As a medical emergency there is nothing more dramatic than sudden cardiac arrest. It is only in the past 50 years that medical therapy and procedures have made it possible for successful resuscitation. When cardiopulmonary resuscitation (CPR) and defibrillation are provided quickly, and there is an effective system of care, the chance of successful restoration of life with full neurological recovery is possible.

Emergency medical services (EMS) personnel, often with the assistance of citizen bystanders, comprise the front line in resuscitation in the out-of-hospital setting. In hospital settings, health care professionals are often faced with the challenge of responding to a cardiac arrest in pediatric and adult patients who suffer from other serious medical conditions. Although breakthroughs in understanding and treatment are impressive, the ability to consistently deliver timely interventions and high-quality care is less than impressive. The result is too many people dying from cardiac arrest. Based on recent estimates, more than 1,600 people suffer a cardiac arrest every day in the United States, defining an immense and sustained public health problem.

Equally unacceptable are the disparate survival rates within our population. Minorities and those in the lower economic strata fare worse compared to others. And where one resides is determinant of survival. There is wide diversity in survival rates among communities and hospitals in America. In some communities more than 60 percent of persons with out-of-hospital cardiac arrest (due to bystander-witnessed ventricular fibrillation) survive and are discharged from the hospital. In far more communities, the survival rate is 10 percent or less. Why is this, and what can be done?

This report examines the complex challenges and barriers to successfully treat cardiac arrest, both in the community and in the hospital, and offers concrete suggestions to improve, what the committee believes to be, an unacceptably low survival rate. Observing high-performing EMS and health care systems allows best practices to be identified and, in turn, offers strategies for other communities to adopt. Recommendations are made that the committee believes will lead to higher survival rates and give everyone, everyplace, a better chance of survival.

The primary goal in treating cardiac arrest, whether in the community or in hospitals, is to provide high-quality care quickly. For out-of-hospital cardiac arrest this is no easy feat considering the challenges of bystanders recognizing the event and calling 911; emergency telecommunicators identifying the problem, providing guidance to the rescuer, and dispatching emergency responders; and emergency medical technicians (EMTs) and paramedics responding to the call, arriving at the scene, and beginning CPR (if not already started), providing a defibrillatory shock (if required), achieving airway control, inserting an intravenous line, and delivering medications. Different yet similar challenges exist for cardiac arrest occurring within hospitals.

This report represents the collective conclusions and recommendations of a diverse group of experts, each of whom brought their expertise and perspectives. The charge to the committee was clear. How can we improve survival and quality of life following cardiac arrest both in the community and in the hospital? This report emphasizes the following strategies:

1.

Establish a national registry of cardiac arrest in order to monitor performance in terms of both success and failure, identify problems, and track progress.

2.

Enhance performance of EMS systems with emphasis on dispatcher-assisted CPR and high-performance CPR.

3.

Develop strategies to improve systems of care within hospital settings and special resuscitation circumstances.

4.

Expand basic, clinical, translational, and health services research in cardiac arrest resuscitation and promote innovative technologies and treatments.

5.

Educate and train the public in CPR, use of automated external defibrillators, and EMS-system activation.

6.

Create a national cardiac arrest collaborative to unify the field and identify common goals to improve survival.

This report benefited immensely from the skilled work and dedication of the Institute of Medicine staff, led by Margaret McCoy, and assisted by Catharyn Liverman, Sarah Domnitz, Ashna Kibria, and R. Brian Woodbury. We also wish to thank our colleagues on the committee for their passion, expertise, contributions, and unflagging patience as we considered, debated, and reached consensus on the complex issues.

The committee's work was enhanced by testimony and presentations by dozens of individuals from a host of federal and community agencies. Throughout the United States, the response to community cardiac arrest is provided by emergency medical services. Hundreds of thousands of dispatchers, telecommunicators, EMTs, first responders, and paramedics work together to provide the highest level of care directly at the scene of the cardiac arrest. Similarly, we extend our appreciation in equal measure to hospital professionals who provide care for patients who arrest in the hospital and who continue the intensive and complex care after the transfer of care for patients who respond to treatment in the field. We thank all of these individuals for their dedication and professionalism. We applaud the citizen bystanders, patient and family advocates, and community leaders who have the courage and compassion to step forward and provide CPR and defibrillation and who promote cultures of action within their communities. Finally, we acknowledge those individuals and families who have been affected by cardiac arrest and encourage them to continue to share their experiences with others as important examples of what is at stake and what is possible.

Robert Graham, Chair

Mickey Eisenberg, Vice Chair

Committee on the Treatment of Cardiac Arrest: Current Status and Future Directions