SCOPE OF WORK

In 2013, the American College of Cardiology, the American Heart Association, the American Red Cross, the Centers for Disease Control and Prevention, NIH, and the U.S. Department of Veterans Affairs asked the Institute of Medicine (IOM) to conduct a consensus study on the factors affecting resuscitation research and outcomes in the United States. The IOM committee was charged with evaluating the public health dimensions of cardiac arrest treatment, with a focus on the following five areas: CPR and the use of AEDs, EMS and hospital systems of resuscitation care, national cardiac arrest statistics, resuscitation research, and future therapies and strategies for improving health outcomes from cardiac arrest within the next decade. The committee's charge did not include examining the role or impact of prevention. Additionally, because of the quality and availability of evidence about cardiac arrest, the committee focused its analysis on treatments up through hospital discharge and outcomes through 90-days post discharge.

To respond to its charge, the IOM convened a 19-member committee with a broad range of expertise. The committee held five meetings and two public workshops throughout its term in order to solicit input from a variety of stakeholders. In addition to input received through public workshops, the committee examined the available scientific literature and commissioned analyses of recent data on OHCA and IHCA.

A UNIFYING FRAMEWORK FOR CARDIAC ARREST

Since 1991, the chain of survival (see Figure S-1) has been the dominant operational model in the resuscitation field. The model focuses on early activation of basic and advanced life support responses for individuals with cardiac arrest, beginning in the prehospital phase and following through to post-arrest care. The likelihood of a positive outcome decreases if any link is delayed or improperly implemented. This model has been influential in strengthening the delivery of care within discrete systems, leading to increased survival rates for some pioneering communities. Strategies and interventions aimed at enhancing the recognition of cardiac arrest and increasing the timeliness and quality of care have been applied to further reinforce the chain. Although the chain of survival is useful to guide operational decisions within individual systems, a different framework is needed to identify overarching goals for the broader resuscitation field.

FIGURE S-1

Cardiac arrest chain of survival. NOTE: ACLS = advanced cardiac life support; CPR = cardiopulmonary resuscitation. SOURCE: Resuscitation Academy, n.d., p. 14.

Promoting advances in cardiac arrest health outcomes will require coordination, cooperation, and consultation across many disciplines and actors. Fluid and formal transitions between sites of care help identify and target factors influencing patient care. To facilitate productive discussion between federal, state, local, and community representatives, a comprehensive systems-level framework is needed to guide the development of cohesive short- and long-term strategies that are necessary to reduce the public burden of cardiac arrest. Figure S-2 illustrates a systems-level framework that can be used to identify relationships between actors and organize actions between actors that affect cardiac arrest treatment and outcomes. One goal—to increase the likelihood of survival with good neurologic and functional outcomes for any person who suffers a cardiac arrest (i.e., improved patient outcomes)—provides the roof. Together, the foundation and pillars are part of an integral, comprehensive, system-level response that is necessary to revitalize the resuscitation field and improve population health and patient outcomes from cardiac arrest in the short and long term.

FIGURE S-2

A unifying framework for improving patient outcomes from cardiac arrest. NOTES: This figure is based on an illustration from the Institute of Medicine's Crisis Standards of Care series, which proposed a framework for catastrophic disaster response to (more...)

Effective cardiac arrest response requires the actions of five groups (represented by the five columns in Figure S-2), who directly and indirectly affect patient outcomes. The public includes bystanders, who are at the forefront of the response and have the opportunity to report the event and initiate the response. The public also includes individuals who experience a cardiac arrest, friends and families, and individuals in industry, the workplace, schools, care facilities, and community organizations. EMS systems include 911 call takers, dispatchers, first responders, emergency medical technicians (EMTs), and paramedics, who respond to cardiac arrests and transport patients to local hospitals and emergency medical facilities after initiating resuscitation treatment. Similarly, individuals within EMS systems have the opportunity to instruct bystanders on how to administer CPR through dispatcher-assisted CPR.⁴ Hospitals and broader health care systems (which may include rehabilitation services) respond to cardiac arrests, provide essential post-arrest care for patients, and facilitate critical care transitions between EMS systems and various departments within the hospitals. Basic, clinical, and translational researchers generate hypotheses and new insights about the mechanisms and pathophysiology of cardiac arrest identifying novel pathways for rapid delivery of innovative treatments and treatment models. Finally, professional, training, and advocacy organizations can provide opportunities to educate and train various actors across the system, promoting valuable interdisciplinary dialogue, better informed policies, and a culture of action through increased accountability. Improved patient outcomes are more likely when these actors collaborate and coordinate their activities to strengthen the field and kindle progress.

The foundation comprises six steps, each representing fundamental key actions, including (1) comprehensive surveillance and reporting, (2) community engagement, (3) new treatments and treatment paradigms, (4) training and education, (5) local translation of research into practice, and (6) continuous quality improvement. Leadership, along with transparency and accountability, serve as the cornerstones that establish the position and direction of the entire structure.

ESTABLISH ROBUST DATA COLLECTION AND DISSEMINATION

Currently, national surveillance data on the incidence and factors associated with cardiac arrest do not exist. Databases that do exist are voluntary, limiting their scope and generalizability. Moreover, issues related to data harmonization, standardized metrics and measures, common data infrastructures, and varying degrees of oversight across databases contribute to a lack of interoperability and hinder evidence-based decision making related to research support and intervention adoption and evaluation. As a result, significant gaps in knowledge persist related to the epidemiology, pathophysiology, and treatment of cardiac arrest. With critical funding for some of the larger cardiac arrest registries ending (see Chapter 2),⁵ it becomes increasingly important to coordinate existing surveillance activities and broaden the scope of surveillance nationally. A lead organization is necessary to promote data collection, establish sustainability and continuity, and streamline data dissemination that will drive the collective public health efforts to save lives.

Recommendation 1. Establish a National Cardiac Arrest Registry

The Centers for Disease Control and Prevention (CDC)—in collaboration with state and local health departments—should expand and coordinate cardiac arrest data collection through a publicly reported and available national cardiac arrest registry, including both out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) data, to help increase federal and state accountability for current system performance and promote actions to improve cardiac arrest outcomes.

Specifically, CDC should

• establish a cardiac arrest surveillance system for the nation that includes IHCA and OHCA data in pediatric and adult populations;
• make data publicly available through appropriate mechanisms to enable comparisons across data sets in order to increase public awareness about cardiac arrest incidence and treatments, improve accountability for emergency medical services system and health care system performance, and target interventions that will reduce disparities and improve patient outcomes;
• identify and adopt standardized definitions, criteria, and metrics (such as age, gender, race and ethnicity, socioeconomic status, and primary language) for cardiac arrest identification, treatment, and outcome assessment; and
• promote and coordinate the development and implementation of unique diagnostic codes for OHCA and IHCA in International Classification of Diseases (ICD) coding models through its North American Collaborating Center, working with the Centers for Medicare & Medicaid Services and the World Health Organization.

Specifically, state, territorial, and local health departments should

• mandate tracking and reporting of all cardiac arrest events; and
• publicly report the incidence and outcomes of IHCA and OHCA within and across various areas within states and territories, taking appropriate steps to protect patient privacy and confidentiality.

Establishing standard definitions and data elements across local, state, national, and international stakeholders would enhance data harmonization and interoperability. These enhancements would allow for more reliable and accurate data aggregation, enable benchmarking and continuous quality improvement initiatives, and reduce unnecessary confusion in an already complex field of study.

EDUCATE AND TRAIN THE PUBLIC

Although evidence indicates that bystander CPR and AED use can significantly improve survival and outcomes from cardiac arrest, rates of bystander training in CPR and AED use remain less than 3 percent annually in the United States (Anderson et al., 2014). The public's current inability to recognize cardiac arrest, initiate CPR, and apply AEDs presents a call for action. An informed, coordinated, and effective campaign to promote public education and training opportunities and reduce barriers to the provision of bystander CPR and defibrillation would provide immense value to the overall health of the nation.

Recommendation 2. Foster a Culture of Action Through Public Awareness and Training

State and local departments of health and education, and leading organizations in cardiac arrest response and treatment, should partner with training organizations, professional organizations, public advocacy groups, community and neighborhood organizations and service providers, and local employers to promote public awareness of the signs, symptoms, and treatment of cardiac arrest. These efforts require public cardiopulmonary resuscitation (CPR) and automated external defibrillators (AED) training across the lifespan, creating a culture of action that prepares and motivates bystanders to respond immediately upon witnessing a cardiac arrest. Specifically,

• State and local education departments should partner with training organizations and public advocacy groups to promote and facilitate CPR and AED training as a graduation requirement for middle and high school students;
• Employers (e.g., federal agencies, private business owners, and schools) should be encouraged to maintain easy-to-locate and clearly marked AEDs, provide CPR and AED training to their employees, and specifically include cardiac arrest in formal emergency response plans; and
• Local health departments should engage with community and neighborhood organizations and service providers to expand the types and locations of available CPR and AED training to populations over age 65 and caregivers for this population.

IMPROVE DELIVERY OF HIGH-QUALITY RESUSCITATION AND POST-ARREST CARE

Although it is possible to conduct broad assessments of the quality of care provided by EMS or hospital systems that are based on overall survival rates and positive neurologic and functional outcomes, it is more difficult to distinguish which specific care elements, or combination of elements, directly influence patient outcomes. Despite these challenges, a number of EMS and hospital actions related to cardiac arrest care have been associated with higher survival rates in some communities, offering promising strategies that could be more widely adopted in order to reduce the public health burden of cardiac arrest. Standardized training and performance evaluation measures for care processes and protocols would promote a more rapid and uniform adoption and assessment of cardiac-arrest quality of care on a national scale.

Recommendation 3. Enhance the Capabilities and Performance of Emergency Medical Services (EMS) Systems

As the informal agency for EMS, the National Highway Traffic Safety Administration should coordinate with other federal agencies and representatives from private industry, states, professional organizations, first responders, EMS systems, and nonprofit organizations to promote uniformly high-quality emergency medical systems by

• convening interested stakeholders to develop standardized dispatcher-assisted cardiopulmonary resuscitation (CPR) protocols and national educational standards for use by all public safety answering points; and
• establishing a standardized definition and training curriculum for high-performance CPR to be used in basic emergency medical technician training and certification.

Recommendation 4. Set National Accreditation Standards Related to Cardiac Arrest for Hospitals and Health Care Systems

The Joint Commission—in collaboration with the American Red Cross, the American Heart Association, hospital systems, hospitals, professional organizations, and patient advocacy groups—should develop and implement an accreditation standard for health care facilities specific to cardiac arrest care for adult and pediatric populations.

Recommendation 5. Adopt Continuous Quality Improvement Programs

Emergency Medical Services (EMS) systems, health care systems, and hospitals should adopt formal, continuous quality improvement programs for cardiac arrest response that

• assign responsibility, authority, and accountability within each organization or agency for specific cardiac arrest measures;
• implement core technical and nontechnical training, simulation, and debriefing protocols to ensure that EMS and hospital personnel can respond competently to both adult and pediatric cardiac arrests; and
• actively collaborate and share data to facilitate national, state, and local benchmarking for quality improvement.

INCREASE THE IMPACT OF CARDIAC ARREST RESEARCH AND THERAPIES

Resuscitation science should be a major force in advancing patient outcomes. New research findings and emerging discoveries related to pharmaceuticals, devices, and biosensors provide compelling promise for boosting survival and positive outcomes and for reshaping approaches to the cardiac arrest treatments and care delivery models. However, federal agency support for resuscitation research is less than diseases and conditions with similar incidence. Large knowledge gaps about the etiology, epidemiology, pathophysiology, and even the effectiveness of current therapies for cardiac arrest persist. Future research must include a focus on basic, clinical, and translational science that leads to newer therapies. These, in turn, require clinical studies to develop sound evidence for, and the wide adoption of, best practices and interventions, as well as the evaluation of existing and new therapy effectiveness.

Recommendation 6. Accelerate Research on Pathophysiology, New Therapies, and Translation of Science for Cardiac Arrest

In order to identify new, effective treatments for cardiac arrest, the National Institutes of Health (NIH), the American Heart Association, and the U.S. Department of Veterans Affairs should lead a collaborative effort with other federal agencies and private industry to build the nation's research infrastructure that will support and accelerate innovative research on the causal mechanisms of onset, pathophysiology, treatment, and outcomes of cardiac arrest. These actions should

• strengthen laboratory, clinical, and translational resuscitation research support to levels commensurate with the public health burden of cardiac arrest for adult and pediatric populations across federal agencies, including NIH institutes; and
• establish a balanced and comprehensive portfolio of grants across the full spectrum of science translation to encourage the development and application of novel and efficient research strategies and innovative trial designs in preclinical, clinical (e.g., exploratory and hypothesis-generating studies), and population-based resuscitation research.

Recommendation 7. Accelerate Research on the Evaluation and Adoption of Cardiac Arrest Therapies

The National Institutes of Health should lead a collaborative effort with the U.S. Department of Veterans Affairs, the Agency for Healthcare Research and Quality, and the Patient-Centered Outcomes Research Institute to prioritize health services research related to the identification, evaluation, and adoption of best practices; the use of innovative technologies (e.g., mobile and social media strategies to increase bystander cardiopulmonary resuscitation or automated external defibrillator use); and the development of new implementation strategies for cardiac arrest treatments.

STRENGTHEN STAKEHOLDER COLLABORATION

Numerous organizations and institutions have supported valuable activities to advance the science and implementation of resuscitation. These efforts have led to critical progress within the field over the years. These efforts, however, have not established a united advocacy presence to heighten the visibility of cardiac arrest as a treatable public health threat that warrants the attention and support of policy makers and the public. To develop shared strategies, identify and support new leaders and advocates, and maximize the impact of limited resources within a field, formal and sustained collaboration is essential.

Recommendation 8. Create a National Cardiac Arrest Collaborative

The American Heart Association and the American Red Cross—with the U.S. Department of Health and Human Services and other federal agencies, national and international resuscitation councils, professional organizations, private industry, and patient advocates—should establish a National Cardiac Arrest Collaborative to unify the cardiac arrest field, identify common goals, and build momentum within the field to ultimately improve survival from cardiac arrest with good neurologic and functional outcomes. The Collaborative should

• provide a platform for information exchange about key successes and failures in different systems and settings and for stakeholder communication about new research findings and initiatives;
• convene working groups on short- and long-term national research priorities for cardiac resuscitation and post-arrest care, which focus on critical knowledge gaps (such as the impact of care transitions; the organization, composition, and training of resuscitation teams; optimal timing of initial neurological evaluation; and appropriate withdrawal-of-care protocols);
• develop action strategies related to health policy, research funding and translation, continuous quality improvement, and public awareness and training;
• produce and update toolkits for different stakeholders (e.g., emergency medical services [EMS] systems, hospitals, local health departments, and local health care providers) in order to facilitate effective system and individual responses to cardiac arrest;
• hold an annual collaborative meeting in conjunction with a regularly scheduled health professional conference to discuss short- and long-term goals and progress; and
• encourage public–private partnerships to support activities that focus on reducing the time to defibrillation for cardiac arrest, including the development of technologies to facilitate automated external defibrillator registries for use by the public, EMS systems, and other stakeholders.

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Footnotes

1

The 2013 out-of-hospital cardiac arrest (OHCA) incidence statistic (395,000) includes patient of all ages and cardiac arrests events with both cardiac and non-cardiac (e.g., trauma, drowning, poisoning, and other related causes) etiologies. This figure is an approximation based on analysis of data from the Resuscitation Outcomes Consortium-Epistry, the limitations of which are described in Chapter 2. The calculation of incidence is available in the committee's commissioned paper (Daya et al., 2015).

2

The reported statistics for in-hospital cardiac arrest (IHCA) are based a 2011 analysis, using the most recent available data (years 2003 through 2007) from the Get with the Guidelines-Resuscitation Registry (Chan, 2015). The study used three separate approaches to calculate the estimated ranges of annual in-hospital cardiac arrest (IHCA) events in the United States.

3

This statistic is an approximation based on annual case counts of OHCA and IHCA.

4

Dispatcher-assisted CPR (also referred to as dispatcher-assisted bystander CPR, just-in-time instruction, and telecommunicator CPR) is a term that includes the identification of cardiac arrest and the provision of CPR instructions to a 911 caller prior to the arrival of EMS providers at the scene of a cardiac arrest (see Chapter 4). Because dispatchers and 911 call takers may not be the same person, especially in large 911 centers, “telecommunicator” is used as an umbrella term to refer to any individual who works in a 911 center and has responsibility for receiving calls and/or sending help. However, to remain consistent with recent Utstein core measures and with terminology generally used in emergency medicine and by the public, this report uses the term “dispatcher-assisted CPR” to mean CPR instruction provided over a phone to a rescuer by a trained individual.

5

Personal communication, J. Brown, NIH, May 22, 2015.