30-minute CPR protocol raises issues

EMTs to deliver 30 minutes of CPR before transporting cardiac arrest victims to a hospital

By John Howell
Posted 12/28/16

By JOHN HOWELL The Department of Health protocol requiring emergency response personnel to conduct 30 minutes of onsite CPR on those whose who have ceased breathing because of a heart attack has the director of Kent Hospital concerned - Warwick Mayor

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30-minute CPR protocol raises issues

EMTs to deliver 30 minutes of CPR before transporting cardiac arrest victims to a hospital

Posted

The Department of Health protocol requiring emergency response personnel to conduct 30 minutes of onsite CPR on those whose who have ceased breathing because of a heart attack has the director of Kent Hospital concerned – Warwick Mayor Scott Avedisian fearing the public won’t understand and Johnston Fire Chief Timothy McLaughlin critical of how the department has handled the new directive.

According to the Health Department, the new protocol along with revised protocols on stroke victims and the use of backboards for transporting patients take effect March 1. Jason Rhodes, chief of the Rhode Island Department of Health Center for Emergency Medical Services, described Warwick Fire as a “leader in the state.” The department started using the 30-minute CPR protocol on Nov. 1. According to Warwick Fire Chief James McLaughlin, the practice has already produced positive results with the resuscitation of two people suffering from cardiac arrest.

Dr. Michael Dacey, chief operating officer at Kent Hospital, doesn’t dispute the value of CPR, but he questions the long range outcomes of those not moved to a hospital sooner rather than later.

He said restoration of a heart beat may be viewed as a “win” when, in fact, because of the prolonged lack of blood flow to the brain, the patient could face lasting neurological damage. He said Kent has had “good neurological outcomes” with the use of Targeted Temperature Management (TTM) or therapeutic hypothermia, where the body is cooled down to as low as 93 degrees and then slowly raised. Time following resuscitation is critical to the therapy.

Dacey, who has worked the emergency department, said he had no knowledge of the new protocol until reading a story about Warwick’s use of 30-minute CPR in last Thursday’s Beacon. He said he knows of no consultation over the protocols with the hospital community and has asked for a meeting with the state.

He said his concern is that the initial care of cardiac arrest cases – there are 90 licensed ambulance and rescue units serving the state’s 39 cities and towns – is being given to people who may deal with two cases a year instead of those who may handle 30 cases. According to the protocol, the distance to a hospital makes no difference to the directive of 30 minutes of onsite CPR.

The protocol reads, “Regardless of proximity to a receiving facility, absent concern for provider safety or a traumatic etiology for cardiac arrest, resuscitation should occur at the location the patient is found. Resuscitative efforts should continue for a minimum of 30 minutes prior to moving the patient to the ambulance or transporting the patient.”

Rhodes said a 25-member advisory board that included four physicians and a representative from the Hospital Association of Rhode Island developed the protocols over 18 months. Additionally, he said the protocol is based on recommendations of the American Heart Association (AHA).

“You can’t do quality CPR in the back of a rescue,” Rhodes said.

AHA guidelines do not specify how long CPR should be administered. In an email, Michelle Karn, director of communications for the Rhode Island AHA, wrote, “The American Heart Association’s guidelines are treated like a road map when states such as Rhode Island decide to look at their own EMS protocols for improvement. The states ultimately make their own final decisions based on their resources and geography.”

Karn added that the Rhode Island Metro EMS Association sponsored a resuscitation academy to improve the quality of CPR being provided by the state’s EMS personnel.

“It was designed based on best practices from other states and the AHA’s 2015 guidelines,” she said.

John Potvin, from the East Providence Fire Department, who worked with the Rhode Island American Heart Association on the protocols, could not be reached for comment.

What if rescue personnel don’t follow the policy?

“If they choose not to follow they would be subject to discipline,” Rhodes said.

It’s not that Johnston Fire Chief Timothy McLaughlin doesn’t want to follow protocol; he feels the Health Department has done a poor job of communicating how the program is to work and training for it.

He said his 88-member department has started training, “but the roll out with the hospitals is horrible.” He said a half hour of CPR is a long time and he doubted many on the department could do it (Rhodes suggests responders tradeoff).

“They didn’t explain it and we’re stuck with it,” he said.

Chief McLaughlin (no relation to Warwick Fire Chief James McLaughlin) also shares the concern of Mayor Avedisian that family members and friends at the scene of a cardiac arrest wouldn’t understand why the patient isn’t being rushed from the scene. Avedisian imagines situations where anxious friends and family could interfere and even provoke an incident. He said Warwick Police are being informed of the protocol and are prepared to deal with such an adverse situation.

Warwick Fire Chief McLaughlin reports positive results using the 30-minute protocol. Department personnel have been trained. The Warwick department responds to about 16,000 incidents annually, of which about 12,000 are rescue related, he said.

Rhodes said Department of Health data shows an average of 700 cardiac arrest cases a year. He didn’t have data on how many of those cases survived.

“Besides having a hospital interest, I have a professional interest in this, too,” Dacey said. “We want to do the right thing for the patient.”

Dacey questions the directive that stroke patients be transported to a comprehensive stroke center. Rhode Island Hospital offers the only comprehensive center, whereas Kent has a primary center.

“We treat 200 [stroke] patients a year with great outcomes,” said Dacey.

Rhodes said a third new protocol discourages the use of backboards for transporting patients. As practiced now, EMTs will outfit a patient with a neck brace and strap them to a board for transport to a hospital. Rhodes said boards can be used for moving patients, but patients are more comfortable on a gurney than a board for transport.

In reference to CPR, Karn said the AHA emphasizes the importance of high quality CPR (bystander and provider CPR) to improve survival rates. She listed the following key statistics relative to cardiac arrests;

l Each year, over 326,000 out-of-hospital cardiac arrests occur in the United States.

l When a person has a cardiac arrest, survival depends on immediately getting CPR from someone nearby.

l According to the American Heart Association, 90 percent of people who suffer out-of-hospital cardiac arrests die. CPR, especially if performed immediately, can double or triple a cardiac arrest victim’s chance of survival.

l Most Americans (70 percent) feel helpless to act during a cardiac emergency because they don’t know how to administer CPR or they’re afraid of hurting the victim.

l 70 percent of out-of-hospital cardiac arrests happen in homes and residential settings.

l Unfortunately, only about 39 percent of people who experience an out-of-hospital cardiac arrest get the immediate help that they need before professional help arrives.

Comments

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PaulHuff

Granted I'm no doctor.....But god forbid if I drop of a heart attack at the Warwick Mall, or the Stop and Shop in Meadowbrook, or at a soccer game at Pilgrim I would want the rescue people to throw me in the rescue and do CPR enroute to the hospital. I'd rather be in a trauma unit in 5-10 minutes than laying on the ground for 30 minutes, then take the 5 minute ride to the hospital.

Living in close proximity to the hospital I wonder if we might see more people choosing to self transport to the hospital instead of waiting for a rescue?

Thursday, December 29, 2016
Warwick Man

Paul, you don't need a trauma unit unless you suffered a trauma. Drs in the ER are going to do the exact same thing as WFD will do. Kent just wants more money that's why they are putting up a stink. Statistics show your better off in the ground with early intervention.

Thursday, December 29, 2016
PaulHuff

Sorry but I'd rather have a team of doctors and nurses working on me in the Trauma room (sorry if my definition wasn't precise but cardiacs get treated in the trauma room at Kent right?) with all it's resources than a bunch of paramedics, EMT's and cops, doing chest compressions.

Grab me and go any day of the week.

Friday, December 30, 2016
Jayp0629

Paul, no people are not treated for cardiac after in the trauma room at Kent. The trauma room is used for trauma. There are 2 cardiac rooms next to the trauma room. One that's well equipped for pedi and the other that is equipped for adult. It would be very bad for you if you did not get high-quality CPR, uninterrupted as soon as possible along with IV or I/O epinephrine and other recessive cardiac drugs that you will get from a Paramedic or cardiac, defibrillation and all the other things that we do in the field. We can do more than a nurse can as paramedics and the doctors are going to give orders for exactly the same stuff we were going to do it's just now you got it delayed. if we weren't so worried about bringing you to the truck as fast as possible you would've got the same medications and the good CPR EARLIER.. that's huge because your body starts to literally self-destruct after just a few minutes without those things. Paul I can assure you as a professional who has been in this field for many years that it is without a doubt in your best interest to have highly trained and qualified paramedics and cardiacs working on you right where you went down as rapidly as possible. If it was my family member on the ground and I saw them loading them up and taking away right away I would not be happy because I know how important it is to get that blood circulating with oxygen and get ACLS drugs in their system. Everything that paramedics and cardiacs are going to do are all the same things that the physician will do at the hospital.

Friday, December 30, 2016
Warwick Man

Paul, TRAUMA ROOM IS FOR TRAUMA. For cardiac related issues you don't need a surgeon, therefore you will not be placed in a trauma room. If your cardiac issue were Cassie's by a trauma that's a whole different story and yes you will be brought to a surgeon in the TRAUMA ROOM. I'm not sure if want the Dr. At Kent working on me if he doesn't even know the new protocols... just saying

Saturday, December 31, 2016
Warwick Man

Damm Autocorrect

Saturday, December 31, 2016
PaulHuff

Jayp0629...they certainly do get treated in the trauma room at Kent. They use their "CPR" room first and when that is full, which happens often, they use the trauma room. I didn't realize we were splitting hairs here when I said the "Trauma unit". Perhaps I should have said trauma wing to signify those 4-5 rooms in that hallway. My wife is an RN there and since she has TNCC she works those rooms often.

Perhaps you guys out in Central Coventry might be better off with your 30 minutes. To be right around the corner and not get to the CPR ROOM (you snowflakes feel better?) seems foolish.

Monday, January 2, 2017
JP2017

January 3, 2017

Beacon Communications

Dear Editor:

The article titled “30 minute CPR protocol raises issues “published in several of your publications on December 28th 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 which 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 (ie. 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 which 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

John Potvin

Both authors are members of the Rhode Island Ambulance Service Advisory Board.

Tuesday, January 3, 2017