Back in October, I was fortunate to attend the Resuscitation Academy in Seattle, WA. As many of you already know, the Academy is run by Seattle Medic One and King County EMS, with the goal of improving survival from out of hospital cardiac arrest. EMS directors, managers and medical directors convened for a three day "mini-fellowship" program, immersing ourselves in lectures and discussions about developing strategies we could bring back to our own communities.
I returned home inspired and motivated. As the STEMI/Cardiac Arrest Coordinator for my agency, I was eager to affect change. My original plan was to write this post back then. In the words of David Hiltz, a fellow RA alumnus, I knew I would "drink the kool-aid". I just wanted to know how long it would last.
Would I, after several months, be just as motivated and inspired as I was when I returned from the Academy?
This was a tremendous opportunity to learn from the best. Medic One and King County EMS are well known for their impressive survival to discharge rates from witnessed VF arrests of cardiac origin (they classify asystole and PEA as a different disease process). Their survival to discharge rates, north of 50%, top any list I have seen. Of course, detractors will question the "narrow" definition used to achieve those rates, and in fact I did pose that very question to Dr. Mickey Eisenberg himself on day one.
When asked about this, he acknowledged the question, and told me simply that he invited any system to use the same narrow definition, and see where they stack up. I was impressed with his candor, and the accessibility I had to the minds of such esteemed Physicians.
In addition to Dr. Eisenberg, our faculty included Drs. Tom Rea, Leonard Cobb, Peter Kudenchuk, and others. You may recognize their names from some of the major studies that shape our practice. We discussed such topics as "Measuring Performance and QI", "Dispatcher Assisted CPR", "High Performance CPR", "Cardiac Arrest Registries", "Response Times", "The ineffectiveness of ACLS" (yes you read that correctly), and "Community CPR". There were other engaging topics as well.
They also like to speak in mantras:
- "Pick the 'low hanging fruit'"
- "Change happens iteratively"
- "Measure and improve, measure and improve"
- "Performance, not protocol"
There are two more mantras that I think impressed me the most. The first is what they call their "Culture of Excellence". And it is easy to see why. This is a high functioning system, with leaders in academics and research who are intimately involved in their delivery of patient care. No matter how much success they seem to have, they do not rest on their laurels. They continually measure and research, striving to be better. They set goals that seem unrealistic to many, but very realistic in Seattle/King County.
Did I hear someone say 70% survival to discharge rates? Every cog in their machine from the doctors and administrators to the medics I spoke with all work together for one common goal… which leads me to the last mantra which impressed me so much: "Everybody in VF survives."
"What? Well, they don't where I come from," was a common thought running through the room. And of course, even in King County not everyone survives sudden VF arrest. But the message is clear: they expect them to survive. "Hearts too good to die", as they say. Even though not everyone survives, the expectation is that sudden VF arrest is a treatable entity. Get the care to them in a timely fashion, and deliver it expertly, and they will survive. And when they don't, they do QI until they can find out why they didn't survive. Lessons learned are added to the mix and the cycle continues.
I could not wait to return to my system, full of ideas and hope. To me, Seattle/King County serves as a beacon to what is possible. As Tom Bouthillet is fond of saying, "a system achieves exactly what it is designed to achieve". If you want different results, you have to change your system. If I had my way, it could be done top down, on a larger scale. Why settle for little steps, agency by agency, when it can be changed on a "system" level by the highest administrators. Of course, system design, politics, geography all play a role in the character of each EMS system.
It is up to all of us to decide the best way to get the job done in our own systems. Some may achieve this in a top down approach, and others may have to start at the bottom, at the agency level, and go up and out from there. Either way, the important part is setting change into motion. Get some momentum going. Aim for the top, and don't settle for less.
That is what I have been working on since I have returned. As they say at the Academy, "it's not complicated, but it's not easy either." We have made a commitment to measuring performance, We have stepped up our QI of cardiac arrests, including structured debriefings, and utilization of data from our cardiac monitors. And of course, we have focused our training on what works, namely CPR skills and defibrillation, trying to increase our compression fractions as much as possible.
A culture changes when you start looking at and talking about issues in a different way. Time will tell how long it will take for us to see meaningful changes in our survival rates. Armed with the attitude and lessons learned at the Resuscitation Academy, I know we will get there. A culture of excellence starts somewhere, and it might as well start with us.