Angelo Salvucci, MD, FACEP A Systematic Approach to EMS Cardiac Arrest Management Improves Survival for Out of Hospital Cardiac Arrest Angelo Salvucci, MD, FACEP

Contributing Authors AMR Medicine: Santa Barbara County EMS: Lynn White, MS Ventura County EMS: Chad Panke, EMT-P Katy Hadduck, RN David Chase, MD Santa Barbara County EMS: Jennie Simon, RN Les Hugie, EMT-P Alexia Armenta, BS Gregory Shinn, BS

Presenter Disclosure Information FINANCIAL DISCLOSURE: None UNLABELED/UNAPPROVED USES DISCLOSURE:

Santa Barbara Co. 440,000 5 Hospitals 2 SRCs Ventura Co. 840,000 8 Hospitals 3 SRCs EMS: MPDS EMD BLS & ALS FD FR ALS Ambulance ROSC to SRC: TTM & PCI

Presentation Slide Title

New York Times; December 7, 2015 “My fear is that they won’t make much of a difference. You have this information in the ether, but there’s no point if people aren’t doing it to patients.” Sam Parnia, MD Director, Resuscitation Research Stony Brook Hospital

“WHAT” VS “HOW”

OHCA Survival 1980-2008 Figure 2. OHCA survival to hospital discharge by 5-year time periods (based upon final year of patient enrollment into study). Sasson C et al. Circ Cardiovasc Qual Outcomes 2010;3:63-81

Disparities ROC: 12,000, OHCAs 10 systems Overall survival 3.0% - 16.3%, median 8.4% VF survival 7.7% - 39.9%, median 22.0% Increase from median to max would prevent 15,000 deaths Nichol: JAMA. 2008;300(12):1423-1431. Sanders: JAMA. 2008;300(12):1462-1463.

Objective To determine if a comprehensive system of education, training, treatment protocols and quality improvement would affect survival of patients in sudden cardiac arrest. This would be the “what you implemented” with some specifics included (what is targeted goal directed education? All EMS personnel received x hours of hands on…)

Cardiac Arrest Management (CAM) System of care: Commitment of all participants Evidence-based treatment protocols 10:1 compression/ventilation w/o pause BLS airway preferred Targeted, goal-directed education 60 minutes didactic Teamwork, Positioning, CPR (CC, BMV), ALS, ROSC Individual and team training: 120 minutes Mandatory minimum proficiency thresholds Organized explicit system of rescuer roles QI program with process and outcome measures

Process Multidisciplinary Development Committee All EMTs and Paramedics in the EMS system were trained Santa Barbara: December 2012 Ventura County: December 2013 Cardiac Arrest Registry to Enhance Survival (CARES) utilized for data management and comparison. Patient populations studied: All cardiac arrests of presumed cardiac etiology Bystander-witnessed cardiac arrest with shockable first rhythm This would be the “what you implemented” with some specifics included (what is targeted goal directed education? All EMS personnel received x hours of hands on…)

Goal To maximize the number of cardiac arrest patients that return home to their families neurologically intact I think it would be good to make sure you are clear on the Goal of the Study vs. the goal of CAM So this and the next slides would be the “What you implemented” Your education program or whatever.

HOW TO ACHIEVE THE GOAL: Strategies HOW TO ACHIEVE THE GOAL: Assigned roles Rapid and accurate assessment Adequate work space Continuous high quality chest compressions Airway with synchronized ventilations Prompt defibrillation ALS: Vascular access with medications Resuscitation Management & Teamwork Recognition of ROSC How to achieve the goal

Back to Basics Cornerstones of treatment: Assessment Patient Positioning CPR Continuous Chest Compressions Airway/Ventilation/Oxygenation Defibrillation Possible, but unproven value: Intubation Vascular access (IV/IO) Pressors (epinephrine) Antiarrhythmics (lidocaine, amiodarone)

Continuous High Quality Chest Compressions Strategy #4 Continuous High Quality Chest Compressions Rate 112/Minute (metronome) Depth 2-2.5 Inches Full Chest Recoil Increases likelihood of successful defibrillation Maintains brain viability Describe high quality chest compressions

Competency-Based Training Who here has failed an ACLS course?

Process Measures QI This is likely part of the education part right?

RESULTS

Cardiac Etiology – All Rhythms Survival to Hospital Discharge (%) National CARES Santa Barbara County p=0.002 Results 2012 2013

Bystander-Witnessed Shockable 1st Rhythm Survival to Hospital Discharge (%) National CARES Santa Barbara County P> 0.05 Results 2012 2013

Cardiac Etiology – All Rhythms Survival to Hospital Discharge (%) 15.8 Post- CAM 8.1 Pre- CAM 2011-12 2013-1Q15

Bystander-Witnessed Shockable 1st Rhythm Survival to Hospital Discharge (%) 45.0 Post- CAM 25.9 Pre- CAM 2011-12 2013-1Q15

Cardiac Etiology – All Rhythms Survival to Hospital Discharge (%) National CARES Ventura County CAM 2009 2010 2011 2012 2013 2014

Bystander-Witnessed Shockable 1st Rhythm Survival to Hospital Discharge (%) National CARES Ventura County CAM 2009 2010 2011 2012 2013 2014

Lessons Learned Engage entire system. Build interest. Insist on consistency. Will sell itself. Process improvements (organization, CPR) precede outcome benefits. Costs are modest. Dr. Rea’s answer. w/ Telephone CPR.

Conclusions Introduction of an organized Cardiac Arrest Management (CAM) program resulted in a significant improvement in survival. Simultaneous introduction of entire bundle of care resulted in more convincing single-step improvement.

Conclusions Emphasis on early, continuous, high-quality chest compressions with infrequent low-volume ventilations. System to enable that: Clear and detailed protocols Assigned roles EMTs responsible for BLS Competency-based individual and team training Ongoing active data-driven QI

Survivor Group