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Ref: Atlanta response model seen as best practice template

USA Today

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Atlanta becomes a template for improving EMS

By Robert Davis, USA TODAY
When Atlanta's emergency medical system needed rescuing, Mayor Shirley Franklin started performing CPR — in more ways than one.
In 2003, she started issuing orders that have resulted in lifesaving changes to Atlanta's emergency system. She began looking for ways to hold emergency crews more accountable, and last year she ordered all 8,000 city employees — including herself — to be trained in cardiopulmonary resuscitation.

"All you need to do is save one life and it's worth it," Franklin says. "It's miraculous."

Thanks to those efforts and a program created in Atlanta by Emory University and the Centers for Disease Control and Prevention, the city is saving more residents who collapse of sudden cardiac arrest. Since September 2005, the survival rate for such patients in Atlanta has jumped from less than 3% to 15%. That's well above the 6% to 10% survival rate for most cities that was identified in a 2003 analysis by USA TODAY.

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Atlanta's success has made it, and the program it's following, a template for cities trying to improve cardiac-arrest survival rates, an often murky set of figures complicated by communication problems among government agencies.

Several cities — including Houston, Anchorage, Austin, Cincinnati, Kansas City, Mo., Raleigh, N.C., and Tucson — are following in Atlanta's footsteps by signing up for the Emory/CDC program. It allows cities to use its Internet database to combine data from 911 dispatch centers, paramedic run reports and hospital discharge records to reveal more about the performance of EMS units — widely viewed as a key step in improving cardiac survival rates. Many cities have no system to effectively track such rates.

A few cities in the program or planning to join it were identified in the USA TODAY report four years ago as having particularly good systems for tracking emergency crews' performance. Those include Houston, Kansas City, Tucson, Boston, Nashville and San Francisco. Other cities taking part or planning to — such as Atlanta, Austin and Columbus, Ohio — were identified as having less-than-stellar systems for tracking cardiac survival rates.

The program — known as Cardiac Arrest Registry to Enhance Survival, or CARES — is a five-year, $1.5 million CDC project launched three years ago. It was partly inspired by the USA TODAY investigation, which found that emergency medical systems in most of the nation's 50 largest cities were fragmented, inconsistent and slow.

Why the focus on cardiac arrest survival rates and not those from something else, such as car accidents or cancer? Cities use cardiac arrest survival rates as a key measure of EMS performance because such victims typically live or die depending on the care they get in the first minutes after collapse, unlike other emergencies in which survival hinges more on hospital care.

"The system has to deliver in order to save a cardiac arrest victim," says Arthur Kellermann, an emergency physician at Emory University School of Medicine. "If it can deliver in a consistent manner for cardiac arrest victims, there is every reason to expect that it will deliver for trauma victims, asthma victims, women in labor."

More than 250,000 people die outside of hospitals each year when their hearts stop beating. Many are reaching the natural end to battles with disease, but others are healthy when struck by an electrical short circuit of the heart called ventricular fibrillation. "V-fib" can be caused by anything from a blocked coronary artery, to a ball striking the chest, to changes in the heart muscle from an infection.

In 2003, USA TODAY found disparities in emergency medical care across the nation, and said cities that carefully track their EMS performance save many more lives. In most cases, such cities also make a point of teaching residents CPR by, among other things, sending firefighters into homes, churches or businesses to train people.

The reason: If a bystander or acquaintance can quickly perform CPR when a person is stricken with cardiac arrest, they can buy the victim precious time before emergency personnel arrive. Businesses also are encouraged to have defibrillators and people trained to use them so victims can be shocked if rescue crews can't arrive quickly.

Bryan McNally, the emergency physician from Emory Healthcare who heads CARES, told an EMS conference in February that the impetus for the program included USA TODAY's finding that a lack of data regarding EMS responses to cardiac arrest victims is a "major obstacle to improving pre-hospital emergency cardiac care."

Atlanta's huge challenge

Franklin says she learned from USA TODAY's report that Atlanta was losing more than 10 times as many cardiac arrest victims as cities such as Boston, Seattle and Rochester, Minn. The newspaper's analysis ranked cities' EMS efforts in three tiers, with Atlanta's in the bottom tier of cities that had no idea how many lives their rescue units were — or were not — saving.

"Shirley Franklin was furious to see Atlanta as a 'Class C' city," Kellermann says. "She felt it should be in the first tier."

When Franklin took a closer look, what she saw was grim.

From August 2005 through March 2006, her city saved only one person considered by doctors to be among the "most saveable" victims of sudden cardiac arrest. They were deemed saveable because people saw them collapse, and what the victims needed was to be treated quickly with a defibrillator shock to restore their heart's rhythm.

USA TODAY found that in such cases, life and death usually is decided within six minutes of an attack. If the heart is not restarted by then, brain damage can be so severe that the victim is not likely to wake up, even if he or she survives.

"It became really clear to us when we looked at the statistics that the availability of trained personnel close by when somebody is experiencing cardiac arrest can save a life," Franklin says.

She vowed to do more to help the city improve, including enrollment in CARES.

It's paying off. From September 2005 through July 2007, months in which the city has tracked its performance using CARES, 10 of 66 cardiac arrest victims in the "most saveable" category survived with normal brain function.

Atlanta's 15% survival rate is a dramatic improvement, but still well behind leading cities such as Boston, where the survival rate for such cardiac patients is 38%.

One patient's good fortune

The response to save 69-year-old Ronald Williams on May 21 shows how the Atlanta area's system is still moving too slowly to save a life without help from bystanders.

Williams, of Tucker, Ga., was undergoing a stress test in his cardiologist's office when his heart went into V-fib. The medical staff called for help, began CPR and delivered a shock with a defibrillator.

The call for help went first to a 911 center, then to fire department rescuers from Sandy Springs, an Atlanta suburb. By the time paramedics reached Williams and delivered a second shock with their defibrillator, nine minutes had passed since he had gone into arrest.

Williams says he's lucky he was in his doctor's office. "It could have happened anyplace," says the retired aerospace technician, whose blocked arteries were cleared in a hospital after he was revived.

Jing Fang, a physician and researcher in CDC's Division for Heart Disease and Stroke Prevention who is technical director for CARES, says the program ultimately should help save more people like Williams.

Using the system's database, city leaders can track how many cardiac arrest victims their crews tried to save, how many of the victims had their hearts restarted in the field, and how many went home from the hospital with good brain function. The leaders also can see how many victims got help before rescuers arrive. By seeing how each part of the system performed, EMS leaders say they can determine what improvements are needed.

The CARES program allows cities to tell how their crews are performing compared with others in their region and, soon, to the other cities participating nationally.

Some cities that are struggling to determine their cardiac arrest survival rates are not in CARES. In Dallas, officials see CARES as "valuable and laudable," but they are creating their own system to track cardiac arrest survival, says Marshal Isaacs, medical director for the city's fire and rescue units. He says the system could be in place next year.

In Chicago, Philadelphia, El Paso and San Diego, medical directors report having problems getting hospitals to share data on patient survival rates. Jim Dunford, medical director for San Diego's EMS, says a law is needed to force cooperation.

"How can it be that the No. 1 killer of Americans remains heart disease and we still can't accurately measure outcome from cardiac arrest?" he asks.

El Paso's EMS medical director, James "Randy" Loflin, says his city is unable to track survival rates because "hospitals tell us they can't share survival data due to HIPAA," a federal law that protects patient privacy. CARES was designed to share data while complying with the law, McNally says.

'Community response' is key

When Atlanta started crunching its cardiac arrest survival numbers, it became clear that when rescue crews reached a patient, there often were people standing around, unsure how to help.

Only 7% of the city's cardiac arrest victims were getting CPR from bystanders when the CARES program was introduced. Houston, Tucson and other cities that save the most lives in such situations have raised their CPR rates for bystanders through training programs and by having 911 dispatchers give simplified CPR instructions over the phone. Chest compressions alone — even without mouth-to-mouth breathing — can buy minutes for a cardiac arrest victim until rescuers arrive.

"It's not just about streamlining or improving the professional response, it's also about the community response," McNally says. "What is happening before the ambulance or first responders get there? Are people doing CPR?"

When Franklin told city employees to get CPR training, she says, "each of us took a pledge that we would train others."

Atlanta's bystander CPR rate has more than doubled to more than 17%. To give an idea of how far Atlanta has to go to catch up with cities that save the most lives, McNally cites bystander CPR rates of 30% to 40% and higher in places such as Seattle and Boston.

"A lot of us think … the only solution is a doctor," Franklin says. "Having a trained workforce is part of the solution."

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Copyright 2007 USA TODAY, a division of Gannett Co. Inc.

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