STRATEGIES TO IMPROVE
A Time to Act
Committee on the Treatment of Cardiac Arrest:
Current Status and Future Directions
Board on Health Sciences Policy
Robert Graham, Margaret A. McCoy,
and Andrea M. Schultz, Editors
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine.
This study was supported by Contract No. 200-2011-38807, TO #24, between the National Academy of Sciences and the Centers for Disease Control and Prevention; Contract No. HHSN26300031 between the National Academy of Sciences and the National Institutes of Health; Contract No. VA791-14-P-0865 between the National Academy of Sciences and the U.S. Department of Veterans Affairs; and with support from the American College of Cardiology, the American Heart Association, and the American Red Cross. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the views of the organizations or agencies that provided support for the project.
International Standard Book Number-13: 978-0-309-37199-5
International Standard Book Number-10: 0-309-37199-6
Library of Congress Number: 2015947581
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Suggested citation: IOM (Institute of Medicine). 2015. Strategies to improve cardiac arrest survival: A time to act. Washington, DC: The National Academies Press.
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Willing is not enough; we must do.”
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
Advising the Nation. Improving Health.
THE NATIONAL ACADEMIES
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COMMITTEE ON THE TREATMENT OF CARDIAC ARREST:
CURRENT STATUS AND FUTURE DIRECTIONS
ROBERT GRAHAM (Chair), Milken Institute School of Public Health, George Washington University, Washington, DC
MICKEY EISENBERG (Vice Chair), King County Emergency Medical Services, Seattle, Washington
DIANNE ATKINS, University of Iowa Carver College of Medicine, Iowa City
TOM P. AUFDERHEIDE, Medical College of Wisconsin, Milwaukee
LANCE B. BECKER, University of Pennsylvania Health System, Philadelphia
BENTLEY J. BOBROW, University of Arizona College of Medicine, Tucson
NISHA CHANDRA-STROBOS, Johns Hopkins University, Baltimore, Maryland
MARINA DEL RIOS, University of Illinois, Chicago
AL HALLSTROM, University of Washington, Seattle
DANIEL B. KRAMER, Harvard Medical School, Boston, Massachusetts
ROGER J. LEWIS, University of California, Los Angeles
DAVID MARKENSON, Sky Ridge Medical Center, Denver, Colorado
RAINA M. MERCHANT, University of Pennsylvania, Philadelphia
ROBERT J. MYERBURG, University of Miami, Florida
BRAHMAJEE K. NALLAMOTHU, University of Michigan, Ann Arbor
ROBIN P. NEWHOUSE, University of Maryland School of Nursing, Baltimore
RALPH L. SACCO, University of Miami, Florida
ARTHUR B. SANDERS, University of Arizona College of Medicine, Tucson
CLYDE W. YANCY, Northwestern University School of Medicine, Chicago, Illinois
MARGARET A. MCCOY, Study Director
CATHARYN T. LIVERMAN, Senior Scholar
SARAH DOMNITZ, Program Officer
ASHNA KIBRIA, Associate Program Officer
R. BRIAN WOODBURY, Senior Program Assistant
JUDY ESTEP, Program Associate
ANDREW M. POPE, Director, Board on Health Sciences Policy
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:
ROBERT A. BERG, Children’s Hospital of Philadelphia, PA
SUMEET S. CHUGH, Cedars-Sinai, Los Angeles, CA
LESLEY HUNTLEY CURTIS, Duke University, Durham, NC
DAVID M. CUTLER, Harvard University, Cambridge, MA
RALPH B. D’AGOSTINO, SR., Boston University, MA
DANA P. EDELSON, University of Chicago Medical Center, IL
IGOR EFIMOV, George Washington University, Washington, DC
ARTHUR L. KELLERMANN, Uniformed Services University of the Health Sciences, Bethesda, MD
RUDOLPH W. KOSTER, University of Amsterdam, The Netherlands
VINAY M. NADKARNI, The Children’s Hospital of Philadelphia, PA
GRAHAM NICHOL, Harborview Medical Center, Seattle, WA
PAUL E. PEPE, University of Texas Southwestern Medical Center, Dallas
JOHN T. WATSON, University of California, San Diego
MYRON L. WEISFELDT, Fund for Johns Hopkins Medicine and Business Development, Baltimore, MD
JAMES O. WOOLLISCROFT, University of Michigan Medical School, Ann Arbor
Although the reviewers listed above have provided many constructive comments and suggestions, they did not see the final draft of the report before its release. The review of this report was overseen by HUGH H. TILSON, Adjunct Professor of Public Health Leadership, University of North Carolina, and CHARLES E. PHELPS, Provost Emeritus, University of Rochester. Appointed by the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
As a medical emergency there is nothing more dramatic than sudden cardiac arrest. It is only in the past 50 years that medical therapy and procedures have made it possible for successful resuscitation. When cardiopulmonary resuscitation (CPR) and defibrillation are provided quickly, and there is an effective system of care, the chance of successful restoration of life with full neurological recovery is possible.
Emergency medical services (EMS) personnel, often with the assistance of citizen bystanders, comprise the front line in resuscitation in the out-of-hospital setting. In hospital settings, health care professionals are often faced with the challenge of responding to a cardiac arrest in pediatric and adult patients who suffer from other serious medical conditions. Although breakthroughs in understanding and treatment are impressive, the ability to consistently deliver timely interventions and high-quality care is less than impressive. The result is too many people dying from cardiac arrest. Based on recent estimates, more than 1,600 people suffer a cardiac arrest every day in the United States, defining an immense and sustained public health problem.
Equally unacceptable are the disparate survival rates within our population. Minorities and those in the lower economic strata fare worse compared to others. And where one resides is determinant of survival. There is wide diversity in survival rates among communities and hospitals in America. In some communities more than 60 percent of persons with out-of-hospital cardiac arrest (due to bystander-witnessed ventricular fibrillation) survive and are discharged from the hospital. In far more communities, the survival rate is 10 percent or less. Why is this, and what can be done?
This report examines the complex challenges and barriers to successfully treat cardiac arrest, both in the community and in the hospital, and offers concrete suggestions to improve, what the committee believes to be, an unacceptably low survival rate. Observing high-performing EMS and health care systems allows best practices to be identified and, in turn, offers strategies for other communities to adopt. Recommendations are made that the committee believes will lead to higher survival rates and give everyone, everyplace, a better chance of survival.
The primary goal in treating cardiac arrest, whether in the community or in hospitals, is to provide high-quality care quickly. For out-of-hospital cardiac arrest this is no easy feat considering the challenges of bystanders recognizing the event and calling 911; emergency telecommunicators identifying the problem, providing guidance to the rescuer, and dispatching emergency responders; and emergency medical technicians (EMTs) and paramedics responding to the call, arriving at the scene, and beginning CPR (if not already started), providing a defibrillatory shock (if required), achieving airway control, inserting an intravenous line, and delivering medications. Different yet similar challenges exist for cardiac arrest occurring within hospitals.
This report represents the collective conclusions and recommendations of a diverse group of experts, each of whom brought their expertise and perspectives. The charge to the committee was clear. How can we improve survival and quality of life following cardiac arrest both in the community and in the hospital? This report emphasizes the following strategies:
- Establish a national registry of cardiac arrest in order to monitor performance in terms of both success and failure, identify problems, and track progress.
- Enhance performance of EMS systems with emphasis on dispatcher-assisted CPR and high-performance CPR.
- Develop strategies to improve systems of care within hospital settings and special resuscitation circumstances.
- Expand basic, clinical, translational, and health services research in cardiac arrest resuscitation and promote innovative technologies and treatments.
- Educate and train the public in CPR, use of automated external defibrillators, and EMS-system activation.
- Create a national cardiac arrest collaborative to unify the field and identify common goals to improve survival.
This report benefited immensely from the skilled work and dedication of the Institute of Medicine staff, led by Margaret McCoy, and assisted by Catharyn Liverman, Sarah Domnitz, Ashna Kibria, and R. Brian Woodbury. We also wish to thank our colleagues on the committee for their passion, expertise, contributions, and unflagging patience as we considered, debated, and reached consensus on the complex issues.
The committee’s work was enhanced by testimony and presentations by dozens of individuals from a host of federal and community agencies. Throughout the United States, the response to community cardiac arrest is provided by emergency medical services. Hundreds of thousands of dispatchers, telecommunicators, EMTs, first responders, and paramedics work together to provide the highest level of care directly at the scene of the cardiac arrest. Similarly, we extend our appreciation in equal measure to hospital professionals who provide care for patients who arrest in the hospital and who continue the intensive and complex care after the transfer of care for patients who respond to treatment in the field. We thank all of these individuals for their dedication and professionalism. We applaud the citizen bystanders, patient and family advocates, and community leaders who have the courage and compassion to step forward and provide CPR and defibrillation and who promote cultures of action within their communities. Finally, we acknowledge those individuals and families who have been affected by cardiac arrest and encourage them to continue to share their experiences with others as important examples of what is at stake and what is possible.
Robert Graham, Chair
Mickey Eisenberg, Vice Chair
Committee on the Treatment of Cardiac Arrest:
Current Status and Future Directions
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The Institute of Medicine (IOM) Committee on the Treatment of Cardiac Arrest: Current Status and Future Directions would like to express its sincere gratitude to everyone who made this report possible. This report was informed by the contributions of many individuals who provided expertise, personal insights and perspectives, data, and analysis. This report was generously supported by the American College of Cardiology, the American Heart Association, the American Red Cross, the Centers for Disease Control and Prevention, the National Institutes of Health (NIH), and the U.S. Department of Veterans Affairs.
The committee held two public workshops in May and July 2013 and gained valuable insights from the substantive presentations provided by the following speakers:
Mark Alberts, University of Texas Southwestern Medical Center
Amer Aldeen, Chicago Cardiac Arrest Resuscitation Education Service
Robert Berg, University of Pennsylvania
Scott Berry, Berry Consultants
Robin Boineau, National Heart, Lung and Blood Institute
Bernd Böttiger, University Hospital of Cologne, Germany
Steven Bradley, Veterans Affairs Eastern Colorado Health Care System
Jeremy Brown, NIH Office of Emergency Care Research
Paul Chan, St. Luke’s Health System
Allison Crouch, Emory University
Gregory Dean, Washington, DC, Fire Department
Dana Edelson, University of Chicago Medicine
Jim Fogarty, King County Emergency Medical Services System
Romer Geocadin, Johns Hopkins University
Louis Gonzales, Office of the Medical Director at Austin-Travis County EMS System
Stephen Grant, Division of Cardiovascular and Renal Products, Food and Drug Administration
Amy Burnett Heldman, Centers for Disease Control and Prevention
Ahamed Idris, University of Texas Southwestern Medical Center
David Jacobs, Durham Fire Department
Peter Kudenchuk, University of Washington
Jonathan Larsen, Captain, City of Seattle Fire Department
Bryan McNally, Emory University
Vinay Nadkarni, Children’s Hospital of Philadelphia
Robert Neumar, University of Michigan
Mary Newman, Sudden Cardiac Arrest Foundation
Graham Nichol, University of Washington-Harborview Center for Pre-hospital Emergency Care
Sue Nixon, Ardent Sage
Joseph Ornato, Virginia Commonwealth University Medical Center
Mary Ann Peberdy, Virginia Commonwealth University
Thomas Rea, South King County Medic One Program
Comilla Sasson, American Heart Association
Cleo Subido, King County Emergency Medical Services System
Myron Weisfeldt, Johns Hopkins University
Michele Wenhold, Parent Heart Watch
Demetris Yannopoulos, University of Minnesota Medical School
Bram Zuckerman, Center for Devices and Radiological Health, Food and Drug Administration
The committee would like to thank the following individuals, who generously provided their time and expertise, and whose contributions were essential in informing deliberations: Paul Chan, Allison Crouch, Leslie Curtis, Mohamud Daya, Susanne May, Bryan McNally, Laurie Morrison, Monica Rajdev, Rob Schmicker, and Kimberly Vellano.
We also thank the city of Seattle, Washington, and Councilman Nick Licata for hosting, and Ann Doll for helping prepare for the committee’s second meeting, which provided a beautiful backdrop for the committee’s information-gathering activities and deliberations.
The committee benefited from the work of the IOM study staff team: Margaret McCoy directed the study, and Sarah Domnitz, Ashna Kibria,
and R. Brian Woodbury provided research support. Our thanks to Andrew Pope and Catharyn Liverman for their leadership and advice. Additionally, Judy Estep, Jeanette Gaida, and Claire Giammaria were instrumental in finalizing the report. Thanks to the IOM and the National Research Council staff members who worked behind the scenes to ensure successful production and dissemination of this report: Anton Bandy, Porter Coggeshall, Laura DeStefano, Chelsea Frakes, Molly Galvin, Greta Gorman, Linda Kilroy, Fariha Mahmud, Maureen Mellody, Abbey Meltzer, Lora Taylor, and Jennifer Walsh.
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