About the Community CARE ProgramBack to Community CARE Program Page
— Russ McCallion
Assistant Chief, East Pierce Fire & Rescue
Sixty-one million Americans have cardiovascular disease, resulting in approximately 1 million deaths per year. One-third of these deaths (300,000 – 400,000) are due to cardiac arrest, the sudden and unexpected loss of heart function. Survival rates for out-of-hospital cardiac arrest are only 1 to 5 percent. Most often cardiac arrest is due to chaotic beating of the heart (ventricular fibrillation), which can be restored to a normal rhythm if treated early with electric shock (defibrillation). Treatment of witnessed ventricular fibrillation with immediate defibrillation can result in greater than 90 percent survival. With each minute of delay in defibrillation, nearly 10 percent fewer survive, so that at 10 minutes, survival is dismal.
The average age of sudden cardiac arrest (SCA) is 65 years old. In 2010 according to the U.S. Census Bureau, 19.1% of the Orland Park community was age 65 or older. Over the next 16 years it is estimated that the 65 and older population will grow to over 30% of the population in Orland Park.
Community Cardiac Arrest Rescue Enterprise (CARE) addresses this emerging trend, saving lives by engaging the whole community.
Understanding the occurrence of SCA and the corresponding survival rate addresses the very core of the Community CARE program. Gathering older data has been a very difficult task as the information was not initially obtained for this purpose.
In 2011, the Orland Fire District responded to 42 cardiac arrests, 5 confirmed Ventricular Fibrillation (VF), and 1 (20%) obtained Return Of Spontaneous Circulation (ROSC). In late 2011, AHA changes in CPR were implemented affecting the compression rate and depth. These updates may have impacted the increase in ROSC in 2012. In 2012, the Orland Fire District responded to 46 cardiac arrests, 9 confirmed VF and 5 (45%) obtained ROSC.
Our data does not indicate if a patient survived a SCA or returned home from the hospital. Further, the data does not determine quality of life after SCA. This data can only be obtained from the hospital, the patient or the patient’s family. This information is important when determining the quality of care that we provide for SCA patient survival.
The Way Forward
Bellow is the plan to improve our community’s cardiac arrest survival rate. It consists of 11 specific but diverse steps. Four of the steps are relatively easy to achieve and do not require much in the way of resources. There are seven steps that are more difficult to achieve requiring modest to considerable support in order to obtain equipment and resources. The total picture must entail the Chain of Survival and the Frame of Survival.
Chain of Survival
What we know is that successful treatment of cardiac arrest, particularly ventricular fibrillation, is associated with delivering care quickly. The chain of survival, with its five links of early access, early CPR, early defibrillation, early advanced care, and early post resuscitative care illustrates the most critical elements of addressing sudden cardiac arrest.
The factors that comprise the links in the chain of survival have a specific value and can be measured. Some factors are time related (time to CPR, time to defibrillation); others can be measured by their presence (dispatcher-assisted CPR, community CPR training, community PAD, hypothermia) and two can be scored (quality of CPR can be determined by compressions per minute of CPR and duration of pauses, and the interaction of CPR and defibrillation can be determined by the duration of pauses before and after defibrillation).
Frame Of Survival
To fully understand success (or lack of success) we need to address the factors that determine performance. These factors are far more difficult to measure or score but are just as or more important than the tangible metrics. The links in the chain cannot stay connected unless they are embedded in a context of strong medical and administrative leadership, continuous Quality Improvement (QI), a culture of excellence, stellar training and continuing education for dispatchers, EMTs and paramedics. These four elements literally frame, surround and embed the core links of care. The elements are termed the Frame of Survival.
System of Care
Together the Chain of Survival and Frame of Survival form a complete and comprehensive System of Care. The frame surrounding the chain of survival can be reduced to a single word: accountability. It is accountability achieved through leadership, quality improvement, training and excellence that holds the chain of survival in place and ensures that its links are strong. EMS care that is not accountable to the citizens it serves will at best be mediocre.
The elements comprising the frame are far more difficult to measure than those inside the frame. Elements like leadership, culture of excellence and accountability are softer and less scientific than the tools that directly contribute to the chain of survival.
Outstanding leaders can install in their organizations their vision of high expectations and relentless striving for excellence. They also continuously ask the question, “How can the system be improved?” Ongoing QI is the mechanism by which we know where and how to improve. Training and continuing education are the vehicles by which expertise and professionalism are brought to every cardiac arrest.
11 Components of Community CARE
Our objective is to increase SCA survival rate. Many factors influence setting goal timelines. Time, availability and financial support are some of the influencing issues. Engaging enterprise members among the community is the greatest variable involved here. Some of the goals we have a great deal of control and other component we rely upon working with others. All of these factors have been weighed to determine which goals have been assigned to short-range, mid-range and long-range goals.
- Rapid Dispatch — Currently the Orland Fire Protection District provides Emergency Medical Dispatch (EMD) to direct callers in CPR. This program will fine tuning this process by training dispatchers to more quickly recognize signs of sudden cardiac arrest and to guide callers to perform CPR. Action items include:
- Train dispatchers to determine unconsciousness, recognize abnormal breathing, dispatch units within 15 seconds, and direct bystander CPR
- Every sudden cardiac arrest incident will be evaluated through the QI process
- High Performance CPR — A more effective method of performing CPR has been established through clinical research. Action items include:
- Evaluate current CPR performance
- Train our responders in High Performance CPR utilizing an improved call management model
- Quality Improvement — Review each aspect of sudden cardiac arrest incidents and determine the need for improvement. Action items include:
- Listen to Dispatch tapes
- Evaluate Patient Care Reports
- Collect data from cardiac monitors and defibrillators
- Review incident with responding crew
- Provide feedback to dispatchers and responders relating to patient outcome
- Induced Hypothermia — Follows existing Standing Medical Orders -SMO(medical direction to all paramedics by the Project Medical Director, Dr. Heilicser). Following this protocol results in a significant difference in neurological outcome for the patient. Action item includes:
- Continue training on the Induced Hypothermia protocol, practice and accountability
- Public Access to Defibrillators (PAD) — Early defibrillation is a key component is sudden cardiac arrest patient survival. Public access to Automatic External Defibrillators (AED) is imperative. Action items include:
- Initiate a PAD program in the community, leveraging the network of the business community and other existing organizations to promote public access defibrillators
- Utilize existing grant opportunities to help fund the program
- Cardiac Arrest Registry — Data collection that measures more than if a patient lives or dies but all aspects related to care. Action item includes:
- Grant funding has been awarded to establish a registry in Illinois. We have established a relationship with the administrators of this grant in order to support our Community CARE program
- Voice Recording — Voice recording along with the cardiac rhythm and shocks delivered can help to reconstruct the actual events of the resuscitation and identify reasons for gaps in performance. Action items include:
- Upgrade cardiac monitors for voice recording capability
- Suggest all community purchased AED’s have the voice recording feature
- Community CARE Steering Committee — Partners and participants in the enterprise need to have direct involvement in the future of the program. This goal offers participation from all members of the enterprise. Action item includes:
- Meet with Grantees, Community organizations and other partners in the enterprise to establish and execute program goals and objectives
- Police Defibrillators — Police officers with AED’s and CPR training have the potential to increase survival rates of sudden cardiac arrest patients. Police intervention has already made a difference in several saves. Action item includes:
- Obtain total support from Orland EMS, Orland Park Police and Orland Hills Police
- Long Range Funding — Sustainability is key to the success of this program. Funding sources need to be identified to support the Cardiac Arrest Rescue Enterprise. Action items include:
- Work with the Orland Fire Foundation to support Community CARE
- Provides a vehicle to support all aspects of this program
- Culture of Excellence — Changing culture is a long process. The Orland Fire Protection District has maintained an aggressive EMS service since 1976. CARE strives to enhance our existing program while working with the public, our partners in the community and our local hospitals. Creating a Culture of Excellence is an effort that will take a period of time incorporating all elements, driven by the accountability process. Benchmarks in the Culture of Excellence include improvements in the outcomes of sudden cardiac arrest patients.