Progressive cardiac protocol improves neurologically-intact discharge rates
Jackson County EMS’s cardiac arrest and STEMI protocols demonstrate how leadership and front-line crews can come together to save lives
By John Pethel
Jackson County (Georgia) EMS works closely with Northeast Georgia Medical Center to track outcomes of STEMI and out-of-hospital cardiac arrest patients. We receive real-time feedback on each individual patient, as well as regular reports to better understand how our protocols and treatment are working, to identify trends to better make decisions for the people of Jackson County.
Jackson County EMS operates seven 24-hour ambulances and we have double paramedic trucks. We run approximately 9,000 calls a year. We formed a research committee in an attempt to improve our cardiac arrest success rates. Our goal was not only to increase our ROSC rates, but also to increase our post-arrest neurologically-intact discharge rates.
After quite a bit of research and collecting data from all over the country, we developed our protocols. Our committee worked very hard on this, we trained extensively and our paramedics really embraced these changes. Aside from standard ACLS, here are the changes we implemented to improve cardiac arrest success:
- Immediate LUCAS CPR
- Elevation of the head to decrease ICP and increase cerebral blood flow
- Impedance threshold device (The decrease of intrathoracic pressure has shown to increase the pre-load and increase perfusion)
- Passive oxygenation with a nasal cannula at 15 LPM to combat hypoxia by allowing the alveoli to take up oxygen during CPR without lung expansion
- Immediate administration of norepinephrine bitartrate when indicated upon ROSC
Prior to implementing the new protocols, we had a ROSC rate of 31%, and a neurologically-intact post-arrest discharge rate of less than 5%. We implemented these protocols late in 2018, and our success was remarkable. In 2019, we started keeping data from all of our arrests, including trauma cases. Keeping all-inclusive numbers did impact our ROSC rates, but we wanted a true measure of what we were doing. So far in 2019, we have a ROSC rate of 43.5%, with a neurologically-intact post-arrest discharge rate of 29%. Some arrests from multi- system trauma were unsurvivable, but were aggressively resuscitated for the possibility of organ donation.
We are very proud of our 43.5% ROSC rate, especially since we are keeping all-inclusive stats. However, our neurologically-intact post arrest discharge rate is our ultimate goal. Our success has not gone unnoticed. Several surrounding agencies have expressed interest in our protocol and some have even attended our training. The architects of our protocol were invited to speak to a group of cardiac interventionalists on the topic.
An unconventional STEMI protocol
Our chest pain/STEMI protocols are somewhat unconventional for our area as well. Keeping in mind that time is muscle, we ty to be as efficient with the clock as possible. Aside from the standard umbrella treatment of acute coronary syndrome, here are the steps in our specific STEMI protocol:
- Rapid 12-lead ECG and identification
- Field activation of the cath lab and initiation of STEMI protocol
- Transmission of serial 12 leads
- Administration of 180 mg Brilinta
- Administration of 50 units/kg Heparin
- Morphine or Fentanyl as an analgesic/anxiolytic
Our goal is to not only treat the STEMI in the field, but also to save precious time in the ED. More often than not, we are able to bypass the ED and go straight to the cath lab.
Jason Grady, STEMI coordinator, Northeast Georgia Medical Center, noted, “Jackson County EMS was an early adopter of the most progressive STEMI protocol in the United States and became a leader in the Northeast Georgia STEMI system, setting an example of how leadership and front-line crews can come together to save lives.”
As pre-hospital medicine changes, we are committed to change and adapt with it. Our success has been a collaborative effort starting from the top. A progressive medical director and EMS director, an aggressive group of educators, proactive paramedics and wonderful support from the surrounding hospitals have put us in a position to better serve our citizens.
About the author
John Pethel is training officer, Jackson County EMS. He has been a paramedic for 25 years.