Case study: How 911 dispatch improvements increased cardiac arrest survival

Correcting inefficiencies reduced average ambulance dispatch time, led to significant improvement in survival rates among out-of-hospital cardiac arrest victims

July 26, 2012 07:44 AM

By The Agency for Healthcare Research and Quality (AHRQ)

What They Did | Did It Work? | How They Did It | Adoption Considerations

Summary

Grady Emergency Medical Services collaborated with the Emory University Department of Emergency Medicine to develop an out-of-hospital cardiac arrest registry in the city of Atlanta. Through this initiative, known as the Cardiac Arrest Registry to Enhance Survival program, Grady identified weaknesses in its dispatching process and made changes to decrease delays in handling 911 calls. Evaluations suggest that these improvements, in conjunction with a community-wide training program on cardiopulmonary resuscitation, led to a significant increase in the cardiac arrest survival rate in Atlanta.

Evidence Rating

Moderate: The evidence consists of pre- and post-implementation comparisons of dispatch time, response time, and survival rates. Although the data show marked improvements, the sample size was small and the data collection period was brief. Results have not been analyzed for statistical significance. During the same time period, moreover, an American Heart Association program addressing community-level response to cardiac arrest was also being implemented. Therefore, improvements in survival rates could be due to this initiative as well.

Developing Organizations

Emory University Department of Emergency Medicine

Fulton County, GA

Grady Health System Emergency Management System

Date First Implemented

2006

Patient Population

Vulnerable Populations > Urban populations

What They Did

Problem Addressed

Out-of-hospital cardiac arrest is the leading cause of death among adults in the United States, killing approximately 325,000 individuals each year, the majority of whom die before reaching the hospital. The Greater Atlanta area experiences many deaths due to out-of-hospital cardiac arrest each year, deaths that could potentially be prevented by the rapid arrival of emergency medical services (EMS) personnel.

Many preventable deaths nationwide: Only approximately 20 percent of cardiac arrest victims who are found in a shockable rhythm (patients with the greatest likelihood of survival) currently survive the event. Out-of-hospital cardiac arrests can be treated successfully through early intervention, including cardiopulmonary resuscitation (CPR), defibrillation, and advanced cardiac life support, but only if this treatment is delivered within minutes of collapse. Each minute of delay reduces the chance of survival by roughly 10 percent.1 Up to 50,000 deaths could be prevented through use of CPR and an automated external defibrillator (AED) at the time of the emergency.2
Large variations across communities: Nationally, few communities actively monitor and report their survival rates from out-of-hospital cardiac arrest. Among those that do, survival rates vary more than 10-fold, from 2 to 35 percent.3 Low rates can be attributed to both poor professional and community-level response to out-of-hospital cardiac arrests. Fragmented interagency communications often result in delayed EMS response, whereas a lack of community awareness frequently leads to low rates of bystander intervention.1
Atlanta area a poor performer: Between December 2006 and June 2007, Atlanta’s overall survival rate for cardiac arrest averaged 1.8 percent, while the Utstein rate (which considers only those patients most likely to benefit from resuscitation) was 4.2 percent. Delays in EMS arrival contributed to these low rates, as few patients were found in a shockable rhythm when emergency responders arrived.1

Description of the Innovative Activity

Grady EMS used data from the Cardiac Arrest Registry to Enhance Survival (CARES) program to identify and address weaknesses in the EMS communication system and to streamline its 911 dispatching and ambulance deployment processes. The system is used on an ongoing basis to monitor performance and promote continuous improvement.

Key Elements

The CARES database: The CARES database includes the following information:
Response times: Grady EMS reports and tracks its EMS response times, including receipt of the 911 call, dispatch of the ambulance, and on-scene arrival of the ambulance.
EMS data: Grady EMS uses CARES to collect data related to the treatment of cardiac arrest, including location of the event, bystander intervention (if any), etiology of the arrest, first arrest rhythm, and destination hospital.
Hospital outcomes: Area hospitals report discharge information for cardiac arrest patients transported to their facility, including outcomes in the emergency department and hospital and neurologic status at the time of discharge.
Initial identification of communication and deployment problems: Analysis of CARES data from December 2006 to June 2007 (before implementation of the program) revealed significant delays in ambulance dispatching. At that time, the established process required three separate steps before an ambulance could be dispatched to the scene of an emergency: 911 calls first came to the Atlanta police department, which determined the nature of the emergency; the call was then transferred to a Fulton County dispatcher who established the priority of the medical emergency; and then the call was transferred to Grady EMS to dispatch an ambulance. Not surprisingly, the use of multiple transfers resulted in significant time delays; on average, it took 1 minute, 47 seconds from receipt of the 911 call to dispatch of an ambulance and more than 7.5 minutes for an ambulance to reach the patient.
Communications consolidation and streamlining: In June 2007, Grady EMS consolidated its communications system and removed Fulton County from the dispatching process. Calls came into Atlanta’s police department and then transferred directly to Grady EMS.
Strategic deployment of ambulances: To facilitate faster response times, Grady EMS began deploying ambulances throughout the city, often sitting in shopping center parking lots or other busy areas. Grady EMS chose locations based on CARES data that identified high-risk areas for cardiac arrests.
Ongoing monitoring and continuous improvement potential: A steering committee that includes representatives from each hospital and agency meet regularly to review performance and determine additional streamlining and changes that could improve EMS response times and patient survival. Improvements are not limited to reducing ambulance response times. For example, some departments have expressed interest in identifying new communication technologies to allow paramedics to communicate a patient’s condition more effectively to hospital staff. However, budget cuts made to the county’s EMS budget during the 2008 to 2009 fiscal year have prevented acquisition and development of new technologies.

References/Related Articles

Sasson C, Hegg A, Macy M, et al. Prehospital termination of resuscitation in cases of refractory out-of-hospital cardiac arrest. JAMA. 2008;300(12):1432-8. Available at: http://jama.ama-assn.org/cgi/content/full/300/12/1432

McNally B, Kellermann A. Boosting the odds of surviving cardiac arrest. Med Gen Med. 2006;8(3):44. [PubMed]

CARES Summary Document. Available at: https://mycares.net/downloads/INTRODUCTION%2010.1.08.pdf (If you don’t have the software to open this PDF, download free Adobe Acrobat Reader® software.)

Additional Information and Resource Documents. Available at: http://mycares.net

Contact the Innovator

Monica Mehta, MPH
Program Coordinator
Department of Emergency Medicine
Emory University School of Medicine
531 Asbury Circle - Annex N340
Atlanta, Georgia 30322
(404) 712-2772
E-mail: mmehta5@emory.edu

Dawn Brand, EMTP
Quality Improvement Coordinator
Grady Emergency Medical Services
80 Jesse Hill Jr. Dr. SE
Atlanta, GA 30303
(404) 616-6676
E-mail: dbrand@gmh.edu

Did It Work?

A comparison of CARES data during the 6-month period before and after implementation found that the changes made by Grady EMS reduced the average ambulance dispatch time and led to a significant improvement in survival rates among out-of-hospital cardiac arrest victims in the Atlanta area.

Reduced dispatch time: The average time between the receipt of a 911 call and the deployment of an EMS ambulance fell by more than 1 minute, from 107 seconds to 43 seconds. The average time from the 911 call to ambulance arrival fell by 32 seconds, from 7 minutes, 37 seconds to 7 minutes, 5 seconds after implementation of the improved response system. However, budget cuts made during the 2008 to 2009 fiscal year reduced the county’s EMS operating budget by nearly one-third. As a result, there are fewer ambulances available on standby to respond to calls, and response times have begun to increase, although specific response data is not available.
Improved survival rates: Overall survival rates among out-of-hospital cardiac arrest victims increased from 1.8 to 4.2 percent, and the total number of cardiac arrest survivors increased from 2 during the 6-month period before implementation to 5 during the 6 months after implementation.4 The Utstein* survival rate rose from 12.5 percent before implementation to 14.7 percent during the first year and to 22.2 percent during the second year of implementation, between October 2006 and September 2007. However, because budget cuts have reduced the number of ambulances available to respond to calls, the Utstein survival has declined to 5.7 percent between October 2007 to September 2008.

*The Utstein rate is an internationally accepted standard for measuring out-of-hospital cardiac arrest outcomes for patients most likely to benefit from resuscitation.

Evidence Rating

How They Did It

Context of the Innovation

Grady Health System’s EMS, the designated 911 ambulance provider for Atlanta, is the largest hospital-based ambulance service in the nation, serving 142 square miles. Grady EMS employs 280 paramedics, responds to 96,000 calls, and transports approximately 67,000 patients annually. At peak times, Grady EMS has as many as 28 ambulances on the road. Grady EMS’ participation in CARES was implemented at approximately the same time as two other major initiatives in the Atlanta area—Mayor Shirley Franklin’s mandate that all 8,000 city employees be trained in CPR, and The American Heart Association’s Restart Atlanta’s Hearts program to teach 50,000 Atlanta residents how to perform CPR and apply a publicly accessible AED. For more information, please see the Innovations Exchange profile on the American Heart Association program.

Planning and Development Process

Key planning and development steps related to participating in CARES include the following:

Choosing a method to collect EMS data: Data for the CARES registry can be collected in one of three ways: (1) completion of an optically scannable form, (2) direct entry into the Web-based database, or (3) automatic data extraction from an electronic patient care report.
Assigning an EMS agency contact: CARES requires that a program contact be identified at each participating EMS agency; this individual serves as the local site administrator for the agency, oversees CARES operations, and serves as the liaison between the EMS agency and CARES staff.
Encouraging hospital participation: CARES encourages voluntary participation from hospitals that receive cardiac arrest patients from participating EMS agencies. Participating hospitals also assign a CARES contact person who receives notification via an automatically generated e-mail to provide outcomes data on cardiac arrest patients. The hospital contact enters data directly into the registry via the CARES Web site. The hospital data set consists of five simple questions, including emergency department outcome, hypothermia treatment, hospital outcome, disposition location, and neurologic status at time of discharge. Although not required, representatives of a participating hospital can sign a CARES data use agreement acknowledging the confidentiality of data exchange.
Collecting computer-aided dispatch data: The data are collected through automatic export/import and/or direct entry into the Web-based database by the computer-aided dispatch system administrators who have also signed participation agreements. Administrators enter three data elements (time of call, ambulance dispatch, and ambulance arrival) for each event, with events being matched based on date, approximate time, and location.

Resources Used and Skills Needed

Staffing: This program relies primarily on existing staff. As noted, a CARES contact person must be identified to oversee the data collection process at each participating agency.
Costs: There is no fee to participate in CARES. The only cost relates to staff time spent on the program. The startup phase requires the most staff time, including planning, training, and implementation. Once operational, the program requires little staff time for ongoing maintenance.

Funding Sources

Centers for Disease Control and Prevention; Grady Health System Emergency Management System

The Centers for Disease Control and Prevention (CDC) has increased its funding to the program to approximately $500,000/year. The funds cover the continued expansion of the CARES Registry into many new communities across the country and the hiring of an additional coordinator to coordinate its implementation. Originally, the CDC provided $1.5 million over 5 years (2003 to 2008) for Emory University’s Department of Emergency Medicine to develop the CARES Registry. Grady funded the changes in 911 call routing.

Tools and Other Resources

The CARES database is available free of charge to communities. More information can be found at https://mycares.net/.

Adoption Considerations

Getting Started with This Innovation

Develop an implementation plan: This step should include a timeline for becoming operational and a data collection plan.
Establish responsibility for data collection: As noted, someone needs to be made responsible for overseeing the data collection process.
Reach out to key stakeholders: Approach hospitals to elicit their participation and encourage local political, business, and community leaders to actively and visibly endorse the program.

Sustaining This Innovation

Continually monitor performance: Evaluate data generated by CARES on an ongoing basis to identify opportunities to improve cardiac arrest survival in the community, including improvements in how 911 calls are dispatched, the placement and deployment of ambulances, EMS response times, the placement of AEDs, and bystander interventions.

Use By Other Organizations

As of April 2012, CARES has now expanded to more than 50 sites across the country. In addition, the group is working at the state-level with eight states and internationally with Singapore and multiple Pan-Asian countries as collaborative participants.

References

McNally B, Kellermann A, Park A. Cardiac Arrest Registry to Enhance Survival (CARES). Final. Centers for Disease Control and Prevention (CDC), the American Heart Association (AHA) and the Emory University Department of Emergency Medicine, Section of Prehospital and Disaster Medicine. Sept. 20, 2007. Available at: https://mycares.net/downloads/CARES%20Summary%20Document%209.10.07.pdf
American Red Cross. Saving a Life Is as Easy as A-E-D. Available at: http://www.redcross.org/services/hss/courses/aed.html.
Rea T, Eisenberg M, Sinibaldi G, et al. Incidence of EMS-treated out-of-hospital cardiac arrest in the United States. Resuscitation. 2004;63(1):17-24. [PubMed]
McNally B, Park A. Utstein Survival Report: Grady EMS. Dates of cardiac arrests, 12/1/2006-6/1/2007 and 6/1/2007-12/1/2007. Final. Department of Emergency Medicine, Emory University School of Medicine. March 2008.

911 and Dispatch Cardiac Care