Arizona Initiative Ups Cardiac Arrest Survival

ACEP News
August 2010 

By Doug Brunk
Elsevier Global Medical News 

SAN DIEGO - Of the estimated 310,000 cases of cardiac arrest each year in the United States, three-quarters of those occur out of the hospital--and on average only 5%-10% of these patients survive, according to a database study.

In addition, the rate of survival after out-of-hospital cardiac arrest (OHCA) varies significantly from region to region, Dr. Ben Bobrow said at the annual meeting of the California chapter of the American College of Emergency Physicians.

"I don't think the public really thinks about or understands that you have a 500% better chance of survival if you collapse in one city than another," said Dr. Bobrow, clinical associate professor of emergency medicine at Maricopa Medical Center and the University of Arizona, and medical director of the Bureau of Emergency Medical Services (EMS) and Trauma System for the Arizona Department of Health Services in Phoenix.

"I believe that making cardiac arrest a reportable illness would help improve survival rates," he noted.

In 2004, Dr. Bobrow led an effort to regionalize Arizona's cardiac arrest care by collecting and analyzing data from first care reports of OHCA patients on whom resuscitation was attempted in the field (Prehosp. Emerg. Care 2008;12:381-7). Data for the effort, known as the Save Hearts in Arizona Registry and Education (SHARE) program, were initially obtained voluntarily from 35 EMS agencies and are now obtained from more than 80 EMS agencies.

Dr. Bobrow found that between Jan. 1, 2005, and April 1, 2006, 1,484 cases of OHCA were reported by the 35 departments, of which 1,104 were of presumed cardiac etiology occurring prior to arrival of EMS.

Only 37 (3.4%) of 1,076 OHCA patients survived to hospital discharge. Bystander CPR had a positive effect on survival (odds ratio of 3.0), yet was provided only 25% of the time.

Because there were so few OHCA survivors, the SHARE program's directors decided to modify the state's OHCA protocol based on current evidence, and to track the results closely.

The program's directors adopted a multipronged strategy that was disseminated to the state's EMS agencies. The strategy included training EMS dispatchers to provide chest compression-only instructions to 911 callers; advocating for chest compression-only CPR to increase the likelihood that bystanders will provide CPR; increasing the odds of early defibrillation by establishing a more structured public-access defibrillation program; enabling minimally interrupted cardiac resuscitation by EMS providers; and a creating a statewide system of cardiac receiving centers (CRCs) where patients would get guideline-based postarrest care such as therapeutic hypothermia.

One of the main changes was the shift from conventional CPR (with breaths) to chest compression-only CPR (without mouth-to-mouth breathing). This approach "is designed to minimize interruptions to chest compressions," Dr. Bobrow explained. "There's a lot of data to show that even brief, 10-second interruptions in chest compressions are enough to decrease the chance of successful defibrillation."

The program used a series of public service announcements on radio, on television, and in print to educate citizens in Arizona about how to perform chest compression-only CPR. The state also partnered with the American Heart Association to launch a hands-only CPR campaign (handsonlycpr.org).

Other education efforts included free chest compression-only CPR classes sponsored by local fire departments.

At the AHA's 2009 Resuscitation Science Symposium, the SHARE team presented data showing that the overall incidence of bystander CPR rose from 25% to 40% after the program, while the overall incidence of hands-only CPR rose from 16% to 77%.

"This really simple intervention of bystander chest compression-only CPR was incredibly powerful," Dr. Bobrow remarked. "Survival was significantly better for OHCA victims if they received chest compression-only CPR than no CPR or conventional CPR."

To further improve survival after cardiac arrest, Arizona implemented the Arizona Cardiac Arrest Center Consortium in order to deliver standardized, guideline-based postarrest care to as many OHCA patients as possible.

To be recognized as a CRC, a hospital must have the following:

• A therapeutic hypothermia method and associated protocol for OHCA.Around-the-clock primary percutaneous coronary intervention (PCI) capability with protocol for OHCA, including consultation with a cardiac interventionist for possible emergent PCI.
• Around-the-clock primary percutaneous coronary intervention (PCI) capability with protocol for OHCA, including consultation with a cardiac interventionist for possible emergent PCI.
• A system for timely completion and submission of a one-page data form for each OHCA patient.  
• An evidence-based termination of resuscitation protocol (including a 72-hour moratorium on ending care in patients getting therapeutic hypothermia).
• A protocol for organ donation.
• CPR training for the community.

Evaluation of the initial 1,500 OHCA cases in the state revealed that the rate of survival to discharge for the subset of patients with a witnessed collapse and ventricular fibrillation upon EMS arrival increased significantly, from 20.3% to 39.5%, after centers earned a CRC designation. The all-rhythm survival rate to hospital discharge also rose significantly, from 10.1% to 20.1%.

"Developing a culture of high-quality resuscitation is a multistep process," Dr. Bobrow concluded. "It requires a commitment to accurate data collection, reporting and benchmarking, feedback, and training and retraining," he said.

Dr. Bobrow disclosed receiving funding from the National Institutes of Health, the American Heart Association, and the Medtronic Foundation.