CPC 1-2 Witnessed
2011 2012 2013 2014 2015 2016
Figure 1: Alameda County EMS v fb/v tach
survival with good neurologic function
increase in ROSC (from 29% to 34%) and a 76%
relative increase in those patients surviving with
good neurologic outcome. (See Figure 1.)
The subgroup that received mechanical CPR and
hospital hypothermia had the greatest improvement with a survival rate of 24%. We also found that
for those that experience OHCA and not achieving
spontaneous circulation promptly following initial
EMS effort, optimizing a therapy-specific system of
care that focuses on enhanced circulation during
CPR and cerebral recovery after ROSC improves
survival with favorable neurologic outcome.
In 2013, ALCO EMS had a fairly mature ST-elevation myocardial infarction (STEMI) receiving
center (SRC) program with six of 13 hospitals participating. Those same centers also had three years
of therapeutic hypothermia experience managing
comatose ROSC patients, hence leading those specialty SRCs to also be designated as cardiac arrest
receiving centers (CARCs) for the system.
EMS field protocol directs patient transport
to these CARCs if ROSC or a shockable cardiac
rhythm is achieved at any time. This allows the
patient to be taken to a facility that has the capability and experience in 24/7 emergent cardiac
catheterization, targeted temperature management and metabolic support in the ICU, as well
as electrophysiology and rehabilitation services.
ALCO EMS established a contractual agreement
with all SRCs/CARCs in our system by a memorandum of understanding. This has fostered an
instrumental collaboration with system stakeholders regarding ongoing review and revisions of pre-hospital protocols, as well as in-hospital order sets
and treatment pathways based on current scientific
evidence. These continuous professional relationships are pivotal to help ensure the continuity of
care from dispatch to discharge.
ALCO EMS performance and survival data
captured and reported by CARES demonstrates
that in 2016, the system demonstrated its highest
treatments from 2005 to the present
with annual training on pit-crew CPR,
advanced airway placement with the
availability of a supraglottic backup air-
way, intraosseous access and the use of
mechanical chest compression devices.
The training includes a renewed focus
on high-quality CPR that emphasizes
the correct compression rate and depth,
minimal interruptions, full recoil of the
chest wall, and proper use of the impedance threshold device (ITD), which
was introduced systemwide in 2009
for both bag-valve mask ventilation
as well as with any advanced airway.
In 2009, ALCO EMS started collecting all data
elements (dispatch, EMS and hospital) from
the Cardiac Arrest Registry to Enhance Survival
(CARES) and we continue to work closely with our
receiving hospitals to obtain patient outcomes.
After the third complete year of data collection
in 2012, a marked increase was noted in both the
return of spontaneous circulation (ROSC) and
those discharged alive with a cerebral performance
category (CPC) score of 1–2 (good neurologic function). Closer scrutiny and analysis of those data was
published in Prehospital Emergency Care as an EMS
systems quality improvement article. 19
During the study period (2009–2012), patients
with ROSC with coma received prehospital surface
cooling and were transported to hospitals capable
of therapeutic hypothermia, with transport times
generally less than 10 minutes.
All receiving hospitals in the study area had surface cooling protocols that included patients with
primary ventricular fibrillation (v fib) or ventricular
tachycardia (v tach), and a few included primary
Prior to 2012, mechanical CPR devices were available on approximately 10% of our first responder
engines, which are all ALS staffed and equipped.
Beginning in 2012, all first responder paramedic
engines were equipped with a LUCAS mechanical
CPR device and responded to all cardiac arrests.
We hypothesized that the increased use of therapies in 2012 that focused on perfusion during CPR
using mechanical adjuncts and protective post-resuscitation care with in-hospital therapeutic
hypothermia would improve survival with good
neurologic outcome (CPC score of 1 or 2) compared
to the lesser use of such therapies in 2009–2011.
Statistical findings on final analysis suggested
that multiple strategies for OHCA implemented in
our community over time resulted in a significant