Strategies to Improve Cardiac Arrest Survival A Time to Act (2015) / Chapter Skim
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4 Emergency Medical Services Response to Cardiac Arrest
4 Emergency Medical Services Response to Cardiac Arrest
Pages 173-242
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early cardiopulmonary resuscitation (CPR)
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OVERVIEW OF EMS For purposes of this report, the committee defines an EMS system as a system that provides emergency medical care in response to serious illness or injury, such as a cardiac arrest, in the prehospital setting. An EMS system comprises a wide range of responders who provide critical services, such as response to 911 emergency calls, dispatch of medical personnel, triage, treatment, and rapid transport of patients by ground or air ambulances to appropriate care facilities (IOM, 2007)
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EMS Personnel Involv in Cardia Arrest Res ved ac sponse Within an EMS system, a nu W S umber of train professio ned onals act in co oncert wh respondin to a cardia arrest (see Box 4-1)
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The state medical director oversees the entire EMS system and evaluates performance within each link in the chain of survival, while local medical directors support EMS agencies at the local, city, or county level. The responsibilities of medical directors at any level typically include, but are not limited, to establishing medical protocols for dispatchers, EMTs and paramedics; providing medical supervision online and offline; promoting evidence-based practices; supervising ongoing medical quality improvement; supervising training and continuing education; establishing controlled substance policies; and providing medical discipline (ACEP, 2012a)
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Emergency medical technicians are emergency health care providers who are trained to respond quickly to emergency situations regarding medical situations, traumatic injuries, and accident scenes. There are several different levels of providers and variations in the exact scope of practice between different EMS systems.
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The medical director acts as a liai son between public and private EMS agencies; hospitals; local, re gional, state, and national EMS systems; national professional organizations; and other community stakeholders. The medical direc tor assists in the development, implementation, and measurement pro tocols, and also ensures training and proficiency of EMS personnel.
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has taken the informal lead for EMS oversight through its Office of EMS, which is responsible for reducing "death and disability by providing leadership and coordination to the EMS community in assessing, planning, developing, and promoting comprehensive, evidence-based emergency medical services and 911 systems" (NHTSA, 2015a)
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, and development of national EMS education standards and performance standards (NHTSA, 2015a)
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Clear designation of a lead federal agency "with primary programmatic responsibility for the full continuum of emergency medical services and care for adults and children" would contribute to a "coordinated, regionalized, and accountable emergency and trauma care system" (IOM, 2007, p.
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. The curricula available through these organizations are not identical and may not adhere consistently to the NHTSA guidelines for training emergency medical dispatchers.
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141, 292) .7 State EMS offices are usually managed by state medical directors, a role that has been recognized by several professional organizations (Na 5 NASEMSO Survey Question: "Where is the State EMS Office organizationally positioned within the State?
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8 NASEMSO Survey Question: "Do you have a State EMS Medical Director? " and "Please select the appropriate response regarding the authority of the State EMS Medical Director within your State." 9 NASEMSO Survey Question: "What are the roles and responsibilities of the State EMS Medical Director?
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EMS providers must also complete a certain number of continuing education credits covering various aspects of EMS care (e.g., trauma, pediatrics, and cardiac) in order to recertify, which usually occurs on a biennial basis.
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and calls 911,14 the 911 dispatcher works with the bystander to confirm the nature 13 NASEMSO Survey Question: "How many local EMS Medical Directors are functioning within your State? " 14 Communities have unequal access to 911 services.
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. Although many post-arrest ca treatments are tradition are s nally delivere in the hosp ed pital settting, EMS personnel ma also provi some elements of post p ay ide arrest care before or during trans c r sport to a hosppital (Pinchal 2010)
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As discussed later in the chapter, emergency medical dispatchers can help callers correctly identify cardiac arrest and perform CPR prior to the arrival of EMS services, contributing to increased survival rates. EMS response intervals are strongly associated with cardiac arrest survival rates, with longer response intervals linked to worse outcomes (Stiell et al., 1999)
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These technological capabilities are powerful assets for EMS systems in relationship to cardiac arrest. They can quickly and accurately identify the precise location of a cardiac arrest patient, allowing specially trained and equipped EMS providers to arrive within a few minutes of the 911 call.
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Delays may also occur in collecting information from bystanders, routing calls between PSAPs and dispatchers, assessing a patient's medical condition, locating available nearby EMS responders, or in transitions between individuals performing BLS or ACLS and the transfer of care to hospital staff. Although some studies have found no significant differences in EMS response times for minority patients (Becker et al., 1993; Cowie et al., 1993; David and Harrington, 2010; Sayegh et al., 1999)
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3.4 1.4 1.9 NOTE: OHCA = out-of-hospital cardiac arrest; pVT = pulseless ventricular tachycardia; VF = ventricular fibrillation. SOURCE: Galea et al., 2007.
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. In the majority of OHCA cases where bystander CPR is not provided, cardiac arrest survival is extremely low.
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Unlike bystander CPR (discussed in Chapter 3) , CPR provided by first responders and EMS personnel includes both compressions and ventilations.
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In one observational study, intubation-related interruptions in chest compressions averaged 109.5 seconds, with one-quarter of patients not receiving chest compressions for more than 3 minutes (Wang et al., 2009)
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• Out-of-hospital clinical trials have been infrequent because of the large multi-center trials needed to achieve adequate power. The Pediatric Emergency Care Applied Research Network adminis tered by the Emergency Services for Children has been the most successful.a ___________________ a For more information, see http://www.pecarn.org.
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Third, new technological capabilities may allow rescuers to continue chest compressions, eliminating the preshock pause. Defibrillators and other patient monitoring devices that provide real-time performance feedback can improve the quality of CPR or allow rescuers to adapt their interventions to meet physiological targets, such as a specific patient blood pressure.
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. Conversely, a recent Medicare database review found higher survival rates among OHCA patients treated by BLS-only EMS units than among those treated by ACLS units, an analysis of Canadian EMS systems found no improvement in survival from OHCA after ACLS capability was added to BLS units with defibrillation, and a study of 189 pediatric OHCA patients found no survival benefit associated with ACLS over BLS care (Pitetti et al., 2002; Sanghavi et al., 2015; Stiell et al., 2004)
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A more thorough discussion of postresuscitation phase of care is included in Chapter 5. Understanding pathophysiological processes can yield treatments, some of which can be administered by EMS providers prior to arrival at a hospital, to help improve OHCA outcomes.
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However, prolonged transport intervals, particularly in rural settings, may require EMS providers to be competent in managing hypotension (low blood pressure) as well as rearrest.
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. This non-use of TOR protocols can be the result of a combination of factors, including legal mandates that restrict use of TOR protocols to a small subset of OHCA patients, cultural values that prohibit or discourage termination of resuscitation, EMS leaders without the authority to set or enforce such protocols, and poor communication between medical directors and EMS personnel (Sasson et al., 2009, 2010a)
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. Given the multifaceted nature of postarrest care, EMS providers need ready access to predetermined protocols and transport plans that are designed to integrate EMS providers into multidisciplinary hospital teams in order to optimize post-resuscitation care.
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Another emerging practice that is technically feasible and associated with survival in some case reports is the transport of OHCA patients with refractory ventricular fibrillation directly into the cardiac catheterization laboratory, while providing continuous, mechanically aided CPR. This practice can improve the chance of achieving ROSC and survival rates in some patients (Bangalore and Hochman, 2010; Dumas et al., 2010; Frohlich et al., 2013; Kern, 2012)
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. These investigations have highlighted the importance of emphasizing collaboration and standardized transition 17 NASEMSO survey question: "Does your State have a regulatory requirement for EMS Agencies to provide a formal copy of the EMS patient care report to the receiving hospital or healthcare facility at the time care is transferred (before EMS leaves the facility)
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If documentation is completed and transferred with the patient, the EMS systems must be able to track that patient to hospital discharge in order to evaluate the relationship between specific care components and cardiac arrest survival or neurologic outcomes. According to a recent survey, of 49 states for which data were available, 36 states require local EMS agencies to collect patient data based on the National Emergency Medical Systems Information System (NEMSIS)
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. Specifically, clinical studies have shown a strong association between dispatcher-assisted CPR and increased bystander CPR rates and improved CPR quality and cardiac arrest survival rates (Eisenberg et al., 1985; Kellermann et al., 1989; Lewis et al., 2013; Rea et al., 2001; Song et al., 2014; Vaillancourt et al., 2007)
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Training should acquaint dispatchers with scientific findings that relate to cardiac arrest outcomes and dispatcher-assisted CPR -- the nature and frequency of cardiac arrest, the importance of dispatcher-assisted CPR, and the role that dispatchers can play in improving cardiac arrest survival. Training could include didactic and simulation modules that focus on the three phases of dispatcher-assisted CPR: (1)
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Although the committee does not endorse any particular set of dispatcher-assisted CPR performance metrics or guidelines, there are categories of performance metrics that should be considered by any organization developing a training curriculum for dispatcher-assisted CPR including those listed in Box 4-6. Training and Participation in High-Performance CPR and Other Quality Improvements High-quality CPR is associated with improved survival in numerous studies (Bobrow et al., 2013; Cheskes et al., 2011b; Christenson et al., 2009;
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. The lack of team practice for EMS providers may also contribute to lower CPR quality in high-stress and uncontrolled environments.
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. Implementation of high-quality CPR can help improve the quality of CPR delivered by EMS personnel, leading to improved cardiac arrest patient outcomes (Bobrow et al., 2013; Idris et al., 2012; Meaney et al., 2013; Monsieurs et al., 2012; Stiell et al., 2012; Travers et al., 2010)
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. Perishock Pause in Compressions: A study of 815 adult OHCA patients found that perishock pauses longer than 40 seconds in duration were associated with decreased odds of survival as compared to pauses less than 20 seconds in duration (Cheskes et al., 2011)
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Several well-trained EMS providers may be preferred in order to effectively deliver high-performance CPR, rapid defibrillation, and other EMS interventions for cardiac arrest. Without sufficient numbers of care providers, a person performing chest compressions may quickly fatigue, cease to deliver the optimal depth and rate of compressions, and begin leaning on the chest -- all of which are associated with worse patient survival rates (Meaney et al., 2013)
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. Another trial found that OHCA patients treated with extracorporeal cardiopulmonary resuscitation had survival-to-discharge rates similar to IHCA patients receiving the same treatment (Wang et al., 2014)
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, these centers could improve CPR quality and other aspects of emergency medical care provided by EMS agencies. These centers could also introduce EMS personnel to emerging technologies and therapies, potentially speeding the translation of novel treatments to the patient.
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At the macro level, local and state EMS systems need to examine and disseminate overall system performance data to identify areas for improvement and adopt new processes, training, and care protocols. The AHA has issued a consensus statement on CPR quality recommending that every EMS system "should have an ongoing CPR QI program that provides feedback to the director, managers, and providers" (Meaney et al., 2013, p.
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For example, specific EMS systems have been able to shift attitudes and promote changes in culture through a range of initiatives that have also 20 NASEMSO Survey Question: "Does your State have a performance improvement plan or guideline which is required to be implemented within each EMS Agency? " and "Does your State monitor EMS Response times at the local EMS Agency level?
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. Similarly, FICEMS has recommended that state-level EMS systems should be required to have state EMS medical directors as a condition for receiving grants from the federal government (Cunningham et al., 2010)
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Lo medical directors have an enormou impact on the culture and ocal d us perform mance of ind dividual EMS agencies. In addition to providing o S n o onscene medical direction, they ar responsibl e for setting practice prot re tocols, tr raining and assessing personnel, educat ting the publi and integra ic, ating EM with other health services (Alonso-S MS r Serra et al., 1998)
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Through coordination and guidance, appropriate resuscitation team leadership can limit unnecessary interruptions in chest compressions. In these circumstances, team leaders can help minimize the number of people involved in secondary activities (e.g., trouble-shooting devices, analyzing cardiac rhythms, and securing the patient to a gurney)
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2012a. Medical direction of emergency medical services.
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2005. Incomplete chest wall decompression: A clinical evaluation of CPR performance by EMS personnel and assessment of alternative manual chest compression-decompression techniques.
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2010. Part 13: Pediatric basic life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.
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2008. Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest.
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Prehospital Emergency Care 10(2)
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2010. The role of state medical direction in the comprehensive emergency medical services system: A resource document.
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Journal of Emergency Medical Services. http://www.jems.com/ articles/2011/02/white-paper-addresses-creation.html (accessed July 31, 2015)
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2010. The association between emergency medical services staffing patterns and out of-hospital cardiac arrest survival.
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2015. Mechanical chest compression: An alternative in helicopter emergency medical services?
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2011. Consolidated federal leadership for emergency medical services.
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2007. Emergency medical services at the crossroads.
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2014. The state of leadership education in emergency medical services: a multi-national qualitative study.
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2012. Emergency medical service dispatch cardiopulmonary resuscitation prearrival instructions to improve survival from out-of-hospital cardiac arrest: A scientific statement from the American Heart Association.
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2015. Optimizing the patient handoff between emergency medical services and the emergency department.
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2010. NAEMT position statement: Medical direction of emergency medical services.
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2009b. National emergency medical services education standards.
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Journal of Emergency Medical Services. http://www.jems.com/ article/patient-care/managing-post-cardiac-arrest-s (accessed March 27, 2015)
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2014. Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: The LINC randomized trial.
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Prehospital Emergency Care 14(2)
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2009. Designated medical directors for emergency medical services: Recruitment and roles.
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2009b. Physician medical oversight in emergency medical services: Where are we?
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2005. Interruptions of chest compressions during emergency medical systems resuscitation.
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2015. Volume versus outcome: More emergency medical services personnel on-scene and increased survival after out-of-hospital cardiac arrest.
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2010. Leaning during chest compressions impairs cardiac output and left ventricular myocardial blood flow in piglet cardiac arrest.
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