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It takes a system: Thinking holistically about improving OHCA outcomes

When asked to picture the human body, what comes to mind? Most people don’t focus on a single component like a limb or an organ. Instead, they think holistically — looking at the body as an artfully designed system, where every component works in tandem to create life.

Ideally, we’d all have that same holistic “systems” viewpoint when tackling the overlooked epidemic known as out-of-hospital cardiac arrests:

  • An estimated 350,000 OHCAs annually in the U.S. alone
  • Between 70-90% of patients die before reaching a hospital
  • That’s 10x more deaths from opioid overdoses, auto fatalities or gun violence

Yet OHCA garners no headlines. No public outrage. No push for funding to end this unnecessary loss of life.

Why? In theory, because it’s a hard problem to solve.

You’ve likely heard of the “Chain of Survival” — the five links that improve a cardiac arrest victim’s chances of survival and recovery:

  1. Recognition of cardiac arrest and activation of the emergency response system
  2. Early CPR with an emphasis on chest compressions
  3. Rapid defibrillation
  4. Basic and advanced emergency medical services
  5. Advanced life support and post-cardiac arrest care

From a family member or bystander to a telecommunicator, EMT and hospital personnel, each link in the chain of survival can involve someone of widely varying knowledge and training. So, it’s difficult to think holistically when no single entity has accountability for every link in the chain. It’s human nature — we’re focused on playing our role to the best of our abilities rather than looking at the larger picture.

It takes a system to save a patient

Improving OHCA outcomes starts with a shift in thinking. Rather than focusing on individual links in the chain, it’s vital to start thinking in terms of systems: “How do we all work together to optimize our processes from start to finish?”

It’s been proven that survival rates in a community will improve if their EMS and PSAPs work together, have strong leadership, and foster a culture of excellence. In other words, forming a true end-to-end system.

When the Chain of Survival works seamlessly from beginning to end, an out-of-hospital cardiac arrest doesn’t have to be a death sentence. It can mean more years for 350,000 people to live, love and contribute to our world, and the end to a truly unnecessary public health epidemic.

Starting the process of improving OHCA outcomes

To reverse dismal survival rates, every community should be looking at ways to improve how they manage cardiac arrests. But where to begin? It all starts with data — understanding how effective your chain of survival is right now. We recommend first asking these six questions:

  1. What is our community’s Utstein survival percentage?
  2. How frequently do bystanders perform CPR?
  3. What is our time between 911 call and delivery of T-CPR?
  4. What is our department’s median compression fraction for CPR calls?
  5. How do our telecommunicators and EMS personnel train for cardiac arrest?
  6. How do we measure performance on cardiac arrest calls?

Once you’ve established a benchmark for your current performance, you can then identify and prioritize the areas that need improvement and begin the process of developing an effective quality improvement plan.

Bystander CPR rates are highest in communities where public safety answering points (PSAPs), or dispatch centers, provide telephone CPR (T-CPR) instructions.”

— Michael Christopher Kurz, MD, MS-HES, FACEP, FAHA, Chair of American Heart Association T-CPR Taskforce

Is your team operating within High-Performance Standards?

Start by taking the T-CPR Pulse Check. American Heart Association T-CPR Recommendations and Resources provides guidance to construct and maintain a science-based T-CPR program.

 Want to dive deeper into the science behind successful training and quality improvement initiatives?

Read the full AHA scientific statement or download the summary. Have questions on implementing a resuscitation quality initiative in your community? Ask an RQI expert — we are always here to help. Contact us for more information.

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911: Is Your Organization Really Prepared for a Cardiac Arrest Emergency?

Over 350,000 individuals will suffer an out-of-hospital cardiac arrest this year — that’s 900+ people each day. Unfortunately, in the U.S. survival rates are dismal; in some communities, as low as 10%.

On out-of-hospital cardiac arrest calls, telecommunicators own the first 600 seconds of the call. They are the first responders and the first to deliver care by guiding callers through life-saving telephone CPR (T-CPR). But it’s up to each agency to ensure that their telecommunicators’ CPR skills remain strong and competent, rather than merely compliant.

To improve patient care, and ultimately survival, the American Heart Association (AHA) recommends addressing six foundational elements essential to improving survival in your community. Is your call center on the same page?

  1. Commit to T-CPR. Without receiving bystander CPR, a cardiac arrest victim has virtually zero chance of survival. To help make bystander CPR happen, telecommunicators must be equipped with high-quality T-CPR skills. It’s up to your agency’s leadership to set the expectation and hold staff accountable to make sure T-CPR is always part of the critical life-saving process.
  1. Provide initial and ongoing training. While cardiac arrest calls account for less than 1% of all calls taken, they are arguably the most critical. According to the AHA, telecommunicators should receive no less than four hours of initial training, as well as a minimum of two hours of continuing education each year relevant to resuscitation and T-CPR.
  1. Conduct continuous QI. Are all cardiac arrest calls reviewed for adherence to protocols? Are you measuring key time intervals? Auditing and measuring performance is key. An effective QI process should have clear, objective data sets with specific individuals assigned to conduct reviews. At a minimum, data should be aggregated annually to identify challenges and inform training needs.
  1. Connect to an EMS agency. A strong EMS system must behave as a team to boost survival rates. Look to your EMS providers for critical feedback on cardiac arrest events. Was there a missed opportunity? Did external factors make an impact? EMS reports can fill in the gaps of your call data to create a more complete picture.
  1. Appoint a designated medical director. To implement high-quality T-CPR, agencies need continuous physician oversight. Medical directors are responsible for establishing guidelines and protocols, and ensuring implementation and liability of your T-CPR program.
  1. Recognize outstanding performance. From the second a call is answered, everything must align perfectly for a patient to survive an out-of-hospital cardiac arrest. That’s why you should honor survivors and telecommunicators, and also recognize the first responders that do everything right to contribute to a patient’s chance of survival.

 A cardiac arrest call is a race against the clock. Every second matters. Empower your telecommunicators to act quickly and correctly, providing high-quality T-CPR instructions and improving the outcome for cardiac arrest victims in your community.

Don’t know where to start? Use RQI’s Pulse Check to see if you’re operating within the latest high-performance standards.

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Taking Ownership to Improve an Agency’s CPR Skills

Cardiac arrest survival rates vary widely across the country, but overall, these rates are dangerously low — as low as six percent for out-of-hospital cardiac arrests (OHCA).¹ Clearly, there is room for marked improvement.

The better the CPR, the better a patient’s chances of survival. But how does an agency know exactly how strong its CPR skills are — especially if there’s no mechanism in place to measure and improve?

That question drew Glori Strickler, EMS training coordinator for Matanuska Susitna Emergency Services in Palmer, Alaska, to the RQI Prehospital Healthcare Provider program. She explains, “MatSu is a very diverse agency with varying levels of staff experience. There was ‘tribal knowledge’ in our organization that our providers possessed excellent CPR skills, which was proven not to be the case.”

MatSu’s CPR fraction numbers were in the single digits; team members also lacked the assurance to direct others on critical CPR instruction. There were no interventions in place to boost their performance, and consequently, lives were hanging in the balance.

When it came time to renew MatSu’s traditional two-year BLS, PALS and ALS training — and the expenses associated with those renewals — Strickler was prompted to look for more effective alternatives. “Employing an option we knew was inferior and inadequate to continue the status quo was senseless,” she says. “More importantly, the potential CPR improvement equated to lives saved.”

RQI Prehospital Healthcare Provider provides a high-reliability platform for simulation-based mastery learning, implemented through low-dose, high-frequency quality improvement sessions that measure and verify competence. For Strickler, it represented fresh thinking across several key areas:

  • Learners receive objective, real-time feedback through program’s skills sessions.
  • Fiscal responsibility. RQI began to look very affordable when judged against traditional, yet less effective, options.
  • Staff confidence. According to Strickler, “With an absence of clear roles and responsibilities and communication, even on routine calls, I believed RQI could provide structure and boost confidence in this basic, yet lifesaving, skill.”

MatSu launched its RQI Prehospital Healthcare Provider initiative in January 2017. The program had 100% leadership investment from the start, resulting in full staff participation. And for team members who believed they had been delivering solid CPR already, the results were a huge eye-opener, recalls Strickler.

She points to many benefits of adopting the program — some rather unexpected. “Within a few months, our CPR fraction on actual calls jumped from single digits to the 70th percentile, and now hover around 90% on average. ROSC rates have doubled since implementation. And team members now take ownership and confidently direct others, particularly our fire department colleagues.”

Best of all? “Our survival rates are finally starting to climb.”

With COVID-19 cases starting to appear across Alaska, Strickler especially appreciates how RQI Prehospital Healthcare Provider allows MatSu’s EMS workers and staff to maintain their CPR competence and ability to deliver high-quality CPR. “Our teams can adhere to social distancing, since the program essentially stands alone,” she explains.

Ready to help save more lives?

RQI Prehospital Healthcare Provider is the only program that provides a high-reliability platform for simulation-based mastery learning, through low-dose, high-frequency quality improvement sessions. Find out more.

¹ Berger, S., Survival From Out‐of‐Hospital Cardiac Arrest: Are We Beginning to See Progress?, Sep 2017, Journal of the American Heart Association; 6:e007469.

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Staying Committed to Quality T-CPR During a Crisis

Cardiac arrests don’t stop during a pandemic. And we all know the statistic –— immediate bystander CPR can double or even triple a cardiac arrest victim’s chance of survival, and T-CPR could double the number of victims who get CPR from bystanders.

Telecommunicators need to be ready. But skills decay, hesitation and lack of confidence all contribute to delays in recognition of cardiac arrest and increased hands-to-chest time.

“COVID-19 has definitely changed things, for example the safety questions we now have to ask for the first responders,” says Antonella “Toni” Volpe, Support Service Captain for 911 Fire/EMS Communications in Charles County, Maryland. ‘Have you been in contact with anyone who has a confirmed case of COVID-19? Does the patient have a fever 100.4 or greater, Hot to the touch in room temperature? Chills? Trouble breathing or shortness of breath? Persistent coughing, sneezing or wheezing?’ The challenge is asking more questions while not delaying bystanders’ hands to chest.”

Fulfilling the commitment to saving more lives

T-CPR skills improvement can’t come to a halt during a crisis. But traditional classroom EMD training and continuing education are more complicated than usual in the age of COVID-19:

  • Classroom training may not allow for social distancing, creating exposure for staff
  • Training may be canceled due to building closures and stay-at-home orders
  • Required certifications and credentials may lapse due to lack of training

Volpe’s Charles County agency, which began implementing the RQI-Telecommunicator (RQI-T) quality improvement program in August 2019, has been able to continue its efforts despite the current COVID-19 crisis.

RQI-T meets the challenge of providing training and continuous resuscitation quality improvement, reducing the preventable harm caused by poor quality CPR, while addressing the significant challenges presented by the pandemic. Rather than the typical instructor-led group training, it leverages online, simulation-based learning in small doses, along with facilitated coaching and debriefing sessions.

Columbia County, Oregon’s 911 Communications District has had a similar experience with RQI-T, according to Operations Manager Lara Marzilli. “We had other training scheduled that was supposed to be classroom training, so we had to cancel. But we can continue with RQI-T because it can be done individually.”

For PSAPs concerned about the difficulty of implementing a quality improvement effort during the pandemic, Marzilli has some practical advice. “The RQI-T program hasn’t been disruptive to operations at all. If anything, I think our staff appreciates the ‘normalcy’ of continuing the program and seeing the trainer’s familiar face, hearing his voice. The routine of it is appreciated right now.”

Marzilli and Volpe note the positive feedback from their staff members taking part in the program. Says Volpe, “We’ve seen some great changes, some really positive changes. People are getting hands to chest more quickly. I’ve heard staff on the floor saying, ‘If they don’t say yes, you must compress.’ These observations are being made more quickly. And more lives have been saved in the process.”

Adds Marzilli, “In the beginning, people were nervous about doing the RQI-T scenarios. Now, they really appreciate the feedback — both the information itself and the way it’s delivered.”

RQI-T: Simplifying CPR quality improvement initiatives

As both agencies adjust to life during a pandemic, Volpe and Marzilli reflect on the positives RQI-T has made possible. “RQI-T has been a very good experience for us. Staff is appreciative of it,” according to Marzilli. “When I’m at a conference, staff from other centers will ask, ‘Hey, are you using RQI-T?’ and I tell them it’s been really, really positive for us. It’s something we’ll be continuing long-term.”

Adds Volpe, “The RQI-T program is something we really needed — and I’m glad we could continue without interruption during the pandemic.” She continues, “We’ve gotten into a comfortable rhythm. Even with changing state protocols, RQI has been able to incorporate updates very quickly so everything stays current.”

For more information on implementing a T-CPR quality improvement program, visit T-CPR.