Heart Rescue Project

[medicRob]

We have all seen Seattle's SCA survival rates (45%[1] vs a national average of 4-8% respectively[3]). One study even went so far as to say, "Your chances of survival fluctuate by as much as 500 percent, depending on where you live in the country.[3]"

"Initiated and funded by the Medtronic Foundation, the HeartRescue Project assembles the country's leading emergency and resuscitation experts committed to improving how Sudden Cardiac Arrest (SCA) is recognized, treated and measured in the United States.

Working in five pilot states, these expert partners will implement statewide programs that align EMS programs and hospitals to improve and coordinate an "integrated-community response" to SCA.

The goal will be to improve SCA survival rates significantly in each state within five years by expanding and replicating successful city and county out-of-hospital cardiac arrest response programs to statewide levels.

Within their states, HeartRescue partners will

Develop an integrated community response to SCA.
Coordinate education and training efforts.
Help communities apply best-practice treatments among the general public, first responders (police/fire), emergency medical services (EMS) and hospitals.
Implement a common, systemic method of measuring performance and outcomes of SCA."

I came across the site this morning, I was wondering if any of you have direct experience with the project. What are your thoughts?



References:

1. Services, K. C. D. o. E. M. (2010). Seattle & King County EMS 2010 Annual Report: . Seattle.

2. http://www.medtronic.com/heartrescueproject/resources.html

3. Nichol G, Thomas E, Callaway CW, et al. Regional Variation in Out-of-Hospital Cardiac Arrest Incidence and Outcome, JAMA, 2008;300(12):1423–1431.

 

[Veneficus]

We have all seen Seattle's SCA survival rates (45%[1] vs a national average of 4-8% respectively[3]). One study even went so far as to say, "Your chances of survival fluctuate by as much as 500 percent, depending on where you live in the country.[3]"

"Initiated and funded by the Medtronic Foundation, the HeartRescue Project assembles the country's leading emergency and resuscitation experts committed to improving how Sudden Cardiac Arrest (SCA) is recognized, treated and measured in the United States.

Working in five pilot states, these expert partners will implement statewide programs that align EMS programs and hospitals to improve and coordinate an "integrated-community response" to SCA.

The goal will be to improve SCA survival rates significantly in each state within five years by expanding and replicating successful city and county out-of-hospital cardiac arrest response programs to statewide levels.

Within their states, HeartRescue partners will

Develop an integrated community response to SCA.
Coordinate education and training efforts.
Help communities apply best-practice treatments among the general public, first responders (police/fire), emergency medical services (EMS) and hospitals.
Implement a common, systemic method of measuring performance and outcomes of SCA."

I came across the site this morning, I was wondering if any of you have direct experience with the project. What are your thoughts?



References:

1. Services, K. C. D. o. E. M. (2010). Seattle & King County EMS 2010 Annual Report: . Seattle.

2. http://www.medtronic.com/heartrescueproject/resources.html

3. Nichol G, Thomas E, Callaway CW, et al. Regional Variation in Out-of-Hospital Cardiac Arrest Incidence and Outcome, JAMA, 2008;300(12):1423–1431.

Heard of it, don't think it will make a significant difference numerically, but will probably help some people.

 

[medicRob]

Heard of it, don't think it will make a significant difference numerically, but will probably help some people.

Umm .. 45% is not a numerical difference?

Also, have you taken a look at this 30 year prospective study into V-Fib survival rates?

 

[reaper]

No one will ever believe their inflated rates.

 

[medicRob]

No one will ever believe their inflated rates.

Do you have anything to back up that their rates are inflated (Not picking a fight, just interested in why you feel they are inflated). In the 2008 study in the Journal of the American Medical Association, survival to discharge rates in Ventricular Fibrillation were 39.9% [1], two years before the annual report came out.

http://www.resuscitationacademy.org/downloads/CARegionalVariation-Nichol.pdf

References:
1. Nichol G, Thomas E, Callaway CW, et al. Regional Variation in Out-of-Hospital Cardiac Arrest Incidence and Outcome, JAMA, 2008;300(12):1423–1431.

 

[reaper]

When you use only vfib pts, that had rosc, and made it to discharge. Everyone's percentage would be that high.

They do nothing special. Other services don't pad their stats and have 7-8% rates. Which are very good.

 

[NomadicMedic]

The actual criteria is “a witnessed cardiac arrest due to presumed underlying heart disease with the initial rhythm of ventricular fibrillation”. See how King County makes it look good?

Here's a nice little one page take on the Utstein criteria that King County uses http://blacklistinc.com/survive/utstein.php

 

[jjesusfreak01]

I'm at 50% (1 of 2), and the one we lost would have been viable except for end stage cancer (the family DCd treatment, though we had ROSC). Just gotta stay ahead of Seattle.

 

[silver]

I'm at 50% (1 of 2), and the one we lost would have been viable except for end stage cancer (the family DCd treatment, though we had ROSC). Just gotta stay ahead of Seattle.

"With cardiac arrest survival, the best just keep getting better. For the second straight year, the Medic One Foundation announced in May, Seattle's survival rate for witnessed ventricular fibrillation arrests has topped 50%. Nationally, the rate is between 2% and 25%."

http://www.emsworld.com/web/online/Top-EMS-News/Seattle-V-fib-Survival-Tops-50-percent-Again/1$17007

sorry...

 

[mycrofft]

Why has Seattle been #1 in cardiac arrest survival virtually for forty years?

At least that's been my impression, although I can't say I've been hip deep in the literature since 1980. Just seems suspicious.

Spell it out for me and the others who don't read all the links. What are the chances of survival of clinical death due to cardiac arrest, addressed in the field, and transported to a hospital, until discharge, and until say three years out?

I'm reminded of the original Roux-en Y studies, touting an extremely low post-op mortality; turns out they were cherry-picking their time line, just citing out to 18 months; another study, this time not done by the manufacturers (yikes), went out three years and showed twice the morbidity and mortality as the original study done by Ethicon. They deserve public flogging.

 

[Flight-LP]

Do you have anything to back up that their rates are inflated (Not picking a fight, just interested in why you feel they are inflated). In the 2008 study in the Journal of the American Medical Association, survival to discharge rates in Ventricular Fibrillation were 39.9% [1], two years before the annual report came out.

http://www.resuscitationacademy.org/downloads/CARegionalVariation-Nichol.pdf

References:
1. Nichol G, Thomas E, Callaway CW, et al. Regional Variation in Out-of-Hospital Cardiac Arrest Incidence and Outcome, JAMA, 2008;300(12):1423–1431.

I don't think it is necessarily an issue of inflated rates vs. the actual significance of the populations involved. King Co. has always played on the ease of information maipulation to convince the general public that they are actually doing something remarkable. Something so remarkable that no one else in the nation is doing it. C'mon, most of us here are smarter than that.

When you have agencies out there providing neuro intact rates at 17 - 20% for ALL populations, not just the Utstein criteria folks, King County's number really aren't all that and a bag of cookies. Sorry, it is what it is. There are much more productive, progressive, and aggresive systems out there doing a hell of a lot more than King County. Systems such as Wake County and Cypress Creek to name a couple, are doing more for all of the population of EMS patients through different initiatives. So what does that mean to the simple layperson? It means there is more to advancing EMS and providing quality service than running for over a decade on the same manipulated story. King County needs to get a new tag line to promote their self perceived "awesomeness"

 

[medicRob]

I don't think it is necessarily an issue of inflated rates vs. the actual significance of the populations involved. King Co. has always played on the ease of information maipulation to convince the general public that they are actually doing something remarkable. Something so remarkable that no one else in the nation is doing it. C'mon, most of us here are smarter than that.

When you have agencies out there providing neuro intact rates at 17 - 20% for ALL populations, not just the Utstein criteria folks, King County's number really aren't all that and a bag of cookies. Sorry, it is what it is. There are much more productive, progressive, and aggresive systems out there doing a hell of a lot more than King County. Systems such as Wake County and Cypress Creek to name a couple, are doing more for all of the population of EMS patients through different initiatives. So what does that mean to the simple layperson? It means there is more to advancing EMS and providing quality service than running for over a decade on the same manipulated story. King County needs to get a new tag line to promote their self perceived "awesomeness"

I have actually taken a closer look since I first made this post. I looked at the utstein criteria, the data tricks, etc. I am inclined to agree with the others at this point.

Btw, it's nice to see you coming around. It's been a while since I've seen you post.

 

[mycrofft]

Ditto that Flight LP

.........

 

[medicsb]

wait a second...

I don't think it is necessarily an issue of inflated rates vs. the actual significance of the populations involved. King Co. has always played on the ease of information maipulation to convince the general public that they are actually doing something remarkable. Something so remarkable that no one else in the nation is doing it. C'mon, most of us here are smarter than that.

When you have agencies out there providing neuro intact rates at 17 - 20% for ALL populations, not just the Utstein criteria folks, King County's number really aren't all that and a bag of cookies. Sorry, it is what it is. There are much more productive, progressive, and aggresive systems out there doing a hell of a lot more than King County. Systems such as Wake County and Cypress Creek to name a couple, are doing more for all of the population of EMS patients through different initiatives. So what does that mean to the simple layperson? It means there is more to advancing EMS and providing quality service than running for over a decade on the same manipulated story. King County needs to get a new tag line to promote their self perceived "awesomeness"

Wow.

Where are you getting your data from? Wake County uses the SAME measures as King County. In 2009, Wake County had an overall survival rate of 15.2% for all non trauma, presumed cardiac arrests. That number includes patients witnessed by EMS. If you factor out the patients witnessed by EMS, their number drops to 12.6 (which is really good, actually). However, for the same time period, King County had an overall of 19.2. When you factor out those witnessed by EMS, their number drops to... 14.6% For bystander witnessed, VF/VT of presumed cardiac origin, Wake County had produced a survival of 42% in 2009. King County produced 46%. Both are outstanding. But, the only place I know of that reaches the 17-205 range is King County, and that is only if you include arrests witnessed by EMS. So... who are these systems that are beating out medic one?

Anyhow... Almost any place that tracks or reports cardiac arrest outcomes will use the utstein template, it is essentially the gold standard for data collection and reporting on prehospital cardiac arrest. When you compare the Seattle/King County bystander-witnessed, VF arrest outcomes against other EMS systems bystander-witnessed, VF arrest outcomes, they (Seattle/KCM1) tends to be at the top. Seattle/KCM1 have NEVER hid the fact that they use the utstein template. Any other system that uses it, doesn't hide it.

Also, there is no secret as to why they do so well... An affluent population (generally healthier) that has few minorities (their outcomes aren't as good compared to "whites" for various reasons) and lots of lay people trained in CPR in combination with extensive PAD programs (probably the most important factor) in relatively small geographical area (most of KCs population is on the West side of the county) with rapid EMS response (BLS engines to every EMS call) makes for good outcomes.

Compare for yourself:
Wake County, 2009: http://emscompare.org/media/public_records_requests/wake_county_09.pdf
King County, 2009: http://www.kingcounty.gov/healthser...lichealth/documents/ems/2010AnnualReport.ashx (got to page 63)

Compare them to others (this person did a pretty good job of compiling information): http://emscompare.org/cardiac_arrest/

So other than Wake County, who are these "much more productive, progressive, and aggresive systems"?

Oh, here is the website for the Office of Research Integrity: http://ori.hhs.gov/
Report any scientific/research misconduct to them. Considering the amount research grants that the folks with Medic One have received over the years and are receiving, the ORI would seriously love to know of any misconduct. Also, considering how many researchers medic one has collaborated with, they must be passing around a ton of hush money to keep so many quiet about their manipulation of data.

 

[Flight-LP]

Wow.

Where are you getting your data from? Wake County uses the SAME measures as King County. In 2009, Wake County had an overall survival rate of 15.2% for all non trauma, presumed cardiac arrests. That number includes patients witnessed by EMS. If you factor out the patients witnessed by EMS, their number drops to 12.6 (which is really good, actually). However, for the same time period, King County had an overall of 19.2. When you factor out those witnessed by EMS, their number drops to... 14.6% For bystander witnessed, VF/VT of presumed cardiac origin, Wake County had produced a survival of 42% in 2009. King County produced 46%. Both are outstanding. But, the only place I know of that reaches the 17-205 range is King County, and that is only if you include arrests witnessed by EMS. So... who are these systems that are beating out medic one?

http://circ.ahajournals.org/cgi/content/meeting_abstract/114/18_MeetingAbstracts/II_1209-b

Cypress Creek produced neurologically intact results of 17% for ALL presenting rhythms, not just witnessed V-Fib. The inclusion of Wake County in my last post was to demonstrate that there are systems out there that are producing viable improvements in EMS as a whole, not just touting the same line about their cardiac arrest save results. That listing was not complete, nor nearly inclusive of the many great agencies out there that is leading the progression of the challenged industry we call EMS.

Anyhow... Almost any place that tracks or reports cardiac arrest outcomes will use the utstein template, it is essentially the gold standard for data collection and reporting on prehospital cardiac arrest. When you compare the Seattle/King County bystander-witnessed, VF arrest outcomes against other EMS systems bystander-witnessed, VF arrest outcomes, they (Seattle/KCM1) tends to be at the top. Seattle/KCM1 have NEVER hid the fact that they use the utstein template. Any other system that uses it, doesn't hide it.

Not true, nor conclusive. Unfortunately, there is no "gold standard" when it comes to EMS research as the medical community still to this day does not place heavy weight on the unproven methods EMS systems use to report data. To validate this point, take another look at the link provided above. There was no utilization of the Utstein criteria.

Layperson CPR emphasizes early defibrillation and quality compressions to increase circulation. It isn't rocket science. We know how to get these folks back, the key to advancing the science is developing quality methods to improve the "more stubborn" cases (i.e. the prolonged resuscitation or the non-witnessed, non-VF cases). Regardless, each individual resuscitation will be different. Many variables associated with resuscitation are out of our hands, regardless of the science involved or its advances. If we keep the bar at the Utstein level, I really feel as though we are limiting ourselves and the potential advances that could be made.

Also, there is no secret as to why they do so well... An affluent population (generally healthier) that has few minorities (their outcomes aren't as good compared to "whites" for various reasons) and lots of lay people trained in CPR in combination with extensive PAD programs (probably the most important factor) in relatively small geographical area (most of KCs population is on the West side of the county) with rapid EMS response (BLS engines to every EMS call) makes for good outcomes.

Again, there is no question that any of these factors can improve outcomes, IN A SMALL POPULATION of overall cardiac arrest patients. Again, the point of comparison being that other agencies are expanding deeper into the survivability and subsequent discharge of ALL cardiac arrest populations.

Oh, here is the website for the Office of Research Integrity: http://ori.hhs.gov/
Report any scientific/research misconduct to them. Considering the amount research grants that the folks with Medic One have received over the years and are receiving, the ORI would seriously love to know of any misconduct. Also, considering how many researchers medic one has collaborated with, they must be passing around a ton of hush money to keep so many quiet about their manipulation of data.

Yeah, could be. Honestly don't know, nor do I really care to enter into one's passionate attempt to produce a conspiracy theory that fails to focus on the point of my rebuttal. I get that you think Medic One is the cat's meow. That's fine, you have very right to your opinion. Just as I have the right to mine. I enjoyed your presentation of viable research statistics, up to the dramatic point you seem to include in several of your posts that involve anything to do with cardiac arrest statistics or any mention of King County / Medic One. You lost credibility points from that point forward.

 

[mycrofft]

Dumb question about cherrypicking (skewing sample)

What if they are excluding cases whose cause of death can be chalked up to something like GSW, drug overdose, or disease, or where the pt has multifactorial collapse (meth abuser with vegetative valve disease and Hep C and HIV...) but were initially treated with CPR/AED because their presentation was cardiac standstill?

In cases resuscitation is enormously more tricky and special measures delayed or nonextant due to the CPR imperative and spotty hx (multifactors found on necropsy, for example). The sample is defined and limited (whether officially or not) to cardiovascular disease patients in one study, and open to all etiologies in others?

 

[medicsb]

http://circ.ahajournals.org/cgi/content/meeting_abstract/114/18_MeetingAbstracts/II_1209-b

Cypress Creek produced neurologically intact results of 17% for ALL presenting rhythms, not just witnessed V-Fib. The inclusion of Wake County in my last post was to demonstrate that there are systems out there that are producing viable improvements in EMS as a whole, not just touting the same line about their cardiac arrest save results. That listing was not complete, nor nearly inclusive of the many great agencies out there that is leading the progression of the challenged industry we call EMS.

That abstract was interesting and impressive on the surface, but it quickly turned out to be not as great as it seems. The abstract doesn't give a specific p value for the before and after difference, but it does say "p=ns" as in p value > 0.05 as in not statistically significant, which is probably why it (the whole study) was never published; their sample size was too small. If they published results that show they averaged 17% over, say, 5 years, then I'd be really impressed. However, their data was collected as part of a larger study (Implementing the 2005 American Heart Association Guidelines improves outcomes after out-of-hospital cardiac arrest. Heart Rhythm. 2010 Oct;7(10):1357-62).

Not true, nor conclusive. Unfortunately, there is no "gold standard" when it comes to EMS research as the medical community still to this day does not place heavy weight on the unproven methods EMS systems use to report data. To validate this point, take another look at the link provided above. There was no utilization of the Utstein criteria.

How many papers on cardiac arrest have you read? Utstein is commonly cited and if not out-right cited, you can determine survival for primary VF/VT patients in order to make an accurate comparison between EMS systems. The lead author of that abstract was the lead author for another study (Lancet. 2011 Jan 22;377(9762):301-11) whereby it is explicitly stated in the abstract: "we assessed outcomes for patients with out-of-hospital cardiac arrest according to Utstein guidelines". I'm willing to bet that he used the Utstein guidelines for his analysis of Cyprus Creek.

The Utstein template/criteria was devised as multinational effort to standardize capturing and reporting of cardiac arrest data. It's promoted by almost all (if not all) the major cardiac care/resuscitation organizations world wide. It is not intended just for prehospital cardiac arrests and is applicable to the inhospital setting, too. I suppose I can concede and throw out the term "gold standard" but I can't think of any standardized template/criteria that is used as an alternate. Again, most systems that track cardiac arrests are using it (see CARES and ROC).

Layperson CPR emphasizes early defibrillation and quality compressions to increase circulation. It isn't rocket science. We know how to get these folks back, the key to advancing the science is developing quality methods to improve the "more stubborn" cases (i.e. the prolonged resuscitation or the non-witnessed, non-VF cases). Regardless, each individual resuscitation will be different. Many variables associated with resuscitation are out of our hands, regardless of the science involved or its advances. If we keep the bar at the Utstein level, I really feel as though we are limiting ourselves and the potential advances that could be made.

Limiting ourselves or being realistic? There has been very little to improve outcomes from nonshockable rhythms. Just about everything that improves outcomes only does so for VF/VT with minimal impact on other rhythms. Ultimately, when someone shows you an improvement for cardiac arrests of all rhythms, you can bet that it was due to changes in outcome for VF/VT (which only comprises about 1/4 of all arrests, yet accounts for half or more of the survivors). For example, the study that included Cyprus Creek had an overall improvement from 10.1 to 13.1% across all rhythms.
The improvement for VF/VT was 20.0 to 32.3% (a 61.5% relative increase), while the change for non VF/VT was 6.78 to 7.12% (a 5.01% relative increase that is likely not statistically significant). I'll bet that the change in survival from 10 to 17% for Cyprus Creek in the abstract you posted was almost solely due to VF/VT.

For better or worse, the focus on VF/VT among some (most?) researchers is that it is the most salvageable of all the CA rhythms and most likely to respond to treatment (as seen above), which is also the reason that many EMS systems only report VF/VT survival and not survival across all rhythms.

Yeah, could be. Honestly don't know, nor do I really care to enter into one's passionate attempt to produce a conspiracy theory that fails to focus on the point of my rebuttal. I get that you think Medic One is the cat's meow. That's fine, you have very right to your opinion. Just as I have the right to mine. I enjoyed your presentation of viable research statistics, up to the dramatic point you seem to include in several of your posts that involve anything to do with cardiac arrest statistics or any mention of King County / Medic One. You lost credibility points from that point forward.

I've been interested in cardiac arrest research for years now and have read many many studies from all over the world. I think when it comes to cardiac arrest, they're one of the best in the world. If one wants to say they suck at everything other than cardiac arrest - fine, I can't necessarily say they don't. But, when it comes down to it, they are very good at managing cardiac arrests. I think most systems have a lot to learn from them when it comes to cardiac arrest management. To suggest that they pad their numbers or manipulate a story is an attempt to cut them down, and, to me, is suggesting that others can't achieve what medic one can and that you can only reach the numbers they produce through manipulation of data. I don't think that is true and I think it silly to try and cut them down for being very good at something. Again, they are very specific about what they measure and they don't hide it at all. It is very easy to compare other systems to them and almost everytime, they're better. Just the way it is.

Now, having again looked at what you said, I see you were turning the conversation in a different direction - to that of whole EMS population and not just cardiac arrest victims. To me, this change in direction is part based on the belief that KCM1 focuses on CA to the detriment of the whole EMS patient population, no? If so, I'd have to disagree. If you were to skim through the annual reports where they document their cardiac arrest outcomes you'd see that they do have programs dedicated to the whole EMS population (e.g. Injury prevention programs for children and senior, community medical technician, etc.) and that they do perform research on other topics. So, while I would agree that they don't do more than many others and that others probably do a lot more, they still do something, which is more than what many EMS systems do.

So yeah, when I comes to cardiac arrest, I'd argue that they are the cats meow (along with places like Wake County). And yeah, if someone is going to insinuate that the researchers at University of Washington, King County M1, etc. (or anywhere else, for that matter) are somehow manipulating data, then you should have more than a simple suspicion to back yourself up. It's a serious accusation in my opinion and one that I might respond to more than just once. (I'm flattered that you'd research my posting history, by the way.)

 

[medicsb]

What if they are excluding cases whose cause of death can be chalked up to something like GSW, drug overdose, or disease, or where the pt has multifactorial collapse (meth abuser with vegetative valve disease and Hep C and HIV...) but were initially treated with CPR/AED because their presentation was cardiac standstill?

In cases resuscitation is enormously more tricky and special measures delayed or nonextant due to the CPR imperative and spotty hx (multifactors found on necropsy, for example). The sample is defined and limited (whether officially or not) to cardiovascular disease patients in one study, and open to all etiologies in others?

Generally, studies focus on arrest of "presumed" cardiac etiology or on trauma (overdoses, etc. don't seem to get too much attention). So, yes, all overdoses, trauma, etc. get excluded from analysis. Authors are very explicit when they state the population studied. I don't think I've seen a study yet that has lumped non-cardiac etiology CAs with cardiac etiology CAs.

 

[mycrofft]

Thanks

.........

 

[TomB]

The Utstein template is the accepted academic standard for resuscitation research. Those who say that King County Medic One (or any of the top performing EMS systems in the United States) are somehow acting unethically or being deceitful by using it simply don't understand resuscitation research and do a disservice to all of those who have devoted their lives to helping to help alleviate the death and suffering associated with cardiovascular disease. The HeartRescue Project and other programs like HEARTsafe Communities and Take Heart America help strengthen the chain-of-survival and implement best practices and process improvement in cities all around the nation. As paramedics, as health care professionals, and as human beings we should applaud these efforts and wish them well. To quote Thom ****, "Your agency is not the best in the nation. It's not the best in the state, either. In fact, it's probably not very good at all, unless you can prove it." Congratulations to EMS systems who collect data and use it to improve their service delivery every day.