There aren’t many areas where EMS has leverage against bigger players in the healthcare system. It’s a rare and wonderful thing, then, when an EMS service can tell a hospital how things are going to be.
“Strong-arm is a hard word,” chuckles Mike Jacobs, EMT-P, prehospital care coordinator for California’s Alameda County EMS. “But trust me, I’ve had some hospital officials say, ‘How in the hell can EMS dictate what we do?’”
Dictate is a hard word too, but when it comes to patients who’ve suffered out-of-hospital cardiac arrests, EMS does hold some power. And when EMS tells hospitals they won’t be receiving EMS’ high-revenue OHCA patients if they can’t meet the required criteria of cardiac arrest receiving centers, hospitals tend, grumbling or not, to meet those criteria.
“We feel like these are our patients,” says Jacobs. “Someone called 9-1-1, and it’s our responsibility to take them to the most appropriate facility for the best care. It doesn’t matter what kind of memberships or anything else they have. When you put it that way, hospitals generally recognize that’s our decision to make.”
That leverage is leading to the establishment of five new cardiac arrest receiving centers among Alameda’s 13 hospitals. Those centers are the latest milestones in a years-long journey to improve cardiac arrest survival in the county—a trek that’s embraced therapeutic hypothermia, pit-crew resuscitation and bystander CPR among the full suite of best practices—that’s already shown benefits: As of 2010, around 32% of all VF/VT patients treated by Alameda County EMS survived to hospital discharge. Among witnessed events, the rate topped 40%.
Cardiac Arrest Centers
For the last eight years, Alameda has had a quartet of STEMI centers dispersed conveniently around the county. These receive 12-leads from the field, which are reviewed by docs who can activate cath labs with patients in transit (average door-to-intervention time last year: 65 minutes). The labs can do emergent PCI around the clock; the hospitals share outcome data back to EMS. Leaders meet regularly.
It made sense, then, to piggyback cardiac arrest centers onto these existing resources. (A fifth one comes online late this year.)
“It’s an intuitive fit,” says Jacobs. “These hospitals already have emergent cardiac cath capabilities and cooling protocols. Three of the four have open-heart backup for emergent bypasses. They’ve been doing it for a long time, and we work with them very closely.”
The cooling protocols also came at the behest of EMS; in 2008, just one of the 13 hospitals had such a thing. Jacobs gave the rest 16 months to get it, telling them that by December 2009, ALCO would be cooling in the field, and if they couldn’t continue that, those patients would go elsewhere. By the deadline, all 13 had cooling protocols.
Now, when a hospital renews its STEMI center designation, it’ll have to be a cardiac arrest center too. This makes sense: Around 40% of SCA victims ultimately need to go to cath labs, with or without ECG changes. The move ensures continuity of care.
Of course successful OHCA resuscitation hinges largely on fast, good-quality CPR for victims. To promote that ALCO looked to its schools. Using the CPR Anytime program, it trained 7th- and 10th-graders in CPR, then had them go teach others. The junior-high kids were more effective, each training an average of 4.5 additional people, to 2.8 for the sophomores. This led to the CPR7 program, now in its third year of training 7th-graders. By the end of the 2011–12 school year, it had reached more than 20,000, each of whom taught an average of 3.7–3.8 others.
“Extrapolating those numbers,” Jacobs notes, “we’ve theoretically exposed 90,000-plus people in two years to the skill set of CPR.”