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

2. 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

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

4. 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

5. Presentation Slide Title

6. 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

7. “WHAT” VS
“HOW”

8. OHCA Survival
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

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

10. 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…)

11. 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

12. 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…)

13. 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.

14. 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

15. 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)

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

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

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

19. RESULTS

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

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

22. Cardiac Etiology – All Rhythms Survival to Hospital Discharge (%)
15.8
Post-
CAM
8.1
Pre-
CAM
Q15

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

24. Cardiac Etiology – All Rhythms Survival to Hospital Discharge (%)
National CARES Ventura County
CAM

25. Bystander-Witnessed Shockable 1st Rhythm Survival to Hospital Discharge (%)
National CARES Ventura County
CAM

26. 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.

27. 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.

28. 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

29. Survivor Group