# Presentation: 263350

## C.A.R.E.S. 

- Cardiac Arrest Registry to Enhance Survival

- Bryan McNally, MD, MPH
- Principal Investigator

- Allison Park, MPH
- Program Co-coordinator

- Allen Stokes, BSc, NREMT-P
- Program Co-coordinator

- Michael Matters, PhD, MPH
- CDC Healthcare Analyst

## Presentation Outline

- Presentation
- Background and Overview
- Partnerships and Overcoming Obstacles
- Software Demonstration
- Future Considerations
-  Panel Discussion
- Question and Answer

## Sudden Cardiac Death (SCD)

- Is the sudden, unexpected natural death from a cardiac cause a short time (generally < 1 hour) after the onset of symptoms in a person without any previous condition that would seem fatal.
- Gillum and colleagues have defined SCD as any cardiac death occurring outside the hospital or taking place in the emergency department or DOA in the ED.

## Slide 4

## Critical Early Minutes of SCA

- 0

- 20

- 40

- 60

- 80

- 100

- Survival Rate
- (percent)

- Time to Defibrillation(minutes)

- 5

- 10

- 15

- 20

- 25

**Survival reduced by about 10% each minute defibrillation delayed**

**Notes:**
For every minute that defibrillation is delayed, the chances of surviving sudden cardiac arrest (SCA) are reduced by approximately 10%.  Survival chances drop particularly fast in the first five minutes.
Since rapid time to defibrillation is so critical, expanding the number of early defibrillator responders offers SCA patients a real chance to survive an otherwise lethal event.
In fact, by extending defibrillation skill using AEDs to more responders, survival rates have increased dramatically in some settings; e.g.:
40% survival-to-hospital-discharge (neurologically intact) in Rochester, MN with police first responders (White RD. Resuscitation 1998).
70% survival-to-hospital-discharge in Nevada casinos (Valenzuela TD Acad Emerg Med 1998).
80% survival-to-discharge in the Chicago Airport System, compared to a 3.5% save rate in Chicago with a paramedic response (USA Today, December 28, 1999).

## Slide 6

## Nationwide SCD Statistics

- Nationally, few communities actively monitor and report Out of Hospital SCD survival rates.
- The range of reported rates of survival for all cardiac rhythms varies from 1-20% a striking difference.
- Concern exists because the approach to the care of these patients is uniform and no evidence to suggest a regional difference in patients in the country suggesting any biological disparity.

## Utstein Inclusion/Exclusion Criteria

## “Many Lives are Lost Across USABecause Emergency Services Fail.”  (USA TODAY, 2003, Robert Davis).

- Surveyed the Country’s 50 largest cities.
- 38 of the 50 either could not, or would not, report their communities cardiac arrest survival.
- Article series revealed the major reasons why EMS in most cities save few people.

## USA TODAY, 2003, Robert Davis

- “Most cities don’t measure their performance effectively, if at all. They don’t know how many lives they are losing, so they can’t determine ways to increase survival rates.”

## USA Today First Tier Cities

- Boston
- Houston
- Kansas City, MO
- Milwaukee
- Nashville
- Oklahoma City

- Omaha
- San Antonio
- San Francisco
- Seattle
- Tuscon
- Tulsa

- “Monitor their survival rates scientifically. Rates are defined as the number of people found in venticular fibrillation discharged from the hospital with good function.”

- *CARES Sites

## USA Today Second Tier Cities

- Austin
- Colorado Springs
- Columbus, Ohio
- Dallas
- El Paso
- Indianapolis
- Las Vegas

- Miami
- Oakland
- Philadelphia
- Portland, Ore.
- San Jose, Cal.
- Virginia Beach

- “Use imprecise measures to monitor survival rates.
- Most cities in this group measure arrest patients who were
- delivered to the hospital by EMS with a heartbeat.”

- *CARES Sites

## USA Today Third Tier Cities

- Albuquerque
- Atlanta
- Charlotte, N.C.
- Chicago
- Detroit

- Fort Worth
- Honolulu
- Memphis
- New Orleans

- “Refuse to say.”

- *CARES Sites

## USA Today Third Tier Cities

- Baltimore
- Denver
- Fresno
- Jacksonville
- Long Beach, Ca.

- Mesa, Arizona
- Minneapolis
- Phoenix
- Wichita

- “Unknown.”

## USA Today Third Tier Cities

- Cleveland
- Los Angeles
- Sacramento

- San Diego
- St. Louis
- Washington D.C.

- “Currently Studying.”

## Need for Registry

- Data collection into a registry at the regional, state or national level enables providers or EMS systems to benchmark their outcomes and results with other communities.
- Allows for identification of strengths and weaknesses used to improve the quality of care and to determine if resuscitations are being performed according to evidence based guidelines.

## CARES

- Created a model cardiac arrest registry capable of identifying and tracking all cases in a defined geographic area.
**Year One** -- Fulton County, Georgia.
**Year Two** -- Multi-County Area of metropolitan Atlanta,  Georgia.
**Year Three** – 13 cities across the Country.
- Ultimate goal is to be universally applicable to EMS operations nationwide.

## State of Georgia - EMS Region 3

**State of Georgia - EMS Region 3**

## Progress of EMS Data CollectionRegion III

|  | Date | Agency | County |
| --- | --- | --- | --- |
| 1 | Aug 2005 | Grady EMS | Fulton (ATL) |
| 2 | Aug 2005 | Rural/Metro | Fulton |
| 3 | Aug 2005 | Atlanta Fire (Airport) | Fulton (ATL) |
| 4 | Oct 2005 | Metro-Atlanta | Cobb |
| 5 | Oct 2005 | Gwinnett Fire/EMS | Gwinnett |
| 6 | Jan 2006 | Newton Co EMS | Newton |
| 7 | Jan 2006 | National EMS | Rockdale |
| 8 | Jan 2006 | Puckett EMS | Cobb |
| 9 | Feb 2006 | Morrow Fire/EMS | Clayton |
| 10 | March 2006 | Hapeville Fire/EMS | Fulton |
| 11 | April 2006 | Clayton Fire/EMS | Clayton |
| 12 | April 2006 | Forest Park Fire/EMS | Clayton |
| 13 | April 2006 | Douglas Fire/EMS | Douglas |
| 14 | No data | DeKalb Fire/Rescue | DeKalb |

- 3,10

- 9,12,
- 13

- 7

- 5

- 4,8

- 6

- 14

- 11

- 1,2

## CARES Expansion Cities

## CARES

- Ultimate goal of CARES will be to help local EMS administrators and medical directors identify:
- _Who_ is affected.
- _When_ and _where_ cardiac arrests occur
- _Which_ elements of the system are functioning well and those that are not.
- _How_ changes can be made to improve cardiac arrest outcomes.

## CARES Program Overview

- Identify and collect pre-hospital cardiac arrest events to improve survival outcomes.
- Establish a method for uniform consolidation of EMS, 911, and hospital information.
- Generate reports of response intervals and patient outcomes for involved agencies in useful format.

## CARES NETWORK

## Importance of Data Elements and Linkage to CARES

**Importance of Data Elements and Linkage to CARES**

## CARES Program Database

- Sansio
- Mainframe housed in Duluth, MN
- Internet database system
- https://mycares.net
- HIPAA compliant security
- Unifies EMS, 911, and Hospital data
- Any EMS system throughout US

## EMS Component

- Collection methods
- Scanned CARES form
- Scanalyzer/Analyzer Software
- Direct entry online
- Integration of CARES data fields onto EMS tablet/laptop software
- Query to ensure capture of data
- Manual or through PCR documentation systems
- EMS initiates event and signals other two components
- Generates email to Hospital component
- Matches event with daily 911 import

## 911 Component

- Call number on CARES form identifies Computer-Aided Dispatch (CAD) record.
- Times are forwarded to database daily using auto-extraction tool.
- Unmatched CAD times are identified and matched manually.
- Likely matches ranked based on Date, Time, and Address.
- Matches confirmed by EMS agency liaison

## Hospital Component

- Hospital follow-up only required on patients where outcome is unknown
- ‘ongoing resuscitation’
- Hospital contacts set up through CARES administrator.
- EMS CARES form generates email to primary contact to selected Hospital destination.
- When all three data components form a complete record of the event, the data is de-identified of all unique patient identifiers (name and DOB).

## Reporting Features

- Bystander intervention / community statistics
- AED/CPR use
- Gender, age (mean and range), and location type
- EMS and First Responder Response time intervals
- 911 to arrival
- 911 to dispatch
- Dispatch to arrival
- Utstein flow diagram
- Survival to discharge
- Neurological status (CPC)
- Call volume
- Total volume for agency as a function of time.
- Hospital Destination

## Partnerships 
				  and
Overcoming Obstacles

- 				  and
- Overcoming Obstacles

## Supporting Agencies

- American Heart Association
- National Association of EMS Physicians
- American College of Emergency Physicians
- Georgia Department of Human Resources
- Georgia Hospital Association

## Partners in Data Collection

- County Governmental Officials
- EMS Agencies
- First Responder Agencies
- CAD System Providers
- Hospitals

## Obstacles in Data Collection

- _Ownership of Data_ – need for data use agreement.
- _Data Security_ – need for HIPAA compliance, internet firewall, and encryption of data.
- _Confidentiality_ – need for data use agreement.
- _Fragmented System_ – lack of linkage with 3 silos of data; need to automate data collection process to bring together 3 separate datasets

## Software Demonstration

## Future Considerations

- Expansion
- AED Registry
- Mapping
- Publications
- Funding opportunities

## Geocoded CARES Data

## Racing the Clock to Restart Atlanta’s Hearts

## Recommendations

**Recommendation 1**
- 	Improve public recognition of signs of heart attack and prompt 911 calls
**Recommendation 2**
- Improve bystander CPR rates
**Recommendation 3**
- Decrease time to defibrillation through strategic placement of AEDs

## Panel Discussion