Virginia Commonwealth University Medical Center and the Richmond Ambulance Authority have improved resuscitation and survival rates dramatically for cardiac arrest patients by training and equipping paramedics to begin lowering a patient's body temperature in the field during resuscitation and following up at the hospital with a host of high-tech strategies to improve the odds of survival.
The VCU and RAA initiative, known as the Advanced Resuscitation Cooling Therapeutics and Intensive Care Center, or ARCTIC, is the most comprehensive program of its kind in the United States, and its strategy resulted in an almost two-fold improvement in the return of spontaneous circulation, from 25 percent in 2001 using conventional treatments to 46 percent in 2008. In turn, the survival rate to hospital discharge improved from 9.7 percent in 2003 to 17.9 percent at the end of 2008. The national average is less than 7 percent.
ARCTIC has two goals: to restart the heart as quickly as possible following onset of cardiac arrest, and to protect the brain by starting cooling as early as possible and bringing resuscitated patients to a single specialized post-resuscitation facility. Between 2001 and 2008, the team evaluated 1,598 cases of adult, out-of-hospital cardiac arrest events in Richmond, Va., and concluded that a building block strategy comprised of a unique combination of mechanical chest compressions, airway management, drugs that restart the heart, and cold saline given during resuscitation prior to the return of spontaneous circulation, sequentially improved patient outcomes.
"What we now know is that we have to protect the brain and vital organs during resuscitation and after the heart is restarted and this has led to a totally new strategy for how we treat cardiac arrest patients," said Joseph P. Ornato, M.D., chair in the Department of Emergency Medicine at the VCU School of Medicine and operational medical director of the Richmond Ambulance Authority.
"Richmond Ambulance Authority paramedics are the first in the country to initiate the cooling process during resuscitation. RAA's treatment strategy includes using a combination of drugs given early to support circulation and restart the heart, and performing high quality CPR using a mechanical device - available in all RAA ambulances - that squeezes the chest to achieve better blood pressure and oxygen delivery than that achieved with just standard CPR," he said.
"The Richmond Ambulance - VCU Medical Center partnership is so successful because it provides a continuum of care for the cardiac arrest patient from the time the 911 call is received until the patient walks out of the hospital. We are constantly sharing and assessing detailed data to improve the clinical and operational process, and the dramatic increase in our survival rate reflects this," said Chip Decker, chief executive officer of the Richmond Ambulance Authority.
Decker continued, "The EMS system in the city of Richmond is a team approach between the Richmond Ambulance Authority and Richmond Fire Department, with Fire as first responder, and it works extremely well. Our rapid response times, combined with leading-edge clinical protocols like the cooling process implemented under Dr. Ornato's guidance, have enabled us to deliver a more viable patient to VCU."
VCU Medical Center is continuously staffed with a team of specially trained physicians and nurses experienced in post-resuscitation care who continue the rapid cooling process by placing a high-tech plastic coil into a large vein soon after arrival at the emergency department. Patients are treated by specially trained coronary care unit nurses and physicians who administer complex "goal-directed" treatment protocols and maintain the patient's body temperature at 93- F for at least 24 hours, following which the patient is gradually rewarmed in a computer-controlled sequence.