1. C.A.R.E.S. Cardiac Arrest Registry to Enhance Survival Bryan McNally, MD, MPH Assistant Professor of Emergency Medicine Associate Medical Director Emory Flight Emory University School of Medicine City of Austin-Travis County EMS System Grand Rounds February 19, 2008

2. CARES Grand Rounds The Present – where we are now The Future – where we are going EMS in Georgia Discussion

5. Out of Hospital Cardiac Arrest (OHCA) Is the sudden, unexpected natural death from a cardiac cause a short time (generally < 1 hour) after the onset of symptoms (if present) 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.

6. SCD Etiology

7. Utstein Inclusion/Exclusion Criteria

8.  Registry – focuses on continuous quality improvement.  Research report – examines specific interventions and outcomes Two Database Formats

9. Benefits of Data Collection  Uniform collection and tracking of data facilitates better continuous quality improvement within communities.  Enables comparisons across the systems for clinical benchmarking to identify opportunities for improvement.

10. Why Develop an OHCA Registry? Burden of disease is high Most time critical EMS condition Community variability in measuring OHCA Community variability in survival OHCA Variability in system configuration Patient demographics NEMSIS

11. Burden of Disease is High.

12. 0 20 40 60 80 100 Survival Rate (percent) Time to Defibrillation (minutes) Most Time Criticial EMS Condition 510152025 Survival reduced by ~7-10% each minute defibrillation delayed

13. Most Time Critical EMS Condition

14. Community Variability in Measuring OHCA Survival

15. Community Variability in Survival Rate ALL RHYTHMS DISCHARGE RATE 2-25% VF DISCHARGE RATE 3-33%

16. Variability in System Configuration

17. Patient demographics AgeGenderRace Vulnerable populations? Is there biological disparity in survival?

18. NEMSIS Future language to be spoken

19. “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.

20. 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.”

21. Need for Registry Data collection into a registry at the regional, state or national level enables EMS systems to collect data in a standardized NEMSIS compliant fashion. Strengths and weaknesses in a community can be identified when comparison with the benchmarked dataset is made. Future performance measures need to based on compliance with evidence based guidelines.

22. IOM Report on Emergency Services “What is missing is a standard set of measures that can be used to assess the performance of the full emergency and trauma care system within each community, as well as the ability to benchmark that performance against statewide and national performance metrics.”

23. IOM Report on Emergency Services “While a full-blown data collection and performance measurement and reporting system is the desired ultimate outcome, the committee believes a handful of key indicators of regional system performance should be collected and promulgated as soon as possible.” Cardiac arrest, pediatric respiratory arrest, blunt trauma with shock.

24. 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. Allow participating agencies to confidentially benchmark performance.

25. The THREE SILOS OF DATA Importance of Data Elements and Linkage to CARES

26. CARES NETWORK

27. 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

28. EMS Component Collection methods –Direct entry online –Integration of CARES data fields onto EMS tablet/laptop software –Scanned CARES form 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

29. 911 CAD 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

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

33. 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

34. 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.

35. 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

36. 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 – Began National Expansion. Ultimate goal is to be universally applicable to EMS operations nationwide.

43. Location TypeTotalPercentage Home/Residence294865.25% Public Building2726.02% Street/Hwy2094.63% Nursing Home/Assisted Living Center61813.68% Residence/Institution591.31% Physician Office/Medical Clinic841.86% Educational Institution140.31% Hospital120.27% Recreation/Sport Facility591.31% Industry360.80% Jail140.31% Other1663.67% Airport230.51% Null40.09% Total:4518100.00%

44. Resuscitation Outcome Consortium

46. CARES – 3 Applications Grady EMS – intervention and assessment. Restarting Atlanta Hearts Program – focus on identified weak links in chain of survival. Geomapping and AED Registry Application

47. Grady EMS Sample Reports Change in system dispatch process Before and after metrics - 6 months Date provided to illustrate comparison

48. 0 Survivors 5 Survivors

49. Racing the Clock to Restart Atlanta’s Hearts

50. 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

51. Geocoded CARES Data

52. Targeted AED Placement Targeted Bystander Training

53. What’s next? What’s next?

55. Future Considerations ExpansionHypothermia AED Registry Mapping Agency classification – “not all apples are the same” Longitudinal surveillance tool to measure survival locally, regionally, statewide, nationally. Code summary data integration List-Serve