Improving SCA Survival

      Over the first half of 2009, 27 patients who suffered out-of-hospital sudden cardiac arrests walked out of Ventura County (CA) hospitals. Most of them would not have done so had the Ventura County EMS system not taken the time, energy and effort to start a performance improvement initiative in 2008. We are delighted to report on this success, and hope it might give others some thoughts on how to look at their systems.

   One of the very time-critical, and arguably most important, roles of an EMS system is to care for the victim of SCAs. Modern EMS got its start after a 1967 report by Dr. Frank Pantridge from Northern Ireland described the first out-of-hospital defibrillations. Some believe that since SCAs make up less than 1% of all EMS calls, they should not be the focus of system evaluations. Others point out that of all critical EMS calls—calls where our care actually affects the patient's outcome—SCA makes up quite a large proportion. Further, an EMS system that can rapidly and effectively respond to cardiac arrests will be better organized for other high-priority responses. The care of seriously ill or injured patients requires critical thinking and a well-choreographed approach from all responders. An EMS system that can deliver high-quality comprehensive management to the SCA patient can also do so elsewhere.

   Ventura County has a population of 800,000 and covers 1,900 square miles just north of Los Angeles. It has the typical coastal California benefits and challenges of populous beach areas, sometimes-crowded freeways and remote mountains. The EMS system includes an emergency medical dispatch program, a tiered response system with fire department first responders and private ambulance transport services, aeromedical operations, and eight base and receiving hospitals. Providers have a long history of excellent coordination and cooperation, and meet on at least a monthly basis.

   Early in 2008, we started the process of examining our SCA outcomes. Although we'd gone through this exercise in the past, it had been more of a data collection chore than a basis for improving care. The SCA project was especially attractive for two reasons: 1) It involved every part of our EMS system, from collapse to discharge home; 2) With all the exciting recent advances in resuscitation research, we thought, when we were done, we could point to (and hopefully celebrate) a success measured in lives saved.

IMPROVEMENTS

   First, we looked at the entire system to see what worked well and what needed improvement. We were doing a lot well. Dispatch worked effectively, and responses were fast—the closest and backup units were getting to scenes quickly. On-scene care, transport and hospital care were excellent. Fire departments, ambulance companies and hospitals were active participants in our QI system, and everyone always kept good patient care as the cornerstone of what they did.

   We also found some ways we could improve. First, we had no good way to decide whether anything we did (or changed) for the SCA patient made a difference. We had lots of individual data sitting on a number of different computers (9-1-1, dispatch, fire, ambulance, hospital), but no outcome information and no meaningful system reports. It is helpful to know that a patient has return of spontaneous circulation (ROSC) or is admitted to the hospital, but what we (and our community) really wanted to know was how many patients were waking up, leaving hospitals and going back to their families. We decided that instead of building our own reporting system, we would join the Cardiac Arrest Registry to Enhance Survival (https://mycares.net). CARES is a nationwide project funded by the CDC and run out of Emory University. With more than 20 EMS systems now participating, all entering information using the same definitions into one database, we could see exactly how we were doing to improve neurologically intact survival to hospital discharge, as well as begin to compare ourselves to others.