What Is An Ideal Cardiac Arrest System of Care?

Matthew Sholl, MD, MPH, FACEP

What Is A “System of Care”

First, Where are We At Currently?

Total Cardiac Arrests

Curr Op Crit Care 2004;10:208-212

Rea et all, Resuscitation, 2004

2.2 3.3

16.0 30.0

Why Such Variability in Survival ?

• In large part, due to differences in the system of care – Public relations and

incidence of bystander CPR– Dispatch provision of CPR

instructions– Placement of AED’s in the

community– Timely EMS response– Different community

practices for activation of 911• The SYSTEM of care

surrounding OHCA may have some responsibility for the survivability

Baker et all Resuscitation, 2008

Let’s Think About the Pieces of the System

Saving Lives• Early Access to 911• Layperson training in

CPR• Public Access Defibrillator

(PAD) programs• EMD assisted chest

compressions• First responder

defibrillation – BLS• ACLS

Saving Life Style• Early, goal directed

therapy– Shivering control– Glucose control– Hemodynamic support

• Therapeutic hypothermia• Early PCI• Prognostication• Implantable Cardiac

Defibrillators

The EMS Side: Save A Life – Restore Spontaneous Circulation #1

EVERYTHING we do should promote forward flow of blood

ANYTHING that interrupts forward blood flow should be critically evaluated

The EMS Side: Save A Life – Restore Spontaneous Circulation #2

Normal Flow

No Flow Arest

Low Flow -

CC

ROSC0

2

4

6

8

10

12

Model EMS System of Care #1

1. Establish a Registry – Measure your starting point

2. Improve Layperson Involvement– Layperson Chest Compression Training– Implement Dispatcher Assisted CPR

3. Improve EMS Performance – Implement High Performance CPR

4. Decrease Time to Patient Access– Implement Rapid Dispatch

Model EMS System of Care #2

5. Voice Record All Resuscitations

6. Begin Police Defibrillation

7. Establish Public Access Defibrillation Program

8. Supplemental Funding and Support for Training and QI

9. Work Toward A Culture of Excellence

The Hospital Side: Save Lifestyle – Mitigating Organ Damage #1

Nichol et Al: Regional Systems of Care for Out-of-Hospital Cardiac Arrest: A Policy Statement From the American Heart Association, Circulation 2010

Putting It All Together…

Nichol et Al: Regional Systems of Care for Out-of-Hospital Cardiac Arrest: A Policy Statement From the American Heart Association, Circulation 2010

Questions

Questions