It was the day before their sixth wedding anniversary, and Brek Paul was about to get a whopper of a gift from his wife, Tracy.
Two years ago, Paul, then 45, had returned from Chemult to their home just north of Bend, and wasn’t feeling well. His chest and his right arm hurt. He took a nitroglycerin pill and lay down to take a nap.
His wife found him unresponsive: no pulse, not breathing and white as a ghost. She called 911, and the dispatcher guided her and her daughter, Abby, through CPR.
“The operator walked them through step by step exactly what they needed to do,” Paul said. “They actually did this beat for her. Stayin’ alive, Stayin’ alive. They were singing it over the phone.”
His wife and daughter continued chest compressions for nearly 15 minutes, until Deschutes County sheriff’s deputies arrived and took over.
They applied an automated external defibrillator, trying twice to shock his heart back into a normal rhythm. Paramedics from Redmond Fire arrived soon after and shocked Paul another 10 times and applied a mechanical chest compression device. Finally, 47 minutes after the 911 call was placed, Paul’s heart started beating.
Doctors at St. Charles Bend cleared a blockage in his coronary artery, and a week later, Paul was back at work.
“How long can somebody go without a heartbeat? And breath? I don’t even know how long I was laying there,” Paul said. “(The deputies and paramedics) definitely were trained well and knew what they were doing.”
Resuscitation rates for sudden cardiac arrest have increased dramatically over the past five years after the Bend and Redmond fire departments implemented a new approach to CPR that includes measuring their performance and trying to improve on it. Known as high-performance CPR, the approach focuses not on doing things differently but on doing them better.
“In the old days, you went to a code, and you expected them to die because no one really lived. It was like a 2% survival rate,” said Dr. Bill Reed, an emergency physician and medical director for Bend Fire Department. “Now, the paradigm has completely shifted. They show up, and they expect them to survive. They are stunned when they don’t.”
Performance, not protocol
The concept of high-performance CPR originated in Seattle about 15 years ago when King County and Seattle Fire Department officials set out to improve their success rate in reviving people whose hearts had stopped.
“Although we had great equipment, good people, we were stuck at a certain number for survival,” said Mike Helbock, then director of training for King County EMS. “We started to redesign how to do business.”
They began to measure their performance in providing CPR, measuring things like how rapidly they were compressing the chest and how deeply, how much ventilation they provided and how often they stopped compression to perform other tasks.
“In the old days, we used to pause routinely to perform specific skills,” Helbock said. “We learned in Seattle, King County that every one of those pauses was a chance for the patient to further die.”
They began to collect data on what they called compression fraction, the percentage of the total time that paramedics were giving chest compressions. When they started, their compression fraction rate was in the 50s. By eliminating unnecessary pauses, they got their rates up into the 90s. They now have data, Helbock said, to show that every 1% increase in the compression fraction roughly translated to a 1% increase in survival.
Using special defibrillators that collect data during CPR, they focused on the various metrics that had been shown to improve survival rates. They used special mannequins to help teach their staff to compress the chest the desired 2 to 2.4 inches, and to avoid leaning on the patient in between. That lean prevents the heart from completely refilling with blood, decreasing the amount that can be pumped out again with the next compression.
They also learned they providing too much air when they ventilated patients with a bag mask. They reduced the amount of air provided to a half or even a third of their previous volumes. That too helped improve survival.
To ensure they were compressing the chest at the optimal 100 to 120 beats per minute, they brought metronomes with them, set to 110 beats per minute.
Even before all these interventions could be rigorously tested in clinical trials, Seattle Fire Department and King County EMS saw their survival rates start to climb: 13% in the first year, and another 13% the second year. Within three years, their survival rates had doubled.
“It’s not about protocol; it’s all about performance,” Helbock said, quoting the mantra for high-performance CPR. By collecting the data from each encounter and reviewing their technique in a constant loop of quality improvement, they drove survival rates to some of the highest in the country. They launched the Resuscitation Academy and began teaching their approach to other agencies in the country, including to representatives of the Bend and Redmond fire departments.
Bend Fire Department launched a high-performance CPR program and saw an immediately jump in their survival rates from 20% in 2012 to 42% in 2013. They hit a high of 71% in 2016. The rates have dropped somewhat in 2017 and 2018, although the department sees so few cases of cardiac arrest that can be addressed with CPR and defibrillation, rates can swing wildly from year to year. Redmond Fire Department has had eight cases over the past four years, with a 75% survival rate.
Their crews are trained and drilled on proper technique, and review their data regularly.
The defibrillators track the data and can print out the metrics for the team immediately after the CPR is complete.
“They each have a job and they know what that job is,” said Drew Norris, deputy chief of EMS operation for Bend Fire Department. They designate one leader who manages the entire process, while others handle the administration of drugs or ventilating the patient. Chest compressions can become tiring, so the compressor is switched out a regular intervals.
“You’ll see guys lined up, literally,” Norris said.
While they continue to work on improving their metrics, one limiting factor was response time. Bend Fire Department staff worked with the Bend Police Department and the Deschutes County Sheriff’s Office to train cops in high-performance CPR and how to use the automated defibrillators. Because police are out in the neighborhoods, they often arrive at calls before EMS crews arrive.
EMS officials also worked with 911 dispatchers to be more proactive in getting bystanders to perform CPR. In the past, dispatchers asked if someone was comfortable performing CPR. Now they just tell people what needs to be done. As a result, the rate of bystander CPR has increased from 25% to 75%. New research shows that chest compressions are much more important than ventilation in the first minutes, as the blood remains oxygenated for up to 12 minutes after breathing stops. Without having to give rescue breaths, bystanders are much more willing to try CPR. In 2015, the Oregon Legislature passed a law requiring all high school students to be trained in CPR before graduating. That could further increase the number of people who start CPR before emergency crews arrive, and raise survival rates even further.
“Bend is an excellent example of an organization that is already a good performer that went to a whole different level, and we’re really proud of their work,” Helbock said.
Survival from out-of-hospital cardiac arrest varies widely throughout the United States. Many large cities in the U.S. have average rates under 10%. Seattle and King County, Washington report over 60% survival. According to the Resuscitation Academy, only 40 communities in the U.S. rigorously measure and report their survival rates.
That’s, in part, because it’s still up to individual EMS agencies to seek out training and implement high-performance CPR on their own. That requires the medical directors to buy in to the concept and commit to changing their approach.
“If you’ve seen one EMS system, you’ve seen one EMS system,” said Doug Kelly, Redmond Fire Department EMS division chief. “The way we do it here in Central Oregon is incredibly different than how they might do it on the East Coast.”
Without a national standard, each agency has to make its own decision about how to implement what they’ve learned from the research to fit their own community.
“You take what literature and research you can find, you tweak, you work with that, and then you tweak it some more,” he said.
Helbock recently served on a task force for the National Highway Traffic Safety Administration that developed guidelines calling for a high-performance CPR framework.
“Just because this is a national program doesn’t mean that it’s required,” he said. “There is no requirement anywhere in the United States to do this.”
That’s also true for hospitals. Few hospitals have implemented the same type of continuous quality improvement strategy for improving resuscitation of cardiac arrest within their facilities.
“Generally my experience is they are behind the curve,” Helbock said.
The framework might be more difficult for hospitals to implement. For one, EMS crews tend to work in the same teams, whereas emergencies at hospitals might attract providers from various parts of the hospital.
Reed is co-chair of the Code Blue committee at St. Charles Bend, which is working on improving resuscitation rates. All of the emergency department and intensive care unit doctors have been trained on high-performance CPR. However, the hospital does not have the data-collecting defibrillators that EMS crews use. An EMS agency might need 15 of them, at a cost of anywhere from $15,000 to $36,000 per unit. St. Charles would require four to five times as many.
“It’s on their radar,” Reed said. “They know we have to be collecting the data, not just training the people to do the work.”
— Reporter: 541-633-2162, firstname.lastname@example.org