Multistate implementation of guideline-based cardiac resuscitation systems of care: description of the HeartRescue project.

BACKGROUND: There is large and significant regional variation in out-of-hospital cardiac arrest (OHCA), and despite advances in treatment, survival remains low. The American Heart Association has called for the creation of integrated cardiac resuscitation systems of care capable of measuring and improving evidence-based care from bystanders through to hospital discharge. METHODS: The HeartRescue Project was initiated in 2010 by the Medtronic Foundation in collaboration with 5 academic medical centers and American Medical Response. The HeartRescue Project aims to develop regional cardiac resuscitation systems of care that will implement guideline-based best practice bystander, prehospital, and hospital care with standardized data reporting linked to outcomes. The primary goal is to improve collective OHCA survival by 50% over 5 years. RESULTS: The total population in the 5 participating states is 41.1 million. At baseline, the HeartRescue Project covers approximately 26.1 million people (63.6%) and has engaged 767 emergency medical services agencies and 269 hospitals. Data will be collected for quality improvement, to inform provider feedback, and serve to define effective strategies to improve cardiac arrest care. CONCLUSION: The HeartRescue Project is the largest public health initiative of its kind focused entirely on cardiac arrest outcomes. The project is designed to significantly improve OHCA survival by implementing and measuring model systems of care for cardiac resuscitation.

Regional systems of care for out-of-hospital cardiac arrest: A policy statement from the American Heart Association.

Out-of-hospital cardiac arrest continues to be an important public health problem, with large and important regional variations in outcomes. Survival rates vary widely among patients treated with out-of-hospital cardiac arrest by emergency medical services and among patients transported to the hospital after return of spontaneous circulation. Most regions lack a well-coordinated approach to post-cardiac arrest care. Effective hospital-based interventions for out-of-hospital cardiac arrest exist but are used infrequently. Barriers to implementation of these interventions include lack of knowledge, experience, personnel, resources, and infrastructure. A well-defined relationship between an increased volume of patients or procedures and better outcomes among individual providers and hospitals has been observed for several other clinical disorders. Regional systems of care have improved provider experience and patient outcomes for those with ST-elevation myocardial infarction and life-threatening traumatic injury. This statement describes the rationale for regional systems of care for patients resuscitated from cardiac arrest and the preliminary recommended elements of such systems. Many more people could potentially survive out-of-hospital cardiac arrest if regional systems of cardiac resuscitation were established. A national process is necessary to develop and implement evidence-based guidelines for such systems that must include standards for the categorization, verification, and designation of components of such systems. The time to do so is now.

Synchronization of Timepieces to the Atomic Clock in an Urban Emergency Medical Services System.

STUDY OBJECTIVE: Erroneous time documentation of emergency treatment caused by the variation in the accuracy of timepieces has profound medical, medicolegal, and research consequences. The purpose of this study was to confirm the variation of critical timepiece settings in an urban emergency care system noted in previous studies and to implement and monitor the results of a prospective program to improve time synchronization. METHODS: Timepieces (n=393) used by firefighters, paramedics, and emergency physicians and nurses were randomly sampled immediately before and at two time intervals (1 and 4 months) after attempted synchronization to the US atomic clock standard. The setting on each timepiece was compared with the atomic clock. From the data, a mathematical simulation estimated the number of time-related documentation errors that would occur in 2,500 simulated cardiac arrest cases using timepieces with accuracy similar to those found in the EMS system before and after attempted synchronization. RESULTS: Before attempted synchronization, the timepieces had a mean error of 2.0 (95% confidence interval 1.8 to 2.3) minutes. One month after attempted synchronization, the mean error decreased significantly to .9 (.8 to 1.1) minute. However, it increased to 1.7 (1.5 to 1.9) minutes within 4 months. Mathematical simulation before attempted synchronization predicted that 93% of cardiac arrest cases would contain a documentation error of 2 minutes or more and that 41% of cases would contain a documentation error of 5 minutes or more. Attempted synchronization cut the 2-minute documentation error rate in half and reduced the 5-minute documentation error rate by three fourths. However, the error rates were predicted to return to baseline 4 months after attempted synchronization. CONCLUSION: Emergency medical timepieces are often inaccurate, making it difficult to reconstruct events for medical, medicolegal, or research purposes. Community synchronization of timepieces to the atomic clock can reduce the problem significantly, but the effects of a one-time attempted synchronization event are short-lived. [Ornato JP, Doctor ML, Harbour LF, Peberdy MA, Overton J, Racht EM, Zauhar WG, Smith AP, Ryan KA: Synchronization of time-pieces to the atomic clock in an urban emergency medical services system. Ann Emerg Med April 1998;31:483-487.].

Prehospital management of cardiac arrest: how useful are vasopressor and antiarrhythmic drugs?

Out-of-hospital resuscitation protocols for patients suffering cardiac arrest have historically included cardiopulmonary resuscitation, defibrillation, and rapid transport to a hospital. For many years, use of drugs to improve myocardial perfusion or to correct arrhythmias that occur during cardiac arrest has been part of prehospital efforts to revive patients in ventricular tachycardia or ventricular fibrillation. Use of some of these drugs, however, may be based more on tradition than on well-documented evidence of efficacy. The authors reviewed pertinent data on the vasopressors epinephrine and vasopressin and the antiarrhythmics amiodarone and lidocaine to evaluate the usefulness of these drugs in cardiac arrest. They found little clinical data supporting the prehospital use of lidocaine in cardiac arrest, and despite a great deal of laboratory and clinical data addressing the efficacy of epinephrine, there is no large, randomized, controlled clinical trial supporting its use. Data on amiodarone and vasopressin support the use of these drugs in out-of-hospital resuscitation efforts.