Saving Hearts in the Heartland

When a group of Michigan clinicians and researchers set a goal of doubling the state’s sudden cardiac arrest (SCA) survival rate over the next three years, they knew it would take a team of dedicated, enthusiastic individuals and the help of others like them around the country who’d already found ways to improve cardiac arrest systems of care.

That’s why the state recently partnered with the HeartRescue Project, a national collaborative focused on saving more lives from SCA. Coined in 2014 as “SaveMIHeart,” Michigan’s grassroots effort began with dedicated volunteers and very little funding. Before the state even became a HeartRescue partner, SaveMIHeart had brought together a team of leaders and volunteers committed to improving outcomes for victims of cardiac arrest. 

There is Teri Shields, a nurse who audits the 6,000 or so out-of-hospital sudden cardiac arrests collected by the state of Michigan each year and also serves as SaveMIHeart’s executive director.

“We stress the importance of the simple things, like hands-only CPR for bystanders,” she says. “Calling 9-1-1 and starting hands-only CPR are two simple, lifesaving actions.”

There is Robert Neumar, MD, cochair of the initiative, who provides vision and direction for the team. 
“Cardiac arrest is the most critical condition we treat,” Neumar says. “In addition, treating cardiac arrest requires the most complex system of care. I like a big challenge.”

There is Robert Dunne, MD, the emergency physician who oversees the EMS system in Detroit, the state’s largest metropolitan area, and who is out on the streets with paramedics and EMTs, teaching them the knowledge and skills necessary to achieve SaveMIHeart’s goal.

“As a leader, I must provide best practices for training and support for protocol changes,” says Dunne. “I focus on ways to get the latest knowledge about cardiac arrest out there to the patients who need it.”

And there are others, such as Brian O’Neil, MD, chair of the emergency department at Wayne State University, and Robert Swor, DO, an emergency medicine physician at Beaumont Health System. These two organizations, along with the University of Michigan, Emergent Health Partners and the Kellogg Family Foundation, have provided much of the funding that supports SaveMIHeart.

But the team extends even outside of Michigan’s borders, to the dozens of experts around the country who support their fellow HeartRescue Project members. Like Kim Harkins, program manager of Minnesota’s Resuscitation Consortium, who provides guidance to new partner states, like Michigan, by drawing on the vast repository of lessons learned by HeartRescue Project partners. 

“Cardiac arrest,” says Harkins, “is a public health crisis screaming for national attention and recognition.”

Measure and Improve

The HeartRescue Project began in 2011 with a five-year grant from the Medtronic Foundation to support six states and one private ambulance partner, all renowned for their resuscitation excellence, in their efforts to measure and improve cardiac arrest outcomes.

The partnership emphasized the collection of process and outcome data because only by examining this information could HeartRescue members know whether their efforts were safe and effective. Within a few years the partners saw survival rates increase, thanks largely to improvements in evidence-based actions by bystanders, emergency responders and hospital personnel. 

Those initial successes led to the expansion of the HeartRescue Project and its efforts to support measurement and improvement. Overseeing this new phase is one of the project’s founding partners, Thomas Rea, MD, who also serves as medical director for King County Medic One and is an associate professor of medicine at the University of Washington. Rea helps coordinate a team of HeartRescue partners who continue to collaborate by sharing best practices for treatment of cardiac arrest and researching new and innovative approaches. 

The HeartRescue Project’s ultimate goal is simple: to save more lives and improve public health. Their work is cut out for them, as more than 350,000 people experience SCA in the United States every year, and fewer than 10% survive. 

Creating Systems of Care

As a founding member and codirector of SaveMIHeart, Neumar has worked with his team to examine and improve four distinct aspects of cardiac arrest care: bystander CPR, 9-1-1 dispatch, EMS response and postarrest hospital treatment. These four components make up the all-important system of care.

Each of these important steps in some way relies on the others; none of them will succeed if they aren’t working in concert. Identifying best practices, performing quality improvement (QI) and providing guidance for individual communities within the state are ways Michigan can measure and improve outcomes, according to Neumar.

“We need to figure out how to best optimize the system of care to implement the science we know works,” he says. “Even if we design or discover new therapies, if we plug them into a system of care that’s not functioning optimally, we will not see improved outcomes.”

Improving the rate of bystander CPR. Shields uncovered noteworthy data on Michigan’s bystander CPR rates: Only about 40% of SCA victims get it, though research indicates it’s one of the most critical links in the chain of survival. Michigan wants to raise that rate to 50% or more.

Last year the state enacted legislation mandating CPR and AED education in high schools. In addition, SaveMIHeart created an award-winning public service video about hands-only CPR and showed it to more than 100,000 fans at two University of Michigan football games. The lighthearted video, which has also been viewed more than 150,000 times on social media, features a tailgate party where an SCA victim receives bystander CPR while the school’s marching band plays the University of Michigan fight song—which happens to be at the standard CPR rate of 100 beats a minute.

“SCA victims who receive immediate bystander CPR before EMS arrives have an increased chance for survival,” Shields says.

Within Dunne’s Detroit East Medical Control Authority, SCA survival rates had been some of the lowest in the nation. Dunne willingly shared and published this fact and admits existing approaches weren’t working—so he made changes.

When Dunne and his colleagues mapped data on bystander CPR and identified areas in Detroit with a high incidence of SCA and low incidence of CPR, they knew exactly where to target their training. Now, with grants from FEMA and the American Heart Association, teams are going into the community to teach hands-only CPR in addition to installing smoke and carbon monoxide detectors. AmeriCorps volunteers in the Detroit area have distributed more than 500 CPR kits, and Dunne often joins these home visits.

“It’s one of the most fun things I get to do,” he says.

Harkins knows the value of measurement and improvement. As program manager for Minnesota’s HeartRescue initiative, she appreciates EMS agencies with leaders like Dunne who don’t let the stigma of reporting less-than-impressive data get in the way of what is important.

“Once a HeartRescue Project member state begins engaging in data collection and making improvements, survival rates from SCA increase,” says Harkins. “You don’t know what you need to improve unless you measure it.”

Improving 9-1-1 dispatch and telephone CPR instructions. The SaveMIHeart leadership can proudly claim there are SCA survivors living happy and productive lives in Michigan because a 9-1-1 call-taker gave CPR instructions to a 9-1-1 caller. This success can be documented because Michigan, like all HeartRescue members, participates in the national Cardiac Arrest Registry to Enhance Survival (CARES) database; EMS agencies and hospitals that care for about 75% of Michigan’s population report data to CARES.

In her role as the state’s CARES coordinator, Shields analyzes the incidence of telephone CPR (TCPR) for the state. In Detroit Dunne has focused specifically on upgrading dispatcher training to achieve “hands-on-chest” within 30 seconds of a dispatcher recognizing cardiac arrest. Both Dunne and Shields praise Detroit’s leadership, including the mayor, for engaging in the effort to improve survival rates and seeing the value of TCPR and further training.

“The mayor’s office and city council have paid attention to this issue and to our needs,” Dunne says. “Call-takers are now asking more structured medical questions of 9-1-1 callers, and every one of our call-takers is trained in CPR instructions.”

Measuring and implementing high-performance CPR by EMS. The SaveMIHeart initiative has helped identify the challenges to improving SCA survival rates in the state, especially when it comes to training EMS providers. One of the tenets of the HeartRescue Project is that every community—rural areas and small towns, suburbs and urban centers—can implement the same best practices to improve survival.

At the same time, many HeartRescue partners have also recognized that the process of achieving those practices may look different depending on a community’s resources. SaveMIHeart leaders are focused on disseminating the lessons they and others have learned to all corners of the state, from the rural forests of the Upper Peninsula to downtown Detroit.

For example, an increase in CPR quality happens when EMS agencies take advantage of tools such as real-time CPR quality feedback devices. Indeed, for EMTs or paramedics, a critical skill like CPR is considered “high-risk, low-frequency,” meaning it’s a potentially lifesaving technique but one that may not be applied often.

One EMS agency in Alpena received FEMA support as well as grant funding intended to help rural EMS systems implement CPR feedback devices and train providers in high-performance CPR. Shields would like to see other EMS agencies do the same.

“We need to download the CPR performance data and debrief after the call is over,” she says. “This will help ensure quality CPR is provided during a resuscitation. All providers need feedback about their performance to improve for the next patient.”

Dunne continues to work on certifying more than 1,300 firefighters in the Detroit area as emergency medical responders (EMRs). These firefighters were not traditionally trained as EMTs or EMRs, and cardiac arrest victims were sometimes treated by as few as two providers. Now that number is often closer to six. 

“We’ve had two different cultures of providers in the past,” says Dunne. “These newly trained firefighters who are now medical first responders make our teamwork more seamless and integrated.” 

To help promote evidence-based practices in EMS response to cardiac arrest, the HeartRescue Project ensures that new partners attend a “resuscitation academy.” The academy, which began in Seattle, is intended for EMS managers and medical directors to learn how to measure and improve cardiac arrest response and outcomes in their communities. After attending an academy, HeartRescue partners commit to offering resuscitation academies in their states. The leaders of SaveMIHeart also host a one-day conference to bring together EMS and hospital providers from across the state. 

“The purpose of the annual conference is to come away with best practices we should be working on to achieve our goal of doubling survival by 2020,” Shields says. “We aim high. We set our goals high, and we reach for them.”

Improving in-hospital care of SCA patients. When an SCA victim arrives at the hospital after being successfully resuscitated, the short- and long-term treatment plans are critical to the patient’s outcome. While much has been studied about how to improve a cardiac arrest victim’s chance of meaningful survival, many unknowns remain. While others may be put off by this uncertainty, Dunne finds it energizing.

“I see how fast the science changes, even over the course of a few years of my initial training,” he says. “Cardiac arrest is a wide-open area of research that has a lot of possibilities for improvement.” 

Shields’ data collection efforts are key to informing physicians such as Dunne about performance and effective treatments. Shields, who has a background in cardiac and critical care nursing, uses this training and experience when she shares data with hospital caregivers looking for ways to improve survival for patients who regain a pulse after SCA.

“Are we withdrawing care too soon? What are the outcomes for patients who receive targeted temperature management or cardiac stents?” Shields says, describing the questions she and others are trying to answer about the impact of in-hospital interventions. “What is our level of optimal care?”

The HeartRescue Project focuses on collaboration among its partners so they can analyze information about how, when and where SCA patients are transported. These data will help EMS agencies make determinations about medical protocols, the use of mechanical CPR devices and hospital destination requirements.

Conclusion

None of these initiatives would succeed in Michigan without the leadership of dedicated people such as Dunne, Neumar, O’Neil, Swor and Shields. Together they are tackling a public health problem in their state by taking universal best practices and tailoring implementation efforts to their communities. The HeartRescue Project has given these visionaries access to a network of like-minded leaders in systems with the same goal: increasing survival rates from sudden cardiac arrest. 

The size and scope of an effort to double SCA survival rates may be daunting, but Michigan’s leaders are committed to success. Detroit happens to be one of the largest contributors to the CARES database in the country.

“If we are going to double the survival rate, a lot of the improvement has to come out of Detroit,” Dunne says.

With support from HeartRescue Project collaborators around the country, Michigan’s SaveMIHeart initiative can have a huge impact on residents’ lives by creating a system of cardiac arrest care that focuses on the ultimate outcome, Harkins says. “The big picture in our states is that we are seeing more SCA victims who are living instead of just surviving.” 

Sidebar: The HeartRescue Project

The HeartRescue Project (HeartRescueProject.com) launched in 2011 with support from Medtronic Philanthropy. It brought together leading experts who all shared the belief that sudden cardiac arrest is a treatable condition and public health issue. Together these leaders from six states, as well as the communities served by American Medical Response (AMR), collaborated to share best practices and innovative approaches to achieving the project’s goal of dramatically increasing cardiac arrest survivor rates over five years.

With its recent expansion, the HeartRescue Project now includes both HeartRescue United States and HeartRescue International. With continued support from Medtronic Philanthropy, HeartRescue International is bringing some of the lessons learned from five years of the HeartRescue Project in the U.S. and applying them to communities in China, India and Brazil.

HeartRescue United States continues as a consortium of the original partners as well as several other states that have recently joined. These members have committed not only to collaborating but also to using the Cardiac Arrest Registry to Enhance Survival (CARES), a national database that allows them to measure and evaluate cardiac arrest processes and outcomes. Together these partners help support each other’s efforts to integrate their communities’ response to cardiac arrest, coordinate education of both the public and medical professionals, and introduce and apply best practices. In addition, many HeartRescue partners coordinate and support survivor groups—visit LifeAfterSCA.org to find out more.

Hilary Gates, MAEd, NRP, is program director for EMS World Expo. Reach her at hilary@emsworld.com.