C.A.R.E.S. Cardiac Arrest Registry to Enhance SurvivalAllie Crouch, MPHProgram Coordinator

Bryan McNally, MD, MPHPrincipal Investigator

NAEMSP Presentation January 24, 2008

020406080100Survival Rate(percent)Time to Defibrillation (minutes)A Time-Critical EMS Condition 510152025Survival reduced by ~7-10% each minute defibrillation delayed

JAMA, December 18, 2002-Vol 288, No. 23Three-Phase Time-Sensitive Model of Cardiac Arrest Becker, L., M. Weisfeldt

Utstein Criteria

Timely care is vital!Only 1 in 4 victims receives bystander CPRDefinitive care useless if no ROSC in fieldCurrently, community survival rates vary by a factor of ten or moreDisparate outcomes are almost certainly due to timeliness and quality of treatment

Most cities dont measure their performance effectively, if at all. They dont know how many lives they are losing, so they cant determine ways to increase survival rates.

- Robert Davis, USA Today 2003

Dominos vs. EMSHungry?30 minutes call-to-doorguaranteed.Customer input for QICost: $9.95 (plus tip)

Cardiac Arrest?Call-to-door time rarely trackedNo performance metrics, no QI Cost: Priceless

Angelo Salvucci, MD

IOM Report on Emergency ServicesWhat 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.

CARES SURVEILLANCE NETWORK

CARES DATABASESansioMainframe housed in Duluth, MNInternet database systemhttps://mycares.netHIPAA compliant securityUnifies EMS, 911, and Hospital dataAny EMS system throughout US

NEMSIS

EMS COMPONENTDirect Entry OnlineMobile Field EntryOptically Scanned FormTHREE DATA COLLECTION OPTIONS

Hospital ComponentHospital contacts at receiving facilitiesHospital follow-up only required on patients with:ongoing resuscitationpresumed cardiac etiologyCARES software generates email to primary contact at selected Hospital destination.When CARES dataset is complete, the record is de-identified.

HOSPITAL COMPONENT

COMPUTER AIDED DISPATCH (CAD)COMPONENT

CARES ULTIMATE GOALHelp local EMS administrators/medical directors identify: Who is affected.When and where cardiac arrests occurWhich elements of the system are functioning well and those that are not.How changes can be made to improve cardiac arrest outcomes.

CARESCreate 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 (2006) Began National Expansion.Ultimate goal is to be universally applicable to EMS operations nationwide.

Chart1

269

621

961

1320

1962

2968

3741

4636

6252

7974

9500

11010

Column2

Total CARES Records

Sheet1

Column1Column2

Dec '05269

Mar '06621

Jun '06961

Sep '061320

Dec '061962

Mar '072968

Jun '073741

Sep '074636

Dec '076252

Mar '087974

Jun '089500

Sep '0811010

Chart1

5567

3710

18

Gender

Gender Demographics

Null 0.19%

Female 39.91%

Male59.89%

Sheet1

Gender

Male5567.00

Female3710.00

Null18.00

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Chart1

230

168

392

1057

1802

1871

1714

2006

55

Series 1

Age Demographics

Sheet1

Series 1

0-19230

20-29168

30-39392

40-491057

50-591802

60-691871

70-791714

80+2006

Null55

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Chart1

84

125

2794

17

3577

59

2062

577

Sales

Ethnicity Demographics

Null1%

Asian1.34%

Black/African-American30.06%

Native Hawaiian/Pacific0.18%

Sheet1

Sales

null84

Asian125

Black/African-American2794

Native Hawaiian/Pacific17

White3577

American-Indian/Alaskan59

Unknown2062

Hispanic/Latino577

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Location Demographics

Location TypeTotalPercentageHome/Residence601464.70%Public Building5696.12%Street/Hwy4745.10%Nursing Home/Assisted Living Center131614.16%Residence/Institution1171.26%Physician Office/Medical Clinic1972.12%Educational Institution260.28%Hospital290.31%Recreation/Sport Facility1251.34%Industry1031.11%Jail430.46%Other2352.53%Airport460.49%Null10.01%Total:9295100%

CARES Summary Report Sample

Chart1

0.1720.253

0.0320.04

0.1860.229

Agency

National

Sheet1

Column1AgencyNational

Bystander CPR17.2%25.3%

Bystander AED3.2%4.0%

Utstein18.6%22.9%

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CARES Summary Report SampleUTSTEIN SURVIVAL

Chart1

0.150.231

0.1980.22

0.04950.312

0.1250.337

0.060.176

0.030.111

Agency Utstein

National Utstein

Sheet1

Agency UtsteinNational Utstein

Jan-Feb15.00%23.10%

Mar-Apr19.80%22.00%

May-Jun4.95%31.20%

Jul-Aug12.50%33.70%

Sep-Oct6.00%17.60%

Nov-Dec3.00%11.10%

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CARES Summary Report SampleBYSTANDER CPR RATES

Chart1

0.150.237

0.2490.225

0.1220.255

0.1890.266

0.1380.26

0.190.281

Agency Bystander CPR

National Bystander CPR

Sheet1

Agency Bystander CPRNational Bystander CPR

Jan- Feb15.00%23.70%

Mar-Apr24.90%22.50%

May-Jun12.20%25.50%

Jul-Aug18.90%26.60%

Sep-Oct13.80%26.00%

Nov-Dec19.00%28.10%

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CARES Current & Focus Sites (2008-2009)

Insert TOR Article

SummaryThe CARES Program:Integrates EMS, 911, and Hospital components.Provides feedback to healthcare providers and community stakeholdersAllows systems to internally and externally benchmarkProvides a model national OHCA surveillance registry.Ultimate goal to improve survival for OHCA

SOFTWARE DEMONSTRATION

https://mycares.net/This presentation and more information about the program can be found on the CARES website under the NAEMSP tab.

*CARES is a CDC funded and AHA endorsed program out of Emory University in Atlanta GA.***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).

***********Since hospital outcomes are critical in determining survival from out of hospital cardiac arrest, CARES asks for voluntary participation from every hospital where an EMS agency transports cardiac arrest patients. A CARES contact is identified at each participating hospital who is responsible for entering outcomes for pts transported to their hospital. A CARES event is initiated by EMS personnel. When it is indicated on an EMS dataset that the arrest is of presumed cardiac etiology, resuscitation is attempted by EMS, and there is ongoing resuscitation in the ED, the CARES software generates a generic email to the hospital contact at the receiving facility saying a pt has been transported to their facility. When it is convenient for the hospital contact perhaps once every two weeks or a month (depending on the call volume) the hospital contact can log-in and complete the outcomes for pending pts. The hospital dataset consists of 4 simple questions and only takes a few minutes to complete. Once a CARES event is complete the record is scrubbed of all pt identifiers.

We do ask that the CARES data use agreement is signed by a supervisor at each hospital to ensure confidentiality of data exchange.*This is just a snapshot of the hospital data entry screen. You can see the four hospital questions. There is also a transfer feature where if a pt was transported by EMS to hospital #1 then the pt was transferred from Hospital #1 to Hospital #2 there is a way to indicate this by selecting the transfer hospital in the drop-down menu. The hospital contact at #2 gets an email and the pt is now in there box for pending hospital outcomes. ****In summary, CARES uses the internet to bring together 3 silos of data to streamline the data collection process for OHCA. CARES participants not only have real time access to their own data but also have access to a de-identified national aggregate report which allows for both internal and external benchmarking. The ultimate goal obviously being to improve survival for OHCA.*