Rialto Fire: 71% Neurologic Intact Cardiac Arrest Survival Rate?

[Gurby]

I think this is more of a public health issue than anything else. When people get early compressions, they can do well. If they don't, odds are slim.

Start requiring middle and high school students to take a CPR class on the first day of school every year and I bet the numbers start looking a lot better across the nation.

 

[Tigger]

I don’t run arrests based off of numbers or percentages; if you all do, that’s cool.

Best practices? Yes, absolutely, but define “best practices”. It’s all ever-changing. Good system, bad system, middle of the road system I’m more concerned about what I can do for my particular patient at that moment in time based off of best practices within my scope, power, clinical judgement and yes from collective data. But, the latter comes from constantly evolving. Apples, and oranges, but I just refuse to let numbers (skewed or not) in another system

In an all too ironic twist, on my way back home with the girls my daughter hands me the latest Jems issue in the mail (I thought my scrip had lapsed), and front cover is the Rialto FD. The supplemental mag mentions the OHCA and portable ECMO @cruiseforever mentioned in another thread...

For the record, I’m hardly harping on anyone. The numbers and percentages just isn’t my forte when it comes to how, I, as one measly individual paramedic chooses to serve his populous.

I guess to me, without the numbers we aren't going to know what best practices are actually well, best. If there's an agency that has a neuro intact rate over 70%, you can bet I want to know what they are doing, because we along with most places are not on that train. Even 70% with Utstein criteria is very good, and is helpful in that now we can see yet another agency that has put a priority on teamwork and had their rates go up. Sadly, CCR/Pit Crew CPR is still not even close to the standard in this country, but the more places that publish improvements with it means there will hopefully be better buy in and honestly that's what I need more than anything else these days. Nobody gives 2 craps how I think we should run arrests, but if I can show data from other areas, people might actually embrace best practices.

I think this is more of a public health issue than anything else. When people get early compressions, they can do well. If they don't, odds are slim.

Start requiring middle and high school students to take a CPR class on the first day of school every year and I bet the numbers start looking a lot better across the nation.

We also need to accept that if you live in even slightly rural areas, your chances of surviving OHCA are just incredibly slim.

 

[Bullets]

Like other have alluded to, when i saw the 71% my immediate reaction was "Bull Feces". And sure enough, it is. As far as am concerned, limiting your inclusion to to witnessed, bystander provided, VFIB is disingenuous.

With that criteria, my management agency survival rate is 100%. But its only 2 patients this year and one was a drowning. Our real cardiac arrest survival rate is like 4%. Most of our contacts are really not viable from the get go, and thats largely due to my towns heavy geriatric population.

I also learned that we have been doing "Pit Crew" CPR for 10 years, but no one ever put a name on it until recently. Those articles always confused me since in a tiered system we always had 1-2 BLS units and an ALS unit with 3-4 cops on a scene. Regularly having 10 people participating necessitated assigning roles.

 

[DrParasite]

Like other have alluded to, when i saw the 71% my immediate reaction was "Bull Feces". And sure enough, it is. As far as am concerned, limiting your inclusion to to witnessed, bystander provided, VFIB is disingenuous.

There are lies, damned lies, and statistics. And you can make your statistics show whatever you want by putting criteria on what you are analyzing.

With that criteria, my management agency survival rate is 100%. But its only 2 patients this year and one was a drowning. Our real cardiac arrest survival rate is like 4%. Most of our contacts are really not viable from the get go, and thats largely due to my towns heavy geriatric population.

that sounds about right. I used to have the same issue; All these areas can tout their amazingly high number, when they exclude anyone who doesn't meet their "likely to save" criteria. I would love to know what the save rate was for people found in vfib or vtach, and ignore everything else, and then state "this is our cardiac arrest survival rate", totally ignoring the rest of the people that are found in cardiac arrest.

I also learned that we have been doing "Pit Crew" CPR for 10 years, but no one ever put a name on it until recently. Those articles always confused me since in a tiered system we always had 1-2 BLS units and an ALS unit with 3-4 cops on a scene. Regularly having 10 people participating necessitated assigning roles.

Yep, I was thinking the same thing. When they came out with this new lifesaving CPR method, my exact response was "isn't this the same thing we have been doing for years??

 

[cruiseforever]

What is the time frame that is used to judge a neurologically intact person? I met a survivor that we resuscitated. It was over six months before she became neurologically intact.

 

[EpiEMS]

What is the time frame that is used to judge a neurologically intact person? I

I've seen six months, any time during hospital stay, one month....
Not sure if there is a standard.

 

[EpiEMS]

totally ignoring the rest of the people that are found in cardiac arrest.

Definitely - and it sounds snappier to say "Local Fire Department Has 70% Cardiac Arrest Survival Rate" than "Local Fire Department Has 70% Witnessed Cardiac Arrest Survival Rate for Patients in VFib With Bystander CPR In Progress" or whatever

 

[Tigger]

There are lies, damned lies, and statistics. And you can make your statistics show whatever you want by putting criteria on what you are analyzing. that sounds about right. I used to have the same issue; All these areas can tout their amazingly high number, when they exclude anyone who doesn't meet their "likely to save" criteria. I would love to know what the save rate was for people found in vfib or vtach, and ignore everything else, and then state "this is our cardiac arrest survival rate", totally ignoring the rest of the people that are found in cardiac arrest.Yep, I was thinking the same thing. When they came out with this new lifesaving CPR method, my exact response was "isn't this the same thing we have been doing for years??

The Utstein criteria is a defined benchmark.

 

[medicsb]

Rialto has a population of almost 100,000. The average incidence cardiac arrest is approximately 1 per 1000 people. Based on aggregate cares data, the % of arrests that are bystander witnessed AND primary VF/VT is around 12%. So, we can assume that Rialto treated around 100 arrests and that the Utstein n is around 12. I'd bet that their number is 14 since 10/14 is .7142. In 2015, King Co. Washington treated 192 primary VF, bystander witnessed arrests (more in one month than Rialto in a whole year). It would take almost 14 years for Rialto to match that number. So, basically, lets check in 10-20 years and see how they're doing, because *I* do not think they will be able to match it year after year. There was an article a number of years ago about Anchorage reaching 40% and about how great that was (http://www.sca-aware.org/sca-news/m...-anchorage-alaskan-city-achieves-40-save-rate). They dropped to ~27% the next year, unfortunately.

 

[medicsb]

There are lies, damned lies, and statistics. And you can make your statistics show whatever you want by putting criteria on what you are analyzing. that sounds about right. I used to have the same issue; All these areas can tout their amazingly high number, when they exclude anyone who doesn't meet their "likely to save" criteria. I would love to know what the save rate was for people found in vfib or vtach, and ignore everything else, and then state "this is our cardiac arrest survival rate", totally ignoring the rest of the people that are found in cardiac arrest.Yep, I was thinking the same thing. When they came out with this new lifesaving CPR method, my exact response was "isn't this the same thing we have been doing for years??

As mentioned by others, the reporting of cardiac arrest survival is pretty standard. Most layman news sources don't get too specific about the criteria, but I bet that the number presented is based on the usual template (Utstein) unless the medical director and QA/QI folks have no clue as to what they are doing. Seeing that anyone who track cardiacs arrest survival follows the Utstein template, it is easy to compare between EMS jurisdiction/system. Considering that California is part of CARES, we can be assured that the data capture and reporting is uniform and reliable.

 

[medicsb]

Looks like they don't really know what they're talking about. There really isn't much special about them. They're touting their ROSC. I'll bet that they can't pull this off year after year. Next.

 

[Bullets]

Looks like they don't really know what they're talking about. There really isn't much special about them. They're touting their ROSC. I'll bet that they can't pull this off year after year. Next.

Whats really telling, and i think more important than the percentage, is the actual number of people.

5 people survived cardiac arrest to discharge. No indication of what their neuro function was. In a city of 100k people, 5 survived in this great system they have set up. Just shows the largely futile nature of cardiac arrest.

 

[Airlinepilotmedic]

I work for Rialto as a FF/PM and we are realized a few years ago that we had room for cpr improvement in our dept. We have worked hard, studied a lot of progressive ems depts around the world to ensure, we not only have high ROSC rates but also, patients walk out of the hospital with full neurological function intact. This has lead to the use of autopulses, passive oxygenation, heads up cpr, threshold impedance device and we don’t shock v-fib with a etco2 below 20 (to name a few). We have spent a lot of time and effort training all our crews on the pit maneuver and spending at least 30 minutes on scene. We get ROSC on average 40% of the time on asystole, (much higher in v-fib) and we do everything we can do to assure that they have a quality of life when they get discharged out of the hospital.
Rialto is a lower socioeconomic city with 110,000 people, four stations, 12,000 annual calls and 26 square miles. We run ALS engines and ALS ambulances staffed with non-safety paramedics. We burn ALOT but put a huge emphasis on ems and train every cycle not only fire suppression but also ems. I have personally had four cardiac arrests this year that walked out of the hospital and I got to spend time with. This is not because I am some paragod but directly related to how we now run CPRs.
I agree that statistics are far from the real picture but the medical field and more importantly our LEMSA needs them. After our EMS chief spent time with Departments in South Korea this summer we learned that less is more with regards to epi. So we no longer just load pts up with it.
We take great pride in the numbers but more pride in cardiac arrest pts that come by the stations to thank us. If your dept is doing something cutting edge please let me know and we will implement it. Instead of focusing on our statistics which can be skewered, come see what we are doing and how it has greatly changed the amount of cardiac arrests that go home to hug their family. Follow us on IG @rialtofirefighters3688 to see more about us.

 

[DrParasite]

we don’t shock v-fib with a etco2 below 20

I've never heard of this, can you cite your reasoning? and what do you do since you aren't shocking, especially since CPR is only 30% as effective as the heart beating on it's own?

We get ROSC on average 40% of the time on asystole,

ok, I don't care where you are, that's really impressive.

Rialto is a lower socioeconomic city with 110,000 people, four stations, 12,000 annual calls and 26 square miles. We run ALS engines and ALS ambulances staffed with non-safety paramedics.

out of curiosity, who has more saves, your ALS engines or your ALS ambulances?

We burn ALOT but put a huge emphasis on ems and train every cycle not only fire suppression but also ems.

do you rotate guys from the engines to the ambulance every few months? or once you make it to the suppression side, you don't got back to the ambulance? I'm not sure what a non-safety paramedic is.

 

[DesertMedic66]

I've never heard of this, can you cite your reasoning? and what do you do since you aren't shocking, especially since CPR is only 30% as effective as the heart beating on it's own?ok, I don't care where you are, that's really impressive.out of curiosity, who has more saves, your ALS engines or your ALS ambulances?do you rotate guys from the engines to the ambulance every few months? or once you make it to the suppression side, you don't got back to the ambulance? I'm not sure what a non-safety paramedic is.

To my knowledge they do not rotate since the ambulance personnel are single role only. So once you make it on the engine you do not go back to the ambulance. Usually non-Safety means worse benefits/retirement/pay.

 

[VFlutter]

I've never heard of this, can you cite your reasoning?

Theoretically ETC02 should correlate with CPP. Defibrillation (or ROSC) has a low chance of success if the CPP is under a certain threshold, hence why uninterrupted CPR is so important.

https://www.ncbi.nlm.nih.gov/m/pubmed/28899911/

Edit:
Apparently ETCO2 less then 20 has a 50% chance of successful Defibrillation, 20-30 has a 68%, and over 30 has a 78% chance.
https://www.ncbi.nlm.nih.gov/m/pubmed/28942011/

 

[Airlinepilotmedic]

We learned that for us when we shock below etco2 of 20, 100% of the time we shock them into asystole. So if we continue the autopulse and bagging them with the threshold impedance device (ResQ pod) through an ETT. Once they get around etco2 of 25 and above we have a higher chance of shocking them into a perfusing rhythm.
We rotate between the engines and buggies (ambulances) because we still staff two safety ambulances. A non safety medic is a non firefighter role and they can only be on our ambulances. They get good pay and benifits and are one of the crew just the same as if they wore the yellow pants. We show up at the same time as the ambulances because we come from the same stations so we know each other’s limitations and attributes and insures continuation of patient care.

 

[medicsb]

I work for Rialto as a FF/PM and we are realized a few years ago that we had room for cpr improvement in our dept. We have worked hard, studied a lot of progressive ems depts around the world to ensure, we not only have high ROSC rates but also, patients walk out of the hospital with full neurological function intact. This has lead to the use of autopulses, passive oxygenation, heads up cpr, threshold impedance device and we don’t shock v-fib with a etco2 below 20 (to name a few). We have spent a lot of time and effort training all our crews on the pit maneuver and spending at least 30 minutes on scene. We get ROSC on average 40% of the time on asystole, (much higher in v-fib) and we do everything we can do to assure that they have a quality of life when they get discharged out of the hospital.
Rialto is a lower socioeconomic city with 110,000 people, four stations, 12,000 annual calls and 26 square miles. We run ALS engines and ALS ambulances staffed with non-safety paramedics. We burn ALOT but put a huge emphasis on ems and train every cycle not only fire suppression but also ems. I have personally had four cardiac arrests this year that walked out of the hospital and I got to spend time with. This is not because I am some paragod but directly related to how we now run CPRs.
I agree that statistics are far from the real picture but the medical field and more importantly our LEMSA needs them. After our EMS chief spent time with Departments in South Korea this summer we learned that less is more with regards to epi. So we no longer just load pts up with it.
We take great pride in the numbers but more pride in cardiac arrest pts that come by the stations to thank us. If your dept is doing something cutting edge please let me know and we will implement it. Instead of focusing on our statistics which can be skewered, come see what we are doing and how it has greatly changed the amount of cardiac arrests that go home to hug their family. Follow us on IG @rialtofirefighters3688 to see more about us.

First, good job on the apparent improvement in ROSC. (Based on the numbers seen, you don't know if the survival to discharge has improved, but you should know soon.)

I think something that is important is that when you go to the press, especially a trade journal, you should have all your ducks in a row. Citing a survival of 71% is disingenuous when your are actually speaking of ROSC when everyone else uses survival to discharge (and more specifically survival to DC with CPC 1 or 2). You could have 100% ROSC, but that isn't very meaningful if the actual survival is low. You are correct that a good neurologic outcome is important, but it can be represented with statistics and it usually is. Also, don't ask others to not focus on statistics (especially when you are trying to 'wow' someone with statistics). They are important when the methodology is sound and the data reliable and accurate. They are easy to skewer when you use suspect measurement or reporting.

Keep up the effort for sure. I hope to see a publication in a peer-reviewed journal about your change in the use of epinephrine. Also, you might want to consider doing away with ALS engines. NOTHING progressive about it. It's expensive, and NEVER in the history of EMS and medicine has it EVER been shown to improve outcomes. That's be progressive, and given current trends, it'd actually be novel.

 

[FLMedic311]

Citing a survival of 71% is disingenuous when your are actually speaking of ROSC when everyone else uses survival to discharge (and more specifically survival to DC with CPC 1 or 2). You could have 100% ROSC, but that isn't very meaningful if the actual survival is low. You are correct that a good neurologic outcome is important, but it can be represented with statistics and it usually is. Also, don't ask others to not focus on statistics (especially when you are trying to 'wow' someone with statistics). They are important when the methodology is sound and the data reliable and accurate. They are easy to skewer when you use suspect measurement or reporting.

I am sorry, but there is nothing disingenuous with their statement at all. It very clearly states that ROSC Utsein Criteria is what they are using. Your lack of appreciation for their method of reporting does not constitute false reporting.

 

[medicsb]

I am sorry, but there is nothing disingenuous with their statement at all. It very clearly states that ROSC Utsein Criteria is what they are using. Your lack of appreciation for their method of reporting does not constitute false reporting.

"This article describes the RFD's journey toward increased SCA survival-a journey that, in 2016, resulted in a 71% (Utstein) survival rate from sudden cardiac arrest (SCA) in Rialto. "

Sorry (not sorry), the above is disingenuous. The majority consider survival from cardiac arrest as survival to discharge and not ROSC. I suppose they may have been referring to survival of the event, but no one cares much about that because it is not what ultimately matters. Knowing now what they actually meant and what their survival to DC rate is, I am much less impressed. Maybe they were intentionally vague? I don't think they're doing anything that is newsworthy, at least in a trade journal. I'd be a little more forgiving if it was just a lay person article.