Cardiac arrest survival reporting: It's all in the (right) numbers
EMS needs to improve how we communicate our successes to local media and policy makers with consistent and valid performance measures
As a former newspaper reporter and a paramedic, I have mixed feelings when I read stories like this article from the Salina (Kan.) Journal explaining the fire department’s implementation of a team-based approach to cardiac arrest care.
I am excited to see the department is making efforts to improve resuscitation techniques with evidence-based approaches, even when some of those changes go against years of tradition and practice. And it’s important that we share those achievements with our communities through local media and other outlets.
On the other hand, parts of the article made me cringe. Those of us in EMS need to improve how we communicate our successes, especially to members of the local media who often have little or no background in health care or public safety.
It’s no surprise that articles about EMS quality improvement efforts often struggle to use the right data or interpret it correctly. I’ve also been a quality improvement officer, so I know the struggles from all angles. Journalists often have to become experts in just a few hours of reporting and often they are getting information from self-trained QI officers, as opportunities for formal training are few and far between.
In order to demonstrate to our communities the difference we make every day, it’s vital that we share the right information. Many EMS agencies are adopting standard and valid performance measures to understand their successes and opportunities for improvements. These performance measures make it possible to compare an agency's performance to other EMS systems.
Here are four important explanations about cardiac arrest performance that are valid, patient-centered and meaningful, to share with the public, through the local news media.
1. Many cardiac arrest victims did not have a heart attack
As I learned while writing a profile about three cardiac arrest survivors, many victims of cardiac arrest did not have a heart attack. We know that a heart attack can cause cardiac arrest, but the two are not synonymous. This might seem like a minor detail, but imagine how it might confuse members of the public to hear that heart attack victims need immediate chest compressions – in addition to aspirin. Or how it might complicate the discussion when you share door-to-balloon times and cardiac arrest survival rates to local elected officials, who may not understand the difference between a STEMI and a cardiac arrest.
When promoting initiatives to improve STEMI or cardiac arrest care, take the opportunity to educate the public on what causes sudden cardiac arrest and how it differs from a heart attack. Every story in the media is an opportunity to provide education and outreach.
2. Survival to discharge
It is widely agreed in the EMS community that survival-to-hospital discharge (with good neurological function) – not return of spontaneous circulation (ROSC) – is the metric we should be using to evaluate cardiac arrest systems of care. After all, many cardiac arrest patients have ROSC, only to end up dying minutes, hours, or days later.
Unfortunately, survival to discharge is not as easy to calculate as ROSC, as it requires getting hospital outcome information on each patient. For this reason, every EMS agency in the country needs to be talking to their local hospitals about data sharing. Every time we bring them a patient, we provide them a record with a significant amount of patient information. The least they can do is tell us whether our cardiac arrest patients walk out of the hospital or not.
For agencies struggling to get this information, there are several routes. When hospitals use patient privacy laws as an excuse, we should present them this letter from a high-ranking federal health official, which points out that HIPAA does not prevent hospitals from sharing outcome data with EMS agencies.
Some agencies have established direct links between their electronic patient care record systems and hospital medical records. But there are also simpler approaches. Working with your medical director, who often has a relationship with local receiving hospitals, can help you obtain information on outcomes for your cardiac arrest patients.
3. Witnessed, shockable rhythm
The often-cited 62 percent "save rate" in Seattle/King County is the percentage of patients who survive after suffering a witnessed, non-traumatic cardiac arrest that presents to initial responders in a shockable rhythm. In other words, someone saw the patient collapse, and the initial AED (or manual defibrillator) indicated to shock. Many systems only run a few of these patients each year – some paramedics can remember each witnessed, shockable arrest they’ve seen during their entire career.
A large percentage of EMS agencies are still reporting overall cardiac arrest survival rates, but wondering why their communities don’t have the same success as Seattle. To compare your success to Seattle, use the same method, which is the Utstein approach, of calculating performance for cardiac arrest victims.
4. Overall cardiac arrest survival
The survival rate for all cardiac arrest patients (witnessed and unwitnessed, traumatic and non-traumatic, presenting in shockable and non-shockable rhythms) across the nation is 10 percent. Though this is a meaningful measure it is quite different than reporting ROSC. Make sure you are comparing rates between agencies that were calculated using the same method. Otherwise those comparisons are meaningless and may give an incorrect impression of either success or failure.
Until EMS agencies around the country begin measuring performance and outcomes in consistent and valid ways, comparisons among them will range from confusing to meaningless. And until we learn how to explain our performance to the public in a way that is valid and patient-centered EMS will continue to struggle to demonstrate our value to the communities we serve.