Teaching hands-only adult CPR to 7th-Grade students
Resuscitation Council, United Kingdom – Community Training: Mandatory CPR training in schools
Resuscitation Council, United Kingdom – Community Training2: LifeSaver virtual reality program training for bystanders
Scotland – Community: 15-Minute Lunchtime lifesaver training in Scotland
Scotland – Community Butchers: Save a Life for Scotland – Butchers at the heart of the community
Singapore – Community Training: Residential public access defibrillation program
Singapore – Community Training Update: DARE: The Dispatcher-Assisted First REsponder Program in Singapore
South Central Ambulance Service, United Kingdom – Community Training: Defib awareness training program
Worldwide – Community Training: World Restart a Heart 2019 trains 800K+ in CPR globally
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.
King County, Seattle, WA, United States – Accountability: Cardiac arrest data featured in annual report
New Zealand – Accountability: Reporting cardiac arrest data in New Zealand
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.
Australia and New Zealand – Culture of Excellence: Working collaboratively to improve cardiac arrest survival across Australia and New Zealand
Fort Lauderdale, FL, United States – Chain of Survival: Resuscitation Academy helps Fort Lauderdale evaluate chain of survival
Michigan, United States – Culture of Excellence: Learning Health Systems approach to improving OHCA survival
Montana, United States – Culture of Excellence: The Montana Cardiac Ready Communities Program
Philippines – Culture of Excellence: Davao City, Philippines posts a 50-fold increase in survival
St. John, Western Australia – General Successes: Boosting total survivors by 50% in Western Australia