One day in 1991, early in his career as an emergency room physician, Ben Bobrow, M.D., worked furiously, and ultimately futilely, to resuscitate a patient in sudden cardiac arrest. “Don’t get too worked up about it,” a more experienced physician told him, clapping him on the shoulder. “They’re all dead already.”
Until very recently, that emergency room doctor wasn’t the only one to have such a dire outlook on SCA. In most places, survival from out-of-hospital SCA was mired in the low single digits. And even those people initially resuscitated by paramedics or EMTs weren’t likely to survive for long. Data suggested that for every 100 people who were revived prior to arrival at the hospital, only 25 survived to discharge, and about half of those would have serious neurological damage, says Karl B. Kern, M.D., a cardiologist and chair of the University of Arizona Sarver Heart Center’s Resuscitation Research Group.
But in Arizona, where in 2004 Bobrow became medical director of the state’s Department of Health Services’ Bureau of Emergency Medical Services and Trauma, a transformation would happen.
Kern, Bobrow and their colleagues helped lead a statewide initiative, launched in 2004, that more than doubled the odds of surviving SCA and has led the way in changing the way CPR is done nationwide. Because of their efforts, between 2004 and 2009, the state boosted its SCA survival rate from a dismal 3.7 percent to nearly 11 percent. For witnessed ventricular fibrillation, survival rates rose from about 11 percent to 31 percent statewide, with some hospitals boasting survival rates of 50 percent. “After 30 years of having survival rates stuck, we are finally moving the needle,” Bobrow says.
Research hints at a better way
The road to Arizona’s success started in Tucson. In 2003, the captains of the Tucson Fire Department paid a visit to Kern and Gordon A. Ewy, M.D., director of the Sarver Heart Center. With a 5 percent cardiac arrest survival rate, Tucson’s was slightly better than the rest of the state, but not by much. The fire captains were frustrated, and they wanted to know if Kern and Ewy had any ideas of how to save more patients.
It just so happened that the two doctors had been studying CPR, and their research was hinting at an intriguing possibility: that the key to saving lives lay in the compressions.
In 2000, the AHA’s CPR guidelines called for two breaths followed by 15 compressions for lay and professional rescuers. The breaths should take about four seconds, the guidelines said. But Kern’s research was showing that when tested, trained lay rescuers took much longer to do rescue breaths: about 16 seconds on average. “You can write anything you want in guidelines, but if people can’t do it, it’s not very helpful,” Kern says. “To be honest, I made that mistake; I was the American Heart Association’s ACLS chair in 2000.”
The evidence for compressions continued to mount. In 2002, Kern and his colleagues published a study in Circulation showing that pigs in induced SCA were more likely to survive if they were given continuous chest compressions than if they’d been given standard CPR with typical lay rescuer delays.
“When we showed that chest compressions produced greater survival and much better neurological outcome, that’s when we really got excited,” Kern says.
And it wasn’t just lay rescuers who were going “off the chest” for too long. Trained responders would run over to the body, check the airway, search for a pulse, deliver stacked shocks with a defibrillator, check the airway, place a tube in the trachea (which could take minutes), search for a pulse, deliver stacked shocks, then check the airway and pulse again to see if defibrillation had worked—all before starting compressions. “They were going for 30 or 60 seconds or more with no circulation,” Kern says, even though later research would show delays as little as 10 seconds can affect survival.
In 2003, Kern, Ewy and their colleagues trained 800 Tucson firefighter/paramedics to do their new CPR method, which called for 200 compressions before delivering the first shock, and then another 200 before checking for a pulse or attempting active ventilation. They called the method “cardiocerebral resuscitation” to emphasize the importance of restoring blood flow to the heart and brain.
“Bless their hearts. In 2003, they stuck their necks out and went with this new concept even when it wasn’t the recommended guidelines,” Kern says. “And we immediately began to see survival double and triple.”
Making progress
Bobrow was following what was going on in Tucson and wanted to take the concept statewide. In 2004, he launched the Save Hearts in Arizona Registry and Education (SHARE) program to involve the entire chain of survival—the public, EMS and hospitals—in tracking and improving SCA survival.
The initiative evolved to include a performance improvement program for EMS; training EMS dispatchers to provide compression-only CPR instructions to 911 callers; increasing the availability of public access defibrillators; a mass media campaign to educate the public about compression-only CPR; and enlisting the help of fire and EMS agencies to teach compression-only CPR in the community and at schools.
One of the biggest obstacles to improving CPR was getting bystanders to act, Bobrow says. For a variety of reasons—fear of doing it wrong, being unsure if CPR is really needed, aversion to doing mouth-to-mouth—even previously trained bystanders froze. By simplifying CPR, the compression-only method helped overcome that. The annual rate for bystanders attempting CPR improved from about 28 percent in 2005 to nearly 40 percent in 2009; that increase coincided with more bystanders doing compression-only CPR. In 2005, only about 20 percent of lay rescuers did compression-only compared to nearly 76 percent in 2009.
“What we have tried to do is take out all of the reasons people don’t act—fear, panic, indecision, confusion, unwillingness to do mouth-to-mouth breathing,” Bobrow says. “There is no reason not to try to do compression-only CPR.”
Today, 80 EMS systems are part of SHARE. Mark Venuti, director of Guardian Medical Transport, which operates out of Flagstaff Medical Center and covers 6200 square miles of northern Arizona, was among the first in EMS to sign on. At first, the idea of skipping the A-B-Cs and going straight to compressions was met with resistance. “For so long, we’d all been trained to do A-B-Cs. Now we’re telling them we’re not going to do breaths for the person, sometimes for eight to 10 minutes. It took a lot of convincing,” Venuti says. “But they figured we couldn’t do much worse than not resuscitating 97 percent of people.”
Their first SCA call, in 2006, helped win over Venuti’s staff: A college student from Northern Arizona University was hit by lightning and went into cardiac arrest. Cardiocerebral resuscitation saved him. “That definitely helped with the buy-in,” Venuti says.
Understanding that high-quality CPR is critical, Venuti and his team put their emphasis on training, including role-playing and scenario-based exercises, and making sure to debrief responders after SCA incidents to assess performance. In January, Guardian implemented Zoll’s Real CPR Help, which gives real-time visual and audio feedback on rhythm and depth of compressions.
“We did several years of realistic, scenario-based training, and we had really good results,” Venuti says. “As soon as we added the immediate feedback, we saw an immediate improvement in performance and outcomes.”
And to help make sure patients are getting the best care once they arrive at the hospital, SHARE has established a network of cardiac receiving centers that provide standardized, guideline-based care for SCA patients. To be recognized as a cardiac arrest center, a hospital must use therapeutic hypothermia, have 24-hour primary percutaneous coronary intervention (PCI) capability and submit data on outcomes.
Tom Aufderheide, M.D., a nationally known resuscitation expert and a professor of emergency medicine at the Medical College of Wisconsin, praises the Arizona program. “There is no single magic bullet that is going to transform cardiac arrest,” he says. “It’s a comprehensive approach that really makes the difference, and Arizona is leading the way.”
Compressions are king
With Arizona helping to lead the way, the emphasis on high-quality compressions and minimizing interruptions began to take hold. The American Heart Association’s 2005 CPR guidelines reflected the shift: Instead of a 15:2 ratio of compressions to breaths, the guidelines called for 30:2 (except for newborns). To minimize delays, instead of three stacked shocks, rescuers should do only one before starting compressions.
The 2010 guidelines went further, replacing A-B-C with C-A-B, emphasizing proper compression depth and rhythm, recommending compression-only CPR for untrained bystanders and further emphasizing that “compressions are king,” Kern says.
Arizona’s approach seems to be working. From 2005 through 2009, 4,415 adults experienced out-of-hospital cardiac arrest in Arizona. Of those, 2,900 received no CPR from witnesses, 666 (about 15 percent) received conventional CPR that included rescue breathing, and 849 (about 19 percent) received compression-only CPR. About 13.3 percent of those who received compression-only CPR survived and were discharged from the hospital, compared with 7.8 percent of those who received conventional CPR, a 60 percent difference. Those who received no bystander CPR fared the worst—only 5.2 percent lived, according to a study in the Journal of the American Medical Association by Bobrow, Kern and colleagues.
“In 2004, fire departments, EMS ambulance companies and hospitals across Arizona collectively said, ‘We cannot accept the current dismal survival rates from cardiac arrest in our state,’ and they made an enormous collective effort to teach chest compression-only CPR to their communities and train their medical providers for free,” Bobrow says. “This has resulted in hundreds of lives saved in Arizona.”
Still, not all of Arizona’s methods have been fully accepted. The AHA has not yet adopted Arizona’s 200-compressions-before-the-first-shock strategy. While the studies out of Arizona show promise, more research needs to be done to determine if it’s the compressions or other aspects of the Arizona program that account for the gains in survival, Aufderheide says.
“We don’t know if the improvement is because of a general increase in awareness of the importance of high-quality CPR or whether it’s specifically due to providing more compressions initially,” he says.
Recently, SHARE celebrated its 500th survivor. “Each survivor has an incredible story,” Bobrow says. “It’s impossible to die and come back to life and not have it be simply amazing.”
