Strategies to Improve Cardiac Arrest Survival: A Time to Act (2015)

7

Recommendations and Key Opportunities

Cardiac arrest is a treatable medical event that requires immediate action to save a life. Affecting nearly 600,000 people per year (Daya et al., 2015; Merchant et al., 2011), cardiac arrest can strike indiscriminately and without warning, often leaving grieving family members and friends to question what could have been done differently. Regardless of the outcome, individuals who experience a cardiac arrest encounter many care providers—including bystanders, first responders, emergency medical services (EMS) personnel, and health care providers. These providers administer essential and interdependent treatments along a continuum of care that may vary in quality and effectiveness. Given the range of negative effects that cardiac arrest can have on the length and quality of a person’s life, intensive efforts are needed in order to expand the use of evidence-based practices and to optimize the delivery of known, effec-

tive treatments, which can increase likelihood of survival. In the long term, a reexamination of the current understanding of the causes, diagnosis, and treatment of cardiac arrest will be necessary to generate new knowledge that can be used to enable high-quality care across the continuum of care and overcome the longstanding plateau in cardiac arrest survival rates. Additionally, a more cohesive and coordinated approach is required to enhance public education, training, and advocacy across all communities and settings.

In 2012, the Institute of Medicine published a report focused on improving care at reduced cost for patients within the health care system (IOM, 2013). The report described a vision for a learning health care system, which is characterized by the alignment of “science and informatics, patient-clinician partnership, incentives, and culture … to promote and enable continuous and real-time improvement in both the effectiveness and efficiency of care” (IOM, 2013, p. 17). The learning health care system expands upon the concepts of continuous quality improvement (CQI) discussed in Chapter 6 by focusing not only on the practical and technical elements required to engage in CQI, but also on action-oriented, system-level characteristics that are essential to encourage continous learning through measurement and evaluation across and throughout a system of care. In the case of cardiac arrest, the system of care encompasses numerous facets including the public, EMS systems, health care systems, and hospitals. Building on the concept of a continously learning health care system, the committee identified foundational elements of a learning system of response for cardiac arrest and resuscitation research (see Table 7-1).

These foundational elements provide substance to the framework presented in Chapter 1, defining overarching principles—across multiple dimensions and stakeholders—that can be used to guide efforts to save additional lives each year. Given the current gaps in cardiac arrest knowledge, care, and training, the committee examined the available evidence on cardiac arrest surveillance, epidemiology, treatment, training, and education programs and then developed recommendations and priorities for further research to improve existing cardiac arrest programs, protocols, and outcomes. The evidence-based recommendations described in this chapter present interrelated, action-oriented steps that, when combined, should enable short- and long-term improvements for people with cardiac arrest. The research opportunities provide directions for further developing the evidence base for the resuscitation field.

TABLE 7-1 Foundational Elements of a Continuously Learning System of Response to Cardiac Arrest and Resuscitation Research

SOURCE: Adapted from IOM, 2013, p. 18.

ESTABLISH ROBUST DATA COLLECTION AND DISSEMINATION

Resuscitation research in the United States is hindered by a paucity of high-quality data for both out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA). Because of the lack of national EMS and health care system performance metrics to guide cardiac arrest treatment, the quality, scope, and type of data collected varies across health care organizations. Existing cardiac arrest registries are voluntary, which leads to questions about generalizability of the data and analyses. Furthermore, decreasing support for registries threatens existing data sources and current quality improvement activities. As a result, researchers are limited not only in their ability to estimate the public health burden of cardiac arrest, but also in their capacity to identify correlations between patient characteristics and incidence rates, and associations among treatments, care quality, and outcomes. Consequently, current

guidelines for many cardiac arrest treatments may be based on incomplete and insufficient evidence.

Despite these limitations, some epidemiological trends have been observed, and factors correlated with incidence and survival have been identified. For example, reducing the time between collapse and initiation of cardiopulmonary resuscitation (CPR) and defibrillation has been significantly associated with better survival rates and improved outcomes. The available data can help identify geographic variation in cardiac arrest outcomes, and wide regional variation has been identified. While patient characteristics such as race and gender have been associated with disparities in outcomes, these factors cannot explain the wide variations that have been observed, thus pointing to concerns about access and quality of care.

Holding EMS and health care systems accountable for performance first requires improving the state of data collection, reporting, and analysis across the cardiac arrest field. The committee has identified several key areas for action related to data collection and dissemination, including the development of a national cardiac arrest registry, standardization of terms used to measure patient treatment and outcomes, and identification of performance metrics that should be measured and recorded for all cardiac arrest patients. Further opportunities are discussed in Box 7-1.

Currently, a national surveillance system for cardiac arrest does not exist. Registries for OHCA and IHCA rely on voluntary participation, and, therefore, do not provide comprehensive geographic coverage. In fact, many communities and states do not track cardiac arrest incidence and outcomes nor do they report to a larger registry. Moreover, data on important determinants of outcomes (e.g., race and ethnicity, socioeconomic factors) are not fully captured and may not be reliable in existing registries. This lack of data leads to an under-representation of the disparities that relate to factors such as variation in care, race and ethnicity, and urban versus rural settings. There are also limited data on long-term outcomes of cardiac arrest following hospital discharge. As a result, significant knowledge gaps about the incidence and predictors of cardiac arrest, as well as the effectiveness of specific treatments, persist.

With some of the larger cardiac arrest registries expected to lose funding soon, a lead organization is needed to develop and maintain the infrastructure and oversee national data collection related to cardiac arrest. These efforts would allow for more reliable and accurate data aggregation, enabling benchmarking and continuous quality improvement initiatives. The existence of one national data collection effort would also reduce unnecessary confusion in an already complex field of study.

CDC has traditionally served as the primary institution responsible for creating and maintaining national surveillance systems for infectious, chronic, and acute conditions, often in collaboration with appropriate state government and local health agencies. For example, a federal mandate provided CDC with funds for creating new registries and setting national quality standards for the National Program for Cancer Registries. This mandate also granted states the authority to require data reporting and ensure that patient privacy and confidentiality were maintained (Izquierdo and Schoenbach, 2000). In its effort to create a national cardiac arrest registry for reporting and tracking OHCA and IHCA incidence and outcomes, CDC should ensure that data from EMS agencies and hospitals are sufficient and reliable enough to provide a precise assessment of the public health burden of cardiac arrest in the United States.

Importantly, the national cardiac arrest registry should allow public reporting of both incidence and outcomes, while maintaining compliance with patient privacy regulations. This serves multiple purposes. It allows members of the public, policy makers, and advocates to be aware of how their locality performs on a national scale and to make informed decisions regarding resource allocation and targeted interventions for vulnerable populations within their community. It also allows participating EMS agencies and hospitals to assess their own performance, and allows benchmarking at the local, regional, and national levels. Enhanced transparency is likely to drive accountability at multiple levels, improving quality of care and ultimately patient outcomes.

Implementing a national registry will require using a standard data-reporting template that identifies essential, core data elements for mandatory reporting and includes additional supplementary metrics that can enrich the data source and enhance research efforts. Existing databases such as the Cardiac Arrest Registry to Enhance Survival (CARES) and the Resuscitation Outcomes Consortium (ROC) Epistry¹ have already created reporting templates for OHCA, while the Get With The Guidelines-Resuscitation (GWTG-R) registry has done the same for IHCA. These registries have certain limitations, as described in previous

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¹The National Institutes of Health (NIH) has not renewed funding for ROC, and this clinical trials network will end in 2015 (personal communication, J. Brown, NIH, May 22, 2015). NIH recently announced plans to form a new clinical trials network for emergency care, SIREN, which will focus on “heart, lung, and blood-related emergency care in adults” (NHLBI, 2015).

chapters, but they could be used as an initial template from which the national registry could be built.

Although the international resuscitation community has proposed standard definitions and metrics for reporting OHCA and IHCA, these have not yet been uniformly adopted by existing registries (Cummins et al., 1997; Jacobs et al., 2004; Perkins et al., 2014). The 2014 Utstein-Style update, as described in Chapter 2, also reversed the previous guidelines, which had proposed a common data collection template for both OHCA and IHCA, because of differences in the epidemiology, treatment, and care delivery of the two types of cardiac arrest. The updated guidelines expanded the list of core (essential) and supplemental (desirable) data elements (see complete list in Appendix F), but they did not include race and ethnicity or socioeconomic factors (e.g., primary language, income) as either core or supplemental metrics. These data are important in identifying vulnerable populations that are traditionally less likely to have adequate access to, and utilization of, care. CDC could collaborate with other federal agencies, such as the National Institutes of Health (NIH), to create a working group of multidisciplinary experts to identify standard metrics for optimal use in a national cardiac arrest registry. The committee suggests expanding data collection to include important predictors such as race and ethnicity, socioeconomic status, and primary language, when available, in order to identify potential disparities in cardiac arrest and to better target interventions to rectify these with the goal of improving national survival rates.

A national surveillance system should collect accurate and complete data for OHCA and IHCA, regardless of whether the data sets are combined or separate. Current surveillance for IHCA, based on hospital claims and administrative data, presents unique challenges for investigators because of the lack of a specific diagnostic code for IHCA. The multiple codes for “cardiac arrests,” as well as the comorbidities that IHCA patients often have, can also lead to preferential coding by hospital administrators, who may choose to rank other conditions higher than the arrest experienced by the patient (Morrison et al., 2013). Investigators currently rely on algorithms that use a combination of different diagnostic and procedural codes for other proxy conditions to capture incidence. This approach can lead to an inaccurate picture of the overall situation. Creating separate diagnosis codes for IHCA and OHCA will facilitate more accurate data collection and analysis, which will benefit activities to improve both IHCA and OHCA treatment in the long run. CDC’s North American Collaborating Center currently serves as the U.S. liaison

to the World Health Organization, which maintains and amends the ICD coding system, and is therefore the national authority to take the lead on developing and implementing unique ICD codes for OHCA and IHCA.

PUBLIC AWARENESS AND EDUCATION

Bystanders who witness an OHCA are key to providing early access, CPR, and defibrillation—the first links in the chain of survival and the links that are most strongly associated with improved outcomes (see Chapter 1). Many communities that demonstrate high rates of survival and positive neurological outcomes have succeeded with the help of high-performing EMS systems and an engaged public that is trained in bystander CPR and the use of automated external defibrillators (AEDs). Despite strong evidence indicating that bystander CPR and AED use can significantly improve survival and outcomes, rates of annual bystander CPR training remain low across the United States (Anderson et al., 2014). Rates of training vary based on a number of factors, which could be used to develop targeted interventions to reach broader populations. For example, individuals over the age of 50 are less likely than younger populations to attend traditional CPR training courses (Brennan and Braslow, 1998; Selby et al., 1982), yet they are more likely to experience cardiac arrest, especially in a home setting (see Chapter 1).

Communities are faced with many challenges in developing programs to educate and motivate the public to respond to cardiac arrest with CPR and AEDs. Funding for CPR training programs is difficult for many communities, CPR guidelines vary and can create confusion, and concerns about harm when delivering CPR and subsequent liability are common. Further complicating the situation is the lack of a single AED registry, so members of the public and emergency care providers who do know how to use AEDs are often unaware of the location, number, and operational status of AEDs in their area. Dispatcher-assisted CPR can also be an effective tool for treating cardiac arrests that are witnessed by bystanders, but individuals must first know when and how to initiate and engage the EMS system.

An informed, coordinated, and effective campaign to promote public education and training opportunities and to reduce barriers to bystander CPR and defibrillation use would greatly contribute to efforts to reduce mortality and poor outcomes from cardiac arrest. Further opportunities and areas for action are discussed in Box 7-2.

Developing and implementing strategies to better educate members of the public about what cardiac arrest is, how to identify it, and how to respond to it is a public health priority that can improve health outcomes in the near future. To create a culture of action, public awareness campaigns and CPR and AED training initiatives must target whole communities, including older children, young adults, the workforce, and retired populations. School-based CPR and AED training programs present an opportunity for great impact, because these programs can educate large numbers of individuals across a wide range of age groups, all socioeconomic groups, and all geographic locations. Furthermore, these programs can be administered at a comparatively low cost and in a short amount of time. Another naturally occurring ideal training location is the workplace, where employers have many opportunities to provide CPR and AED training. For example, new employee orientation, recurring professional education requirements, and annual health fairs could all be used to teach employees who have never received training and to refresh skills.

CPR and AED training initiatives should also prioritize the mitigation of disparities in bystander CPR rates, by training populations that have a high risk of experiencing cardiac arrest, or that are more likely to witness an arrest. For example, a variety of community and neighborhood organizations in partnership with state and local health departments should develop training programs that specifically target retirement communities and older adults. Targeted training programs could also focus on populations that are currently underrepresented in CPR training programs or that are less likely to receive rapid, high-quality prehospital care. Moreover, existing and newly developing training modules or platforms that account for differences in community and neighborhood characteristics, socioeconomic factors, race and ethnicity, and language barriers in the most at-risk populations should be explored.

To respond to concerns about liability, CPR and AED training programs and modules should explain what Good Samaritan laws are and how they apply within specific jurisdictions. Additionally, federal and state governments have an obligation to review and strengthen existing Good Samaritan laws in order to protect any lay rescuer who provides

emergency care, including CPR and use of an AED, from civil liability, regardless of the lay rescuer’s CPR and AED certification status.

Effectively educating the public to respond to cardiac arrest is no small undertaking. Implementation of such training programs throughout individual communities will require the expertise, resources, and commitment from multiple organizations and government entities. State and local governments, philanthropic organizations, and advocacy groups could serve as possible funding sources, while medical, public health, and local community organizations could be sources of necessary training equipment and personnel. Digital coursework, simplified training aids, and abbreviated courses provide alternative ways to decrease the costs, without diminishing the effect of basic life support education.

Creating a culture of action will not be easy, but it is necessary in order to make a real difference in survival rates nationwide. In addition to improving outcomes, training the public to respond to cardiac arrest will likely have the added benefit of improving the public’s response to many other types of emergencies that require the timely activation of the emergency medical system.

IMPROVE THE DELIVERY OF HIGH-QUALITY RESUSCITATION CARE

IHCA and OHCA each have unique epidemiological patterns, etiologies, and treatments. IHCA is less common and is less often fatal than OHCA; the arrests within monitored units of the hospitals are witnessed more often, and therefore response times are shorter. In comparison to IHCA, a greater portion of OHCA patients has an initial ventricular fibrillation/ventricular tachycardia (shockable) rhythm. Hospitalized patients who experience an arrest tend to be older and have more severe illnesses and secondary comorbidities. While a majority of OHCAs result from preexisting cardiovascular conditions and occur unexpectedly, IHCA cases often exhibit a period of decline prior to an arrest and are caused by cardiac conditions less than half the time (Chan et al., 2015; Morrison et al., 2013). These factors and others contribute to differences in the available treatments, care protocols, and likelihood of survival with positive neurologic and functional outcomes by location following a cardiac arrest.

The health care providers and systems responsible for treating OHCA and IHCA all have distinct limitations, strengths, challenges, and

opportunities. High-performing EMS systems exist. However, the extreme heterogeneity of agencies and systems across the United States makes the successful adaptation of organizational models a sizable challenge. Promising interventions, such as high-performance and dispatcher-assisted CPR, have been developed, but the effective implementation of these types of interventions requires a culture dedicated to CQI efforts. Among hospitals, there is considerable variability in staffing models, patient monitoring, emergency code protocols, and resuscitation team characteristics (e.g., size, composition, organization, team member expertise). Variation in these factors affects treatment and can cause considerable disparities in outcomes, which often affects minority patients disproportionately. Although multiple professional organizations and consensus committees have issued guidelines informing treatments (e.g., targeted temperature management) and care models (e.g., goal-directed therapy) for post-arrest care, the evidence base for such therapies is often limited and/or mixed. Persistent gaps in post-arrest research will need to be filled in order to have a considerable impact on the quality of treatment and outcomes.

Advancing cardiac arrest treatment inside and outside the hospital will require developing a cardiac arrest registry with standardized definitions and metrics upon which research efforts can be based. Additional opportunities for improving patient outcomes include the creation of powerful diagnostic tools, training programs to development nontechnical resuscitation skills, and regional cardiac arrest care centers. These and other opportunities identified by the committee are discussed below, and further opportunities and action areas are discussed in Box 7-3.

A number of EMS and hospital actions have been associated with higher cardiac arrest survival rates in some communities. These exemplar EMS and hospitals systems offer promising strategies that could be more widely adopted in order to reduce the public health burden of cardiac arrest. For example, dispatcher-assisted CPR has been associated with improved patient outcomes from OHCA (Eisenberg et al., 1985; Kellermann et al., 1989; Lewis et al., 2013; Song et al., 2014). Like dispatcher-assisted CPR, high-performance CPR has been demonstrated to have a positive impact on cardiac arrest survival (Bobrow et al., 2013; Christenson et al., 2009; Stiell et al., 2012). However, there is no standardized training program available for dispatcher-assisted CPR. Moreover, a single, nationally recognized definition of high-performance CPR does not exist, making training and implementation efforts difficult. Standardized definitions, training, and performance evaluation measures for care processes and protocols would promote a more rapid and uniform adoption and assessment of cardiac arrest quality of care from the community to the national level.

Developing standardized protocols, educational standards, and training curricula is the first step to encourage the adoption of practices that have demonstrated a positive effect on saving lives from cardiac arrest. By establishing standardized protocols and educational standards for dispatcher-assisted CPR, as well as standardized definitions and training for high-performance CPR, NHTSA will accomplish two things. First, it will light a clear path for communities that want to adopt dispatcher-assisted CPR and high-performance CPR. These protocols and standards should be based on collective knowledge and experience that have been gained through the successful implementation of such programs in the field. Second, it provides a standardized foundation from which communities can measure improvements in cardiac arrest outcomes as part of CQI activities. This information can then be used to develop a stronger evidence base for updating protocols, educational standards, and curricula.

One way to effectively disseminate and educate EMS professionals about new dispatcher-assisted CPR and high-performance CPR standards may be for NHTSA to create “EMS Training Centers of Excellence.” EMS agencies could send appropriate personnel to these centers for training in state-of-the-art treatment, monitoring, and CQI strategies and practices. NHTSA has offered similar programs in the past. For example, NHTSA established a course called “Development of Trauma Systems” (NHTSA, 2004). As part of this program, NHTSA provided instructors to train individuals.² By establishing regional training centers of excellence, NHTSA could bring in leaders from EMS systems across the country, who could then train others in their states, counties, and communities.

ASSESSING HOSPITAL PERFORMANCE TO IMPROVE CARDIAC ARREST OUTCOMES

There is considerable variation in the treatment, care delivery, and outcomes across hospitals in the nation for IHCA and post-arrest care. A

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²Personal communication with D. Dawson, NHTSA, March 10, 2015.

majority of hospitals in the United States do not monitor patient outcome following cardiac arrest nor do they publicly report standard measures of cardiac arrest survival to discharge and neurological outcomes. As discussed throughout the report, this lack of data collection and reporting creates a dearth of available evidence from which new treatments and care models can be developed. Although the American Heart Association’s GWTG-R registry provides a platform for data reporting, benchmarking, and quality improvement, a majority of hospitals do not participate in this type of registry. Furthermore, it is unclear whether the hospitals that do participate in the GWTG-R registry use the data to improve processes and outcomes. A lead organization that is responsible for setting minimal monitoring and reporting standards for cardiac arrest and that requires hospitals to adhere to such standards as part of accreditation criteria is needed. This change would create new levels of accountability and transparency in hospitals across the nations, and it represents an important opportunity for improving nationwide survival rates.

The Joint Commission provides accreditation for approximately 3,300 hospitals across the United States, ensuring that these facilities meet required standards in order to maintain high levels of quality of care and patient safety (The Joint Commission, 2014). Although accredited hospitals must adhere to standards for resuscitation services and general standards for quality improvement, currently there are no requirements for hospitals to report patient outcomes for cardiac arrest. Because many state governments, regulatory agencies, and third-party payers require The Joint Commission accreditation as a condition for payment or reimbursement (The Joint Commission, 2011), setting national accreditation standards for cardiac arrest would create incentives for hospitals to improve cardiac arrest care and outcomes.

Numerous studies of cardiac arrest registries, both in-hospital and out-of-hospital, have demonstrated significant improvements in overall

outcomes among health care systems that regularly monitor and report data on patient outcomes. These positive results are likely due to the fact that participating hospitals are using outcomes data to inform processes and protocols, thus continuously improving the quality of care. Precisely measuring and meeting standards for care process (e.g., delivery of defibrillation within 2 minutes of arrest) may be difficult for all hospitals to achieve; however, hospitals that participate in the GWTG-R registry regularly measure and report Utstein guideline’s recommended data elements for survival and neurologic outcomes, which can be easily implemented in most hospital settings (Cummins et al., 1991; Peberdy et al., 2003). The Joint Commission could consider adopting this achievable and widely recognized cardiac arrest measurement tool as a part of national accreditation criteria. The outcome data collected could be tied to a formal CQI system in order to inform better care processes. As an example of similar efforts, The Joint Commission’s ORYX initiative assists accredited hospitals in improving quality of care by making the collection of outcomes data a part of the accreditation process (The Joint Commission, 2014). This initiative provides flexibility for small hospitals and critical care hospitals to meet reporting standards, by requiring internal data collection but providing exemptions for external reporting. The committee recognizes that a small rural hospital with limited specialty coverage is very different from a major teaching hospital that has numerous residents and trainees who are capable of responding 24 hours per day. However, all hospitals should be capable of assessing their cardiac arrest treatment protocol and working to improve survival.

The committee encourages The Joint Commission to work with guideline-setting organizations, such as the American Red Cross and the American Heart Association, and collaborate with hospitals, health care systems, and related stakeholders, including professional organizations and patient advocacy groups, in order to develop achievable national standards for hospital accreditation. This collaborative effort to develop national standards complements the committee’s recommendation to create a national surveillance system for OHCA and IHCA, because accreditation standards will ensure completeness of data from hospitals as they adhere to collection and reporting requirements for accreditation. This effort would also complement the following recommendation, which builds on the concept of measuring outcomes, as a first step in improving overall quality of care.

As described throughout this report, the small number of EMS systems, hospitals, and health care systems that have adopted CQI programs or are informally monitoring performance are demonstrating tremendous improvements in outcomes over time (Chan, 2015; Travers et al., 2010). The communities that are achieving the greatest improvements in survival rates are doing so by

• establishing systems that regularly collect and evaluate data on system processes, patient outcomes, and overall performance;
• benchmarking performance against comparable health care systems or national standards;
• providing nonpunitive feedback to providers; and
• developing strategies for making adjustments in care protocols, as necessary, in order to improve outcomes.

Cardiac arrest is a complex systems problem in health care settings and is a public health problem in communities. Each community is unique—a small, rural community with volunteer EMS providers and long transport times is very different from an urban city with a well-equipped EMS system that is connected to major academic medical centers. Even different hospitals in the same community may have varying functions, staffing patterns, and capabilities. Therefore, one protocol may not be optimal in all community and hospital settings. However, the committee concludes that every hospital and EMS system that treats car-

diac arrest patients should be capable of analyzing its outcomes, protocols, training, and performance using CQI. Although not every system may achieve the results seen in the highest-performing systems, each health care agency and institution should be able to continuously work to improve its survival rates.

In the recommended CQI system, every cardiac arrest would be entered into a database that could then be reviewed by leaders within that EMS or hospital. Thus, each arrest and treatment would contribute crucial information that could be used to improve treatment protocols and care for future cardiac arrest patients. The committee recognizes that CQI has been recommended in the American Heart Association’s guidelines for the past decade (Meany et al., 2013). However, few CQI initiatives have been adopted and are fully functional despite current recommendations. Meaningful CQI requires a strong commitment from hospitals and EMS systems, and it also requires adequate resources, data, authority, and accountability. Communities that have succeeded in improving survival clearly define the people and entities that are responsible for the survival rates and often identify a leader who is charged with overseeing and managing cardiac arrest CQI efforts. This leader must have access to necessary resources in order to identify and assess the gaps (e.g., less than optimal bystander CPR rates, resuscitation protocols) and work with health care professionals to improve outcomes.

Another example of how CQI could be used by hospitals and EMS systems to improve care and outcomes is the assessment and improvement of training and teamwork. Recently, a number of international and national consensus committees and professional organizations recognized the critical importance of multidisciplinary teamwork in high-quality resuscitation care, and these groups issued statements regarding training that emphasize both technical and nontechnical skills (Bhanji et al., 2010; Nolan et al., 2010). Technical training focuses on improving basic and advanced life support skills, while nontechnical training targets skills to enhance communication, cooperation, leadership, and decision making (see Chapter 5). Strategies such as formalized debriefing sessions, which assess provider performance and review resuscitation interventions, have been associated with improved survival rates and positive neurological outcomes (Wolfe et al., 2014; Zebuhr et al., 2012). Simulation training has also been identified as an effective strategy for enhancing performance; studies have found improvements in both technical and nontechnical skills when simulation training is used. In the recommended CQI paradigm, systems and hospitals would assess how well health care

providers work together and whether they are delivering high-quality CPR in order to determine how often retraining is necessary and the best strategies for providing feedback. The committee reiterates that a fully functioning CQI program with clearly defined lines of responsibility, strong leadership, and authority to make necessary changes is essential to improving systems of cardiac arrest treatment and care.

CARDIAC ARREST RESEARCH AND THERAPIES

The challenges within cardiac arrest research go beyond a simple lack of data and reporting. There are also fundamental limitations in the trial designs and research methods that are employed by resuscitation scientists that lead to inefficient, expensive, and often inconclusive studies. The sequential nature of multiphase trials forces researchers to focus on research questions one at a time, while the highly controlled conditions of randomized trials limit the populations for which a given treatment is demonstrated to be effective. Adaptive trial designs that concurrently test multiple hypotheses and update experimental conditions as the trial progresses are less likely to lead to increased expenses and failures and are more likely to lead to rapid translation of research findings to clinical treatments.

Effective treatment of cardiac arrest is also limited by enduring misconceptions of health care systems and professionals regarding the status of scientific guidelines and recommendations. Although the American Heart Association and International Liaison Committee on Resuscitation (ILCOR) guidelines are based on rigorous reviews of the best available evidence, they are consensus statements that reflect varying levels and strength of evidence. Therefore, a number of guideline statements, many of which apply to usual cardiac arrest care, are based of expert opinion and consensus rather than strong evidence. Additionally, guidelines may not represent the most recent research findings and are often developed by extrapolating from available evidence because of limitations of existing data and lengthy review processes. In order to activate the principles of a learning health care system, health care leaders and systems must adapt best-practice guidelines to their own needs and limitations and must be prepared to revise treatment protocols as evidence changes, rather than waiting for guidelines to be updated. In order to better prepare health care systems for the practical challenges of operating a CQI program, the committee also identified a need for more robust research

efforts within implementation and translational science. Further opportunities and areas for action within cardiac arrest research and therapies are discussed in Box 7-4.

Resuscitation science is a major force in advancing patient outcomes. New research findings and emerging discoveries in pharmaceuticals, devices, and biosensors provide compelling promise for boosting survival and positive outcomes. These advances also hold promise for reshaping approaches to the cardiac arrest treatments and care delivery models. However, federal support for resuscitation research is dwindling, and resources are insufficient given the impact of cardiac arrest on society and the potential to decrease this burden through research advances.

Large knowledge gaps about the etiology, pathophysiology, epidemiology, and the effectiveness of current therapies for cardiac arrest persist. Future research must focus on basic, clinical, and translational science that supports the development of progressively newer therapies. Additionally, clinical studies are needed in order to evaluate the effectiveness of existing and new therapies, develop a stronger evidence base for currently accepted best practices, and promote the widespread adoption of evidence-based models of care.

To speed the development, evaluation, and use of effective treatments for cardiac arrest, and thus increase survival rates with positive neurological outcomes, the research enterprise will require sufficient scientific expertise, research capacity, efficiency, and focus on population health. A coordinated effort among multiple federal and nonfederal fun-ders will be needed in order to increase support for pathophysiological and treatment research across the full time course of cardiac arrest—from onset to long-term neurological outcome. Additional emphasis should also be placed on the inclusion and study of populations most affected by cardiac arrest and the settings in which arrests occur. Maximizing the yield of research investments will require improving the efficiency of both early- and late-stage clinical research, by leveraging innovative in clinical trial design that have demonstrated value in other medical domains. Combined, these efforts could increase the rate at which new treatments are identified, evaluated, and found to be effective, in need of further testing or refinement, or definitively without benefit.

The demonstration of benefit from new approaches to treatment is not sufficient, in and of itself, to improve patient outcomes. New approaches must be applied broadly and consistently and in a manner that can be sustained, regardless of the setting (i.e., in-hospital or out-of-hospital setting). Translating clinical research findings into improvements in patient outcomes will require substantial efforts to define evidence-based best practices and to understand the factors that influence adoption in routine care. When adoption is lagging, new implementation strategies that overcome existing barriers must be developed. Similar efforts will be needed to effectively employ new technologies that can be used to improve the speed and effectiveness at which cardiac arrest care is delivered.

To fully realize the potential and promise of the resuscitation field, research that focuses on advancing treatment options and translating science into effective care models must be pursued in parallel with implementation research that focuses on strategies for deploying new treatments and care options in a widespread manner throughout communities across the United States. The full spectrum of research from the most basic science through the translation of findings into care through

the implementation of evidence-based practices across populations will be vital in overcoming the stagnation in cardiac arrest survival rates and outcomes. Furthermore, advances in the field will not be made without cohesive support and meaningful collaboration across the research community, from individual researchers to advocacy and professional organizations to government agencies that support the research.

STAKEHOLDER COLLABORATION

Collaboration among cardiac arrest stakeholder groups, and the promise of advances in treatment that collaboration could bring, has been a largely missed opportunity in the resuscitation field to date. Not only is collaboration between organizations with different objectives and responsibilities (e.g., research institutions and patient advocacy organizations) uncommon, but also even stakeholder groups with similar missions (e.g., multiple EMS agencies) rarely connect in meaningful ways. In the first case, varying goals lead to differences in administration, funding, staffing, and culture that make cooperation difficult because of structural challenges. In the second case, organizations may perceive competition across organizations and stakeholders, as research institutions, educational groups, and hospital facilities often vie for grants, students, and patients. This type of challenge originates with the social and economic systems that define organizations. In both cases, stakeholders are governed by values that may not overtly discourage cooperation, but do not necessarily promote or require it. Cultural shifts will be required for organizations to fully embrace and maximize effective partnerships and collaboration.

The recent emphasis on establishing a culture of accountability within health care systems across the United States offers a new impetus for cooperation among stakeholders. Because collaboration can be foundational to performance improvements, fully accountable organizations must seek it out and actively engage with other organizations. To compare and improve their performance, hospitals and EMS systems must be able to standardize and share patient data and be willing to undertake quality collaboratives and other CQI efforts. Furthermore, building a more collaborative culture may also allow organizations to more easily overcome structural, contextual, and systemic barriers that may hinder collaboration. In light of the potential for collaboration to affect cardiac arrest outcomes and advance the field, the efforts of educational, advo-

cacy, professional, and guideline-setting organizations must be better aligned and leveraged wherever possible. The committee has identified specific opportunities for collaboration that are detailed in Box 7-6.

Numerous organizations and institutions have supported valuable activities to advance the science and implementation of resuscitation, and these activities have led to critical progress within the field over the years. However, these efforts have not established a united advocacy presence to heighten the visibility of cardiac arrest and convey the message that cardiac arrest is a treatable public health threat that warrants the attention and support of policy makers and the public. To develop shared goals and strategies, identify and support new leaders and advocates, and maximize the impact of limited resources within a field, formal and sustained collaboration is essential.

• provide a platform for information exchange about key successes and failures in different systems and settings and for stakeholder communication about new research findings and initiatives;
• convene working groups on short- and long-term national research priorities for cardiac resuscitation and post-arrest care, which focus on critical knowledge gaps (such as the impact of care transitions; the organization, composition, and training of resuscitation teams; optimal timing of initial neurological evaluation; and appropriate withdrawal-of-care protocols);
• develop action strategies related to health policy, research funding and translation, continuous quality improvement, and public awareness and training;
• produce and update toolkits for different stakeholders (e.g., emergency medical services [EMS] systems, hospitals, local health departments, and local health care providers) in order to facilitate effective system and individual responses to cardiac arrest;
• hold an annual collaborative meeting in conjunction with a regularly scheduled health professional conference to discuss short- and long-term goals and progress; and
• encourage public–private partnerships to support activities that focus on reducing the time to defibrillation for cardiac arrest, including the development of technologies to facilitate automated external defibrillator registries for use by the public, EMS systems, and other stakeholders.

Successfully improving cardiac arrest outcomes in the coming decades will require more resources—resources to train and educate emergency responders, health care personnel, and the public; resources to identify and assess current practices; resources to disseminate findings about best practices; and resources to pursue new research goals and treatment opportunities. In order to generate enough visibility and momentum to propel changes in policy and initiate action in communities across the United States, a broad alliance of stakeholders is needed.

With the goal of developing strategic collaborations that could advance the resuscitation field, the NCAC would find the most success by actively engaging an inclusive array of cardiac arrest stakeholders, such as government agencies, professional organizations, academic researchers, state and local public health officials, patient and family advocacy groups, industry, health care providers, and international entities. Specific stakeholders could include, but are not limited to, ACEP, American Academy of Neurology, American College of Cardiology, the American Heart Association, American Hospital Association, American Nurses Association, the American Red Cross, Association of State and Territorial Health Officials, CDC, the Centers for Medicare & Medicaid Services, Heart Rhythm Society, The Joint Commission, Metropolitan Municipalities EMS Medical Directors Consortium, National Association of Community and County Health Officials, National Association of EMS Physicians, NHTSA, NIH institutes, Parent Heart Watch, Sudden Cardiac Arrest Association, Sudden Cardiac Arrest Foundation, U.S. Army Medical Research and Material Command, U.S. Food and Drug Administration, and the VA, as well as leading academics institutions, researchers, and policy makers.

The NCAC would provide an essential venue for promoting shared experiences and expertise, creating an effective communications platform for ongoing information exchange and developing a widely support research agenda that could be used to frame high-priority research areas for a national dialogue and collective action. The NCAC could also produce materials and informational resources based on member input, which could be used to facilitate action in local communities. For example, action strategies targeting different stakeholders and community needs would be more effective if these strategies were part of a comprehensive plan to elevate cardiac arrest response and treatment. Toolkits that present effective strategies for EMS and health care systems to adopt CQI programs could be developed and disseminated. The results of these efforts could then be shared and evaluated across the collaborative.

Involving such a wide range of perspectives in activities and initiatives with shared goals could help identify the most salient challenges and limitations and may generate novel approaches to overcoming traditional obstacles that continue to bedevil cardiac arrest survival rates nationally.

Given the number of lives affected by cardiac arrest each year, it is important that the NCAC have a sustained presence and be built on mutually agreed upon terms by the collaborators. As described in Chapter 6, there are many examples of successful collaboratives and partnerships from other fields that can provide guidance and lessons learned, especially in the context of public–private partnerships. The necessary tools to effect change are available; now the resuscitation field must work together to build a successful trajectory.

CONCLUSION

A national responsibility exists to significantly improve the likelihood of survival and favorable neurologic outcomes following a cardiac arrest. This will require important changes in cardiac arrest data capture and reporting, research, citizen and professional rescuer training, and EMS- and hospital-based care and treatment. Specifically, it requires collaboration among informed stakeholders and a new framework for cardiac arrest care that promotes real-time access to knowledge, multistakeholder partnerships, accountability and transparency, leadership to instill a culture of learning, and supportive system competencies.

The consequences of inaction when faced with a cardiac arrest suggest that bystanders need to be prepared and willing to deliver basic life support (BLS). BLS training programs based in schools, the workplace, and other public locations and adapted to the needs of the communities can foster a lay public that is willing a capable of providing lifesaving care. Training EMS dispatchers to provide CPR and AED instruction to 911 callers can provide additional support for members of the public when they activate emergency response systems.

Surviving cardiac arrest depends on the provision of high-quality care by first responders, EMS providers, and hospital personnel. These individuals must be adequately educated and properly trained to deliver the best possible care in team environments. High-performing communities provide examples of how functional public health infrastructures and well-organized health system responses can facilitate timely and effective treatment, including high-performance CPR.

Improvements in cardiac arrest outcomes will require sustained federal, state, and local commitment to the development of evidence-based practice. At a national level, enhanced surveillance is key to informing national research, implementation, and evaluation efforts. Basic and clinical research can provide insights about causal mechanisms and pathophysiology of cardiac arrest, potentially leading to novel treatments and therapies. Local translation of research and guidelines into practice and adoption of CQI programs could generate new data streams across all care sites, enabling benchmarking of cardiac arrest outcomes within and between systems to identify more effective treatment protocols and inform evidence-based practices.

Many of the necessary pieces and strategies to improve cardiac arrest outcomes and to save lives already exist throughout the resuscitation field and within individual communities and health care systems across the United States. To effect change, this knowledge must be strategically shared and communicated among all stakeholders. By mobilizing transparent, coordinated levels of action and accountability, the resuscitation field can generate change that is necessary to improve cardiac arrest outcomes across the United States.

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