United Press International (UPI) is reporting that according to a study by the University of Michigan Health System, the chance of surviving an out-of-hospital cardiac arrest remains unchanged over the last 30 years.
The analysis of 79 studies involving 142,740 patients, published in Circulation: Cardiovascular Quality and Outcomes, found 23.8 percent of the patients survived to hospital admission and 7.6 percent lived to be discharged from the hospital.
While half of cardiac arrests were witnessed by a bystander, only 32 percent received bystander cardiopulmonary resuscitation.
“Increasing bystander CPR rates, increasing the awareness and use of devices to shock the heart and keeping paramedics on scene until they restore a person’s pulse needs to occur if we are ever going to change our dismal survival rate,” Dr. Comilla Sasson, the study’s lead author, said in a statement.
I find this study to be interesting because it shows that only about half of cardiac arrests are witnessed. Unwitnessed cardiac arrests have a very poor prognosis, which is not surprising when you consider that this is the most time sensitive of all emergencies.
Knowing how many cardiac arrests are witnessed by a bystander is important when estimating how many “savable” cardiac arrest patients a given EMS system interacts with in a given year.
According to the best data I could find, the incidence of out-of-hospital cardiac arrest in the general population is approximately 1/10 of 1% (or 1 out of 1000).
That means that each year, a community of 50,000 people can expect about 50 out-of-hospital cardiac arrests.
If half of them are witnessed, the number is down to 25.
It’s reasonable to assume that not all of those are VF/VT arrests. This isn’t evidence based, but let’s say that 20 of them are primary cardiac VF/VT arrests.
According to the Utstein template, the number of these patients that walk out of the hospital is a community’s save rate. If the save rate is 10% (generous) then a community of 50,000 can expect 2 patients to survive to hospital discharge each year.
It’s worth mentioning that most communities don’t measure their outcomes at all, so this is just speculation.
Let us assume for a moment that this same community started to save 35% of its cardiac arrest patients. Instead of saving 2 patients each year they would save 7 or an additional 5.
Five may not seem like a lot of patients, but in 30 years that’s 150 people, or enough to fill up a Boeing 737 (or Airbus A320).
Do you remember when Captain Sullenberger saved 150 passengers (plus the crew) on US Airways Flight 1549?
He was recognized as a hero, and justifiably so! Here’s New York City Mayor Michael Bloomberg showing off the “key to the city” that was specially made for Captain Sullenberger.
Stengthening a community’s “chain of survival” is a lot less dramatic than saving 150 people in a single afternoon, but we need to remember that these are real people, and they are loved just as much by their wives, husbands, daughters, sons, mothers, and fathers.
So what are we waiting for?
See also:
Essential Features of Designating Out-of-Hospital Cardiac Arrest as a Reportable Event
Cardiac Arrest Registry to Enhance Survival (CARES)
I think that they are missing some of the studies that use the most recent resuscitation guidelines, or they are not weighting them appropriately to reflect the improved outcomes over the last few years.
RM -That's possible, but it's worth remembering that the vast majority of EMS systems in the United States don't measure their outcomes, and they're not out there doing anything innovative! Tom
Once the next revision of the guidelines comes out, it will not be innovative. Even though there will be resistance among the Luddites, this will be the official version that these same traditionalists will have adopted and be defending at the following revision of the guidelines.
RM – I can't disagree with you. It's extremely difficult to get buy-in from all the stakeholders to stray off the AHA reservation.It's unfortunate, especially since the guidelines are sometimes outdated by the time they're published, let alone another 5 years! Tom
Tom,I have a feeling it is less the AHA that is the problem. Rather, some of the old timers on the committees seem to be defending their outdated expert opinions, rather than saying, OK, that was based on what we knew at the time. It was our best guess, but now that we know that these treatments do not improve outcomes, we need to try something else. That would be the responsible medical position.The AHA seems to be very open to reviewing research critically. At least, that is the impression I get. The AHA does not appear to be opposed to changes, regardless of what they may be.
RM – You raise a good point in that we need to exercise care when we say things that imply an organization has a mind."The government" does this. "Admin" does that. Who in government? Who in admin?I do have some issues with the AHA (I think they behave like a for-profit corporate entity as opposed to a non-profit with a mission statement), but I'm happy to acknowledge the worth of the ILCOR conference.I'm talking about what happens when organizations treat AHA ECC guidelines (or even worse, the attainment of an ACLS card) as the end-all and be-all of EMS education or protocol development.Consensus guidelines exist for a reason, and it wouldn't be practical to hold the ILCOR conference every other year, for example. But certain developments are so compelling, and certain health burdens so severe, that EMS systems should be more bold when it comes to adapting protocols to new evidence.Is that the AHA's fault? Not necessarily, except when or if the AHA discourages this type of variation between updates when the evidence points in one direction or another.Tom
Tom,I am less interested in whether it appears that we are attributing specific traits to an organization (the AHA), rather than to individuals (various ACLS committee members).My point was that, as an organization, the AHA appears to be more open to change, even open to dramatic revision, than the collective members of various ACLS committees.Yes, the AHA has many things we might criticize elsewhere, but I don't think that is relevant to whether the AHA is open to change.The bigger problem is the way that many in EMS (or even broadly in medicine) blindly follow the flow sheet that is the current representation of any guideline. Reading the text is much more important. By reading the text, we see that there is significantly more flexibility than transfers easily to a flow sheet. Even ACLS instructors often do not know anything more than the flow sheet, but they have memorized it, and have an instructor card, so their word is respected by those, who have not memorized the magic flow sheet. This is not understanding.Then there is the fear of lawyers, with everyone saying that they know of a case of evil consequence X resulting from allowing appropriate patient care. When we try to track things down, evil consequence X often turns out to be something like an out of court settlement and allowing appropriate patient care actually turns out to have been a case of malpractice. It is all about the bogey man in the closet of EMS mythology. This is no different from the factor workers criticizing the new employee, who works faster than they do, because he is making them look bad. The ignorant flow sheet worshipers do not want to look bad. They do not understand and many do not want to even try to understand. They want to protect their jobs, rather than do the right thing.Then there is the mistaken belief that, if I just follow the protocol, even if the wrong protocol, I am not responsible for my actions. This is complete BS, but people believe it.When we have people making decisions that ignore the patient, while focusing on removing responsibility for our actions, we are not going to do anybody any good (except those who profit off of the legal consequences).
RM – I am confused by something. It is the consensus view that holds sway at the ILCOR conference so it's the "ACLS committee members" who rate the evidence upon which the AHA ECC guidelines are based.The "AHA" is as willing to change the guidelines as they are. I'm not I understand how you separate the two.Just out of curiosity, why don't you think it's important to distinguish between "faceless nameless bureaucracies" and the individuals who actually make the decisions?Tom
Tom,I am confused by something. Aren't we all? It is the consensus view that holds sway at the ILCOR conference so it's the "ACLS committee members" who rate the evidence upon which the AHA ECC guidelines are based. I would state that a bit differently. I think the distinction is what is important, here. The committee members seem less than willing to act on the science. The AHA overall seems to be very open to science and change. The "AHA" is as willing to change the guidelines as they are. I'm not I understand how you separate the two. The AHA delegates the authority to change the guidelines to the committees, or at least they used to. I have not paid much attention to the way things happened during the last revision. Just out of curiosity, why don't you think it's important to distinguish between "faceless nameless bureaucracies" and the individuals who actually make the decisions? I thought that I was.The AHA oversees a lot of things and coordinates with ILCOR, the American Academy of Pediatrics, the American College of Cardiology, et cetera. It has been my impression that the AHA is more like a parent, trying to encourage a child (any of the ACLS Committees) to slide down a slide. The child is scared and refuses to go down the slide. The AHA does not push the child down the slide, choosing to let the child grow and develop at a pace comfortable to the child.Both the AHA and the ACLS committees are faceless bureaucracies. I suppose I am distinguishing between faceless bureaucracies, rather than between a faceless bureaucracy and individuals.