5

Enhancing the Emergency Medical Services Response to Cardiac Arrest

Emergency medical services (EMS) systems across the United States provide professional prehospital cardiac arrest care and are essential to the efficacy of the chain of survival (see Chapter 1). EMS systems are operated primarily on a local level and include a range of trained personnel, including 911 dispatchers, emergency medical technicians (EMTs), and paramedics. Despite fragmented oversight and variations in structure and operations, exemplar EMS systems have implemented data collection systems and performance improvement initiatives that have led to sizable increases in survival rates for out-of-hospital cardiac arrest (OHCA) (IOM, 2015). These advances offer the potential to reduce gaps in performance and outcomes through broader adoption of evidence-based best practices nationwide. Recommendations 3 and 5 from the Institute of Medicine’s (IOM’s) report describe opportunities for strengthening the capabilities and performance across EMS systems, while implementing continuous quality improvement programs (see Box 5-1).

CARDIAC ARREST AS A POLICY PRIORITY

Myron Weisfeldt, Johns Hopkins University

Since the development of cardiopulmonary resuscitation (CPR) nearly 60 years ago, a number of public policy changes have been adopted in order to expand access to CPR treatments and increase survival rates for out-of-hospital cardiac arrest (see Box 5-2), began Myron Weisfeldt. Each of these policy changes shared a set of similar characteristics that

contributed to their adoption and success. First, all of the policy changes were singular, notable events. Second, they were supported by solid, scientific evidence. Third, they captured the public’s imagination and interest. Finally, they gained multiple endorsements before becoming informed public policy.

Weisfeldt cited two promising examples of activities that could develop into major public policies to advance resuscitation science and survival in the United States. The first initiative uses technology to link layperson responders to people who suffer an arrest and automated external defibrillators (AEDs). Citing an earlier presentation by Raina

Merchant (see Chapter 4), Weisfeldt pointed to the PulsePoint program, which is being piloted in Los Angeles and Seattle. The program uses cell phone technology to map AEDs in public spaces. It also alerts bystanders trained in CPR and AED use to the location of potential cardiac arrest patients, following a 911 call.

The second initiative trains police officers as first responders for cardiac arrest and equips every police vehicle with an AED. In a preliminary study conducted in the Netherlands between 2006 and 2012, researchers found that AED use nearly tripled during the study (21 percent to 59 percent). The overall increase was attributed to rises in rates of both public use of stationary, onsite AEDs (from 6 to 11 percent) and police use of mobile AEDs (from 16 to 49 percent) (Blom et al., 2014). Over the course of the study, researchers also observed an increase in survival rates with

positive neurological outcomes—from 16 to 20 percent overall. More specifically, survival rates for cardiac arrests exhibiting shockable rhythms increased from 29 to 41 percent (Blom et al., 2014).

Weisfeldt concluded by underscoring the potential of these initiatives to have a lasting impact on cardiac arrest survival rates if adopted into broader public health policies. The initiatives are singular, evidence-based advances that can spark public engagement and interest. All that is needed is the endorsement of important stakeholders to fuel implementation at the national level.

DISPATCHER-ASSISTED CPR¹: CURRENT PROGRESS AND EMERGING TECHNOLOGIES

Drew Dawson, National Highway Traffic Safety Administration (retired)

Dispatcher-assisted CPR increases rates of bystander CPR, decreases the time between collapse and preliminary chest compression, and if done correctly, emphasized Drew Dawson, increases survival rates following cardiac arrest. Dispatcher-assisted CPR programs can provide significant return on investment when they are set up within established EMS systems. Dawson noted that training dispatchers to provide CPR instruction has a multiplier effect when compared with bystander CPR training. For example, CPR-trained bystanders may witness only one cardiac arrest in their lifetime. However, when dispatchers are trained to provide CPR instruction over the phone, they are able to coach numerous bystanders in CPR techniques, thus expanding the reach and value of their training.

Effective dispatcher-assisted CPR programs require dispatchers to be confident and proficient in rapidly identifying cardiac arrest, convincing bystanders to begin chest compressions—ideally within 120 seconds—and conveying clear, assertive CPR instruction, said Dawson. At the systems level, successful programs require commitment and a supportive culture across the EMS system and the public safety answering point (PSAP). In order to establish accountability and continually improve, mechanisms to measure and report performance benchmarks need to be an integral part of the program, stated Dawson. Despite the possible benefits and the relatively small investment required, only about half of PSAPs in the United States provide dispatcher-assisted CPR. Of those PSAPs that do offer dispatcher-assisted CPR, most do not measure or report their performance. Dawson stressed that “delivering instructions late or poorly is like not delivering them at all.” On the national level, performance standards

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¹ Dispatcher-assisted CPR is also referred to as dispatcher-assisted bystander CPR, just-in-time instruction, telecommunicator CPR, and telephone CPR.

for dispatcher-assisted CPR do not exist. Dawson observed a frequent lack of awareness and enthusiasm, and he hypothesized that most health care systems do not recognize the potential return on investment that these programs offer.

From a technical perspective, continued research is essential to augment dispatcher-assisted CPR processes and techniques, said Dawson. New studies could be used to devise and test strategies to help dispatchers quickly identify cardiac arrest over the phone and persuade callers to perform CPR without hesitation. As PSAPs transition to the next generation of 911 technologies, dispatchers will have greater flexibility to seamlessly transfer calls, which could be useful in developing a more regionalized approach to dispatcher-assisted CPR. Although every emergency call should have access to guideline-based CPR instruction, said Dawson, not every PSAP needs to actually provide the CPR instruction. Applying this model, 911 calls that require CPR instruction could be quickly transferred to a regional center equipped to provide high-quality, dispatcher-assisted CPR. Regional centers and PSAPs that comply with standards and maintain high performance could be awarded a special designation, such as 911 center of life-saving excellence, suggested Dawson.

Within the EMS and dispatcher community, a variety of organizations are engaged in standard-setting initiatives (e.g., National Emergency Number Association, National Fire Protection Association, Association of Public-Safety Communications Officials, ASTM International) that could help promote the benefits of dispatcher-assisted CPR. Dawson called on these organizations and the American Heart Association to develop and endorse national dispatcher-assisted CPR standards. Stronger partnerships at the state level among state EMS offices, state health agencies, state 911 offices, and health care systems are also needed to bolster certification requirements, increase awareness, and expand implementation, he said. To advance dispatcher-assisted CPR in the United States, Dawson suggested that the National Highway Traffic Safety Administration (NHTSA) convene a national summit on dispatcher-assisted CPR. The summit could involve key decision makers from across the country and should culminate with the development of a coherent national action plan with commitments from agencies and organizations to implement that plan. Dawson emphasized that dispatcher-assisted CPR should be a national priority and that there should be a national expectation that CPR instruction will be readily available for every single cardiac arrest call that comes through a PSAP.

In response to a participant’s question about the possibility of implementing an automated dispatcher-CPR system to reduce variation in performance, Dawson pointed out that the interaction between the caller and dispatcher is often a critical element of successful bystander CPR.

He noted that part of that interaction is the dispatcher being able to calm down the caller, listen to what is happening at the scene, hear what is going on with the patient, and determine how all of these aspects should be factored into the instructions given to the caller. One workshop participant, who had performed dispatcher-assisted CPR and saved her husband’s life, noted that the human connection with the dispatcher is what gave her the strength to do CPR. The participant said she and the dispatcher worked as a team that day while waiting for the ambulance to arrive and take over her husband’s care.

Dawson also noted that regionalizing dispatcher-assisted CPR would have greater advantages over automating the system. For example, a regionalized system would ensure that trained dispatchers, who have experience providing CPR instruction to callers regularly, are the personnel providing support to callers. This approach would reduce the need to train all dispatchers and would allow some dispatchers to become highly proficient, said Dawson.

Although there are technological challenges associated with improving 911, most of the gaps are a result of communication and relationship barriers, Dawson said in response to a participant who noted a disconnect between some local law enforcement agencies and EMS medical directors and personnel regarding PSAPs. Both Dawson and Arthur Kellermann reiterated that strong partnerships at the local level are required to improve 911 systems and cardiac arrest care, regardless of who operates the PSAP (e.g., law enforcement, fire, EMS). Dawson indicated that the relevant stakeholders need to build these relationships and work together to develop and review protocols relevant to cardiac arrest care. Peter Taillac, another panelist, noted that the disconnect could also be resolved through regionalization if the law enforcement agency that operates the PSAP could transfer medical calls to a regional call center staffed by dispatchers who are trained to provide high-quality instruction before arrival.

ACHIEVING STANDARDIZATION AND ADOPTION OF HIGH-QUALITY CPR PERFORMANCE ACROSS THE COUNTRY

Arthur Kellermann, Uniformed Services University of the Health Sciences

Prior to organizational changes in 2015, the IOM publications included a quote from Goethe, “Knowing is not enough; we must apply. Willing is not enough; we must do.”² In the context of OHCA, Arthur Kellermann

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² Beginning in July 2015, the consensus studies and convening activities of the Institute of Medicine were integrated into the work of the National Academies of Sciences, Engineering,

asked, what is already known about strategies to increase survival rates? A meta-analysis conducted by Sasson and colleagues (2010) identified four main factors that are associated with increased rates of survival, including whether

• the collapse is witnessed by a bystander or EMS personnel;
• the individual receives bystander CPR;
• the rhythm can be shocked; or
• return of spontaneous circulation is achieved at the scene.

We know what needs to be done to improve survival rates for OHCA, said Kellermann. Rates of bystander CPR should be optimized, defibrillators should be applied as quickly as possible, and efforts should be focused on resuscitating the patient at the scene. But despite all the resources expanded on OHCA research, training, and equipment, Sasson and colleagues (2010) found that survival rates for OHCA remained flat between 1980 and 2008 at just 7.6 percent. Kellermann emphasized that this is not a failure of knowledge, but rather a failure to consistently apply what we know.

The Cardiac Arrest Registry to Enhance Survival (CARES) was created with support from the Centers for Disease Control and Prevention more than a decade ago and, as of the workshop, included 17 state-based registries and approximately 50 large communities, covering nearly 90 million Americans (CARES, 2016; see also Chapter 2). The registry collects outcomes data, measures critical performance parameters, and allows health care systems and communities to compare their performance to similarly situated systems and communities. CARES data have demonstrated that survival rates vary significantly from one city to another—ranging from 5 to more than 50 percent (Kellermann, 2016). This 10-fold difference cannot be explained by genetics or city-to-city variation in comorbidities (e.g., hypertension) or lifestyle (e.g., high-fat diets), said Kellermann. This variation in outcomes reflects wide disparities in the quality of prehospital care. The registry costs less than $100 million per year or about one penny per individual—it is quite cost-effective, said Kellermann.

Many communities that joined CARES have subsequently improved their OHCA survival rates. Kellermann suggested this may be due to the Hawthorne effect, which means that performance typically improves when it is observed and measured. “When we know how we stack up compared to others, we raise our game,” said Kellermann. In his opinion,

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and Medicine (the National Academies), and the program unit that carries out these activities is now called the Health and Medicine Division.

Kellermann believes that all communities should participate in an OHCA registry that benchmarks performance around key measures associated with the chain of survival. In the past, the “ABCs” of cardiac arrest stood for (A)irway, (B)reathing, and (C)irculation, said Kellermann. More recent research indicates that this is not the optimal sequence of response, with the first priority being placed on chest compressions to restore some degree of circulation. Kellermann urged that the ABCs be redefined for the modern era to emphasize what communities should do to improve their approach to treating OHCA (see Box 5-3).

At the community level, an increase in rates of bystander CPR is possible through a variety of strategies. As described previously by Dawson, dispatcher-assisted CPR is an effective way to increase bystander CPR rates within communities. Video self-instruction and mobile technologies are also expanding training opportunities for individuals and may be more effective than a sponsored 4-hour course, said Kellermann. Merchant and colleagues (2010) found that providing audio instruction via cell phones can also help bystanders to perform better CPR, regardless of prior CPR training experience (see also Chapter 4). In terms of improving the quality of CPR administered by health care providers, Bobrow and colleagues (2008) demonstrated that minimal interruptions during chest compressions can result in increased chances of survival. Kellermann reflected on his experiences performing CPR in the emergency room and said interruptions occurred on numerous occasions for many reasons, and those interruptions were almost certainly detrimental to the patients he treated.

In response to an audience question, Kellermann hypothesized that cardiac arrest survival rates across the United States could be doubled or tripled within 24 months if a concerted national effort were made to improve a few simple processes. These include a relentless focus on boosting rates of bystander CPR, ensuring optimal EMS performance, and promoting universal accountability with a national OHCA registry, emphasized Kellermann. Additionally, the resuscitation field needs to generate public confidence and excitement to support a research agenda that will lead to further progress. This is an attainable goal. “We know we can do better,” said Kellermann, as he called for action.

PROMOTING QUALITY IMPROVEMENT PROCESSES IN EMS SYSTEMS

Peter Taillac, National Association of State EMS Officials

The United States has more than 21,000 licensed EMS agencies (NHTSA, 2011). Because each of these agencies was established to meet the respective needs of communities across the country, there is great variety in the structure, budgets, and operational policies and protocols that are used to manage these agencies. Nationwide, EMS agencies cover the complete spectrum—from large urban systems associated with medical centers that include professional paid personnel to tiny rural agencies that are managed completely by trained volunteers. Coordinating these agencies and ensuring that best practices are implemented consistently is a complex undertaking. Historically there have been few national standards to guide and coordinate the provision of emergency care, noted Taillac. However, the IOM’s report Emergency Medical Services: At the Crossroads (IOM, 2006) established a strategic template that EMS leaders have since championed. Through their efforts over the past decade, EMS leaders and organizations have developed a range of national EMS standards and guidelines that are now available to promote the development of coherent protocols and emergency care across all agencies (see Box 5-4).

Taillac observed that another valuable step forward since the release of the IOM report in 2006 occurred in 2010 when the American Board of Medical Specialties authorized a subspecialty certification in EMS under the auspices of the American Board of Emergency Medicine. The recognition of EMS as a subspecialty allows physicians who are interested in EMS to complete a fellowship, gain board certification, and become experts and leaders in the field and in their communities. Across the EMS community, there has also been a greater emphasis on research in the past decade, said Taillac. Medical directors and paramedics in the field are working

to generate a research foundation on which evidence-based practices and guidelines can be built.

At a national level, measuring performance and outcomes can help determine whether EMS agencies are following available guidelines and whether the implementation of those guidelines is leading to better outcomes, said Taillac. NHTSA and the National Association of State EMS Officials are currently developing EMS performance measures for cardiac arrest, trauma, and ST-elevation myocardial infarction (STEMI) through the EMS Compass program. Now in the testing phase, the cardiac arrest measures include rates of bystander CPR, rates of dispatcher-assisted CPR, time from 911 call to first compressions, time to defibrillation, average rate and depth of compression, among others. During this phase, vendors are integrating some of these measures into the electronic patient care record systems in order to increase awareness across individual EMS personnel and agencies. In addition to these efforts, Taillac also suggested that organizations that develop evidence-based guidelines should include corresponding performance measures. If there is guidance on a given treatment or technique, said Taillac, there should be a way to measure that it is being done correctly and making a difference in care.

Now that standards and guidelines are being put in place and a new focus on research has been kindled, Taillac called for incremental moves toward a culture of excellence through performance improvement within all EMS agencies. To establish a culture of excellence, EMS agencies need more feedback, noted Taillac. Performance needs to be linked to outcomes

for EMS personnel, and they need to receive the data to be fully invested, he added. For example, EMS personnel should know the rates of survival to discharge for their patients and how those rates shift from one year to the next. Regardless of whether it is the Hawthorne effect or the inherently competitive nature of paramedics and EMTs that underlies change at the local level, “if we don’t measure [performance], we can’t improve,” emphasized Taillac.

In terms of challenges, Taillac highlighted education and incentives as the two primary challenges. First, state and local EMS agencies and personnel need to understand what performance improvement is, why it is important, and how to use it to improve outcomes. This will require education, stated Taillac. Incentives will be necessary to realize the full potential of performance improvement, and this comes down to resources—funding and time—said Taillac. Many of these agencies have limited resources and may view additional requirements as unfunded mandates. However, Taillac pointed out that the provision of high-quality patient care, including performance improvement, should not be considered an unfunded mandate. Although state-level officials could require some form of performance improvement program as part of a licensing requirement, Taillac believes the incentives should be positive rather than punitive.

In response to a question about the appropriate balance between publicly available data and private EMS data, Taillac noted that most of the EMS registries (e.g., CARES) are voluntary. He believes that if the data were publicly available and posted on a website, EMS agencies and hospitals would be much less inclined to participate. At this early juncture, said Taillac, it makes sense to provide EMS agencies with their own data and comparison data. This approach provides motivation to improve, and when outcomes do improve, the agencies can release the data and advertise their achievements. “I see the argument for the public having access to all of these data,” said Taillac, “but I think you have to be careful. It could become counterproductive, especially early on in these efforts.”

One workshop participant endorsed making data available internally to EMS personnel. In the participant’s health care system, outcomes related to STEMI are posted in the emergency departments within 24 hours to recognize the achievements of specific EMS teams, which also stokes competition to improve. The hospitals and EMS agencies within this system have moved regional EMS meetings into the hospitals, where EMS personnel and physicians review the data and discuss cases in terms of what went well and what could be done better next time. Paul Pepe reiterated that the systems need to collect and review the data or they cannot improve, and it often takes a strong, committed medical director to guide change. Another workshop participant reported that the EMS

agencies in Palm Beach County, Florida, were able to double cardiac arrest survival rates in 3 months because of the dedication of the EMS medical directors and personnel in the county.

BREAKOUT SESSION REPORT: DISPATCHER-ASSISTED CPR

Paul Pepe, Planning Committee Member³

Paul Pepe facilitated a breakout session focused on enhancing and expanding the use of dispatcher-assisted CPR across the United States in response to the third recommendation in the IOM’s report (see Appendix A). Pepe noted that only about half of 911 PSAPs in the United States formally use emergency medical dispatchers, who can provide pre-EMS arrival instructions (PAIs). This represents a fundamental challenge to expanding dispatcher-assisted CPR, remarked Pepe.

The participants from this breakout session contemplated regionalization of dispatcher-assisted CPR tasks. Pepe said the adoption of new technologies (e.g., smart phone communication apps, geolocation technologies) holds significant potential for enhancing dispatcher-assisted CPR. For example, cell phone video capabilities could give dispatchers a much better understanding of the scene and even the patient’s condition. This could expedite recognition of the need for PAI and even improve the quality of CPR by giving enhanced guidance to callers, explained Pepe. Additionally, the availability of an up-to-date AED registry or database that documents AED locations, especially in highly trafficked public areas, could allow dispatchers to routinely instruct callers where to find the nearest AED, noted some members of the breakout session.

Enhancing dispatcher-assisted CPR procedures may require constant monitoring and reevaluation of the PAIs used by dispatchers, said Pepe. This includes review and feedback to the emergency medical departments, as well as implementation of emerging technologies coupled with research efforts, said Pepe. Some individuals identified a need to develop an inventory of available protocols, best practices, and lessons learned across the United States and to review the availability and effectiveness of dispatcher procedures, especially as they affect underserved communities, such as language and cultural barriers. Although standardization of

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³ Breakout session presenters were asked to summarize the major ideas and opinions proposed by individual participants during their respective breakout sessions. Individual statements described below are not necessarily the position of the presenter and should not be interpreted as consensus statements from the breakout group as a whole or of the National Academies of Sciences, Engineering, and Medicine.

CPR protocols nationwide theoretically could be beneficial, especially if they drive quality improvements, Pepe emphasized flexibility to account for local needs and the testing of innovative practices—standardized protocols should not stifle inventive thinking or limit modifications that enhance local needs.

Deviating from standardized protocols should be documented, tested, and reported to strengthen the evidence base for changes in practice and guidelines, said Pepe. He cited the successful No-No-Go protocol that was designed to promote prearrival instructions. In cities where this simplified protocol has been deployed, dispatchers ask callers if the individual is awake (or can be wakened) and if the individual is “breathing normally.” If the answer to both of those questions is no (no-no), then the dispatcher initiates CPR instruction (go). This can reduce the time from collapse to first compressions, Pepe stated.

Education and quality assurance (QA) reviews, either in real time or by assessing taped files, are key to improving the quality of dispatcher-assisted CPR, said Pepe. Such reviews should involve constructive feedback that can lead to procedural modifications, said Pepe. As part of both regular group training and individual QA review, dispatchers could receive feedback on performance and outcomes as a form of closure and as a motivating factor to improve performance. Too often the dispatcher answers a cardiac arrest call, provides dispatcher-assisted CPR, and then moves on to the next call without ever knowing the outcome of the guidance and instruction, said a participant. In addition to education and feedback, Pepe reported that some breakout group members suggested the development of external dispatcher accreditation processes as another opportunity to fortify dispatcher education and preparation as well as instilling local pride in emergency medical department functions. One participant stated that providers should receive accolades for excellent performance.

To achieve these goals and advance dispatcher-assisted CPR nationwide, a few individuals suggested that NHTSA convene a stakeholder summit to develop an action strategy that would be focused on enhancing and expanding dispatcher-assisted CPR performance nationwide. Pepe noted that the resuscitation community should also consider engaging the National Conference of State Legislatures (NCSL), in part by inviting NCSL members to that national summit.

At a local level, Pepe called for increased involvement between EMS medical directors and the PSAP teams, noting that these types of strong partnerships and coordination can lead to better dispatcher performance, innovations, and improved outcomes. As in the discussions of community and public engagement, Pepe said that outreach and collaboration with local organizations, foundations, and advocacy groups could prove

exceptionally valuable in understanding both the needs and the potential barriers within those given communities.

BREAKOUT SESSION PREPORT: CONTINUOUS QUALITY IMPROVEMENT IN EMS SYSTEMS

Arthur Sanders, Planning Committee Member⁴

Arthur Sanders moderated the breakout session that discussed challenges and barriers related to continuous quality improvement programs in EMS systems, addressed in the IOM’s fifth recommendation (see Appendix A). The group discussion focused on financing, messaging, and infrastructure to further continuous quality improvement initiatives. Sanders pointed out that measurement, benchmarking, and feedback/change are three interrelated elements that provide the foundation of any quality improvement effort within the resuscitation field, regardless of setting. Some breakout session members also identified a number of exemplary communities and systems that have effectively implemented continuous quality improvements, leading to better cardiac arrest outcomes. A few of the examples included efforts in Seattle/King County, Washington (e.g., the Resuscitation Academy), Arizona, and rural Wisconsin; the Take Heart America program in Minnesota; and the Resuscitation Outcomes Consortium experience.

Sanders first described the financing for EMS systems, stating that the mechanisms and policies that underpin EMS financing could be reassessed. EMS personnel are not currently paid as health care providers; they are only paid for transporting patients. This financing structure offers no incentives for providing high-quality care or improving the quality of care, said Sanders. Changing the status quo would likely require engaging the Department of Health and Human Services and the Department of Transportation through NHTSA. Sanders emphasized that EMS systems need to be viewed as providers rather than suppliers in order to establish incentives and align EMS care with the principles of value-based health care.

Sanders noted that messaging was a recurring theme that emerged from the plenary presentations and discussions. Communities should be encouraged to know their numbers in terms of survival rates, noted a

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⁴ Breakout session presenters were asked to summarize the major ideas and opinions proposed by individual participants during their respective breakout sessions. Individual statements described below are not necessarily the position of the presenter and should not be interpreted as consensus statements from the breakout group as a whole or of the National Academies of Sciences, Engineering, and Medicine.

number of workshop participants. Sanders said that broader messaging to describe the magnitude of the problems and progress to date is also needed as a part of continuous quality improvement initiatives for EMS systems. He indicated that messaging and public engagement can serve as mechanisms to establish accountability across EMS systems and communities. The importance of uniform messaging reinforces the need for a collaborative of public, private, and governmental organizations to clearly define priority messaging to improve cardiac arrest survival.

The breakout group discussed building and expanding infrastructure for incentives and information exchange to promote continuous quality improvement programs across EMS systems. Sanders noted that there are several examples of demonstration projects with solid infrastructure (e.g., HeartRescue Project, the Resuscitation Academy, EMS Compass); however, the reach of these projects has been limited, and expansion efforts are needed. Some members of the breakout group reiterated the need for leadership and local champions to promote cultures of improvement and excellence, which could use existing infrastructure. Sanders also called for the development of performance measures that can be used to respond to local challenges, noting that performance measures could be tailored based on local needs. However, all EMS systems should be employing measures based on the locally collected performance data, some individuals said. Best practices, lessons learned, and general information from local EMS quality initiatives could be shared at regional and national meetings in order to motivate further improvement efforts, concluded Sanders.

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