Saturday, December 7, 2013
Bentley J. Bobrow, MD
Bystander CPR is a critical link in the
chain of survival. It has been shown to more than double a victim’s
chance of surviving an out-of-hospital cardiac arrest (OHCA).1 Using an
automated external defibrillator (AED) in addition to performing
bystander CPR further improves the chances of survival.2 Yet, both
bystander CPR and AEDs are not provided in a majority of OHCA events.1,2
Because time is so critical in cardiac
arrest, immediate bystander action (calling 9-1-1, performing CPR, and
early defibrillation) is the cornerstone of maximizing the effectiveness
of subsequent EMS and hospital interventions and ultimately survival.
This is especially true in rural and congested urban areas with
prolonged response times.
Bystander CPR lengthens the duration of
ventricular fibrillation (VF) and provides critical blood flow to the
heart and brain during cardiac arrest.3 This improves the likelihood of
shock success, return of spontaneous circulation (ROSC), survival, and
the chance of a good functional outcome.3,4 The combination of quickly
calling 9-1-1, immediately doing chest compressions and applying an AED
as soon as possible works synergistically to increase survival. Each of
the successive links in the chain of survival depends on the preceding
links—the whole is greater than the sum of the parts.
Because of this, EMS (in fact, our
entire healthcare system) has a vested interest in the delivery of care
before the arrival of professional rescuers on scene. Everything EMS
does to improve the readiness of lay rescuers (training, public
awareness, 9-1-1 pre-arrival instruction, assistance locating AEDs,
etc.) will pay heavy dividends in an increased survival rate in our
communities.
Measuring Interventions
There is wide and unacceptable variability in cardiac arrest outcomes
between communities,5 which likely results from differences in
implementation and performance of important interventions such as 9-1-1
pre-arrival CPR instructions, bystander CPR and early defibrillation.
Continuously measuring these interventions and analyzing their impact is
the only way to know specifically what needs improvement and whether a
system is functioning as intended.
Current registries exist to help
communities measure their cardiac arrest incidence and outcomes. The
CARES (Cardiac Arrest Registry to Enhance Survival; https://mycares.net)
registry is a national data collection system for OHCA. This registry
includes data collection on OHCA incidence and process of care,
including bystander CPR, AED use and, recently added, data for 9-1-1
pre-arrival CPR instructions.
The need to take this a step further and
systematically track data from 9-1-1 centers has come about due to the
realization that the quality of telephone CPR instructions has a
significant impact on survival. Details such as whether the cardiac
arrest was correctly identified, whether CPR instructions were provided,
how long into the 9-1-1 call before CPR was started, and what type of
CPR was given can make the difference between life and death. There is
growing interest in pre-arrival CPR metrics and the need to quantify
this critical intervention. To illustrate the point: If the 9-1-1 system
provides pre-arrival CPR instructions at eight minutes into a call, it
will obviously have much less impact on survival than if the
instructions were provided one minute into the call. And yet both
callers received “pre-arrival CPR instructions.”
The state of Arizona and King County,
Wash., have piloted a data collection tool and reporting system for
suspected cardiac arrest dispatch calls, which is integrated into their
OHCA registries and linked to EMS care, hospital care and patient
outcomes. In Arizona, the 9-1-1 pre-arrival CPR program is part of the
Save Hearts in Arizona Registry and Education (SHARE) Program, a
collaboration between the Arizona Department of Health Services and the
University of Arizona (see http://azdhs.gov/azshare/911/index.htm). The
Arizona and King County, Wash., models have now been incorporated into
CARES to help dispatch and EMS systems across the country.
Why You Need an AED Registry
Like bystander CPR data, AED information is a critical component of an
ongoing cardiac resuscitation system of care. When various data points
along the continuum of care (bystander CPR, 9-1-1 data, AED
placement/use, and outcomes) are integrated into a standardized
registry, such as CARES, an entire system can be measured and improved
over time.
AED information needs to be integrated
into registries in order to know where AEDs are placed, if they are
checked for maintenance (pads, batteries), if potential users are
trained on-site, when they are used, and the ultimate patient outcome.
Event data should include the location of the arrest, who did CPR, what
kind of CPR was performed, who applied the AED, and whether a shock was
delivered. Detailed data after an AED is used should be made available
to other healthcare providers such as emergency physicians and
cardiologists.
What follows is a closer examination of why you need an AED registry:
• You can’t use them if you don’t know where they are: We
know AEDs are extremely safe and effective.2 We also know they are only
used by the public in approximately 4% of OHCAs.6 Knowing where AEDs
are located and if they are being used is important information. For
example, if AEDs are placed in a certain area of town but they aren’t
being used in cardiac emergencies, likely more public education is
needed. In contrast, if cardiac arrest is occurring more frequently in a
certain location where few AEDs are available, then more attention
should be given to acquiring and placing additional AEDs throughout that
community.
• You can’t use them if they’re not maintained: Just
as an AED that is not found cannot save a life, neither will an AED that
is not properly maintained. Maintenance includes making sure expired
pads and batteries are replaced and software upgrades are installed. A
Web-based AED registry can assist in ensuring the functionality of AEDs
by sending maintenance reminders. Just as fire departments check fire
extinguishers in a community, it makes sense that you need to have a
system to ensure that all AEDs are maintained in a ready-to-use state.
• You can’t use them if they’re not there: Another
reason for having an AED registry is the fact that the information can
be useful in the submission of grants for the deployment of additional
AEDs. To secure and receive either private foundation or government
grants, a Public Access to Defibrillation (PAD) program needs accurate
data—both utilization and patient outcome information. AED grants can
come from both private foundations and government. An example of a
private foundation offering grants is The Ramsey Social Justice
Foundation (http://ramseyjusticefoundation.org), which has donated AEDs
to communities participating in the SHARE Program in Arizona. An example
of a government AED grant is the one offered through the U.S.
Department of Health and Human Services’ Rural Health program.
Finding AEDs with Social Software
Keeping tabs on the locations of existing AEDs has been a challenge.
There have been several large-scale efforts to locate AEDs within
communities. One such program in Philadelphia used a crowdsourcing
approach. In 2012, the MyHeartMap Challenge
(www.med.upenn.edu/myheartmap) set up a competition and offered monetary
awards for those submitting the most AED locations. Using a smartphone
application, participants photographed and recorded GPS coordinates for
AEDs they found throughout the city.
Also using mobile phone technology, the
PulsePoint App (http://pulsepoint.org) takes locating AEDs one step
further—tying the location of the AEDs directly to nearby cardiac arrest
incidents through the community’s 9-1-1 system. The mobile app (iPhone
and Android) sends real-time AED location information to those within a
certain radius of a suspected cardiac arrest with the goal of increasing
both bystander CPR and the use of the life-saving devices.
Potential lay rescuers must normally
witness an arrest to take action. PulsePoint seeks to improve the
efficiency of both CPR-trained citizens and publicly available AEDs by
making bystander rescuers aware of cardiac events occurring nearby so
they can retrieve an AED and begin CPR while paramedics are making their
way to the scene. No one is in a better position to make a difference
in the first few minutes of an OHCA than a nearby CPR/AED-trained
individual. PulsePoint has been successfully implemented in many U.S.
cities.
Disparity Issues: Location of Arrests
The location of a cardiac arrest has a significant influence on patient
survival. Patients who arrest in public have a higher probability of
having their arrest witnessed, receiving bystander CPR, and receiving
defibrillation with an AED—all of which strongly increase the chance of
survival.2
National data on bystander CPR and PAD
programs have uncovered large and unacceptable disparities. For example,
using the CARES registry, Sasson and colleagues found that in
low-income black neighborhoods the odds of receiving bystander-initiated
CPR was approximately 50% lower than in high-income non-black
neighborhoods.7 Their study showed that both the racial composition and
the median income of a neighborhood have a significant effect on the
likelihood of receiving bystander CPR. Studies like this help identify
where to concentrate public training and education efforts.
In Arizona, Dr. Sungwoo Moon (a visiting
professor from Korea University) found OHCA victims in mainly Hispanic
neighborhoods received bystander CPR less frequently and had worse
neurologic outcomes than those in mainly white, non-Hispanic
neighborhoods.8
Using Geographic Information System
(GIS) technology and SHARE Program OHCA event data, Dr. Moon was also
able to identify the areas where OHCAs occurred most frequently but
where AEDs were lacking. This is a great example of how important it is
to have both cardiac arrest event and AED location data.9
A Variety of AED Registries
AED registries can take different shapes. Most states require reporting
of AED locations to local EMS and/or dispatch centers. However, it
varies widely as to how agencies capture and actually use this
information.
Arizona’s SHARE Program AED registry is
voluntary; however, it fulfills the statutory requirement that AED
owners enter into an agreement with a physician to oversee a PAD
program. In the SHARE registry, medical direction is free of charge to
those complying with the training and reporting requirements. The
registry uses a Web-based data entry system.
AED owners must keep their units
functioning and registries can play an important role in helping to
ensure that AEDs are always in a ready-to-use state. A Web-based AED
registry can send general reminders to registrants or targeted reminders
based on expiration dates entered into the system. Several companies
offer subscription services to assist with this.
The Future of AEDs
Tracking AEDs that are placed in static locations is one thing;
however, tracking the location of AEDs that are mobile, such as those
used during high school athletic events, requires a higher level of
sophistication. Also, many AEDs are moved from one “permanent” location
to another. In the future, AEDs will include technology (perhaps GPS,
WiFi, Bluetooth, or other methods) that will allow tracking in real
time, thereby allowing more efficient monitoring of the units’ placement
and readiness. This technology will likely be integrated into CAD
systems in the future, aiding dispatchers in locating AEDs and relaying
that information to callers, in an effort to increase AED use. And of
course, more AED use and more bystander CPR will translate into more
lives saved.
References
1. Sasson C, Rogers MA, Dahl J, et 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. Hallstrom AP, Ornato JP, Weisfeldt M, et al. Public-access
defibrillation and survival after out-of-hospital cardiac arrest. N Engl
J Med. 2004;351:637–646.
3. Eftestol T, Wik L, Sunde K, et al. Effects of cardiopulmonary
resuscitation on predictors of ventricular fibrillation defibrillation
success during out-of-hospital cardiac arrest. Circulation.
2004;110:10–15.
4. Bobrow BJ, Spaite DW, Berg RA, et al. Chest compression-only cpr by
lay rescuers and survival from out-of-hospital cardiac arrest. JAMA.
2010;304:1447-1454.
5. Nichol G, Thomas E, Callaway CW, et al. Regional variation in
out-of-hospital cardiac arrest incidence and outcome. JAMA.
2008;300:1423–1431.
6. Weisfeldt ML, Sitlani CM, Ornato JP, et al. Survival after
application of automatic external defibrillators before arrival of the
emergency medical system: Evaluation in the resuscitation outcomes
consortium population of 21 million. J Am Coll Cardiol.
2010;55:1713-–1720.
7. Sasson C, Magid DJ, Chan P, et al. Association of neighborhood
characteristics with bystander-initiated cpr. N Engl J Med.
2012;367:1607–1615.
8. Moon S, Kortuem W, Kisakye M, et al. Disparities in Bystander CPR
and Neurologic Outcomes from Cardiac Arrest According to Neighborhood
Ethnicity Characteristics in Arizona. Poster presentation to the
American Heart Association, Resuscitation Science Symposium, Scientific
Sessions in Dallas, Texas. November 2013. Circulation; in press.
9. Moon S, Kortuem W, Kisakye M, et al. Analysis of Out-of-Hospital
Cardiac Arrest Location and Public Access Defibrillator Placement in
Metro Phoenix, Arizona. Poster presentation to the American Heart
Association, Resuscitation Science Symposium, Scientific Sessions in
Dallas, Texas. November 2013. Circulation; in press.
I
hope the NYSATA endorsement of PHW is the first of many state athletic
training associations and similar organizations joining forces in the
common goal of protecting our youth.
