Improve sudden cardiac arrest survival with systems and design thinking

By Carissa Caramanis O’Brien

SAN DIEGO — Conquering the challenge of improving sudden cardiac arrest survival (SCA) requires the application of systems and design thinking. At the Emergency Cardiovascular Care Update (ECCU) Larry M. Starr, PhD, presented “Systems and Design Thinking Applied to Out-of-Hospital CPR and AED Performance” to challenge health care practitioners to think outside the traditional box.

While analysis is the conventional way to think about and understand problems, and the application of evidence-based research is the conventional method to solve problems, this doesn’t often work with complex problems, particularly within a complex health care system, says Starr. The complexity of health systems is multidimensional, including mechanical (technology), biological, social, political and organizational systems.

Systems thinking applied to sudden cardiac arrest focuses on interactions and interdependencies within the system, as well as a solving method that uses design-based methods and seeks changes that will improve or optimize the whole system, not the parts. Systems thinking is appropriate for health systems and their complex problems, requiring health care providers to consider a situation or challenge in its entirety — including external elements — and to focus on the relationships of the parts with each other, rather than considering the parts individually.

Starr shared the results of two studies he conducted with colleagues Allan Braslow, PhD, John Pourdehnad, PhD, and Gnana Bharathy, PhD. Both studies sought to apply a systems thinking framework and a design thinking methodology.

Study 1: “Need (Sell) More AEDs” revealed that people think about at least eight interacting elements when considering an AED purchase or placement. These include legal environment, culture, trust, training readiness, access, decision-making, cost and governance. The study concluded that:

1. AEDs are perceived similar to other enabling technologies, e.g., computer hardware and software, communication devices.
2. What many lay responders desire is an “AED (SCA) system integrator” because SCA is understood as a system and they want a person or process to connect and manage the many interacting elements into a cohesive whole.
3. A bystander has difficulty when confronted by a community SCA because he/she must personally assume responsibility for system integration.
4. When integration is accomplished within an organization, AEDs contribute to the organization’s SCA system of survival.
5. To say “SCA survival is low because there are too few AEDs” is improperly formulating the problem.
   1. The relationship between AEDs and SCA survival is indirect, complex, interactive and nonlinear.
   2. To sell more AEDs requires improved understanding of how people think about AEDs, and application of systems thinking.

Study 2: “Design the Ideal Bystander CPR/AED Learning Experience” compared a “mess formulation” to the traditional perspective of the CPR/AED experience, and found the ideal CPR/AED learning experience includes more than 300 characteristics aligned within 12 categories. It concluded with 10 recommendations:

1. CPR/AED course completion cards should include Good Samaritan Law protections printed on the card.
2. CPR/AED rehearsal training should be included with all facility public safety scenario drills (e.g., fire).
3. CPR/AED program participants should demonstrate performance outside the classroom in the presence of bystanders.
4. The educational system support of SCA, CPR and AEDs should begin descriptions of lifesaving in preschool, and progress in complexity with grade levels.
5. Hands-only CPR should begin in middle school. CPR/AED competency should be required for all high school, college sports and for graduation.
6. Online and in-person training integration should be available for CPR/AED practice and assessment (virtual reality).
7. CPR/AED training and assessment should be available at no cost to the learner.
8. All smart phones should have an app that includes early access instructions and a link to EMS help.
9. Companies that sell products that contribute to SCA risk (e.g., tobacco) should be required to financially support CPR and AED training, and support the purchase of associated equipment.
10. U.S. highway food/gas service areas should have employees trained in CPR and equipped with AEDs (like airports).

Memorable quotes on applying systems and design thinking
Providing context to why applying systems and design thinking makes sense, Starr said, “Much of what we do in life is working on mazes.”

“Why, after so many years and so many resources devoted to improvement in CPR and defibrillation, is the SCA survival rate so low? Perhaps because SCA survival is a different type of problem than addressed by the community. What if we change our way of thinking and understanding? What if we change our method of problem solving?”

Dr. Larry M. Starr

Dr. Starr offered up two quotes from the World Health Organization’s Systems Thinking for Health Systems Strengthening (2009):

“Given these complex relationships and characteristics of a health system, applying conventional approaches … will not take us far enough. These approaches are usually described as linear input-output-outcome impact.”

“We need a radical shift in the intervention and evaluation approaches for (the type of problems in) health systems, along with an accompanying shift in mindset among designers, implementers, stewards and funders.”

Key principles on application of systems thinking and design method
Systems thinking and the design method rely on abductive reasoning (as opposed to analytic thinking and the scientific method, which rely on deductive and inductive reasoning.) Applications of systems thinking and design method is based on these key principles.

1. Working backward from what is desired is easier than working forward from what currently exists.
2. Designing by stakeholders and users is more effective and creative than designing with or for stakeholders and users.
3. Implementation is not easy, but it works best when the “what and how to do something” are integrated into the design of a new system.
4. Systems thinking is a mindset or a framework, like wearing glasses. Systems thinking informs what you see and understand, how you make decisions and solve problems, and why you or others act in a particular way.

To close the session, Starr posed a hypothetical scenario: The Bill and Melinda Gates Foundation has provided an unlimited financial gift for the redesign of the ECCU experience. He challenged the audience with this what-if scenario to think innovatively and be the designers of their own solution.

What if you could have an ECCU (or CPR/AED learning experience) that was designed in the best possible way for you? What would be the characteristics of this experience?

Could you apply a systems approach to solving problems in your system or community to improve SCA survival? What challenges do you see? What advantages could this provide?

About the author
Carissa Caramanis O’Brien is an EMT, creative thinker, problem solver, and digital consultant to EMS. She advises many health care and EMS clients on the ideal use of digital marketing and social media to achieve their systems objectives. Find her on Twitter at @CarissaO.