Improving survival from Sudden Cardiac Arrest – can it really work?

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Gary Strong's presentation at the Paramedics Australasia NZ CPD event in Auckland on 3 July 2013.

Gary is the Programme Leader BHSc Paramedic at Whitireia Polytechnic, and prior to that was the Education & Training Manager at Wellington Free Ambulance.

Prior to coming to New Zealand, Gary was the Paramedic Clinical Lead at the Great Western Ambulance Service, an Education and Development Tutor at the Gloucestershire Ambulance Service, and worked as a paramedic with the West Midlands Ambulance Service NHS Trust.

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  • Get started rapidly Recognise agonal breathing Rate Depth Recoil Minimum pauses Do not overinflate Change every two minutes Communicate well Know your roles Nascar Pit Stop 4 Tires Changed 22 Gallons of Fuel Added Wedge Adjustment Total Time: 14 Seconds! Each Second Costs 300 Feet Track Position!
  • Improving survival from Sudden Cardiac Arrest – can it really work?

    1. 1. Sudden Cardiac Arrest Can we do better? Gary Strong July 2013
    2. 2. The challenge: • To reduce the gap between what science tells us is correct and what clinicians actually do • Measure, improve, measure, improve • Change the culture: expect success
    3. 3. • Understand key concepts relating to CPR • Understand how to get better results • Discuss research issues in cardiac arrest management • Save lives! Learning outcomes
    4. 4. • ‘invented’ paramedics • 40 years’ experience • Best place in the world to survive a sudden cardiac arrest • Resuscitation Academy – sharing good practice Why Seattle?
    5. 5. 52%
    6. 6. 5%
    7. 7. 7%
    8. 8. 0%
    9. 9. 33%
    10. 10. 32%
    11. 11. 32%
    12. 12. ??%
    13. 13. Why learn from Seattle and King County? • 46% survival rate for witnessed VF arrest • 40+ years’ experience and research • Whole systems approach • Continuous self improvement • ‘we will never stop looking for new ways to save lives’
    14. 14. Why focus on cardiac arrest? • ‘a community that can successfully respond to & manage this emergency is likely to perform well on the other 99% of emergencies’ Eisenberg (p. 18) • survival from witnessed VF should be the main criteria for rating a community's EMS system (Utstein)
    15. 15. •Eisenberg, M.S. (2009). Resuscitate! How Your Community Can Improve Survival From Sudden Cardiac Arrest. Seattle: University of Washington Press •New edition just published!
    16. 16. •Patient factors •Event factors •System factors •Therapy factors What makes the difference?
    17. 17. Time to CPR Quality of CPR Time to defibrillation Interaction of CPR and defibrillation Time to ALS care Telephone CPR Community CPR Public access defibrillation Chain of Survival
    18. 18. What makes the difference?
    19. 19. Three Phases of Cardiac Arrest • Electrical – 1-5 mins • Circulatory – 4-15 mins • Metabolic – The land of no return
    20. 20. The importance of time to defibrillation
    21. 21. The importance of time to CPR
    22. 22. Time to first shock Time to CPR 0-6 minutes 9-12 minutes 13+ minutes 0-4 minutes 45% 31% 23% 5-8 minutes 34% 21% 17% 9+ minutes N/A 10% 0% Survival from Cardiac Arrest King County, Witnessed VF rhythm 1980-2009
    23. 23. New Zealand Initiatives HEARTsafe New Zealand •http://www.stjohn.org.nz/about-st-john/st- john-projects Operation Heartbeat •http://www.operationheartbeat.org.nz
    24. 24. St John boss in push to improve services Access to patient survival data critical for lifting care, says chief. Survival rates for cardiac arrest, strokes and trauma victims are among the medical records that the new St John boss wants hospitals to provide in order to improve patient care. Chief executive Peter Bradley is making a number of changes to the organisation in a bid to cope with ever increasing 111 calls and funding shortfalls of millions of dollars each year. He told the Herald that a restructure of senior management positions was to ensure "accountability and transparency" in a drive for better performance and a strong focus on patients. Currently, the only measure for St John is response times to emergency calls which have particularly deteriorated in urban areas, such as Auckland. However, Mr Bradley wants access to medical records to measure the survival rates of patients taken to hospital by ambulance after they have suffered from cardiac arrest, strokes and trauma. Similar data was collated by the Department of Health in Britain, where Mr Bradley was running the London Ambulance Service until late last year. The most recent statistics showed the London ambulances had a survival rate of 32 per cent for cardiac arrests, the best in the country and comparable with the best in the world.
    25. 25. THE NEW ZEALAND MEDICAL JOURNAL Survival from out-of-hospital cardiac arrest in Wellington in relation to socioeconomic status and arrest location Aimee L Fake, Andrew H Swain, Peter D Larsen Abstract Aims The study examined the influence of physical location on survival from out-of hospital cardiac arrest (OHCA). Firstly, OHCAs occurring in residential settings were compared to those occurring in public locations. Secondly, the residential OHCAs were classified according to socioeconomic status and the relationship between socioeconomic status and outcome from OHCA was examined. Methods For all OHCAs that occurred between 1 July 2007 and 30 June 2010, we compared OHCA characteristics and outcomes between public and residential locations, and for residential locations examined across deciles of socioeconomic status. Results Of the 445 arrests that occurred during the study period, 413 met the inclusion criteria. Survival from OHCA in public locations was approximately twice that for residential OHCA (19.8% vs 10.7%, p=0.021). We found no association between survival from residential OHCA and socioeconomic status. Similarly, we found no association between socioeconomic status and witnessing of the event, bystander cardiopulmonary resuscitation, the initial presenting rhythm, and ambulance response time. Conclusion Residential OHCA in the Wellington region has a much poorer prognosis than OHCA in public locations. There is no evidence to suggest that any socioeconomic group in the Wellington region is disadvantaged when a community and ambulance response is required for an OHCA.
    26. 26. What makes for good CPR?
    27. 27. • Get started rapidly • Recognise agonal breathing • Rate • Depth • Recoil • Minimum pauses – ‘pit stops’ • Do not overinflate • Change every two minutes • Communicate well • Know your roles Good CPR
    28. 28. Positive & Negative
    29. 29. How good do you think you are?
    30. 30. A cardiac arrest in Seattle (1) • Patient collapses • 911 call • Aggressive telephone CPR advice • Display tells call taker if there is a PAD nearby • BLS crew on scene 4-6 mins • 1st shock 6-8 mins • ALS crew on scene 4-10 mins
    31. 31. A cardiac arrest in Seattle (2) • BLS crew in charge • ‘choreographed’ CPR • CPR ‘density’ 90% + • Continuous chest compressions/30:2 • Change operator every 2 mins • Max interruption 10 secs • Post resuscitation hypothermia • In hospital 100% • Pre hospital trial – active cooling
    32. 32. A cardiac arrest in Seattle (3) • BLS medic downloads data and voice recording from AED • Completes & submits cardiac arrest QI form • ALS medic downloads data and voice recording from LP12 • Completes & submits cardiac arrest QI form • Registry co-ordinator may request further information from either crew
    33. 33. A cardiac arrest in Seattle (4) • Every cardiac arrest is debriefed • Medical Director personally reviews every cardiac arrest • Feedback to crews ‘you should develop the attitude & expectation that a patient who presents with VF as an initial rhythm will make it to the hospital alive’ Eisenberg (p. 129)
    34. 34. CREATE THE CULTURE
    35. 35. Research – the size of the task • ILCOR • http://www.ilcor.org/en/home • CoSTR: Consensus on Science and Treatment Recommendations • Just how much resuscitation research is there?
    36. 36. Why Utstein? • 1990 conference • Utstein Abbey in Norway • Consensus paper • http://depts.washington.edu/survive/utstein .php
    37. 37. Some unresolved questions: • Why is the incidence of VF falling • Do we need oxygen? • What is optimum airway maintenance? • Do we need drugs? • What about human and team performance? • Equipment positioning? • ‘Man vs machine’
    38. 38. Some useful links: • http://www.slideshare.net/Hiltz/improving- community-based-response-to-cardiac- arrest-nz3 • http://www.londoncardiacarrestsymposium .com/videos-whitbread-2012.html • http://circtrial.com
    39. 39. Eisenberg book: Resuscitate! • Print version: http://books.google.com/books/about/Res uscitate.html?id=5daNMgEACAAJ • FREE ebook: https://itunes.apple.com/us/book/ten- steps-for-improving- survival/id603675538?mt=11
    40. 40. The Future ? • Sam Parnia – the Lazarus Effect • The CHEER Study Refractory Out-of-hospital Cardiac Arrest Treated with Mechanical CPR, Hypothermia, ECMO (extracorporeal membrane oxygenation machine) and Early Reperfusion.
    41. 41. Questions?

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