Crime Scene Investigation: Evidence Suggests Improvements Needed

The evidence on the evidence is in, and it ain't pretty. Recent research has shown that, while the 2005 American Heart Association guidelines for CPR and ECC doubled survival from out-of-hospital cardiac arrest, EMS operators and clinicians were slow to adopt the new clinical care guidelines. In fact, it seems thousands of lives could have been saved if EMS services had implemented the guidelines more quickly and providers trained to apply them correctly.

Police tape marks the scene around the Resuscitation Outcomes Consortium, where 178 EMS agencies were surveyed regarding 2005 AHA guideline implementation. Evidence shows that some agencies made the switch from stacked shocks to single shocks, among other changes, in less than 2 months (49 days in the fastest service), while others took as long as 750 days (in excess of two years). The average was 416 days--still well over one year after the guidelines were released in December 2005 until providers began treating patients with the best evidence science has to offer.¹

Overt wiretaps--qualitative interviews--with these agencies identify the reasons behind the delay. Nearly half of EMS agencies report decision-making delays ranging from hesitation by state regulators and medical directors to trying to coordinate with allied agencies and research networks to roll out resuscitation programs in a coordinated manner. More than one-third of agencies were unable to upgrade their defibrillators in a timely fashion, and many had to order new defibrillators because the old AEDs couldn't be upgraded at all. Of course, with many services in the same boat, EMS operators report shipping delays and back-orders further delaying a change in protocol. Lastly, one in three agencies explained their delay was due to training logistics. Many felt they had to use the old textbooks in stock before ordering new ones, while others reported difficulty getting their hands on the appropriate training materials. Others could not find a qualified instructor, and many had fiscal restraints that delayed continuing training time dedicated to resuscitation.²

Regardless of the reason, the results were clear: EMTs and paramedics were using old, inferior guidelines to treat cardiac arrest far too long after the AHA released the 2005 guidelines. But that's not where this drama ends. European data and unpublished North American evidence suggest that, after implementation, it took an additional seven months before EMS providers were proficient delivering the standard to patients.³ Explanations are fuzzy, but it is likely that asking providers to re-choreograph the complicated dance of running a code is not as simple as it sounds. Hundreds of actions are required in sequence, and behaviors die hard. Couple this with the lack of high-fidelity simulator training found in many EMS services worldwide, and one can appreciate that simply delivering a PowerPoint may not be an effective way of implementing new medical practices.

With the 2010 guidelines just around the corner, and acknowledging that resuscitation science is the fast-paced cheetah of medical research, EMS agencies must be ready to implement new, lifesaving science the moment it is available. EMS systems, including regulators, medical directors, agencies and clinicians, would benefit from collaborative planning in advance of these changes so that scientific evidence can leap from bench-side to curbside as quickly as possible. More lives will be saved. And no one would mind leaving behind their fingerprints on the scene of a save.

References

1. Bigham BL, Koprowicz K, Aufderheide TP, Davis DP, Donn S, Powell J, Suffoletto B, Nafziger S, Stouffer J, Idris A, Morrison LJ; ROC Investigators. Delayed prehospital implementation of the 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiac care. Prehosp Emerg Care.Jul-Sep;14(3):355-60, 2010.