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Running head: CONSTRUCTING A CARDIAC HEALTH RISK PROFILE 1
Constructing a cardiac health risk profile: Building the foundation for a community cardiac
wellness program for the City of Twinsburg, Ohio
Gina DeVito-Staub
Twinsburg Fire Department, Twinsburg, Ohio
March 01, 2014
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 2
Certification Statement
I hereby certify that this paper constitutes my own product, that where the language of others is
set forth, quotation marks so indicate, and that appropriate credit is given where I have used the
language, idea, expression, or writings of another.
Signed: ______________________________________________________________________
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 3
Abstract
Eighty-two percent of Twinsburg Fire Department responses were emergency medical
calls yet only ten percent of TFD prevention activities focus on non-fire risk reduction. There is a
disproportionate demand of EMS risk reduction programs in comparison to fire prevention
programs. The problem is that TFD is a fire-based EMS Department that does not have an
emergency medical prevention presence in the City of Twinsburg. The purpose of this research is
to reduce the number of emergency cardiac responses and development of a community cardiac
risk profile. This community cardiac risk profile will provide the foundation to construct a
cardiac risk reduction program for Twinsburg, Ohio. Action research was utilized and the
following questions were addressed: 1. Who is requesting emergency medical responses for
cardiac emergencies in the City of Twinsburg? 2. What are the pre-existing cardiac conditions of
the TFD emergency cardiac patients? 3. Where are the TFD emergency cardiac patients located?
4. What are the locations or population groups that should be the focus of a community cardiac
risk reduction program? 5. What are the components of a community cardiac risk reduction
program? Procedures for this research included a literature review, interviews, and data analysis.
This research generated a cardiac risk profile for Twinsburg, Ohio. Coordination of Twinsburg
resources and collaborative partnerships will aid in reaching the target audiences identified in the
cardiac risk profile.
.
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 4
Table of Contents
Certification Statement ................................................................................................................... 2
Abstract ........................................................................................................................................... 3
Introduction ..................................................................................................................................... 5
Background and Significance ......................................................................................................... 6
Literature Review............................................................................................................................ 8
Procedures ..................................................................................................................................... 15
Results ........................................................................................................................................... 21
Discussion ..................................................................................................................................... 29
References ..................................................................................................................................... 32
Appendix A ................................................................................................................................... 37
Appendix B ................................................................................................................................... 40
Appendix C ................................................................................................................................... 42
Appendix D ................................................................................................................................... 43
Appendix E ................................................................................................................................... 45
Appendix F.................................................................................................................................... 46
Appendix G ................................................................................................................................... 47
Appendix H ................................................................................................................................... 48
Appendix I .................................................................................................................................... 49
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 5
Constructing a community cardiac health risk profile: Building the groundwork for a community
cardiac wellness program for the City of Twinsburg, Ohio
Introduction
Chronic disease mortality rates are expected to increase twenty percent between 2002 and
2030 (Freudenberg & Olden, 2010). Every thirty-four seconds an American will suffer some
type of a cardiac event (Go et al., 2013, p. e186). The cost of cardiac disease in the United States
is approximately $108.9 billion dollars each year causing considerable health and economic
burdens stemming from lost productivity, acute illness, health care demands, disability, and
premature death (Zeng et al., 2013). According to Taniguchi et al. eighty percent of risk factors
attributed to cardiac disease are modifiable risks (Taniguchi, Baernstein, & Nichol, 2012).
The demands of the Twinsburg Fire Department (TFD) emergency medical services
(EMS) impact the entire community and TFD capacity to protect and serve the community. The
problem is that Twinsburg Fire Department is a fire-based emergency medical service that does
not have an emergency medical prevention presence in the City of Twinsburg. The purpose of
this research is to reduce the number of cardiac emergency responses the development of a
community cardiac risk profile.
The expectations of TFD paramedics are to contact social services, welfare agencies and
document the environment of the patient if needed which falls within the sphere of public health.
Recognizing EMS leverage to access target audience who experience increased health risk is the
next logical step for TFD paramedics to enter into the realm of public health (Chubb, 2001). To
uphold the TFD expectations a proactive approach is necessary to encourage health risk
reduction strategies specifically cardiac health and incorporate them into daily responses of the
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 6
fire department, within the fire prevention bureau and extend into the Community. The
prevalence of heart disease coupled with modifiable risk factors opens a door for TFD
paramedics to positively influence not only their patients but an entire community.
The research utilized action research methodology to answer the following questions:
1. Who is requesting emergency medical responses for cardiac emergencies in the
City of Twinsburg?
2. What are the pre-existing conditions of the Twinsburg Fire Department
emergency cardiac patients?
3. Where are the Twinsburg Fire Department emergency cardiac patients located?
4. What are the locations or population groups that should be the focus of a
community cardiac risk reduction program?
5. What are the components of a community cardiac risk reduction program?
Background and Significance
The Twinsburg Fire Department (TFD) provides fire, rescue and emergency medical
services (EMS) to the City of Twinsburg and Twinsburg Township forming a protection district
that is situated between Cleveland and Akron, Ohio. The TFD protects approximately 21 square
miles and is a Class 4 Insurance Service Organization (ISO) rated department. The majority of
the district is considered suburban and serves a residential population of 22,000 (R. Racine,
personal communication, April 25, 2012). The fire district includes industrial facilities and large
commercial buildings that contain high quantities of hazards materials (DeVito-Staub, 2012).
The Department is composed of thirty-two full time employees and twelve part-time employees
all of which are paramedics excluding two full time Captains. In 2013 Twinsburg Fire
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 7
Department responded to 2,232 calls; eighty-two percent were EMS responses (D. Simon,
personal communication, April 15, 2014).
The Twinsburg Fire Department has evolved from a strict fire department to a fire-based
EMS department. The functions of TFD continue to expand. The TFD Fire Prevention Bureau
was designed to save lives through education, enforcement and lessen the demand of fire and
emergency services. Currently eighty-two percent of TFD responses are EMS calls yet only ten
percent of TFD prevention activities focus on non-fire risk reduction (L. Racine, personal
communication, April 15, 2014). There is a disproportionate demand of EMS risk reduction
programs in comparison to fire prevention programs. A cultural shift within TFD is necessary to
expand prevention activities into non-fire risk reduction strategies for the future and
sustainability of operations and prevention. Planning and implementing an EMS risk reduction
strategy will positively impact EMS demand similar to early fire prevention programs within the
City of Twinsburg (L. Racine, personal communication, March 4, 2014).
Construction of a community cardiac risk profile entails a description of the cardiac risks
and demographic characteristics of those affected by cardiac events. The importance of local
data analysis in prevention planning by the TFD will provide the groundwork to analyze the
community risk, identify hazards and causal factors, assess vulnerability, establish priorities
based on cardiac risk, create cardiac risk reduction objectives and recommend cardiac
intervention strategies (United States Fire Administration [USFA], 2012, p. SM1-8). The greatest
advantage to the community is improved cardiac health, cardiac risk reduction, extending life,
providing options for education and a decrease healthcare cost all of which were goals expressed
by Mayor Katy Procop of Twinsburg, Ohio (K. Procop, personal communication, June 2013).
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 8
The fire service has become the principal contractor of EMS (Chubb, 2001). The
increasing demand for EMS generates expenses for TFD including but not limited to staffing,
equipment, and training s impacting the Community coffers. Innovative approaches for cost
containment, improving health outcomes, and reduce EMS demand are vital to sustain, expand,
and tailor the continuum of care for the Twinsburg Community (Zeng et al., 2013). The
traditional role of the fire department has not been involved in non-fire prevention programs
(Bigham, Kennedy, Drennen, & Morrison, 2013).
This applied research project is associated with the goals and objectives of the United
States Fire Administration (USFA) operational objectives to reduce risk at the local level through
prevention and mitigation, improve local planning and preparedness while improving the fire and
emergency professional status (United States Fire Administration [USFA], 2014) The model
utilized for this applied research project was presented in the Executive Analysis of Community
Risk Reduction Course (USFA, 2012).
Literature Review
The literature review focused on understanding cardiac risk, assessing community risk,
intervention strategies and implementing an action plan to reduce community cardiac risk
(USFA, 2012, p. SM1-8).
The leading cause of death for men and women is cardiac disease. One in every four
deaths is attributed to cardiac disease (CDC, n.d.). Risk reduction is critical to decrease acute
illness, disability, lost productivity, premature death, cost containment, and demand on
Twinsburg Fire Department resulting from cardiac etiologies (Zeng et al., 2013). The cost of
healthcare continues to increase with chronic diseases, liable for seventy-five percent of the
national annual health care expenditures (Milani & Lavie, 2009). According to the American
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 9
Heart Association (AHA) a projected 40.8 % of the Unites States population will have some
form of cardiac disease by 2030. In turn, the medical costs are expected to increase one hundred
percent between 2013 and 2030 (Go et al., 2013)
As a consequence of higher health care demands Bigham et al. forecast that EMS demand
will increase as much as eight percent annually producing a noticeable effect on allied health
care professionals (2013). Currently, the roles traditionally performed by physicians are being
extended by allied health professionals through community paramedics and home healthcare
(Bigham et al., 2013). The scope of healthcare is broadening beyond hospital-centered to a
community based approach focusing on diversification, cost containment and interdisciplinary
coordination of services (McAllister et al., 2013). Prevention of illness and injury is one of the
most advantageous tactics to control the rising public and private cost of healthcare (Chubb,
2001). Community health care methodologies involve health activities to safeguard and enhance
the health of the population or community through validation of new approaches, analysis of
issues at hand, expansion of the health care field, implementation and treatment of community
health programs (Ashengrau & Seage, 2014) The most valuable approach for health risk
reduction strategies are debatable according to Pennant et al (2010). Pennant et al. denotes that
targeting the entire community is alluring and will affect widespread community behavior to
promote health risk reduction (Pennant et al., 2010).
A paradigm shift is introduced by Sun et al to reshape the community’s perception of
public health as a collective rather than solely personal responsibility. This reframing of public
health will motivate community involvement, encompass allied health care fields, and become
mindful of health as a collective enterprise addressing chronic diseases including cardiac disease
(Sun, 2014). Solutions to public health do not exclusively revolve around health considerations
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 10
but are embedded in economics, culture, politics and ethics stimulating a multi-faceted approach
(Savitz, Poole, & Miller, 1999). Traditional sickness-based health systems constructed to take
action against acute and communicable diseases are ill-equipped to provide the difficult,
integrated, multifaceted and sustained activities required to tackle chronic disease (Willis, Riley,
Herbert, & Best, 2013)
EMS data has the ability to substantiate an initial point prior to intervention, assess
development and contribute to the health risk reduction program. EMS data can identify the
target populations that are at most risk. The information obtained can be shared and engage
stakeholders within the community and build collaborative partnerships (Johnson, 2011).
Extensive knowledge has been acquired through large databases and registries for myocardial
infarctions and successfully integrated cardiac rehabilitation programs into patient care ensuing
from the collected data (Herlitz et al., 2008).
The systematic retrieval of community health information is limited and local health
departments are further restrained concerning behavioral measurement of their target populations
by survey or observational methods (Roussos & Fawcett, 2000). EMS data is one source of
community health information that assisted with early detection of reportable infectious diseases
but has not been extensively utilized or studied. According to the Center of Disease Control
(CDC) EMS data has been a useful tool to ascertain signs and symptoms using real time
recognition of outbreaks. The Center for Disease Control automatic surveillance of EMS records
enhances detection and supplements public health surveillance (CDC, 2010). Dietz et al
investigated the advantage of EMS electric records in conjunction with heroin overdoses. EMS
data isolated on scene information, location, demographics and relevant clinical data from the
patient care reports. The EMS data provided a cost effective method to employ real-time facts to
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 11
aid in detection of patterns and indication of heroin use (Dietze, Cvetkovski, Rumbold, & Miller,
2000).
Health risk factors generally speaking are situations that individuals favor regarding
particular behaviors and predispose them to health consequences (Sun, 2014). Cardiac risk
factors have been divided into two categories fixed and modifiable. Fixed factors are those that
are unable to change such as biology and genetics. Modifiable risk factors are those that can be
altered or eradicated (Taniguchi et al., 2012). Modifiable factors pertain to the physical
environment, social environment, individual behavior, and health services (Hudmon, Addleton,
Vitale, Christiansen, & Mejicano, 2011). Risk can be expressed in qualitative and quantitative
factors. Statistical information addresses the quantitative factor of risk and aids in expressing
trends and patterns within certain populations (Sun, 2014).
According to the American Heart Association (AHA) from 1999 -2009 the death rates
caused by hypertension, a modifiable cardiac disease risk factor increased approximately
seventeen percent and the approximate deaths escalated forty four percent (Go et al., 2013, p.
e79). Based on the 2007- 2010 data thirty three percent of adults greater than 20 years of age
have hypertension of which eighty two percent are unaware and seventy five percent are
controlled with medication. Seventy-five percent of patients with hypertension have modified
their cardiac risk through medication and reduce the probability of extensive health issues (Go et
al., 2013, p. e79). Stroke, elevated cholesterol and diabetes are other modifiable risk factors for
cardiac health according to the AHA. The AHA identifies seven metrics to characterize
cardiovascular health divided into four health behaviors and three health factors. The four health
behaviors are cessation of smoking, physical activity, healthy diet, and energy balance (weight
control). The three health factors are ideal total cholesterol levels, blood pressure and fasting
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 12
glucose within normal range. The health metrics with the greatest bearing for poor cardiac
health are the three health factors, poor diet, lack of physical activity and body weight (Go et al.,
2013). Zeng et al focused on cardiac risk behaviors, age, gender, race and qualifying events to
determine if a reduction of cardiac risk and behaviors would reduce hospitalizations and
Medicare costs. Modest savings were noted compared to those participants without lifestyle
modifications (Zeng et al., 2013).
Alexander et al developed a worksite cardiac health risk reduction program that
addressed biological, physical and social risk factors within the worksite community. The goals
were to influence lifestyle and health behaviors, augment productivity and shrink future health
care expenditures (Alexander et al., 2012). Health risk assessments of the employees targeted
modifiable interventions and were implemented by a systematic mapping of those at risk and
were directed to the appropriate intervention program to the risk areas identified (Alexander et
al., 2012).
Zeng et al. discussed the benefits of lifestyle modification programs and noted the
achievement of favorable outcomes in cardiac risk factors and cardiac function (2013). The
program was composed of the following:
• Diet and nutrition counseling • Aerobic exercise • Stress management • Small group support (Zeng et al., 2013)
The CDC investigated effective measures to lessen cardiac disease morbidity. They stated
aspirin therapy, blood pressure management, cholesterol control and smoking cessation
contributed to cardiac disease risk reduction (CDC, n.d.). Evidence based programs aid to
improve modifiable cardiac risk but also assist with socioeconomic and cultural issues that
appear in particular populaces. This further supports the critical role of local knowledge,
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 13
community outreach, and public health as interventions that are fostered and put into action
(Trickett et al., 2011).
The Department of Health and Human Services created the Healthy People 2020 program
that strives to bring awareness of nationwide health improvements priorities, comprehend causal
factor of health, raise public awareness, furnish measurable objectives and goals, engage
multiple sectors and strengthen evidence based research and knowledge and stipulate critical
research evaluation and data collection (Healthy People, n.d.). This 30 year program continues
to enrich the health of Americans through collaborative partnerships within the community,
empowering individuals and measurement of prevention interventions. One of the foundational
measures is determinants of health. The CDC defines determinates of health as, “the range of
personal, social, economic, and environmental factors that influence health status (Healthy
People, n.d.)” Individual factors, social factors, health services, biology and genetics, and
individual behaviors create interrelationships that bring about individual and population health.
The AHA refers to a Healthy People 2020 goal; achieve a twenty percent improvement of
cardiac health for all Americans (Go et al., 2013, p. e14). The overreaching goals of Healthy
People 2020 are as follows:
• Attain high quality, longer lives free of preventable disease, disability, injury or premature death
• Achieve health equity, eliminate disparities and improve health of all groups • Create social and physical environment that promotes good health for all • Promote quality of life, healthy development and healthy behaviors across all life
stages(Hudmon et al., 2011, p. 62)
Mobilize, Assess, Plan, Implement Track (MAP-IT) is a component of Healthy People
2020 to support recruitment of collaborative partnerships, evaluate the needs of your community,
generate and execute a program, and track community progress. Through the MAP-IT a vast
amount of information is available for strategic management especially the Community Tool
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 14
Box offering in depth resources to analyze, take action and implement community initiatives
(Community Tool Box, n.d.). Action planning for the community and system implementation is
advantageous because it provides focus and clarity to produce change, develop accountability
and ownership to facilitate community and system change of programs, policies, and practices
(Roussos & Fawcett, 2000).
Throughout the literature review collaborative partnerships or networks were identified as
essential to the success, sustainability, expansion of resources for community outreach programs
(Roussos & Fawcett, 2000) (Trickett et al., 2011) (Willis et al., 2013)(Healthy People, n.d.).
Coalitions of individuals and organizations from a mixture of community sectors can bring
mental and physical resources concurrently to accomplish goals which characterize collaborative
partnerships. The integration of public health professionals, allied health professionals,
politicians, local business leaders, local hospital systems, experts and other community
stakeholders constitute collaborative partnerships simplifying efficient use of resources,
numerous opportunities for learning and better capacity to tackle multifaceted challenges (Willis
et al., 2013). Successful strategies to enrich collaborative partnership are embedded in effective
communication, for example, communicating a clear and concise vision and mission,
communication of ongoing action planning, and engagement of leadership within different
sectors (Roussos & Fawcett, 2000).
The City of Twinsburg recently initiated a general fitness initiative designated as Fitness
in Twinsburg (FIT). The program was developed through a compilation of City employees and
the Cleveland Clinic Foundation (CCF). The goal was to develop a fitness program to create a
healthier community, healthier workplace, build sustainable relationship with community
partners, utilize available resources within the community, impact obesity and chronic disease in
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 15
a positive manner, and development of tracking outcomes. The program consists of health
screenings, education, and a U change U program. The focus of the interactive learning
environment of the U change U program is to tackle integrative health, behavior change, stress
management, physical activity, and nutrition to integrate all the information into a healthy
lifestyle (C. Bronson, personal communication, January 17, 2014).
Community interventions are social processes within the community that are
complicated yet critical. Demographics, culture, economics and geography influence public
health in addition to individuals’ behavior and biological traits (Trickett et al., 2011).
Individuals that share common demographic characteristics have the capability to become a
target audience for cardiac risk reduction program. The demographic characteristics can be
obtained from EMS patient reports to identify needs and determine allocation of resources
(Roussos & Fawcett, 2000).
Procedures
The first step of the applied research project was to select a significant issue within the
Community that has a negative impact for the people of Twinsburg, Ohio. Twinsburg Fire
Department is a fire-based emergency medical service that does not have an emergency medical
prevention presence in the Twinsburg Community. The purpose is to reduce the number of
emergency cardiac responses through collaborative partnerships and development of a cardiac
community risk reduction program. Research questions were developed in order to approach the
problem in a systematic manner. Twinsburg Fire Department EMS data, Interviews, literature
reviews, CDC, AHA, and Census data were utilized to answer the questions.
Twinsburg Fire Department EMS data was obtained from EMS charts.com; an electronic
data base linked to the TFD Medical Director and the Medical Command Hospital System,
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 16
Universities Health Hospitals Systems (UHHS). Twinsburg Fire Department paramedics are
required to document all emergency and non-emergency medical calls into this data base.
EMScharts.com is a software company that designs software specific to EMS organizations. The
second source of data was derived from the U.S. Census providing population data. The
American Fact Finder tool was retrieved and formulated reports for each census tract in
Twinsburg, Ohio. The reports retrieved were the 2007-2011 American Community Survey
(ACS), age and sex and the 2007-2011, American Community Survey (ACS) selected social
characteristics in the United States. According to National Fire Prevention Association (NFPA),
census tract information supplies population and demographic facts that are put to use for
development of public fire prevention planning and is a favored source of information (Johnson,
2011). The Center of Disease Control, National Prevention Council, and the American Heart
Association (AHA) websites were accessed presenting additional statistical data and strategies
for cardiac risk reduction.
A total of 1,716 EMS calls in 2013 were analyzed of which 161 were identified as
cardiac by the medical compliant. Information was organized using a custom report from
EMScharts.com and downloaded into an Excel spreadsheet. The variables consisted of date
dispatched, record identification number, resident status, gender, age, address of incident, city of
incident, outcome, medical compliant, past medical history, medications, and receiving hospital.
The disadvantage of using EMScharts.com is that the accuracy of the data depends on the acuity
of the paramedic data entry. The software is developed for a variety of EMS organizations: the
specificity that is desired for this research is not available at this time in EMScharts.com. Entry
fields have been eliminated and added within EMScharts.com which have benefited the author
but limited the consistency of research to one year.
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 17
Foundation for the paper was acquired through interviews establishing the need,
resources and vision to address the health of the entire community. Conversational-type
interviews were executed with varied questions depending on the job function of those
interviewed. The President of UHHS Ahuja Hospital, Susan Juris was interviewed in addition
to a panel of doctors and nurses. Those in attendance played a significant role in prior research
from the author (S. Juris, personal communication, July 10, 2013) (DeVito-Staub, 2012). The
concept of the research was examined, feasibility to execute, and similar programs in other
communities were also discussed. Mayor Kathy Procop provided her vision for the health of
Twinsburg and health of the employees. During the interview she expressed her concerns and
the direction of the author’s research. Resources were discussed. Prior to our meeting a
representative from the Cleveland Clinic Foundation, (CCF) was in contact with the Mayor
regarding similar concerns as the author. Information was provided to the author and recruited
by the Mayor of Twinsburg to assist in the development of the Fitness in Twinsburg (FIT)
initiative. The information obtained from the FIT meetings was pertinent and substantial to the
direction of the applied research project to construct a community cardiac risk profile. Chad
Bronson a Community Outreach representative from CCF was contacted and offered a great deal
of information and ideas. Lastly, information was gained from Laura Siefert, coordinator for the
Twinsburg Senior Center. She expressed the needs, current programs, and resources that are in
progress pertaining to cardiac wellness for the seniors in the Twinsburg Community.
A series of emails were exchanged between the UHHS EMS coordinator, Dan
Ellenberger and the EMScharts.com coordinator regarding access to medical information for
Twinsburg Fire Department and selected general information for the forty-one fire departments
under the UHHS medical command.
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 18
A literature review was executed focusing on prevention of cardiac emergencies by the
fire service, prevention and prevalence of cardiac health in the community and public health.
The author discovered a large amount of fire prevention information, injury prevention
approaches within the fire service and prevention strategies from the public health community
but limited information regarding fire service initiatives to reduce the risks of medical illness in
the community. Inferences were made that addressed cardiac health in public health and applied
them towards the fire service specifically fire-based EMS.
Who is requesting emergency medical response for cardiac events in Twinsburg?
The author analyzed EMS data, CDC trend tables and a literature review.
Understanding the impact of gender, age, and race were investigated and compared to the general
population. Understanding the vulnerability of the variables and how they correlate with cardiac
wellness was achieved through the literature review. The range of medical categories obtained
from the EMScharts.com 2013 data were narrowed to include cardiac related events which
included cardiac arrest (non-traumatic), cardiac problems (not chest pain), chest pain, and chest
pain STEMI, hypertension, and hypotension. The medical category is based on the paramedic’s
evaluation of the patient not the diagnosis of the emergency department doctor which limited the
research. Complaints of weakness, for example, may indicate a cardiac etiology but were not
included since it did not specifically identify cardiac involvement. Other medical categories were
excluded for this same reason such as flu-like symptoms, headache, dizziness, and changes in
mental status, general medical, general weakness, and unconscious fainting all may be a
symptom of an asymptotic cardiac event.
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 19
What are the pre-existing conditions of the Twinsburg emergency cardiac patient?
EMSchart.com medical data was analyzed. Modifiable predominant risk factors
accessible in EMScharts.com data and identified by the AHA and CDC were scrutinized. The
modifiable risk factors are as follows: hypertension, diabetes, elevated cholesterol and stroke.
The risk factors were employed to establish a level of pre-existing risk for the study population
and the impact of risk on gender and age. The number of total entries and those pertaining to
cardiac issues listed in the medical history were tallied and correlated to age.
This portion of the literature review concentrated on cardiac health prevention,
prevalence of heart disease, and factors that pre-dispose populations to cardiac events
specifically genetic, modifiable risk factors, and social aspects.
Where are the TFD emergency cardiac patients located?
EMScharts.com electronic data, ACS and Census data were used to answer this research
question. The addresses of incidents were obtained from EMScharts.com. The data was mapped
to the corresponding census tract. The author referred to ACS data and applied selected social
characteristics to the findings and investigated trends and alignment with current data. The
location of the incidents were identified as residential, commercial including industrial, senior
living and extended care. Patients were further categorized as resident or non-resident of the
City of Twinsburg. The focus of this division was to target location rather than age, gender, or
race for future cardiac wellness outreach. The literature review investigated sites of cardiac
wellness initiatives such as commercial or business, prevention program delivery based on
occupancy, and national program strategies.
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 20
What are the cardiac events, location or population groups that should be the focus of a
community cardiac risk reduction program?
The TFD medical data was compared to AHA and CDC statistics, trends and forecasts to
project the types of cardiac events. Pre-existing conditions obtained from medical history data
was evaluated to determine concentrations of recurring conditions. Modifiable risk factors and
cost of cardiac events for the people, community and local businesses were reviewed as possible
indicators for cardiac community outreach through a literature review. Interviews with Mayor
Kathy Procop and the Senior Center Coordinator of Twinsburg, Laura Siefert provided guidance
and focus to address this research question.
What are the common components of a cardiac wellness program?
This research questions was delivered by means of interviews and literature review. The
focus of the literature review was to examine a healthy heart lifestyle though preventative
screenings, nutrition, exercise, mental well-being, and stress management. Understanding these
attributes, cost, and correlation with social and demographic aspects of Twinsburg were
examined. Literature review identified customization strategies for sustainability of a community
cardiac wellness program. Lastly action research emphasized the understanding of strategies that
are necessary to implement effective and efficient uses of resources and create a positive heart
healthy impact on the Twinsburg Community. Current literature has established a system to
identify populations at risk and target specific audiences through a community risk reduction
model to assist in getting ready, assessing community risk, intervention strategies, action and
evaluations to identify at risk populations (United States Fire Administration [USFA], 2012).
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 21
Limitations
The EMScharts.com data is limited to the accuracy of the paramedic data entry. Errors
can occur with data entry, transcription of patient notes into the data base, and patient error due
to age or mental status resulting from disease. The data base is developed for an assortment of
EMS organizations with emphasis on billing. Fire based EMS is in the early stage for prevention
of medical conditions. The variables are limited. The medical categories used in this research
are determined by the paramedic’s assessment of the patient and determining the most accurate
medical category that fits with the chief compliant. With cardiac ailments especially in women
asymptomatic presentation is a factor which may lead the paramedic to a medical category such
as general weakness, abdominal pain or mental status changes when in fact the doctor at the
emergency department may diagnose a heart condition. Leading to another limitation of this
research, diagnosis by the emergency department doctor is not associated with the
EMSchart.com information. The information is solely based on the paramedic perception of the
patient presentation. As previously noted the pre-hospital care community is in the early stages
of undertaking a pronounced role in public health. Limited peer-review articles discussing fire-
based EMS and non-injury prevention programs were found. Originally the author included data
from 2010-2013 however due to changes in chief complaint categories in EMScharts.com
discrepancies were noted and data was limited to 2013.
Results
Who is requesting emergency medical response for cardiac events in Twinsburg?
Electronic emergency medical records were retrieved from EMS charts and divided into
medial categories, age, gender, and transport outcomes and compared to the census bureau data.
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 22
According to data retrieved the percentage of cardiac related EMS responses has declined
from 12 % of total call volume in 2012 to 9.7% in 2013. This percentage is higher than the
cumulative data obtained from TFD’s UHHS medical command. The UHHS medical command
included forty-two EMS organizations including fire-based EMS and private ambulance. It
concluded that 8.9% of the total EMS responses were cardiac related as depicted in Appendix A.
The median age of the population of Twinsburg is 40. 4 years old; the median age of cardiac
TFD emergency responses for 2013 was 66 years old with a mode of 85 years old.
Figure 1. Cardiac responses based on age and gender
The male mean age is higher than the total mean age and had fewer requests than females
for EMS responses. Sixty-seven percent of TFD cardiac responses resulted in a patient being
transported to the hospital. Males and females both chose not to be transported 6% of the time.
The most transports were noted in in the age group of 65 years and older. The EMS responses
were further partitioned by age groups. The majority of the EMS responses to cardiac events
occurred in the over 65 year old age group with 53% of the requests followed by 45- 65 year old
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 23
age group with 30%, and 19-44 year old group with 17%. The mean distribution of age was
evaluated in conjunction with cardiac sub categories and gender as noted in Figure 2.
Figure 2. Comparison of Mean Age, Gender and Medical Sub Categories for 2013 TFD Cardiac
Responses based on 2013 Twinsburg Fire EMS data.
According to the data presented males require TFD cardiac responses at an earlier age.
However females requested EMS 56% more often than males. American Community Survey
stated that the population distribution of Twinsburg is 52% female and 48% male which may
attribute to the larger demand by females compared to males. ("U.S. Census Bureau," n.d). The
greatest disparity between age, gender and cardiac sub categories falls within the cardiac (not
chest pain) and hypertension elements. Studies have suggested that females have a greater risk of
asymptomatic chest pain compared to males. Cardiac medical sub categories and gender have
been illustrated in Appendix B.
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 24
Numerous studies have documented the disparity of race and cardiac wellness (Go et al.,
2013). Twinsburg Fire Department cardiac response data is representative of the community and
supported by Table 2.
Female Male Total TFD 2013
Cardiac Data Census Data Asian / Pacific Islander 2.2% 0.0% 1.2% 4.90% Black, Non-Hispanic 19.6% 12.7% 16.6% 15.0% Other 2.2% 1.4% 1.8% 0.5% White, Non-Hispanic 75.0% 85.9% 79.8% 78.7% Multiracial 1.1% 0.0% 0.6% 0.9%
Table 2. Ethnicity of TFD Cardiac Responses compared to U.S. Census ACS Data
Additional ethnicity figures are illustrated in Appendix C that supports the association of
demographic information of gender and ACS data sets compared to TFD EMS data.
What are the pre-existing conditions of the Twinsburg cardiac patients?
Of the four identified risk factors established for this research hypertension was the most
pronounced for males and females. Females were inclined to have a slightly higher number of
hypertension risk factor entries. Diabetes was the second most noticeable risk factor with equal
distribution among genders. Females had a slight decrease compared to males regarding
elevated cholesterol entries unlike stroke which was considerably higher in males than females
as noted in Appendix D Gender differences were limited with the category of one risk factor
and no risk factors. Risk factors with two entries were slightly elevated in females.
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 25
Figure 3. Comparison of gender related to number of pre-existing heart conditions.
None of the TFD EMS patients had a combination of four risk factors. Pre-existing conditions
were identified in the patient past medical history in their electronic chart and summarized in
Appendix D. Twenty-eight percent of TFD cardiac responses did not have a pre-existing
condition documented in their past medical history. Thirty-six percent had one pre-existing heart
condition and twenty-three percent exhibited a combination of two.
Where are the TFD emergency cardiac patients located?
The information obtained from the TFD cardiac response locations were mapped and
categorized into census tracts, occupancy type and cardiac sub categories. The Census tract
information is listed in Appendix E. The locations for Twinsburg were generalized into four
categories residential, commercial (including industrial), senior living and extended care and
linked to the corresponding census track. Sixty-four percent of the TFD cardiac responses were
commercial and residential occupancies. Surprisingly the extended care facilities only composed
twenty-three percent of the total responses. Figure 4. The author predicts that by 2015 this
number will increase with the construction of two large extended care facilities in the City of
Twinsburg. The addition of two free standing emergency departments in 2009 have attracted
medical professionals and extended care facilities including a dialysis center; all of which will
contribute to increased demand of the EMS services within the City.
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 26
Figure 4. Location of TFD cardiac EMS calls by Occupancy
Cardiac sub categories were applied to the occupancies to identify trends. The greatest
number of responses was located in residential and commercial occupancies with the chief
complaint of chest pain. Location and occupancy details are listed in Appendix F. The cardiac
sub categories were applied to the census tracts and noted that census tract 5301.04 was unlike
the other tracts. Census tract 5301.04 is the most populated tract, 65.6% of the cardiac responses
were cardiac problems (not chest pain) however the female to male ration is equal and aspects
investigated appear to within the normal range or equitable to the census tracts. This deserves
further attention. Census tract 5301.01 has a unique identifier that it has a considerable populace
of cardiac responses for cardiac problems (not chest pain). Table 1 illustrates the correlation of
census tracts and cardiac sub categories.
Table 1.Correlation of Census Tracts and Cardiac Sub Categories
5301.01 5301.03 5301.04 5301.05 5301.08 5327.01 Cardiac Arrest (Non-Traumatic) 0.0% 6.3% 12.5% 11.1% 3.8% 0.0% Cardiac Problems (not chest pain) 37.5% 6.3% 65.6% 11.1% 19.2% 6.7% Chest Pain 50.0% 81.3% 21.9% 71.4% 76.9% 86.7% Hypertension 12.5% 0.0% 0.0% 3.2% 0.0% 6.7% Hypotension 0.0% 6.3% 0.0% 3.2% 0.0% 0.0%
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 27
Appendix F depicts age and occupancy type. The two largest response locations were
residential with a median age of 68 years old and commercial occupancies with a median age of
48 years old.
What are the cardiac events, location or population groups that should be the focus of the
community cardiac risk reduction?
The occupancy type most at risk is residential areas with thirty-four percent of the cardiac
responses closely followed by commercial with thirty percent of the EMS cardiac responses.
The occupancy types were superimposed on corresponding census tracts and the findings are
illustrated in Figure 5.
Figure 5. Location types superimposed on corresponding census tracts from 2010
The locations most at risk are census tract 5301.05 and 5301.04. Census tract 5301.05
had the greatest number of cardiac responses and the least amount of recorded population within
the Twinsburg Census Tracts. There are a significant number of commercial and industrial
facilities located within census tract 5301.05 contributing to the high number of cardiac
responses to commercial 0ccupancy types. The average age of commercial type cardiac response
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 28
is 48 years old with approximately seventy-one percent of the requests categorized as chest pain.
Census tract 5301.4 represents the highest population and the greatest number of residential EMS
cardiac responses.
The Twinsburg community cardiac risk reduction program should focus on commercial
type facilities within census tract 5301.05 and residential locations within census tract 5301.04.
The cardiac event cited most frequently is chest pain for census tract 5301.05 and cardiac
problems (not chest pain) in census tract 5301.04.
The literature review and the interview with the Mayor of Twinsburg discussed the cost
of healthcare for businesses and the City of Twinsburg. The increasing cost of healthcare is
increasing with no significant relief in sight however healthcare prevention has proven to
decrease health care expenditures.
What are the common components of a cardiac wellness program?
The components of a cardiac wellness program must be tailored to the demographics and
socioeconomic status of the community. It is critical to have involvement of the community
prior to establishing a program to create empowerment of the people, cultural knowledge, and
build collaborative partnerships. The City of Twinsburg has initiated the first step through a Fit
in Twinsburg (FIT) initiative in collaboration with the Cleveland Clinic Foundation. Initial
screenings for the City employees were completed to highlight modifiable risk and provide
education to understand the results of the screening. The employees were a test group; the plans
are to offer screenings and education to the entire Community of Twinsburg. The U change U
program offered to the Community includes education on diet, exercise, life style modification
and stress management to promote healthy living. The equivalent topics should be included in a
cardiac risk reduction program.
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 29
Discussion
Pre-hospital care has the unique ability to assess the patient and their immediate
environment. The environment provides clues to lifestyle, living conditions, and social
dynamics that may not be accessible to the emergency department physician. The public health
realm provides additional resources to reduce cardiac risk, EMS demand, and healthcare costs
for the community (Bigham et al., 2013). This distinctive perspective allows Twinsburg Fire
Department Paramedics to have access to patients that are inaccessible to most health care
professionals. Paramedics are able to recognize on scene circumstances that impact health,
safety, and welfare of the patient and others who may be present (Chubb, 2001).
Electronic EMS reporting systems provide immediate data accessibility to view trends
identify high frequency patients, high frequency locations and utilize epidemiology studies
(Dietze, Cvetkovski, Rumbold, & Miller, 2000)(CDC, 2010). Public health is a natural extension
of pre-hospital care. Public health and pre-hospital care pose similar challenges to solve with
disparate and incomplete information to guide treatments but not envisage the same result each
time. The product is an undertaking to amalgamate scientific action into community action
(Alexander et al., 2012). The ability of TFD paramedics to influence target audiences on scene
allows an entry point to gain insight and educate risk reduction strategies and lessen demand for
TFD EMS (Chubb, 2001).
Twinsburg Fire Department has collaborated on a community projects that have proven
to be successful in the past. The Twinsburg Cares program was developed in 2012 with the
Twinsburg Senior Center and Twinsburg Police Department. This program helped reduce the
number of public assist responses and increase the safety for homebound citizens. Citizens were
identified by TFD paramedics and provided resource information, and advised the Senior Center
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 30
Coordinator. The Senior Center Coordinator followed-up on patients to ensure the citizen could
access resources to increase their quality of life (L. Siefert, personal communication, September,
2013).
Reduction of cardiac risk factors and promotion of healthy living can be achieved
through collaborate efforts of community leaders and city services (Hudmon et al., 2011). The
City of Twinsburg has invested a great deal in the Parks and Recreational Department which
manages a fitness center, golf course, community center, senior center, aquatic center, multiple
ball park complexes, and 100 acres of natural park land. A variety of programs are offered at
each of the facilities however a coordinated cardiac risk reduction program is not available nor is
a target audience been identified. In addition to City resources there are two free standing
emergency departments located in the City of Twinsburg, the Cleveland Clinic Foundation
(CCF) Medical Campus and the Universities Health Hospitals System (UHHS) Medical Campus.
These entities are two of the largest health hospital systems in Northeast Ohio; both of which
have access to a great number of resources and community health expertise (DeVito-Staub,
2012).
A Twinsburg Cardiac Wellness Program should focus on identification and management
of modifiable risk and education for lifestyle modification based on the author’s findings.
Recruitment of collaborative partnerships is crucial for sustainability, funding, community
leadership and cultural knowledge to customize a program that is effective for the City of
Twinsburg. Coordination of current City resources and collaborative partnerships will aid in
reaching the target audiences located in census tract 5301.04 and census tract 5301.05 as
described in the Cardiac Risk Profile for the City of Twinsburg in Appendix H. Twinsburg Fire
Department and collaborative partnerships intends to create a cardiac risk prevention program to
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 31
concentration on commercial and industrial occupancies similar to previous TFD
Cardiopulmonary Resuscitation (CPR) programs offered to local businesses free of charge. .
Although cardiac risk reduction programs may present similar information the route of
implementation should vary depending on the target audience. The residential cardiac risk
profile must entail implementation strategies to reach the entire population some of which may
never leave their home (Loyo et al., 2013). The Twinsburg Fire Department provides valuable
insight, access, and disperses information to those hard to reach residents inaccessible to general
community wellness initiatives.
Improving the health of the community can translate into a stronger health and welfare of
the citizens and business members. With strength comes a greater ability to improve local
capacity; for instance, EMS response to emerging health issues and sustainability for community
development (Trickett et al., 2011). Alignment of the stakeholders within the community has the
capacity to stimulate cardiac risk reduction strategies but also become an incentive for
community networking and collaborative partnerships (Loyo et al., 2013).
Recommendations
The discoveries from the literature review, original research and data analysis encourage
the development of a cardiac risk profile and deliver guidance to reach those most affected by
cardiac conditions and direct resources more efficiently. The following recommendations will be
proposed to TFD and the Twinsburg FIT initiative committee:
• Establish collaborative partnerships for residential and commercial occupancies
for a cardiac risk reduction program
• Tailor cardiac risk reduction program implementation based on risk profile
• Expand EMScharts.com data compilation to 3-5 years
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 32
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Appendix A
Twinsburg Fire Department Medical Categories 2012
TFD 2012 Number of EMS responses Percentage of Total Call Volume
Cardiac 206 12.0% Injury 435 25.3% Airway/ Respiratory 151 8.8% General Medical 638 37.2% Endocrine 42 2.4% Behavioral 54 3.1% Environmental 12 0.7% Poison 12 0.7% Public Assist 109 6.4% Unknown 57 3.3%
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 38
Appendix A (continued)
Twinsburg Fire Department Medical Categories 2013
TFD - 2013 Number of EMS responses Percentage of Total Call Volume
Cardiac 166 9.7%
Injury 483 28.1%
Airway 126 7.3%
General Medical 745 43.4%
Endocrine 42 2.4%
Behavioral 53 3.1%
Environmental 7 0.4%
Poison 6 0.3%
Public Assist 74 4.3%
Unknown 14 0.8% Note. This table depicts the dispersion of EMS medical categories that Twinsburg Fire Department responded to in
2012 and 2013
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 39
Appendix A (continued)
University Health Hospitals Systems Medical Categories 2013
2013 - UUHS Medical Command Number of EMS Responses Percentage of Total Call Volume
Cardiac 2855 8.9%
Injury 7578 23.7%
Airway 2872 9.0%
General Medical 14871 46.5%
Endocrine 809 2.5%
Behavioral 1318 4.1%
Environmental 78 0.2%
Poison 317 1.0%
Public Assist 465 1.5%
Unknown 797 2.5%
Note. This table depicts the dispersion of EMS medical categories of forty-two local fire EMS based organizations and private EMS organizations
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 40
Appendix B
Appendix B illustrates gender differences and similarities with TFD cardiac responses.
0%20%40%60%80%
100%
Cardiac Medical Sub Categoriesby Gender
Female
Male
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 41
Appendix B (Continued)
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 42
Appendix C
Appendix C illustrates ethnicity data obtained by TFD Cardiac EMS responses for total
population & gender.
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 43
Appendix D
Risk factor analysis by gender and pre-existing conditions
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 44
Appendix D (continued)
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 45
Appendix E
Twinsburg Census Tracts
5301.01 5301.03 5301.04 5301.05 5301.08 5327.01 Population Total 5073 4682 7033.00 2136 4684 6522 Population Males 2596 2270 3527.00 1019 2102 3365 Population Females 2477 2412 3506.00 1117 2582 3157 Population under the age of 18 33.40% 28.90% 0.26 35.6 23.60% 23.40% Population 20- 44 years old 31.10% 28.50% 0.32 15.4 35.00% 35.60% Population 45-64 years old 25.90% 30.80% 0.27 31.2 24.70% 27.70% Population 65 years old and older 9.80% 11.80% 0.15 17.9 16.50% 13.30% Median Age 37.60 41.60 38.60 43.6 39.1 39.7 Median Male Age 36.40 36.7 35.00 38.3 37.9 39.0 Median Female Age 39.40 44.2 42.00 48.5 40.4 40.4 Education Attainment High School 22.20% 31.70% 28% 25.30% 22.00% 26.8 Education Attainment Bachelor 24.80% 27% 27% 25.30% 31.00% 29.7
Education Attainment Graduate 21.60% 14.10% 13% 18.30% 17.50% 16.7 Employed 76.90% 73.20% 58% 47.10% 54% 68.9 Unemployed 1.50% 1.50% 6% 12% 4% 3.0 Not in the labor force 21.70% 25.20% 35% 40.90% 22% 28.1 Median total household income 90,147 76,491 67512.00 26,208 64,451 69,862 Mean total household income 122,946 93,732 72440.00 51,176 51,176 88,731 Median Family Income 96,111 89,601 82273.00 51,927 89,000 69,862 Mean Family Income 134,009 109,152 84771.00 64,408 101,422 88,731 Per capita income 42,000 35,964 30071.00 22,204 39,869 36,410 Median earnings for workers 49,224 39,467 35503.00 29,625 35,503 40,160 Median earnings for male workers 67,328 70,477 59189.00 56,897 64,089 64,147 Median earnings for female workers 56,022 40,556 42176.00 40,530 42,179 45,477 Below poverty level last 12 months (all) 0.80% 1.2% 0.06 5.50% 1.30% 1.20%
("U.S. Census Bureau," n.d)
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 46
Appendix F
Information presented on location, census tract information and occupancy for TFD
Cardiac EMS responses.
Cardiac Sub Categories Commercial Extended
Care Residential Senior Living Totals Cardiac Arrest (Non-Traumatic) 2 5 2 0 9 Cardiac Problems (not chest pain) 6 4 10 1 21 Chest Pain 35 28 40 14 117 Hypertension 4 0 2 5 11 Hypotension 1 1 1 0 3 Total 48 38 55 20 161
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 47
Appendix G
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 48
Appendix H
Twinsburg Community Cardiac Risk Profile
Based on 2013 Twinsburg Fire Department Cardiac Emergency Responses
High Risk Locations:
Census Tract 5301.04
Census Tract 5301.05
Locations of Interest
Census Tract 5301.04 – Residential Locations
Census Tract 5301.05 – Commercial/ Industrial Locations
Cardiac Risk Focus
Census Tract 5301.04 – Hypertension
Census Tract 5301.05 – Hypertension
Age Range Focus
Census Tract 5301.04 – 65 and older
Census Tract 5301.05 – 45 – 65 years old
Gender Focus
Census Tract 5301.04 – Equal focus female and male
Census Tract 5301.05 – Equal focus female and male
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 49
Appendix I
Communication List
Name Organization Method Date Kathy Procop Twinsburg City Mayor Interview 5-Jun-13 Dan Ellenberger UHHS EMS Coordinator Interview 9-Jul-13 Susan Juris University Health Hospital Systems Interview 10-Jul-13 Matt Sabo UHHS & EMS Charts Coordinator Phone conversation 20-Jul-13 Matt Sabo UHHS & EMS Charts Coordinator Phone conversation 9-Aug-13 Matt Sabo UHHS & EMS Charts Coordinator Meeting 9-Sep-13 Laura Siefter Twinsburg Senior Center Phone conversation 14-Sep-13 Dan Ellenberger UHHS EMS Coordinator Phone conversation 20-Sep-13 Dan Ellenberger UHHS EMS Coordinator Phone conversation 30-Oct-13 Chad Bronson Cleveland Clinic Foundation Interview 17-Jan-14 Chad Bronson Cleveland Clinic Foundation FIT Meeting 9-Feb-14 Kathy Procop Twinsburg City Mayor FIT Meeting 9-Feb-14 Lynn Racine Twinsburg Fire Prevention Interview 4-Mar-14 Chad Bronson Cleveland Clinic Foundation FIT Meeting 10-Mar-14 Kathy Procop Twinsburg City Mayor FIT Meeting 10-Mar-14 Don Simon Twinsburg Fire Operations Email 14-Apr-14
CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 50