Cardiac Arrest Registry to Enhance Survival (CARES)

Cardiac Arrest Registry to Enhance Survival (CARES) Bryan McNally, MD, MPH (Principal Investigator) Arthur Kellermann, MD, MPH (Co-investigator) Allison Park, MPH (Program Coordinator) Travis Maiers, BA (Data Analyst) May 9, 2008

INTRODUCTION Out-of-hospital cardiac arrest (OHCA) is the leading cause of death among adults in the United States and Western countries. It is estimated that approximately 300,000-400,000 deaths occur every year. Most of these deaths are due to a fatal heart rhythm disturbance called ventricular fibrillation. Nationally, few communities actively monitor and report their survival rates from OHCA. The range of survival in these communities for ventricular fibrillation is anywhere - from 2% to 35%, a striking difference, since the approach to the care of these patients is uniform and there is no evidence that patients in one part of the country are different biologically from another. The CARES (Cardiac Arrest Registry to Enhance Survival) Program is a collaborative effort of the Centers for Disease Control and Prevention (CDC), the American Heart Association (AHA) and the Emory University Department of Emergency Medicine, Section of Prehospital and Disaster Medicine. The CDC and the AHA are working together to reduce the death rate from heart disease and stroke by 25% from the years 2000-2010. One of the CDC s initiatives is to develop a model national registry to accurately measure our progress in the treatment of OHCA. Using the Utstein style of statistics for OHCA, CARES is capable of identifying and tracking all cases of cardiac arrest in a defined geographic area. The ultimate goals of CARES is to help local EMS administrators and medical directors identify who is affected, when and where cardiac arrest events occur, which elements of the system are functioning properly and which elements are not, and how changes can be made to improve cardiac arrest outcomes. CARES utilizes an internet database system that reduces time involved in registering events, tracking patient outcomes with hospitals, and response intervals associated with First Responders and EMS providers. Multiple reporting features can be generated and monitored continuously through secure online access by CARES participants and allow for longitudinal, internal benchmarking. Presently, the odds of surviving an episode of out of hospital cardiac arrest in the United States vary by a factor of 10 to 20, depending on the community in which it occurs. Disparities in outcome this extreme are unacceptable and are what the CARES project will be able to identify and allow communities to improve upon. As more communities participate in CARES, confidential, external benchmarking can occur between similar systems across the United States. Participating cities include Atlanta (GA) - including Georgia EMS Region III, Kansas City (MO), Anchorage (AK), Raleigh-Durham (NC), Austin and Houston (TX), Cincinnati and Columbus (OH), Nashville (TN), Boston (MA), Tucson (AZ), and Baytown (TX). CARES is expanding to approximately 10 to 15 other communities within the next year. Please refer to the CARES website (https://mycares.net) for more information on the program. Do not hesitate to contact the CARES staff (cares@emory.edu) for additional questions and updates.

Cardiac Arrest Registry to Enhance Survival (CARES) OPERATIONAL OVERVIEW Overview The goal of the CARES program is to establish a model surveillance registry unifying all essential data elements from three, independent sources, which currently record fractured data of a single, cardiac arrest event. CARES is building this model by establishing a relationship with emergency medical services (EMS) agencies, hospitals, and computeraided dispatch (CAD) systems. Through these sources, access to specific data elements and participation allow for understanding of data flow and the ability to develop an efficient and automatic data collection and outcome reporting system. The collection and reporting system is provided by a restricted-access, secure, internet database developed by Sansio/Scanhealth, Inc. and managed locally by the CARES program staff. All participants can view their individual statistics and de-identified, community-aggregate statistics. EMS agencies EMS providers initiate a CARES event based on criteria set forth initially by the project coordinator and the data dictionary. A contact person at each EMS agency (CARES liaison) ensures adherence to the criteria and provides routine communication with the project coordinator for issues, concerns, and questions. The data can be submitted in three ways: completion of an optically scannable CARES form, direct entry into the website database, or exporting electronic data from field software programs. Hospitals Hospitals receive notification to provide outcome data through an email, which is automatically generated by the database. The hospital dataset consists of four basic questions which include emergency department outcome, hospital outcome, disposition location, and neurological status at time of discharge. Through establishing a relationship with the hospital, orientation to the project and website was conducted, HIPAA concerns were addressed, and adequate identification of patients within their system was obtained. CAD system CAD data is collected through automatic export/import and/or direct entry into the website database. Once contact and agreement is made with each CAD system administrator, time elements are sent and/or entered after matching the event based on date, approximate time, and location of the event. In various combinations, multiple CAD systems provide response times for EMS and First Responders. All event and First Responder information is identified by EMS during the initial CARES report. Summary The ultimate goal of CARES is to improve survival for out of hospital cardiac arrest. Using the internet as a data collection tool, CARES links three separate silos of data (911, EMS, and hospital) to create a single record for a cardiac arrest event. CARES allows a participating agency to both internally benchmark their cardiac arrest performance and also externally benchmark against a national dataset.

CARES Current Sites & CARES Focus Sites (2008-2009) Portland Anoka Reno San Francisco Contra Costa Santa Clara Denver Colorado Springs Sioux Falls St. Cloud Kansas City Oakland County Cleveland Columbus Indianapolis Champaign Cincinnati Hershey Boston Springfield Philadelphia Washington DC Richmond Hampton Roads San Diego Ventura Las Vegas Phoenix Tucson Memphis Nashville Atlanta Durham Raleigh Charlotte Plano Honolulu Austin Houston Baytown Anchorage KEY Current Sites Focus Sites Miami

Importance of Data Elements and Linkage to CARES CAD System Provides accurate response intervals by using: 911 Call Received First Responder dispatch EMS dispatch First Responder arrival EMS arrival Computer Interface EMS Likely phase of survival Date and time of event Location type Bystander interventions Etiology of event Rhythm analysis (Utstein) IDs CAD, First Resp, and Hospitals involved w/ event Patient Care Report Hospital Completes Utstein report by providing: Survival to Discharge Report transferred patients Neurological status Manual entry Automatic computer entry by data extract Optically scannable form* Desktop data entry Laptop electronic patient care report entry ** CARES Event (Cardiac Arrest) Email reminder to promote data entry Secure HIPAA compliant site for data entry Integrates each identified occurrence Streamlines data collection process Provides meaningful outcome statistics in report format Reports include survival rates, demographics, response times and bystander intervention Allows for both confidential internal/external benchmarking Query tool to ensure compliance with data reporting methods * Scannable form self populates the registry ** Direct interface between electronic patient care report and CARES registry

CARES NETWORK

Part A : Non - HealthEMS Users start here, otherwise skip to part B 1 - Street Address (Where Arrest Occurred) Cardiac Arrest Registry 1 - City 1 - State 1 - Zip Code 2 - First Name 3 - Last Name 4 - Age First Responding Agency Arrest Information 14 - Location Type Home/ Residence Recreation/Sport Public Building Industrial Place Street/Hwy Farm Nursing Home Mine / Quarry Residence/Institution Physician Office/Clinic Jail Educational Inst. Airport Hospital Other Resuscitation Information 18 - Resuscitation Attempted by EMS Yes No 23 - First Arrest Rhythm of Patient Ventricular Fibrillation Ventricular Tachycardia Asystole Idioventricular/PEA Unknown Shockable Rhythm Unknown Unshockable Rhythm 5 - Date of Birth 6 - Gender Male 13 - Time of 1st CPR 13 - ROSC Time : : 20 - Who Initiated CPR Bystander Bystander Family Member First Responder Fire/Police Responding EMS Personnel Medical Provider Other Days Months Years Part B : To be completed by all Users 7 - EMS Agency ID 8 - Date of Arrest / / Hospital Destination 11 - Fire/First Responder 12 - Destination Hospital 15 - Arrest Witnessed First Cardiac Arrest Rhythm of Patient and ROSC Information 24 - ROSC Yes No 25 - Sustained ROSC Yes No 13 - EMS Notified : : Witnessed Arrest Unwitnessed Arrest First Cardiac Arrest Rhythm Strip (Apply with ScotchTape on Top and Sides) Female Yes No 21 - Was an AED Used During Resuscitation Yes No AED Present but not Used AED Malfunctioned # 0f AED Shocks # 0f Manual Shocks 9 - Call # Dispatch Times 16 - Arrest After Arrival of EMS 13 - CPR Stopped/Termination Time : 26 - Out of Hospital Disposition Resuscitation not initiated at scene due to obvious signs of death, DNR, resuscitation considered futile, or resuscitation is not required Resuscitation terminated at scene due to medical control order, protocol/policy requirements completed Transported to Hospital with or without ROSC 28 - Race/Ethnicity American-Indian/Alaska Asian Black/African-American 10 - Booklet ID (HealthEMS Users Only) 13 - EMS Arrived at Scene : : Hispanic/Latino Unknown Native Hawaiian/Pacific Islander White 17 - Presumed Cardiac Arrest Etiology Presumed Cardiac Etiology Trauma Respiratory Drowning Electrocution Other 13 - Time of 1st Defibrillation : 22 - Who First Applied Monitor/Defibrillator, AED Not Applicable Bystander Bystander Family Member First Responder Fire/Police AED EMS AED or Monitor/Defibrillator ALS First Responder Monitor/Defibrillator 27 - End of the Event Dead in Field Pronounced Dead in ED Ongoing Resuscitation in ED Don't Attach Below this LIne SH3001 (1 of 1), Rev 3, 04/06 Copyright 2006 ScanHealth, Inc. (Page 1)

- Utstein Survival Report National Date of Arrest: From 10/01/2005 Through 05/09/2008 - - May 09, 2008 2000-2008 Sansio. Sansio - mycares 1 of 3

- Utstein Survival Report National Date of Arrest: From 10/01/2005 Through 05/09/2008 - - May 09, 2008 2000-2008 Sansio. Sansio - mycares 2 of 3

- Utstein Survival Report National Date of Arrest: From 10/01/2005 Through 05/09/2008 - - May 09, 2008 2000-2008 Sansio. Sansio - mycares 3 of 3

Demographics Sample Data

911 to EMS Arrival Sample Data

911 to EMS Dispatch Sample Data

EMS Dispatch to Arrival Sample Data

Atlanta becomes a template for improving EMS By Robert Davis, USA TODAY When Atlanta's emergency medical system needed rescuing, Mayor Shirley Franklin started performing CPR in more ways than one. In 2003, she started issuing orders that have resulted in lifesaving changes to Atlanta's emergency system. She began looking for ways to hold emergency crews more accountable, and last year she ordered all 8,000 city employees including herself to be trained in cardiopulmonary resuscitation. "All you need to do is save one life and it's worth it," Franklin says. "It's miraculous." Thanks to those efforts and a program created in Atlanta by Emory University and the Centers for Disease Control and Prevention, the city is saving more residents who collapse of sudden cardiac arrest. Since September 2005, the survival rate for such patients in Atlanta has jumped from less than 3% to 15%. That's well above the 6% to 10% survival rate for most cities that was identified in a 2003 analysis by USA TODAY. Atlanta's success has made it, and the program it's following, a template for cities trying to improve cardiac-arrest survival rates, an often murky set of figures complicated by communication problems among government agencies. Several cities including Houston, Anchorage, Austin, Cincinnati, Kansas City, Mo., Raleigh, N.C., and Tucson are following in Atlanta's footsteps by signing up for the Emory/CDC program. It allows cities to use its Internet database to combine data from 911 dispatch centers, paramedic run reports and hospital discharge records to reveal more about the performance of EMS units widely viewed as a key step in improving cardiac survival rates. Many cities have no system to effectively track such rates. A few cities in the program or planning to join it were identified in the USA TODAY report four years ago as having particularly good systems for tracking emergency crews' performance. Those include Houston, Kansas City, Tucson, Boston, Nashville and San Francisco. Other cities taking part or planning to such as Atlanta, Austin and Columbus, Ohio were identified as having less-than-stellar systems for tracking cardiac survival rates. The program known as Cardiac Arrest Registry to Enhance Survival, or CARES is a fiveyear, $1.5 million CDC project launched three years ago. It was partly inspired by the USA TODAY investigation, which found that emergency medical systems in most of the nation's 50 largest cities were fragmented, inconsistent and slow. Why the focus on cardiac arrest survival rates and not those from something else, such as car accidents or cancer? Cities use cardiac arrest survival rates as a key measure of EMS performance because such victims typically live or die depending on the care they get in the first minutes after collapse, unlike other emergencies in which survival hinges more on hospital care. "The system has to deliver in order to save a cardiac arrest victim," says Arthur Kellermann, an emergency physician at Emory University School of Medicine. "If it can deliver in a consistent manner for cardiac arrest victims, there is every reason to expect that it will deliver for trauma victims, asthma victims, women in labor." More than 250,000 people die outside of hospitals each year when their hearts stop beating. Many are reaching the natural end to battles with disease, but others are healthy when struck by

an electrical short circuit of the heart called ventricular fibrillation. "V-fib" can be caused by anything from a blocked coronary artery, to a ball striking the chest, to changes in the heart muscle from an infection. In 2003, USA TODAY found disparities in emergency medical care across the nation, and said cities that carefully track their EMS performance save many more lives. In most cases, such cities also make a point of teaching residents CPR by, among other things, sending firefighters into homes, churches or businesses to train people. The reason: If a bystander or acquaintance can quickly perform CPR when a person is stricken with cardiac arrest, they can buy the victim precious time before emergency personnel arrive. Businesses also are encouraged to have defibrillators and people trained to use them so victims can be shocked if rescue crews can't arrive quickly. Bryan McNally, the emergency physician from Emory Healthcare who heads CARES, told an EMS conference in February that the impetus for the program included USA TODAY's finding that a lack of data regarding EMS responses to cardiac arrest victims is a "major obstacle to improving pre-hospital emergency cardiac care." Atlanta's huge challenge Franklin says she learned from USA TODAY's report that Atlanta was losing more than 10 times as many cardiac arrest victims as cities such as Boston, Seattle and Rochester, Minn. The newspaper's analysis ranked cities' EMS efforts in three tiers, with Atlanta's in the bottom tier of cities that had no idea how many lives their rescue units were or were not saving. "Shirley Franklin was furious to see Atlanta as a 'Class C' city," Kellermann says. "She felt it should be in the first tier." When Franklin took a closer look, what she saw was grim. From August 2005 through March 2006, her city saved only one person considered by doctors to be among the "most saveable" victims of sudden cardiac arrest. They were deemed saveable because people saw them collapse, and what the victims needed was to be treated quickly with a defibrillator shock to restore their heart's rhythm. USA TODAY found that in such cases, life and death usually is decided within six minutes of an attack. If the heart is not restarted by then, brain damage can be so severe that the victim is not likely to wake up, even if he or she survives. "It became really clear to us when we looked at the statistics that the availability of trained personnel close by when somebody is experiencing cardiac arrest can save a life," Franklin says. She vowed to do more to help the city improve, including enrollment in CARES. It's paying off. From September 2005 through July 2007, months in which the city has tracked its performance using CARES, 10 of 66 cardiac arrest victims in the "most saveable" category survived with normal brain function. Atlanta's 15% survival rate is a dramatic improvement, but still well behind leading cities such as Boston, where the survival rate for such cardiac patients is 38%. One patient's good fortune

The response to save 69-year-old Ronald Williams on May 21 shows how the Atlanta area's system is still moving too slowly to save a life without help from bystanders. Williams, of Tucker, Ga., was undergoing a stress test in his cardiologist's office when his heart went into V-fib. The medical staff called for help, began CPR and delivered a shock with a defibrillator. The call for help went first to a 911 center, then to fire department rescuers from Sandy Springs, an Atlanta suburb. By the time paramedics reached Williams and delivered a second shock with their defibrillator, nine minutes had passed since he had gone into arrest. Williams says he's lucky he was in his doctor's office. "It could have happened anyplace," says the retired aerospace technician, whose blocked arteries were cleared in a hospital after he was revived. Jing Fang, a physician and researcher in CDC's Division for Heart Disease and Stroke Prevention who is technical director for CARES, says the program ultimately should help save more people like Williams. Using the system's database, city leaders can track how many cardiac arrest victims their crews tried to save, how many of the victims had their hearts restarted in the field, and how many went home from the hospital with good brain function. The leaders also can see how many victims got help before rescuers arrive. By seeing how each part of the system performed, EMS leaders say they can determine what improvements are needed. The CARES program allows cities to tell how their crews are performing compared with others in their region and, soon, to the other cities participating nationally. Some cities that are struggling to determine their cardiac arrest survival rates are not in CARES. In Dallas, officials see CARES as "valuable and laudable," but they are creating their own system to track cardiac arrest survival, says Marshal Isaacs, medical director for the city's fire and rescue units. He says the system could be in place next year. In Chicago, Philadelphia, El Paso and San Diego, medical directors report having problems getting hospitals to share data on patient survival rates. Jim Dunford, medical director for San Diego's EMS, says a law is needed to force cooperation. "How can it be that the No. 1 killer of Americans remains heart disease and we still can't accurately measure outcome from cardiac arrest?" he asks. El Paso's EMS medical director, James "Randy" Loflin, says his city is unable to track survival rates because "hospitals tell us they can't share survival data due to HIPAA," a federal law that protects patient privacy. CARES was designed to share data while complying with the law, McNally says. 'Community response' is key When Atlanta started crunching its cardiac arrest survival numbers, it became clear that when rescue crews reached a patient, there often were people standing around, unsure how to help. Only 7% of the city's cardiac arrest victims were getting CPR from bystanders when the CARES program was introduced. Houston, Tucson and other cities that save the most lives in such situations have raised their CPR rates for bystanders through training programs and by having

911 dispatchers give simplified CPR instructions over the phone. Chest compressions alone even without mouth-to-mouth breathing can buy minutes for a cardiac arrest victim until rescuers arrive. "It's not just about streamlining or improving the professional response, it's also about the community response," McNally says. "What is happening before the ambulance or first responders get there? Are people doing CPR?" When Franklin told city employees to get CPR training, she says, "each of us took a pledge that we would train others." Atlanta's bystander CPR rate has more than doubled to more than 17%. To give an idea of how far Atlanta has to go to catch up with cities that save the most lives, McNally cites bystander CPR rates of 30% to 40% and higher in places such as Seattle and Boston. "A lot of us think the only solution is a doctor," Franklin says. "Having a trained workforce is part of the solution."

Atlanta becomes a template for improving EMS Editorial Four years ago, in a special report headlined "Six minutes to live or die," USA TODAY reporter Robert Davis documented how emergency medical services in most of the nation's 50 largest cities were fragmented, inconsistent and slow. He described case after case in which heart attack victims who might have been saved in one city died or suffered brain damage in another, simply because CPR wasn't delivered within that critical six minutes. Davis discovered a critical difference between successful cities, most notably Seattle, which had a remarkable "save" rate of 45% in the year studied (2001), and those like Atlanta, which had no idea how poorly it was doing and only later discovered that it saved an abysmal 3%. Most important, Davis found that the top performers had systems that any city could replicate. In failing cities, meanwhile, emergency services were chaotically managed with little accountability. (Photo Franklin: Atlanta s mayor has improved city s EMS program. / The Atlanta Journal- Constitution) Though good journalism can point the way toward saving lives, change requires official action and commitment. In a follow-up story this week, Davis reported how Atlanta Mayor Shirley Franklin responded. The city's performance has improved fivefold since 2005. Franklin's actions should be a template for lagging cities such as Washington, New York, Nashville, Los Angeles and Chicago. The two key ingredients: * Accountability. A system that works overcomes the all-too typical problem illustrated by the case of baggage handler Andrew Redyk, 64, who died at Los Angeles International Airport after he had a heart attack in 2001. Emergency crews took almost half an hour to reach him, but officials couldn't know that from their data. It listed the response time as six minutes. Atlanta is now one of a handful of cities participating in the Cardiac Arrest Registry to Enhance Survival (CARES), launched three years ago by Emory University and the Centers for Disease Control and Prevention. CARES is a central database that collates information from 911 centers, paramedic run reports and hospital discharge records. The database provides the kind of tracking that can help leaders see problems. CARES designates officials to be responsible for entering the data and pushes them to complete it. City officials can track how their emergency services are doing and compare them with other cities that have signed up. In Chicago, Philadelphia, El Paso and San Diego, by contrast, medical directors report problems getting hospitals to share information on survival rates. * Leadership. Franklin is aggressively pushing solutions when weaknesses are identified. One example borrowed from Seattle: training more ordinary citizens in CPR, boosting the chances that

bystanders can help before medical teams arrive. Last year, Franklin ordered all 8,000 city employees, including herself, to be trained in CPR. She has more than doubled the rate at which bystanders give help, from 7% to 17%. Cities like Seattle or Houston, with the highest "save" rates, go even further, finding creative ways to ingrain CPR training in people's lives. These include CPR training in schools, making CPR mandatory for some professions and streamlining training. Their bystander CPR rates exceed 40%. And, of course, successful cities force coordination, ending turf fights like those that commonly exist between emergency services and fire departments. The bottom line is that if other cities follow Atlanta's template, improvements are guaranteed. Lives can be saved more than 1,000 each year in the nation's biggest cities. As Franklin noted, "All you need to do is save one life, and it's worth it. It's miraculous."

Our EMERGENCY Year of Publication Volume XXX, Number 2 February 2008 www.em-news.com MEDICINE NEWS EMERGENCY MEDICINE S ONLY INDEPENDENT NEWS MAGAZINE PERIODICALS CARES Program Working to Improve Cardiac Arrest Survival By Ruth SoRelle, MPH If you had to have a heart attack, Atlanta may be the best place to do it. Since June 2006, when the American Heart Association began its Restart Atlanta s Hearts, nearly 34,000 Fulton County residents have been trained in cardiopulmonary resuscitation. Add to those another 1,292 people who are trained in the Heartsaver/Automated Electronic Defibrillator program and the 52 AEDs that have been placed at 29 sites over those 18 months, and you may have a new rival to Seattle s legendary cardiac survival rate. Propelling this unprecedented activity in Georgia is the need to improve survival from out-of-hospital cardiac arrest buttressed by the Cardiac Arrest Registry to Enhance Survival (CARES), a combined effort of the U.S. Centers for Disease Control and Prevention, the Emory University Department of Emergency Medicine s Section of Prehospital and Disaster Medicine, and the American Heart Association. Already, several large U.S. cities contribute information to CARES. Included in the registry or soon to be included along with Atlanta are Boston; Columbus and Cincinnati, OH; Louisville, KY; Raleigh-Durham, NC; Nashville, TN; Kansas City, MO; Austin and Houston, TX; Tucson, AZ; and San Francisco. The five-year project, funded with $1.5 million, is designed to put some order in the mishmash of reporting cardiac arrest data to help individual communities identify and correct their own deficiencies. It By Anne Scheck When two scientists filed a patent application for contrast enhancement in nuclear magnetic resonance imaging more than 20 years ago, they cited the reduced burden of toxic contrast material as an unprecedented advantage for the new and improved compounds. One of them was gadolinium. Now, however, the very agent that inspired so much optimism back then is the subject of a boxed warning by the U.S. Food and Drug Administration. Gadolinium-based contrast agents have been linked with a rare but tragic side effect nephrogenic systemic fibrosis is already having an effect in Atlanta, said Mike Willingham, CCEMT-P, the EMS community relations director of the American Heart Association. Restart Atlanta s Hearts would not be possible without the CARES registry cooperative between Emory University and the Centers for Disease Control and Prevention, he said. We use the basic Continued on page 10 FDA Orders Boxed Warning on Gadolinium when used in MRIs for patients with acute or chronic severe renal insufficiency, renal insufficiency due to hepatorenal syndrome, and in liver transplant patients in the perioperative period. However, gado, as radiologists call it, is only one imaging agent to make headlines recently. In the past few months, findings linked a possible heightened cancer risk to radiation dosing for CT, results that were published in November in the New England Journal of Medicine (2007;357:2277), and reports that iodinated contrast agents used in CT cause more allergic reactions than those utilized for MRI. Other accounts Continued on page 8 Vincent Giarrano IN THIS ISSUE LETTERS..................3 VIEWPOINT...............4 QUICK CONSULT...........8 INFOCUS................11 ID ROUNDS..............16 TOXICOLOGY ROUNDS......20 LEGAL NOTES.............20 LEARNING TO LIVE........23 WITH THE LLSA CAREER SOURCE..........26 CLASSIFIED..............28 CME in every issue! InFocus See p. by James R. Roberts, MD This Month: The Medical Effects of TASERs Learning to Live with the LLSA See p. by Daniel K. Mullin, MD This Month: Children and Brain Injuries; Women and AMI; Trauma and Pregnancy 11 23 The only independent emergency medicine publication with CME!

10 EMN February 2008 N e w s CARES Continued from page 1 dataset from CARES to determine our number of cardiac arrests, bystander CPR rates, bystander AED rates, and overall survival rates. We would not be able to fund or coordinate this effort without these measurable data. It is critical also that CARES measures patient survival to discharge, allowing us to realize true saves from sudden cardiac arrest. Bryan McNally, MD, MPH, an assistant professor of emergency medicine at Emory, is the heart of CARES, said Arthur Kellermann, MD, MPH, the chair of emergency medicine at Emory and a co-leader of the project. When Dr. McNally began the project in 2004, statistics describing survival rates from cardiac arrest nationwide were a hodgepodge. While many communities over the past 20 years have developed a variety of methods for reducing the time between an individual s collapse and the start of CPR and eventual defibrillation, few communities monitor how well these strategies work. Those who do found that survival rates vary widely by factor of 10 or more. Without a way to evaluate the four critical links that make up the chain of survival immediate notification of EMS, rapid provision of CPR, early defibrillation, and swift provision of definitive care improvement is almost impossible. Basically a national report would allow for several things, said Dr. McNally. It would report Utstein survival [an international definition of survival for cardiac arrest] in the participating communities. Each community has access to its own data, and can compare them to a general report as a benchmark. Silos of Data CARES has three stores of data, Dr. McNally said. The idea is to link the three silos: computer-assisted dispatch data, EMS data, and hospital and final disposition data. Software developed by Sansio makes the information available through a secure web site, and streamlines bringing the different datasets together. Computer-assisted dispatch systems automatically export or directly enter data into the CARES web site database, he said. The time the call is received and the dispatch and arrival times for EMS or first responders are logged. Questions Asked about MI Patients Did the patient arrive in the emergency department? Where was the patient treated in the hospital? What was the patient s final disposition? What is the patient s neurological status? Convincing EMS officials that data could be collected to comply with the federal Health Insurance Portability and Accountability Act of 1996 took time, Dr. McNally said. EMS can enter data in three different ways, one of which is by scanning it optically after the run and then having it digitally scanned. It automatically fills out the web form after the scan. The web-based system allows EMS personnel with a password to enter the data from any web site, he said. EMS systems with laptops work with CARES personnel to help integrate the CARES data into the electronic medical record. Then the information can be downloaded to the registry daily. Continued on page 15

N e w s February 2008 EMN 15 CARES Continued from page 10 Each hospital involved in the project has a point person who answers four questions about each cardiac arrest patient: Did the patient arrive in the emergency department? Where was the patient treated in the hospital? What was the patient s final disposition? What is the patient s neurological status? The beauty is that a lot of definition has been worked out beforehand, Dr. McNally said. We are collecting data in the same way on the same platform during the same time period. We want to develop a model for a national cardiac death registry so we can compare apples with apples. We want to develop a model for a national cardiac death registry so we can compare apples with apples. Dr. Bryan McNally Data on more than 4,500 patients have been entered into the system so far, and Dr. McNally plans to publish a report on the audited results as soon as possible. More importantly, however, individual systems can look at their own data, compare it with the national numbers, and figure out ways to strengthen their own systems. As Dr. McNally contemplates the end of funding for the project, he hopes to find ways to continue improving the quality of care for out-of-hospital cardiac arrest a continuous process. We are excited about it growing, he said. We think we are in a position to see it grow even more and become a sustainable model. Mr. Willingham is even more optimistic. The American Heart Association considers CARES to be the national model to collect and analyze data from cardiac arrest events. We are assisting in the implementation of CARES nationwide. Dr. McNally and the CARES staff have been critical in the improving survival rates in Atlanta and the future sites of the AHA Restart program, he said. Comments about this article? Write to EMN at emn@lww.com. We would not be able to fund or coordinate this effort without these measurable data. Mr. Mike Willingham The registry looks at other responses as well, he said. Are people doing bystander CPR? Was an AED used? With 70 percent of cardiac arrests occurring at home, you would expect an AED to be available then. Those data are already having an effect, he said. The AHA Restart Atlanta s Hearts initiative is helping train people to use AEDs and also to pinpoint the spots in the community where they would have the most effect. The program also educates the public on the importance of dialing 9-1-1 when a person is in cardiac arrest and starting CPR immediately, he said. Atlanta has used information on the time between calling 9-1-1 and arrival of EMS to change its system for dispatching ambulances, he said. Previously, the central dispatcher with the police department in Atlanta called Fulton County, which then dispatched the ambulance out of Grady Memorial Hospital. Now, the police call Grady EMS directly, he said. It saves minutes, and in a year, they will be able to determine the effect on survival time. Letters to the Editor Emergency Medicine News encourages an open exchange of ideas, and welcomes your comments. Please address correspondence to Lisa Hoffman, Editor, Emergency Medicine News, 333 Seventh Ave., 19 th Fl., New York, NY 10001; emn@lww.com.