The article titled “30 minute CPR protocol raises issues” published in several of your publications on December 28 provides the reader with inaccurate and incomplete information.
Contrary to what was stated, there was “consultation over the protocols with the hospital community.” The composite of the Ambulance Service Advisory Board (ASAB), which approved the 2017 RI Statewide EMS Treatment Protocols, includes, but is not limited to representatives from the Hospital Association of RI, the RI Chapter of the American College of Emergency Physicians, the RI Medical Society, the RI Chapter of the American College of Surgeons, and the RI Chapter of the American Academy of Pediatrics. In addition, Dr. Kenneth Williams, MD, FACEP (attending physician RIH ED) is a member of the ASAB and serves as the Medical Consultant to the RI Department of Health, Center for Emergency Medical Services. All full ASAB and subcommittee meetings are open to the public, with the exception of Medical Affairs Committee meetings in which disciplinary complaints involving EMS providers are adjudicated.
Additionally, the Acute Ischemic Stroke Protocol was drafted by the RI Stroke Taskforce, chaired by Arshad Iqbal, MD who is director of the Stroke Program at Kent Hospital (Dr. Dacey is the president and chief operating officer of Kent Hospital). Membership on the RI Stroke Taskforce also includes representatives from other RI hospitals.
The 2010 and 2015 Emergency Cardiac Care (ECC) Guidelines published by the American Heart Association (ECC guidelines are published every 5 years) recognize and emphasize the importance of minimally interrupted high quality cardiopulmonary resuscitation (CPR) and the timely delivery of defibrillation.
The inferior quality of CPR performed in a moving ambulance is documented in the medical literature. Pauses in compressions, inadequate compression rate and depth, and failure to allow for chest recoil on the upstroke of a chest compression all negatively affect the quality of CPR. All of these factors are associated with patient movement and transportation. This is recognized in these guidelines, which state “Because of the difficulty in providing effective chest compressions while moving the patient during CPR, the resuscitation should generally be conducted where the patient is found.” Performing on-scene resuscitation is in alignment with this recommendation. Readers should also note that the non-trauma related cardiac arrest never fell into the “scoop and run” category and that under the current (old) RI EMS Cardiac Arrest Protocol, providers are not prohibited from providing 30 minutes (or greater) of CPR and other resuscitative efforts on scene prior to transporting a patient in cardiac arrest.
Evidence suggests survival is 10 to 35 times more likely if return of spontaneous circulation (a sustained pulse) is achieved in the field. In a study published in 2010 that examined data from 79 studies involving 142,740 out of hospital cardiac arrests (OHCA), the most powerful criterion associated with survival was return of spontaneous circulation in the field.
Evidence also suggests that survival without neurologic disability is also possible following prolonged resuscitation in the field. For example, after the Wake County EMS system (WCEMS) in North Carolina changed their system protocols emphasizing high quality CPR and not moving the patient (EMS providers in WCEMS initiate resuscitation in the field and do not transport the patient unless there is return of spontaneous circulation i.e. a sustained pulse), the survival rate for cardiac arrest patients increased by 48%. WCEMS researchers reviewed the data from 2,905 OHCA within the (WCEMS) system that occurred after the protocol changes. They noted that the amount of time spent on-scene by EMS providers attempting to resuscitate patients in cardiac arrest increased. The median duration of resuscitation (DOR) was 38 minutes, with the median DOR for survival without neurological disability was 24 minutes. The 90th percentile for survival without neurologic disability was 40 minutes. In a paper recently published in the Journal of the American Heart Association, researchers analyzed the records of 17,238 patients with OHCA. For patients who survived without neurological disability, the critical time spent performing CPR in the field for patients with heart rhythms possibly responsive to defibrillation was 35 minutes and 42 minutes for patients with no heart rhythm (i.e. asystole aka “flatline”). The Salt Lake City Fire Department recently published data following implementation of a multifaceted cardiac arrest protocol, which included several American Heart Association best practices for the resuscitation of patients in cardiac arrest (all of which are emphasized in the new RI EMS cardiac arrest protocol). This protocol also included a directive for on-scene resuscitation (versus early transport) to avoid interruptions in CPR attributable to patient movement and transport. No upper time limit was given for the duration of CPR in the field, but it was suggested that at least 30 minutes of CPR be performed on scene. Similar to the results in the WCEMS system, implementation of the protocol in Salt Lake was associated with improved survival without neurologic disability.
Additionally, research has also identified cases in which CPR performed for greater than 30 minutes in the field may be beneficial. Some of the indicators used to identify these cases include the patient’s heart rhythm, episodes of temporary response during resuscitation, and the amount of carbon dioxide that is exhaled each time the patient is ventilated.
With regard to concerns attributed to a local fire chief related support in implementing the new cardiac arrest protocol, the Rhode Island Department of Health’s Center for Emergency Medical Services (CEMS) has provided multiple protocol updates for departmental EMS training officers, chiefs and EMS providers. CEMS has also released a comprehensive slide set covering changes in the new protocols. These slides are available to all RI EMS agencies and EMS providers. There is no specifically required education regarding the language directing 30 minutes of CPR on scene in the 2017 Cardiac Arrest Protocol. It is simply a directive to do CPR for 30 minutes on-scene. In most EMS services in RI, this likely no more 10-15 minutes longer than the period of time now spent doing CPR on-scene. For reader clarification, CPR is performed by two or more providers taking turns doing compressions in two-minute cycles.
As stated above, the new stroke protocol was drafted by the RI Stroke Taskforce, chaired by Dr. Iqbal who is director of the Stroke Program at a Kent Hospital, a facility that Dr. Dacey is the president and chief operating officer. Contrary to what was stated in the article, the stroke protocol does not direct that all stroke patients be transported to a comprehensive stroke center (CSC). This statement is inaccurate and misleading to the reader. The protocol directs that patients with a high probability for having a stroke related to clot in one of the large vessels of the brain (emergent large vessel occlusion) to be transported to a (CSC). This is because these types of strokes usually require mechanical intervention in addition to the administration of fibrinolytic (“clot busting”) medications. This type of mechanical intervention is only available at a CSC. A stroke is the brain equivalent to a heart attack and as such, timely treatment is required. In stroke, “time is brain” as “time is muscle” in a heart attack. Each minute that stroke passes, approximately 2 million neurons are lost!
Your office was provided with all of the above information and supporting medical research prior to publication of the article. We believe it was irresponsible and disservice to the lay public to not include discussion of the rationale or the prevailing research related to development of the cardiac arrest protocol. In the future, your paper should reach out to credible subject matter experts for comments on such matters.
The biggest factors in the successful resuscitation of patients who experience out of hospital cardiac arrest is the performance of bystander CPR and early use of an automated external defibrillator (AED). The authors encourage readers to take the time to learn CPR and to know where public access defibrillators are in their daily course of activities. Readers are also encouraged to learn the signs of stroke (FAST – Facial droop, arm weakness, speech difficulties and time).
John Pliakas and John Potvin are members of the Rhode Island Ambulance Service Advisory Board.
Editor’s note: As reported in the story published in the Dec. 28 edition, John Potvin could not be reached for comment and Jason Rhodes, chief of the Rhode Island Department of Health Center for Emergency Medical Services, said that the 25-member advisory committee that drafted the protocols included representation from the Hospital Association of Rhode Island. As for the protocol on stroke centers, Rhodes said, and as reported, the protocol is for patients to be transported to a comprehensive center. Rhode Island Hospital offers the only comprehensive stroke center in the state. Kent has a primary stroke center.