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Barriers Hinder EMS Workers From Using Best Resuscitation Practices
Date:6/30/2009

American Heart Association Rapid Access Journal Report:

Study highlights:

Cardiac arrest patients may not be getting the best care by EMS personnel due to a number of external factors.

EMS should have adequate time in the field to give high-quality CPR and other resuscitation efforts before transporting cardiac arrest patients.

EMS should follow national guidelines for transporting cardiac arrest patients and determining when to end unsuccessful resuscitation efforts.

DALLAS, June 30 /PRNewswire-USNewswire/ -- Local laws, insurance reimbursement and public misperceptions impede emergency medical services (EMS) workers from using best resuscitation practices, according to a study reported in Circulation: Cardiovascular Quality and Outcomes.

Less than half of local EMS systems follow national guidelines on transporting cardiac arrest patients and terminating unsuccessful out-of-hospital resuscitation efforts, said researchers who conducted three small focus groups at the 2008 National Association of Emergency Medical Services Physicians meeting in Jacksonville, Fla.

Each focus group had four to 12 participants. The majority (79.1 percent) were physicians, and 66.7 percent were EMS directors at a wide variety of practice settings.

Based on the focus group analysis, researchers identified three key areas where policies or perceptions may impede local efforts to follow the guidelines for terminating unsuccessful resuscitation efforts:

  • Private insurers and Medicare who provide higher reimbursement to EMS for patient transport, regardless of whether the cardiac arrest victim is successfully resuscitated in the field or not;
  • state legislation that requires transport to hospitals and restricts the ability of responders to follow do-not-resuscitate (DNR) orders; and
  • community members who overestimate the chance for survival and believe a hospital can provide better care than responders on site.

"If an EMS team spends 30 minutes and can't get a patient's pulse back, they will not be reimbursed by Medicare for the level of care they have provided, or the time the ambulance was out of service," said Comilla Sasson, M.D., M.S., Robert Wood Johnson Clinical Scholar and a clinical lecturer in the department of Emergency Medicine at the University of Michigan Medical School in Ann Arbor.

"However, transporting a patient before a full attempt at resuscitation reduces the chance of survival -- getting a pulse prior to transport is really important. Paramedics can't provide good CPR in the back of an ambulance while flying down the road at 90 miles an hour, with lights and sirens blazing, to the hospital."

The American Heart Association recommends that paramedics on the scene administer good-quality CPR, shock the heart to try to re-establish a normal heart rhythm and provide appropriate advanced cardiovascular life support. The final decision to stop resuscitation efforts must be based on clinical judgment and respect for human dignity. Cessation of efforts in the out-of-hospital setting, following system-specific criteria and under direct medical control, should be standard practice in all EMS systems.

"The point at which we're talking about terminating resuscitation is when you've done everything you can and there is virtually no chance of survival," said Sasson, lead author of the study. "Unfortunately, the current public policies for reimbursement, state laws and public perceptions, do not allow EMS providers to do the appropriate thing for the patient."

Each year in the United States, EMS treats nearly 300,000 out-of-hospital cardiac arrests, according to the American Heart Association. Less than 8 percent of out-of-hospital cardiac arrest victims survive to hospital discharge.

While participants provided key insights into barriers to implementing national guidelines, researchers said a larger study may discover additional detail and variation.

Co-authors are: Jane Forman, Sc.D., M.H.S.; David Krass, B.A.; Michelle Macy, M.D., M.S.; Arthur L. Kellermann, M.D., M.P.H.; and Bryan F. McNally, M.D., M.P.H. Individual author disclosures are available on the manuscript.

The Robert Wood Johnson Foundation Clinical Scholars Program funded the study.

Statements and conclusions of study authors published in American Heart Association scientific journals are solely those of the study authors and do not necessarily reflect the association's policy or position. The association makes no representation or guarantee as to their accuracy or reliability. The association receives funding primarily from individuals; foundations and corporations (including pharmaceutical, device manufacturers and other companies) also make donations and fund specific association programs and events. The association has strict policies to prevent these relationships from influencing the science content. Revenues from pharmaceutical and device corporations are available at www.americanheart.org/corporatefunding.

Additional information from Dr. Sasson:

Until policy changes are made, you can take steps to help loved ones get the most appropriate care:

  • Recognize if someone is in cardiac arrest and promptly call 9-1-1, doing CPR until help arrives.
  • Don't ask for immediate transfer to the hospital. Allow paramedics to spend all the time they need for a thorough resuscitation effort.
  • Make sure patients wear their Do Not Resuscitate (DNR) jewelry and keep written DNR orders in an easily found spot, such as the refrigerator door, so you won't scramble around the house when you want to be with your loved one.


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SOURCE American Heart Association
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