C.A.R.E.S.

Cardiac Arrest Registry to Enhance Survival

Bryan McNally, MD, MPHAssistant Professor of Emergency MedicineAssociate Medical Director Emory FlightEmory University School of MedicineCity of Austin-Travis County EMS System Grand RoundsFebruary 19, 2008

CARES Grand Rounds

The Present where we are nowThe Future where we are goingEMS in GeorgiaDiscussion

Out of Hospital Cardiac Arrest (OHCA)Is the sudden, unexpected natural death from a cardiac cause a short time (generally < 1 hour) after the onset of symptoms (if present) in a person without any previous condition that would seem fatal.

Gillum and colleagues have defined SCD as any cardiac death occurring outside the hospital or taking place in the emergency department.

SCD Etiology

Utstein Inclusion/Exclusion Criteria

Utstein Criteria

Registry focuses on continuous quality improvement.Research report examines specific interventions and outcomes

Two Database Formats

Benefits of Data Collection

Uniform collection and tracking of data facilitates better continuous quality improvement within communities.Enables comparisons across the systems for clinical benchmarking to identify opportunities for improvement.

Why Develop an OHCA Registry?Burden of disease is highMost time critical EMS conditionCommunity variability in measuring OHCA Community variability in survival OHCAVariability in system configurationPatient demographicsNEMSIS

Burden of Disease is High.

Most Time Criticial EMS Condition 020406080100Survival Rate(percent)Time to Defibrillation (minutes)510152025Survival reduced by ~7-10% each minute defibrillation delayed

Most Time Critical EMS Condition

Community Variability in Measuring OHCA Survival

Community Variability in Survival RateALL RHYTHMS DISCHARGE RATE 2-25%

VF DISCHARGE RATE 3-33%

Variability in System Configuration

Patient demographicsAgeGenderRaceVulnerable populations?Is there biological disparity in survival?

NEMSISFuture language to be spoken

Many Lives are Lost Across USABecause Emergency Services Fail. (USA TODAY, 2003, Robert Davis).

Surveyed the Countrys 50 largest cities.

38 of the 50 either could not, or would not, report their communities cardiac arrest survival.

Article series revealed the major reasons why EMS in most cities save few people.

USA TODAY, 2003, Robert Davis

Most cities dont measure their performance effectively, if at all. They dont know how many lives they are losing, so they cant determine ways to increase survival rates.

Need for RegistryData collection into a registry at the regional, state or national level enables EMS systems to collect data in a standardized NEMSIS compliant fashion. Strengths and weaknesses in a community can be identified when comparison with the benchmarked dataset is made. Future performance measures need to based on compliance with evidence based guidelines.

IOM Report on Emergency ServicesWhat is missing is a standard set of measures that can be used to assess the performance of the full emergency and trauma care system within each community, as well as the ability to benchmark that performance against statewide and national performance metrics.

IOM Report on Emergency ServicesWhile a full-blown data collection and performance measurement and reporting system is the desired ultimate outcome, the committee believes a handful of key indicators of regional system performance should be collected and promulgated as soon as possible. Cardiac arrest, pediatric respiratory arrest, blunt trauma with shock.

CARES Program OverviewIdentify and collect pre-hospital cardiac arrest events to improve survival outcomes.

Establish a method for uniform consolidation of EMS, 911, and hospital information.

Generate reports of response intervals and patient outcomes for involved agencies in useful format.

Allow participating agencies to confidentially benchmark performance.

The THREE SILOS OF DATAImportance of Data Elements and Linkage to CARES

CARES NETWORK

CARES Program DatabaseSansioMainframe housed in Duluth, MNInternet database systemhttps://mycares.netHIPAA compliant securityUnifies EMS, 911, and Hospital dataAny EMS system throughout US

EMS ComponentCollection methodsDirect entry onlineIntegration of CARES data fields onto EMS tablet/laptop softwareScanned CARES formQuery to ensure capture of dataManual or through PCR documentation systemsEMS initiates event and signals other two componentsGenerates email to Hospital componentMatches event with daily 911 import

911 CAD ComponentCall number on CARES form identifies Computer-Aided Dispatch (CAD) record.Times are forwarded to database daily using auto-extraction tool.Unmatched CAD times are identified and matched manually.Likely matches ranked based on Date, Time, and Address.Matches confirmed by EMS agency liaison

Hospital ComponentHospital follow-up only required on patients where outcome is ongoing resuscitationHospital contacts set up through CARES administrator.EMS CARES data triggers an email to primary hospital contact requesting hospital outcome.When all three data components form a complete record of the event, the data is de-identified of unique patient identifiers (name and DOB).

Reporting FeaturesBystander intervention / community statisticsAED/CPR useGender, age (mean and range), and location typeEMS and First Responder Response time intervals911 to arrival911 to dispatchDispatch to arrivalUtstein flow diagramSurvival to dischargeNeurological status (CPC)Call volumeTotal volume for agency as a function of time.Hospital Destination

CARESUltimate goal of CARES will be to help local EMS administrators and medical directors identify: Who is affected.When and where cardiac arrests occurWhich elements of the system are functioning well and those that are not.How changes can be made to improve cardiac arrest outcomes.

Obstacles in Data CollectionOwnership of Data need for data use agreement.

Data Security need for HIPAA compliance, internet firewall, and encryption of data.

Confidentiality need for data use agreement.

Fragmented System lack of linkage with 3 silos of data; need to automate data collection process to bring together 3 separate datasets

CARESCreated a model cardiac arrest registry capable of identifying and tracking all cases in a defined geographic area.Year One -- Fulton County, Georgia.Year Two -- Multi-County Area of metropolitan Atlanta, Georgia.Year Three Began National Expansion.Ultimate goal is to be universally applicable to EMS operations nationwide.

Chart1

2716

1783

19

Gender Demographics

Sheet1

CARES Demographics

Location TypeTotalPercentage

Home/Residence294865.25%

Public Building2726.02%

Street/Hwy2094.63%

Nursing Home/Assisted Living Center61813.68%

Residence/Institution591.31%

Physician Office/Medical Clinic841.86%

Educational Institution140.31%

Hospital120.27%

Recreation/Sport Facility591.31%

Industry360.80%

Jail140.31%

Other1663.67%

Airport230.51%

Null40.09%

Total:4518100.00%

GenderTotalPercentage

Male271660.12%

Female178339.46%

Null190.42%

Total:4518100.00%

EthnicityTotalPercentage

Asian1403.10%

Black/African-American115525.56%

Native Hawaiian/Pacific821.81%

White162035.86%

American-Indian/Alaskan300.66%

Hispanic/Latino2395.29%

Unknown125227.71%

Total:4518100.00%

AgeTotalPercentage

0-191042.30%

20-29821.81%

30-392114.67%

40-4952711.66%

50-5988019.48%

60-6989119.72%

70-7983918.57%

80+94220.85%

Null420.93%

Total:4518100.00%

Sheet1

Gender Demographics

Sheet2

140

1155

82

1620

30

239

1252

Ethnicity Demographics

Native Hawaiian/ Pacific2%

Sheet3

104

82

211

527

880

891

839

942

42

Age Demographics

Chart3

104

82

211

527

880

891

839

942

42

Age Demographics

Sheet1

CARES Demographics

Location TypeTotalPercentage

Home/Residence294865.25%

Public Building2726.02%

Street/Hwy2094.63%

Nursing Home/Assisted Living Center61813.68%

Residence/Institution591.31%

Physician Office/Medical Clinic841.86%

Educational Institution140.31%

Hospital120.27%

Recreation/Sport Facility591.31%

Industry360.80%

Jail140.31%

Other1663.67%

Airport230.51%

Null40.09%

Total:4518100.00%

GenderTotalPercentage

Male271660.12%

Female178339.46%

Null190.42%

Total:4518100.00%

EthnicityTotalPercentage

Asian1403.10%

Black/African-American115525.56%

Native Hawaiian/Pacific821.81%

White162035.86%

American-Indian/Alaskan300.66%

Hispanic/Latino2395.29%

Unknown125227.71%

Total:4518100.00%

AgeTotalPercentage

0-191042.30%

20-29821.81%

30-392114.67%

40-4952711.66%

50-5988019.48%

60-6989119.72%

70-7983918.57%

80+94220.85%

Null420.93%

Total:4518100.00%

Sheet1

Gender Demographics

Sheet2

Ethnicity Demographics

Native Hawaiian/ Pacific2%

Sheet3

Age Demographics

Chart2

140

1155

82

1620

30

239

1252

Ethnicity Demographics

Native Hawaiian/ Pacific2%

Sheet1

CARES Demographics

Location TypeTotalPercentage

Home/Residence294865.25%

Public Building2726.02%

Street/Hwy2094.63%

Nursing Home/Assisted Living Center61813.68%

Residence/Institution591.31%

Physician Office/Medical Clinic841.86%

Educational Institution140.31%

Hospital120.27%

Recreation/Sport Facility591.31%

Industry360.80%

Jail140.31%

Other1663.67%

Airport230.51%

Null40.09%

Total:4518100.00%

GenderTotalPercentage

Male271660.12%

Female178339.46%

Null190.42%

Total:4518100.00%

EthnicityTotalPercentage

Asian1403.10%

Black/African-American115525.56%

Native Hawaiian/Pacific821.81%

White162035.86%

American-Indian/Alaskan300.66%

Hispanic/Latino2395.29%

Unknown125227.71%

Total:4518100.00%

AgeTotalPercentage

0-191042.30%

20-29821.81%

30-392114.67%

40-4952711.66%

50-5988019.48%

60-6989119.72%

70-7983918.57%

80+94220.85%

Null420.93%

Total:4518100.00%

Sheet1

Gender Demographics

Sheet2

Ethnicity Demographics

Native Hawaiian/ Pacific2%

Sheet3

Age Demographics

Location TypeTotalPercentageHome/Residence294865.25%Public Building2726.02%Street/Hwy2094.63%Nursing Home/Assisted Living Center61813.68%Residence/Institution591.31%Physician Office/Medical Clinic841.86%Educational Institution140.31%Hospital120.27%Recreation/Sport Facility591.31%Industry360.80%Jail140.31%Other1663.67%Airport230.51%Null40.09%Total:4518100.00%

Resuscitation Outcome Consortium

CARES 3 ApplicationsGrady EMS intervention and assessment.

Restarting Atlanta Hearts Program focus on identified weak links in chain of survival.

Geomapping and AED Registry Application

Grady EMS Sample ReportsChange in system dispatch process

Before and after metrics - 6 months

Date provided to illustrate comparison

0 Survivors5 Survivors

Racing the Clock to Restart Atlantas Hearts

RecommendationsRecommendation 1Improve public recognition of signs of heart attack and prompt 911 calls

Recommendation 2Improve bystander CPR rates

Recommendation 3Decrease time to defibrillation through strategic placement of AEDs

Geocoded CARES Data

Geocoded CARES DataTargeted AED Placement

Targeted Bystander Training

Whats next?

Future ConsiderationsExpansion HypothermiaAED RegistryMapping Agency classification not all apples are the same Longitudinal surveillance tool to measure survival locally, regionally, statewide, nationally.Code summary data integrationList-Serve

For every minute that defibrillation is delayed, the chances of surviving sudden cardiac arrest (SCA) are reduced by approximately 10%. Survival chances drop particularly fast in the first five minutes.Since rapid time to defibrillation is so critical, expanding the number of early defibrillator responders offers SCA patients a real chance to survive an otherwise lethal event.In fact, by extending defibrillation skill using AEDs to more responders, survival rates have increased dramatically in some settings; e.g.:40% survival-to-hospital-discharge (neurologically intact) in Rochester, MN with police first responders (White RD. Resuscitation 1998).70% survival-to-hospital-discharge in Nevada casinos (Valenzuela TD Acad Emerg Med 1998).80% survival-to-discharge in the Chicago Airport System, compared to a 3.5% save rate in Chicago with a paramedic response (USA Today, December 28, 1999).

This is just a snapshot of the hospital data entry screen. You can see the four hospital questions. There is also a transfer feature where if a pt was transported by EMS to hospital #1 then the pt was transferred from Hospital #1 to Hospital #2 there is a way to indicate this by selecting the transfer hospital in the drop-down menu. The hospital contact at #2 gets an email and the pt is now in there box for pending hospital outcomes.