CARES’ 10 Year Anniversary!

I n s i d e t h i s i s s u e :

New CARES Team

Members

2

CARES/PAROS

Meeting at NAEMSP

2

2014 National Report

Timeline

2

The IOM: Studying

OHCA

2

New Castle:

Realized benefits

3

Illinois Heart Rescue

Program

4

CARES & Plano 5

CARES’ West Coast

Beachhead

6

TTM Module Update 8

T-CPR Worldwide 8

Resuscitation

Academy: High

Performance CPR

10

Better Outcomes in

At-Risk Populations

11

Neurological

Outcomes

13

PAROS Update 14

CARES Team

Thank You

16

CARES Turns Ten! O c t o b e r 2 0 1 4 V o l u m e 4 , I s s u e 2

Sp ec i a l po in t s

o f in t eres t :

CARES Updates

Agency Testimonials

CARES Module Updates

Process Improvement

CARES Thank You

Then & Now

In 2004, the Centers for Disease Control and Prevention (CDC) collaborated

with Emory University School of Medicine's Department of Emergency Medicine to

establish CARES. Data collection began in Atlanta, with nearly 600 cases captured in

2005. At present, the registry now captures that same number of cases weekly. The pro-

gram has expanded nationally to include 13 state-based registries with community sites

in 23 additional states, representing a catchment area of more than 80 million people or

25% of the US population. To date, the registry consists of over 150,000 records and

interest in CARES continues to grow, as more communities express a desire to partici-

pate.

In 2009, CARES began partnering internationally with the Pan Asian Resuscita-

tion Outcomes Study (PAROS) currently representing 8 countries (Japan, Malaysia, Sin-

gapore, South Korea, Taiwan, Thailand, Turkey and the United Arab Emirates). CARES

has collaborated with PAROS on software development, reporting, and technical exper-

tise in an effort to implement a global data collection platform for out-of-hospital cardi-

ac arrest.

Since 2011, CARES has focused on statewide participation in Alaska, Arizona,

Delaware, Hawaii, Idaho, Illinois, Michigan, Minnesota, North Carolina, Oregon, Penn-

sylvania, Washington and Utah, with Nebraska and South Carolina coming on board in

the coming year! Statewide data collection allows for the enrollment of communities of

varying sizes and population densities, while enhancing communication and collabora-

tion between state and local EMS providers, improving cardiac arrest care throughout

the state.

In 10 years, CARES has achieved many milestones in OHCA data collection

and is now looking forward to delving into interventional data measures. Many of the

articles in this issue highlight the utilization of CARES data by participating agencies, as

well as supplemental module updates and motivation for future process improvement.

P a g e 2

CARES/PAROS Meeting at NAEMSP We would like to invite you to the CARES/PAROS meeting during the NAEMSP Conference

at the Hyatt Regency in New Orleans, LA. The meeting will be held on Thursday, January 22, 2015

from 7:30am-8:30am CDT. If you are unable to attend, a conference line will be provided via email

closer to the meeting date.

Brad Swanson Brad is a

native of Chicago, IL. He

graduated from the United

States Military Academy with

a B.S. in Sociology. After-

wards, he served in the Army

as a Medical Service Officer at Ft. Lewis, WA and

Ft. Benning, GA. Brad worked in a primary care

clinic, veterinarian organization, and human

resources office. He recently transitioned out of

the Army and moved to Atlanta, GA to join the

CARES team and be with his wife Joan.

Tiara Sinkfield, MPH Tiara is a Florida native, but

has been living in Atlanta,

GA for 17 years. As an

undergraduate, Tiara attended

Spelman College as an

English major with a Public Health minor. She

went on to pursue her graduate degree in Public

Health at the University of Alabama at

Birmingham. Her love and passion for public

health is a great addition to the team.

New CARES Team Members

2014 National Report Timeline CARES staff will be preparing for the 2014 National Report in the upcoming quarter.

Participating EMS agencies must have all 2014 records entered by the end of January 2015 while

hospitals should complete data entry by the end of February 2015. We appreciate everyone's time and

effort during this busy season!

The Institute of Medicine: Studying OHCA The Institute of Medicine (IOM) is

conducting a study on the current state and future

opportunities to improve cardiac arrest outcomes

across the country. The study reviews statistics

and variability in outcomes as well as the scientific

evidence on existing therapies and public health

strategies that impact survival. The final report

will identify promising areas of research and the

next steps to improve the quality of care for

cardiac arrest in the United States. The topics

addressed by the committee include but are not

limited to: CPR and the use of AEDs, EMS and

hospital resuscitation systems of care, national

cardiac arrest statistics, the state of resuscitation

research, and opportunities for increasing

survival rates nationwide.

In order to fulfill these objectives, the

IOM committee has asked CARES to provide a

summary of the 2013 registry data. This summary

will provide a profile of cardiac arrest in CARES

communities with the goal of extrapolating the

findings to the national population. Bryan

McNally, the Executive Director of CARES, and

Allie Crouch, the Director of Operations, have

presented to the IOM panel on topics related to

sustainable data collection models and strategies to

improve local and national cardiac arrest registries.

The report from the IOM committee is expected to

be available by summer 2015 and will help guide

the future direction of cardiac arrest data

collection, research and treatment in the United

States.

CARES Updates

Welcome Tiara

and Brad!

P a g e 3 Agency Testimonials

New Castle County, Delaware Realizes

Benefits of CARES Participation By: Dr. Robert Rosenbaum, Chief Lawrence Tan and edited by CARES Staff

New Castle County, Delaware is an urban/suburban

area located between Philadelphia and Baltimore along the I

-95 corridor, and has a population of 549,684. The pre-

hospital EMS system consists of a tiered response configu-

ration with basic life support (BLS) services provided by 21

volunteer fire companies, a career fire department, a private

contracted provider in the municipality of Wilmington, and

a student-staffed ambulance at the University of Delaware.

Advanced life support (ALS/paramedic) services are provid-

ed by the New Castle County Government. The New Castle

County Paramedics operate as a “third service” EMS agency

in an ALS-intercept configuration. The county paramedics

provide ALS to the entire county, including the incorporated

municipalities. Medical direction is provided by the state

Office of Emergency Medical Services under the authority

of state code.

"The first time I heard Bryan McNally’s presenta-

tion at NAEMSP in 2009, I was committed to the idea that

we needed to bring CARES to New Castle County," was the

first thought of Dr. Robert Rosenbaum, EMS Medical Di-

rector. The presentation wasn't over and Dr. Rosenbaum

was already in contact with New Castle County EMS Chief,

Lawrence Tan. Both agreed with the concept and potential

benefit and immediately began to work to bring CARES to

Delaware.

“Measuring EMS system perfor-

mance can be extremely difficult,

given the variables in operating

configurations and the multiple

places that data must be obtained,”

said Chief Tan. “CARES has facili-

tated our ability to uniformly col-

lect, analyze and compare our system performance in out-of

-hospital cardiac arrest (OHCA). It also helps us monitor

and trend the consistency of our clinical response to OHCA

in our jurisdiction.”

New Castle County has seen continuous improve-

ment of cardiac arrest survival rates and the numbers of an-

nual survivors of sudden cardiac arrest (SCA) since begin-

ning participation in CARES. The improvement is measura-

ble in the number of survivors presenting with any initial

rhythm, and especially noticeable in patients with witnessed,

shockable rhythms. In the past two years, New Castle Coun-

ty has seen survival rates nearly double from what they were

before 2012. Quarterly survival rates for patients presenting

with witnessed, shockable rhythms reaching 50% are not

uncommon, and we have come to expect quarterly survival

rates for this group of patients to reach 35 to 45% on a regu-

lar basis. Survivors of witnessed arrests with any presenting

rhythm are now over 20%, which is nearly double the rate in

New Castle County for this same group of patients prior to

2012.

Analysis of CARES data

has prompted modifications and

adjustments in practice for para-

medics and BLS providers in

New Castle County. For in-

stance, EMS crews are encouraged to remain on scene, pro-

vide high quality CPR, and make every effort to restore

spontaneous circulation before considering transport. “Pit

crew” CPR is being promoted to facilitate an organized,

consistent approach to providing excellent basic life support

and improve the chances of a return of spontaneous circula-

tion (ROSC). The New Castle County Paramedics were one

of the early services to implement pre-hospital induced hy-

pothermia to treat patients post-arrest and there is ongoing

emphasis on beginning this process on scene after sustained

ROSC is established.

Ongoing use of CARES data will enable

NCC*EMS to target interventions that may further improve

survival rates. Directed education to zip codes and fire dis-

tricts with lower survival rates is already planned. The po-

tential to use technology to enhance and improve bystander

intervention is also being explored. We will track changes in

survival as we implement additional system enhancements

and monitor for ongoing performance improvement. “This

was absolutely one of the best choices we've ever made and

is proving to be one of our most valuable quality assurance

and performance improvement projects,” said Dr. Rosen-

baum.

continued on page 4

P a g e 4

Illinois Heart Rescue (ILHR) is a

statewide, not-for-profit QA/QI project. This pro-

ject is generously grant-funded by the Medtronic

Foundation along with 7 other Heart Rescue states.

The daunting goal of this project is to more than

double neurologically intact survival for victims of

out-of-hospital cardiac arrest (OHCA), within a 5-

year period. As we all know, there is no silver bul-

let to improve survival and as a result, this project

is multi-focal. By identifying, measuring and ad-

dressing the barriers to OHCA survival in the pre-

hospital, hospital and community environment, the

ILHR project can then advocate pathways to pro-

mote best practices.

The cornerstone of this project is DATA.

We have all heard the cliché that we “cannot fix

what we cannot measure”. That statement is very

true for the State of Illi-

nois. When Illinois ap-

plied for the Medtronic

Foundation grant funding

initially, there was no

reliable data. Illinois had

OHCA data that was ob-

tained through NEMSIS

reporting but there was

no information linking these patients to outcomes

after being dropped off at the hospital. Therefore,

EMS measured their success based on whether the

patient had the presence or absence of a pulse upon

hospital arrival. Some hospitals would measure

their survival outcomes, but often OHCA patients

were combined with the statistics of in-house ar-

rests. There was no reliable way to link pre-

hospital behaviors to outcomes. Additionally, there

was no consistent measurement tool for hospitals

to link their practices to patient outcomes. And

then, we met CARES.

Although ILHR is a statewide project,

simple math demonstrates that 2/3 of the State’s

population, and thus 2/3’s of the OHCAs, occur in

the Chicago region. We had numerous discussions

related to CARES rollout. Do we start with smaller

EMS agencies and communities and show proof of

concept or do we start with Chicago Fire Depart-

ment (CFD), one of the largest EMS agencies in

the US? Chicago is often referred to as the “City of

Broad Shoulders” - hardworking, dedicated, and

not afraid of a challenge. Our decision was made,

now to convince Chicago Fire...

Successes and challenges occurred concur-

rently...and they still do. One key advantage is that

for the city of Chicago with a population of 2.7

million, there is only ONE provider. ILHR did not

have to initially convince EMS leadership of nu-

merous providers. CFD leadership cemented that

every OHCA would be captured in CARES.

continued on page 5

Illinois Heart Rescue Program: Chicago

Fire Department By: Teri Campbell and edited by CARES Staff

He and Chief Tan agree that the database

and support of CARES staff has been incredibly

valuable and a key to successful utilization of the

information gathered on OHCA patients. Chief

Tan added, “We look to build on the improve-

ments of the last 5 years and continue to use

CARES data to increase the rate of survival from

OHCA and help us improve the care being deliv-

ered in New Castle County, Delaware.”

For further information regarding New Castle

County EMS, visit their website at

www.nccde.org/ems or follow them on Face-

book (New Castle County Paramedics).

P a g e 5

For decades, the providers of CFD were condi-

tioned that “good” pre-hospital resuscitation meant imme-

diate transport to the hospital. Procedures and patient care

occurred in route. New protocols that included a type of Pit

Crew model, Incident Command for cardiac arrest and

Field Termination protocols, challenged the status quo. As

anticipated, many providers embraced the evidence and

science while others needed to evolve old belief patterns.

To facilitate this culture change, CFD sent leadership edu-

cators to Washington for the Seattle-King County Resusci-

tation Academy.

Fueled with science, documented successes, and

renewed energy, CFD developed a powerful resuscitation

academy and simulation center. All new candidates are

mandated to attend the academy. Challenges still exist with

getting experienced crewmembers through the academy,

due to the thousands that need to be trained. The city must

balance the EMS demands of the day with the number of

crews that can be pulled off the streets for training. The city

has recently hired and is in the process of adding 200 more

paramedics. This should relieve the burden of “boots on the

street” and allow more seasoned medics to attend the acad-

emy.

Culture change for the community was an unantici-

pated challenge. The city itself had been conditioned over

the years to define “good EMS care” with immediate

transport of the patient to the hospital. With the advent of

EMS crews now “staying and playing” and working arrests

in the field, the crews are now encountering tremendous

confusion and occasional hostility from family and by-

standers. Despite an appointed crewmember assigned to

family members on scene, the crews still report scene safe-

ty issues. ILHR is developing community Public Service

Announcements as well as adding this message to our By-

stander CPR education.

A progressive success is the Dispatcher-Assisted

CPR program. ILHR utilized the programs established in

Arizona and promoted by CARES. All communication spe-

cialists at the Office of Emergency Medical Communica-

tion (OEMC) have been trained in dispatcher-assisted CPR

(DA-CPR). OEMC leadership has committed to weekly

call review and feedback to dispatchers resulting in earlier

recognition of OHCA and more consistent DA-CPR.

CARES has also improved the relationship and communi-

cation with the hospitals that receive OHCA patients. The

hospital providers who are answering the outcome ques-

tions are providing valuable details related to the patient’s

hospital course, as well as their neurological outcomes.

Finally, participating in CARES has allowed Chi-

cago to objectively measure their successes and shortcom-

ings — measure, fix, measure again. CARES has allowed

opportunities for additional education resources and re-

warding outstanding crews. Moving forward, Illinois has

expanded beyond the city of Chicago to surrounding areas

and large cities such as Rockford and Peoria. With each

successful rollout, ILHR now has EMS communities con-

tacting us asking “Hey, can we be next?”

CARES and Plano Fire-Rescue By: Dr. Mark Gamber and edited by CARES Staff

CARES data is a source of pride for members of

Plano Fire-Rescue (PFR). Our department has been enrolled

in CARES since 2009. Originally, we were met with inquisi-

tive looks when we tried to explain the importance of the

word “Utstein” and standardized cardiac arrest outcomes

reporting. However, these concepts are now a part of our

common EMS language, as CARES data is shared with our

350 personnel on a monthly basis and actively discussed in

our live quarterly EMS Continuing Education sessions.

CARES data is also an integral part of PFR’s annual report

to the city manager and city council. We believe this pro-

vides transparency and accountability to our local citizens. continued on page 6

P a g e 6

Ventura County EMS was invited to join

the CARES program in 2008 as the first site in the

western U.S., with Santa Barbara County joining

two years later. CARES has been one of the most

important programs our EMS systems have under-

taken. In the 7 years we have been fortunate

enough to participate, we have learned, grown and

continue to make changes to better serve our com-

munity.

Prior to CARES, we had no organized

structure or method to evaluate the treatment we

were providing to our cardiac arrest patients.

Training policies and treatment protocols were in

place, but our QI system consisted of episodic pro-

jects on issues like IV starts, response times, ETI

success, and occasionally ROSC - data we could

reliably obtain from our EMS EMR. But the pro-

cess was really just an exercise in data gathering.

No one particularly cared that the IV start rate was

80% or the ETI rate hung in there at 70%. Why did

it matter? ROSC was a little more impactful, but

dropping off a patient with a pulse was still not the

stuff for celebration.

The first CARES report was the start of a

substantial shift in our understanding and direc-

tion. It gave us meaningful information – how

many of our patients were leaving the hospital and

going back to their families. It’s why we are in

EMS.

We were not satisfied that our survival

rates were at or below the group average, so we

began to use CARES data to refocus our QI ef-

forts. Our first and most important step was to re-

train all of our EMS providers in CPR. By using

feedback training and testing with Ambu Smart-

Man manikin systems, we were able to get every

EMT and paramedic to perform at a consistent,

high level. That measure alone increased our sur-

vival rates (overall and witnessed shockable

rhythm) by 30%. At the same time, we began the

process of shortening the time to first chest com-

pression for dispatcher-directed CPR. With the

clear process improvement of better CPR along

with better outcomes, we reached a tipping point.

The QI efforts made sense and we were doing bet-

ter for our community. Cardiac arrest calls were an

opportunity to help save a life – not an exercise in

futility. Everyone was paying attention.

CARES-based QI efforts:

Since the introduction of CARES and the

initial wins, we have continued to use the data to

cycle through improvements.

9-1-1 and Dispatch:

We use monthly reports of CARES pa-

tients to our EMD dispatch centers to look at caller

interrogation, dispatch priority, and post-dispatch

instructions. Our goal is to have every “seizure”,

“fall”, or “sick person” accurately identified as a

cardiac arrest and to start CPR promptly.

continued on page 7

CARES’ West Coast Beachhead: Ventura County and Santa Barbara County, CA By: Dr. Angelo Salvucci and edited by CARES Staff

CARES data allows us to place an in-

creased focus on cardiac arrest care. This has in

turn led to stronger partnerships between PFR and

our receiving hospitals. As data sharing between

field and hospital providers was implemented, it

built a foundation to work on emergency care such

as therapeutic hypothermia and patient contact-to-

balloon for STEMI. CARES data is shared with all

PFR hospitals that serve as resuscitation centers,

opening the lines of communication and providing

a feedback loop.

Prior to our enrollment in CARES, there

was no benchmark for our cardiac arrest statistics.

Now, Plano Fire-Rescue has a 5-year running aver-

age of greater than 50% survival among Utstein

patients. We owe this to bystander CPR, the work

of the members of Plano Fire-Rescue, our receiv-

ing hospitals, and CARES.

P a g e 7

Bystander CPR:

One of our challenges has been bystander CPR. Our

rate is under 40% - less than the CARES group mean. Our

survival success has motivated the EMS providers, hospitals

and community groups to participate in our brief, chest-

compression-only Sidewalk CPR training efforts.

On-scene EMS Care:

We have developed a comprehensive training pro-

gram and set of treatment protocols for use by all EMS re-

sponders. Our Cardiac Arrest Management (CAM) program

uses evidence-based team education, individual and team

SmartMan training and testing, coordinated pre-assigned

roles and post-incident performance review. This has been

highly successful at standardizing and improving on-scene

care and outcomes. We have improved our airway manage-

ment protocols. Due to its ease of insertion relative to endo-

tracheal intubation (ETI), we began to use the King Airway

as the primary airway device. When we found that patients

with bag-mask ventilation (BMV) or ETI had the same sur-

vival rate, but were more likely to have favorable neurologi-

cal recovery, we changed the protocol to make BMV the

preferred method.

Quality Management:

We use cardiac monitor output reports to give

prompt feedback to crews. The focus is primarily on contin-

uous (CPR density 80% or greater) high-quality CPR with

minimal duration of pauses for defibrillation. This will al-

low us to establish a retraining interval that will be part of

CAM.

In-progress QI:

At this point our systems are performing well. So

far in 2014, we have a better than 15% overall survival rate

and it’s over 50% for witnessed, shockable rhythm cases.

We are looking for ways to improve further as several pro-

jects are planned or have started.

CARES was created to open and join three silos of

data - dispatch, EMS and hospital. But there is a fourth im-

portant silo that is still not connected – 9-1-1. We have cre-

ated teams in each county with every Public Safety Answer-

ing Point (PSAP) as members. Our goal is to track every 9-1

-1 call reporting a cardiac arrest from the first ring at the

first Primary PSAP through to delivery to the EMS dispatch

center. This will be most critical for wireless 9-1-1 calls,

which are now over 80% of the total. Wireless 9-1-1 calls

typically do not have location information available at the

time of the call, so are often routed to regional centers.

There, the caller is queried and the call is transferred. This

introduces a delay in response that averages more than a

minute – an important time in cardiac arrest response. We

will be able to quantify these transfers and delays and look

for opportunities to get responders on the way more quickly

and pre-arrival CPR instructions started.

We are starting a trial of the air-Q. This supraglottic

airway is simple to insert, ventilates effectively, and has a

cuff that self-inflates only during inspiration. We believe it

will be easier than ETI, more effective than BVM and not

have the carotid pressure concern of dual-balloon airways.

The CARES outcome data will be essential in the evalua-

tion.

We have created and are expanding our cardiac ar-

rest survivor network. They are grateful for the support and

are looking forward to assisting in our community CPR

training efforts.

CARES has been the foundation for great improve-

ments in our EMS system. The data have allowed us to ac-

curately examine, plan, and improve. And the positive out-

comes have created excitement in the entire EMS communi-

ty. Everyone enjoys being on a winning and productive

team. With attention and effort the “CAR” is a useful tool

for “ES”. It has certainly worked for us.

P a g e 8

Telephone CPR – the provision of pre-arrival CPR instructions to 9-1-1 callers who witness or

encounter out-of-hospital cardiac arrests – holds tremendous promise for improving OHCA survival

nationwide.

Dispatchers play a vital role in outcomes. By identifying arrests over the phone and directing

bystanders to push “hard and fast” in the center of a patient’s chest, they can increase rates of bystander

CPR. Bystander CPR, in turn, can double or triple the odds that a patient lives.1

A new CARES T-CPR module, created in partnership with the Save Hearts in Arizona Registry

and Education (SHARE) Program, provides partners with free resources needed to implement formal T-

CPR programs: an electronic data collection tool to measure staff performance, a corresponding data

dictionary, a data entry webinar and an interactive, web-based video that covers the nuts-and-bolts of T-

CPR for new and experienced dispatchers alike.

Measurement is the “secret sauce” in quality improvement. Six metrics can provide snapshots

of staff performance through time: the proportion of calls where dispatchers (1) recognize the need for

CPR, (2) start CPR instructions and (3) succeed in achieving the start of bystander compressions; and

the time elapsed from call-receipt to (4) recognition of cardiac arrest, (5) start of CPR instructions and

(6) start of bystander compressions. Only through continuous measurement can 9-1-1 centers gauge

their progress and assess necessary improvements.

One recent T-CPR initiative implemented guideline-based protocols, training, and feedback to

staff at three regional dispatch centers. This “bundle of care” doubled the number of cases where by-

standers started dispatch-directed compressions and reduced the time those compressions started by 80

seconds.2 The initiative proves that 9-1-1 centers nationwide can “move the needle” and achieve the

following performance standards:

continued on page 9

CARES Module Updates

Targeted Temperature Management (TTM) Module Update

This module is now live, and available to participating CARES hospitals! Please contact your

CARES representative to request that the TTM module be activated for your facility. The Targeted Tem-

perature Management (TTM) Module has two potential silos of data: out-of-hospital cardiac arrests

transported by CARES agencies, and in-hospital cardiac arrests. For more information on the TTM

Module, please refer to the data dictionaries and webinars on the CARES website under the ‘Education/

Resources’ tab.

New CARES Module Extends T-CPR Resources to Partners Nationwide By: Micah Panczyk and edited by CARES Staff

P a g e 9

Instituting T-CPR requires no capital investment. Training a few dozen telecommunicators how to recognize car-

diac arrest and provide “just in time” CPR instructions is as productive as training tens of thousands of people in CPR.

The staff of one alarm center has the potential to ensure bystander CPR in virtually every cardiac arrest in the community.

References

1. Sasson C, Rogers MA, Dahl J, Kellermann AL. Predictors of survival from out-of-hospital cardiac arrest: A

systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes. 2010;3:63-81

2. Bobrow B, Panczyk M, Stolz U, Heagerty N, Dameff C, Tully J, Murphy RA, Vadeboncoeur T, Spaite D. Ab-

stract 81: The impact of pre-arrival dispatch-assisted cpr on bystander cpr rates, time to starting cpr and survival

from out-of-hospital cardiac arrest. Circulation. 2013;128:A81

Performance Measure Standard

1. Percentage of cardiac arrests recognized when telecommunicators have a chance to

assess patient consciousness and breathing

95%

2. Time from medical dispatch call receipt to recognition of cardiac arrest 60 seconds

3. Percentage of cases receiving chest compressions when telecommunicators have a

chance to assess patient status and CPR is not already in progress

75%

4. Time from medical dispatch call receipt to first chest compression 120 seconds

For more information on the CARES T-CPR Module, please refer to the ‘Dispatcher Assisted CPR Training’ link under

the ‘Education/Resources’ tab, on the CARES website.

Goa, India - Participants in T-CPR training role play as dispatchers and callers performing CPR

P a g e 1 0

Cardiopulmonary resuscitation, or CPR, is

the support of circulation by means of chest com-

pression and ventilation for the victim of cardiac

arrest until their own pulse is restored. While all

professional health care providers have

been trained in how to perform CPR, the

range of quality at which it is often per-

formed is wide and can all too often spell

the difference between life and death.

This is why the Seattle-King County Re-

suscitation Academy, whose mission is to

improve cardiac arrest survival in all

communities, has placed a strong empha-

sis on teaching high-performance CPR

(HP-CPR). In the Academy, participants

are taught the science behind CPR and

given practical skillsets along with hands

-on experience in its actual performance.

This has in fact proved to be a highlight of the

Academy experience: everyone leaves having

learned why and how to do HP-CPR, and to pro-

mote its practice in their own communities.

HP-CPR consists of training in the skill

with meticulous attention to detail. This means per-

forming CPR to the best known prescribed parame-

ters of chest compression rate, depth, full chest

recoil, and minimized interruptions. The im-

portance of each of these components is all too of-

ten underappreciated. Recent studies from the Re-

suscitation Outcomes Consortium (ROC) have

clinically validated the importance of a number of

CPR parameters in terms of their impact on surviv-

al. For example, a direct association has been con-

firmed between the proportion of time that chest

compressions are administered during the first

minutes of resuscitation preceding a shock

(referred to as the compression fraction) and sur-

vival to hospital discharge. As another example,

even adding a few seconds to the pause in CPR

taken immediately before and after a shock is now

known to diminish survival. Details do count!

HP-CPR encourages maintaining high compliance

standards throughout resuscitation, including a

chest compression rate of 100-120/minute, ade-

quate compression depth, full release, and chest

compressions for no less than 80-85% of the time

that CPR is needed. In the Academy, the real-time

display of these parameters as CPR is being per-

formed on electronically instrumented manikins

reinforces the message “yes, you can do it!” In ad-

dition to striving for “letter perfect” CPR, HP-CPR

also encourages a system of accountability where-

by some measure of feedback of CPR performance

(for example CPR fraction) that is derived from

recordings of actual field resuscitations is con-

veyed back to providers for further quality im-

provement.

Since its inception in 2008, over 550

Emergency Medical Service (EMS) medical pro-

gram directors, chiefs and training officers from

around the world have received training in HP-

CPR at the Resuscitation Academy. In addition to

teaching this skill, the Academy provides instruc-

tion and training in 9 additional steps (10 in all)

that can help improve cardiac arrest survival rates

in any community. Each attendee also receives an

individualized “homework assignment” ̶ to estab-

lish a quality improvement program in their home

community based on the principles learned at the

Academy.

Process Improvement The following article explains the significant role that high-performance CPR plays in OHCA survival.

CARES realizes the importance of measuring CPR quality metrics and is excited to soon be capturing

this data in a future supplemental module.

The Seattle-King County Resuscitation Academy: Promoting High-Performance CPR By: Drs. Mickey Eisenberg, Peter Kudenchuk, Tom Rea and edited by CARES Staff

P a g e 1 1

Academies modeled on the Seattle-King County endeavor

and that incorporate these steps along with HP-CPR in their

core curricula are now being independently conducted

across the United States (in Heart Rescue/CARES partner

states as well as Maryland, Rhode Island, Connecticut,

Massachusetts, Vermont, Oklahoma and Idaho), in Europe

(Germany, Norway and Sweden) and Asia (Singapore).

Even a “virtual” Resuscitation Academy is in development.

EMS systems that have deployed the principles learned

from their Academy experience, coupled with the adoption

of CARES to monitor best practice and outcomes, have

seen a significant improvement in survival from cardiac

arrest … proving that “anyone can do it!”

Michael Charles is a native of Atlanta, Georgia and

has lived and worked in the numerous communities

throughout the city from the early 1980s through the year

2000. He currently lives in the City of College Park, Fulton

County since 2006.

“My grandfather died of sudden cardiac arrest sec-

ondary to heart disease in 1979. It happened in the down-

town Atlanta area in Five Points. Family members were

present when he collapsed. No witnesses started CPR be-

cause no one there knew CPR. AEDs in the community

were unheard of at that time. It took the ambulance 15

minutes to arrive. By that time it was too late. I entered into

the EMS profession to be part of a system saving lives from

heart disease,” Michael says. Michael is currently licensed

as both a State of Georgia and National Registry of EMT’s

paramedic working full time in the 911 field division at

Grady EMS, a participating CARES agency.

“There were 731 out-of-hospital non-trauma adult

sudden cardiac arrests in which resuscitation was attempted

last year in Fulton County with only 62 people surviving.

That’s 669 Fulton County families who lost a loved one to

sudden cardiac arrest in one year; about an 8.5% survival

rate for all types of arrests. Nationally the survival rate is

10.7%. In King County/City of Seattle it’s 21% surviv-

al. This is my hometown community. These are my patients

and my neighbors. I think we should be able to do better

than 8.5% survival,” Michael states.

continued on page 12

This article is an example of how CARES data can be used to inform stakeholders, providers, and citizens of the current

state of OHCA survival in their community. The Better Outcomes Foundation, Inc., introduced below, is making large

strides in improving bystander CPR and AED use throughout the City of Atlanta by partnering with local CARES

participants.

Better Outcomes in At-Risk Populations: Atlanta, Georgia By: Michael Charles and edited by CARES Staff

P a g e 1 2

“As I think back on all the sudden cardiac ar-

rest resuscitation attempts in which I was involved,

the survivors almost always had three things in

common: their collapse was witnessed, someone

started CPR immediately, and the victim received a

shock from a defibrillator in less than a few

minutes. Their survival had less to do with what a

paramedic or a hospital did, but had much more to

do with what happened before EMS got there. It’s

clear to me now that the best way I can help im-

prove the outcome of sudden cardiac arrests in my

community is to educate and train as many mem-

bers of the general public as possible in CPR and

AED use. Bystander-initiated CPR and an onsite

AED is a victim’s best hope of survival,” Michael

states.

In 2013, Michael began developmental work

on The Better Outcomes Foundation, Inc., a non-

profit volunteer-staffed health and safety training

organization which would provide high-quality,

highly accessible, low or no cost training in CPR

and AED use to the lay person population of Fulton

County in at-risk communities and to the pre-

hospital emergency responders who serve them.

Its vision is to play a critical and significant

role in improving the out-of-hospital sudden cardi-

ac arrest survival rate in historically at-risk popula-

tions in Fulton County, Georgia. The mission in-

cludes increasing layperson bystander-initiated

CPR/AED use in out-of-hospital sudden cardiac

arrest incidents in historically at-risk populations in

Fulton County, Georgia that by 2020 will match or

exceed the national average. Its values are high-

quality training, best practices, accountability and

transparency, equal opportunity, community and

cultural awareness in a low-stress, high-comfort

learning environment.

The strategic plans and goals for 2014 are:

to communicate the challenge, the vision, the

mission statement, and the values of the Better

Outcomes Foundation to public safety, public

health, elected leadership, academic institu-

tions, EMS agencies, other health care provid-

ers, media organizations, and philanthropic

entities who serve at-risk communities in Ful-

ton County in an effort to raise awareness and

form partnerships and sponsorships

to teach, in both English and Spanish, 911/

CPR/AED courses to layperson community

and strategic community leaders in a variety of

settings

to identify locations in at-risk communities that

would most likely benefit from the placement,

maintenance, and instructions in the use of

AEDs

to recruit volunteers from the EMS, emergency

medicine, and public health work-force in Ful-

ton County to educate and teach 911/CPR/

AED use in the lay-person at-risk community

to implement an awards and recognition pro-

gram that will thrice annually recognize citi-

zens and providers who are involved in the

successful out-of-hospital sudden cardiac arrest

survivors in Fulton County

to identify and pursue sources of individual

donations, fundraising mechanisms, grant ap-

plications, and the philanthropic foundation

community.

The Better Outcomes Foundation has entered

into a partnership with the City of Atlanta Fire Res-

cue Department to teach 911/CPR/AED courses to

general lay persons and strategic leadership in at-

risk communities within the City of Atlanta.

The Better Outcomes Foundation, Inc. can be

contacted at:

michaelcharles-betteroutcomes@hotmail.com

706-593-2155,

P.O. Box 16581

Atlanta, Georgia 30321

P a g e 1 3

Neurological Outcomes: Share the Success, Dispel the Myths By: Dr. Mike Levy and edited by CARES Staff

How do you define “gob smacked?” How about

this? While having casual drinks with colleagues mixed

with some shop talk, a cardiologist in her early 40s opined

to me, “Well, if I come in to your ED in cardiac arrest, I

want you to call it in no more than five minutes!” Wham!

Sound of a jaw hitting the table. As a disclaimer, this is a

clinically astute, well-trained practitioner who has provided

excellent care for my cardiac arrest patients.

This in a way is a metaphor for what we in the

“better outcomes” business are up against. We are still

swimming upstream against dated perceptions unsupported

by our current reality and sadly we are handing off our pa-

tients to environments where some may still embrace these

biases. Clearly, I hope that this is a vanishing viewpoint but

I still fear that it is not.

I was particularly speechless in this instance be-

cause I had just returned from a Heart Rescue Project spon-

sored luncheon at the Neurocritical Care Conference in Se-

attle. While there, I was buoyed by the potential offered by

closer associations with this group. This event was the

brainchild of none other than Lynn White of AMR and was

a brilliant idea for silo-bridging. She enlisted the full sup-

port of Joan Mellor who made a special trip to Seattle to be

present and inform the participants of the Heart Rescue

Project story. I provided a short warm up act for the star of

the event, Brent Myers, who presented his CARES data on

the optimum duration of cardiac arrest care as guided by

patient outcomes. There was no doubt that the filled room

was hearing new and important information by their rapt

attention and the questions that followed.

Still, in our own worlds we encounter hospital-

based colleagues from emergency medicine to cardiology

to critical care and neurology who may base the intensity of

the care provided upon metrics they have held since resi-

dency. I hark back to such statements that I continue to

hear such as “We’ve gone through two rounds of ACLS

and it’s still VFib…We’re not doing this guy any favors”.

As so many of us are now reviewing the metrics of our re-

suscitations with consideration of bystander CPR, crew

performances regarding High Performance CPR and the

like, it becomes very important for us to get ahead of these

dated truisms and try to help these key players broaden

their understanding of what remains possible.

In terms of bias, I too have more than a few, and

they lean towards a rational and aggressive approach to

resuscitation that includes all of the teachings of Eisenberg,

et al. as well as early invasive strategies (ECMO, revascu-

larization for VF unresponsive to initial electrical therapy)

for a select group of patients. This also includes withhold-

ing resuscitation based upon evidence-based merit. The

bias of my opinion founded upon the anecdotes of my ex-

perience can only find traction beyond my personal passion

and pleas when we have the data to convince ourselves, and

our colleagues, that we have the pre-hospital predictors of a

reasonable chance of a good neurological outcome. This in

turn will only occur as we further integrate ourselves with

the providers of post-resuscitation care, providing the les-

sons we’ve learned but armed with robust data.

The next article describes the importance of using improved pre-hospital measures along with post-resuscitation team-

work to ensure a favorable neurological outcome for OHCA patients. By highlighting the effective exposure of CARES

data, members of resuscitation science are asked to shift their approach to OHCA care.

P a g e 1 4

To date, the PAROS network has collected

66,786 OHCA cases from Singapore, Korea, Tai-

wan, Japan, Malaysia, Thailand, and United Arab

Emirates-Dubai. This marks the closing of Phase 1

of the PAROS study. The network has published

nearly 20 articles in peer-reviewed journals since

its establishment in 2010. The PAROS network has

now expanded to include sites in China, the Philip-

pines, Pakistan, Vietnam, and Indonesia. PAROS

investigators have also undertaken research to in-

vestigate OHCA variation in the pediatric popula-

tion, termination of resuscitation issues, the effect

of scene time on OHCA survival, and several other

topics.

Phase 2 of the PAROS study will focus on de-

veloping and implementing a Dispatcher-Assisted

CPR (DA-CPR) program and comparing survival

outcomes between sites with DA-CPR and without.

An implementation package consisting of a DA-

CPR protocol, training program and quality im-

provement toolkit has been developed in collabora-

tion with Save Hearts in Arizona Registry & Edu-

cation (SHARE; Arizona, USA) and CARES. DA-

CPR training, including the dispatcher workshop,

has been conducted in Japan, Korea, and Singapore

while Malaysia and Thailand have committed to

implementing the DA-CPR package and have com-

menced training for their dispatchers.

continued on page 15

CARES has enjoyed their partnership with PAROS over the last 5 years. Learning about OHCA survival

in Asia and collaborating on cardiac arrest topics for research have opened the arena for OHCA dis-

cussion globally. The following article summarizes what our Pan-Asian partners have been working on

and their future expansion.

Pan-Asian Resuscitation Outcomes Study: Where Are They Now? By: Maeve Pek and edited by CARES Staff

PAROS Meetings - (left) Penang, Malaysia; (right) Sydney, Australia

P a g e 1 5

The PAROS network has also started a grant

application process available to developing countries in

order to support implementation of the PAROS study. To

date, China, Vietnam, and Malaysia have been awarded

funds. The next PAROS meetings will be held in:

October 2014 - Goa, India, in conjunction with the 3rd

EMS Asia Conference

March/April 2015 - Zhejiang, China

November 2015 - Taipei, Taiwan, in conjunction with

the Asian Conference for Emergency Medicine.

P a g e 1 6

Dear CARES Communities,

We’re happy that you are a part of the 10th anniversary CARES celebration! With over a quarter of the

US population participating in the registry representing over 600 EMS agencies and nearly 1 in 5 hospi-

tals nationally, we are especially thankful for your continued participation in the program. Without your

time and support, we would not be able to fulfill our mission and vision statements, which highlight the

program goals and provide a roadmap for the future.

The CARES mission statement is to help communities determine standardized outcome measures for

out-of-hospital cardiac arrest allowing for quality improvement efforts and benchmarking capability to

improve care and increase survival.

The CARES vision statement is to become the standard out-of-hospital cardiac arrest registry for the

United States allowing for uniform data collection and quality improvement in each state and nationally.

The registry’s success over the last 10 years could only have been achieved through the dedication of

participating sites and states. To date, we have a cumulative hospital lost to follow-up rate of less than

1%. This is truly a remarkable achievement and is evidence of everyone’s shared commitment to excel-

lence. The work of CARES participants benefits individuals in our communities, saving lives and im-

proving care at the local level. However, it cannot be overlooked that your efforts also help advance the

field of emergency medicine, enhancing our understanding of cardiac arrest resuscitation nationwide.

We look forward to working with additional communities and States in the future, while we continue to

enhance our functionality for current participants. We can’t thank you enough for helping us achieve

our goals and for improving the treatment of cardiac arrest throughout our country and abroad. We hope

you enjoy this 10th anniversary newsletter and appreciate your continued support of the CARES Pro-

gram!

Sincerely,

The CARES Team

Allison Crouch, MBA, MPH

Monica Mehta, MPH

Bryan McNally, MD, MPH

Brad Swanson

Tiara Sinkfield, MPH

Kimberly Vellano, MPH

CARES Team Thank You By: Dr. Bryan McNally