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IOM Looks to Improve Cardiac Arrest Survival

A new report calls on all parts of the health care system to adopt quality improvement programs in areas such as cardiac arrest, tracking system performance, accountability, and training.

Cardiac arrest is the third-leading cause of deaths in the United States, and yet many think that steps can be taken to improve the survival rate up to 50 and 60 percent. The Institute of Medicine (IOM) is one such organization, as IOM established a Committee on the Treatment of Cardiac Arrest. That panel has laid out a plan for educating communities and improving the survival rate through its recent report, "Strategies to Improve Cardiac Arrest Survival: A Time to Act."

Published in June 2015, the report1 focuses on recommendations from the IOM that should be able to equip communities and organizations with the information and techniques they need to better help those who experience cardiac arrest. According to the report, fewer than 6 percent of people who experience cardiac arrest (which is not necessarily the same thing as a heart attack, it is noted) outside of a hospital survive. Only 24 percent of people who experience it inside a hospital ever leave.

The foundation for this study comes from the fact that survival rates vary to a pretty wide degree across the United States for a number of reasons, both personal and community-based. For example, the quality of the emergency medical services (EMS) and other health care systems, as well as local residents' CPR training, have a profound effect on the likelihood that someone can survive cardiac arrest.

Seattle and King County, Washington, have a survival rate of more than 60 percent for specific types of cardiac arrest. The biggest reason for their success? According to committee member Dr. Diane Atkins of the University of Iowa Carver College of Medicine, research and data are the biggest factors in improving the survival rate.

"They are constantly evaluating their cardiac arrest data, looking to see if there are patterns that they can identify that are advantageous to or potentially promote cardiac arrest recovery," she said. "They have their data and they use it for re-evaluation and for continuous quality improvement."

Other communities have found success by adopting continuous quality improvement initiatives, forcing EMS groups to become proactive and therefore reaching better overall outcomes. The IOM and the committee say that a "national responsibility exists to improve the likelihood of survival and favorable neurologic outcomes following a cardiac arrest."

Educating the Public
In order for this to happen, the IOM says that changes will have to occur in cardiac arrest reporting, research, training, and treatment. The recommendations are wide-ranging and, according to those who served on the committee, they build on one another, meaning that no specific recommendation is necessarily the best one.

More specifically, the committee states in the report that it aims to improve the state of cardiac arrest treatment in the areas of educating and engaging the public, centralizing the collection and distribution of care, increasing the impact of research and therapies, and strengthening stakeholder collaboration.

Educating the public serves as the first building block for improving cardiac arrest care, according to those on the committee.

"The first recommendation is really powerful as the foundation of so many of the other steps, because if you don’t know your survival rate, you don't really have much of a chance to fix it or make it better," said Dr. Lance Becker, from the University of Pennsylvania.

Just because it is the foundational recommendation doesn't necessarily mean it is the most important, however. All of the recommendations are interconnected and therefore depend on one another, according to Atkins.

The need to educate the public comes from the immediacy with which one must provide cardiopulmonary resuscitation or use an automated external defibrillator (AED). Without treatment within 10 minutes of experiencing cardiac arrest, victims' survival rate is almost zero. "In severe trauma we talk about the 'golden hour,'" Atkins explained. "We only have seconds and minutes here."

The more informed the public is on how to handle cardiac arrest, the better the chances a cardiac arrest victim will survive. The IOM committee therefore gives a formal recommendation for an informed, coordinated, and effective campaign to train the public to recognize cardiac arrest, initiate CPR, and apply an AED.

Data-Driven Actions
The aforementioned list is a list of actions that the public must take to help its communities. The report considers those responsible for implementing these actions to be "actors." Some of the actors that are specifically called out in the first recommendation are state and local education departments; employers, such as federal agencies, private business owners, and schools; and local health departments.

In order to fully educate the public, data must exist that can be used as a point of reference. Perhaps surprisingly, no such national database for tracking cardiac arrest incidents, outcomes, and other factors exists. Some exist at the local level thanks to EMS agencies and hospitals, but because there is no national database, it becomes very hard to generalize information and develop trends. This gap in knowledge has made it hard for communities to improve their survival rate, Becker said.

"One of the other things the committee determined is that communities that would regularly measure their survival rate would find interesting ways to improve it. As a nation, we need every community to be protected by something like that," he added.

The report goes on to justify a standardized data set: "a standard set of definitions and data elements across local, state, national, and international lines would help to reduce unnecessary confusion in an already complex field."

While no one recommendation should stand out, it would be hard to properly implement a recommendation later in the report without effectively establishing all of those that come before it.

High-Quality First Responder Care
The next area of focus is the improvement of the delivery of care by first responders, EMS personnel, and hospital providers. A common thread through these first recommendations is the standardization of actions.

"An effort to standardize training and performance-evaluation measures for cardiac arrest treatment would promote a more rapid and uniform adoption and assessment of high-quality care on a national scale," the report states.

More specifically, the committee has included a recommendation to standardize training curricula that would improve system capabilities and promote the delivery of high-performance CPR. All parts of the health care system, from hospitals to EMS and first responders, have been called on to adopt quality improvement programs in a number of areas, such as cardiac arrest, tracking system performance, accountability, and making sure personnel are trained to respond in the correct manner to cardiac arrest.

Reviewing Current Treatment Methods
Treatment methods have also come into question in the IOM study. Much is still unknown about cardiac arrest, according to the report, including how effective inventions such as CPR and AEDs are. The committee has asked that federal agencies, private industry, and nonprofit organizations work together to build a national research network in order to innovate in the areas of causes, treatment, and outcomes.

National Collaboration
The final recommendation takes all of the groundwork laid out by the previous steps and looks to create a collaborative that brings together federal agencies, EMS and health care systems, private industry, professional organizations, patient advocates, and members of the public. The fundamental goal of the collaborative would be to develop a singular strategy that can lead to higher survival rates of cardiac arrest throughout the country.

"What we know is that we can be so much more successful if we can get the whole group together and come up with a more comprehensive plan that goes all the way across the board," said Dr. Becker. "Not only in industry, but every person's community."

The American Red Cross has announced that it will sponsor the first meeting of this kind in San Diego in December 2015 during the Emergency Cardiovascular Care Update conference.

Workplace Training
The workplace could potentially be an area that benefits most from this sort of collaboration; with new training potentially on the way, employers and employees alike will be able to get proper training in order to help the recovery rates increase nationwide.

"Most Americans are not protected in a system that is a real system for taking care of cardiac arrest," Becker explained. "Here are the steps that we can take together as a nation, and each one of these steps is a doable thing that can be done. It can make an enormous impact and save potentially thousands and thousands of lives every year."

The committee members said they are confident all of the recommendations listed are achievable, although any specific timeline is hard to pin down due to the sweeping actions and number of organizations included. All of the recommendations have proven to work on their own in different scenarios, so there is justifiable proof that they can be done going forward.

"This is an important year for resuscitation science, and this report dovetails with critical updates in emergency cardiac care coming in October," said Dr. David Markenson, a member of the committee. "It's important that we in the resuscitation field pay heed to the new recommendations in the IOM report so that we can marshall the necessary resources to continuously improve survival rates. If we want to improve cardiac arrest outcomes, the resuscitation field must demonstrate leadership and accountability. It must take action to safeguard the quality of life for those who suffer a cardiac arrest."

References
1. http://iom.nationalacademies.org/Reports/2015/Strategies-to-Improve-Cardiac-Arrest-Survival.aspx

This article originally appeared in the September 2015 issue of Occupational Health & Safety.

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