Sudden Cardiac Arrest Improvement Plan

Matter of Life and Death

“On Jan. 30 at around 4 a.m., my husband suffered a cardiac arrest in our home in Upper Noe Valley.  Within four minutes of my call, the San Francisco paramedics arrived.  They managed to get him breathing and took him to emergency care at UCSF.  I found out later that 96 percent of people suffering a cardiac arrest in the field - outside of a hospital - die.  Thanks to the rapid response and to UCSF's superb care, my husband is alive and well.

My hope is that we don't cut the budget for our fire and paramedic services and don't close stations.  It takes an experience like ours to truly appreciate how much we need them. “

Alice Trinkl, San Francisco

The testimonial above, published in the July 3, 2011 San Francisco Chronicle, demonstrates the overwhelming value of delivering rapid and effective treatment to patients suffering from sudden cardiac arrest.  In fact, preparing for sudden cardiac events, which includes providing CPR training to the public, keeping up-to-date with the latest cardiac arrest care research, and improving communication with our hospital ERs, has become one of the cornerstones for the overall improvement of out-of-hospital care within San Francisco.
The treatment of sudden cardiac arrest is one of the most important functions of an EMS system; treatment must begin within minutes in order to be effective.  It is also proven to be a good measure of overall system performance.  For that reason, the San Francisco Fire Department developed a plan in 2009 to measure and improve the clinical outcomes among sudden cardiac arrest patients.  Results to date demonstrate the following:

  • Overall survival rate in San Francisco has increased over the two year period, from 2009 to 2010.
  • The survival rate of cardiac arrest patients with a witnessed arrest and shockable rhythm - those that are amenable to defibrillation - improved dramatically (from 9% to 23%).
  • San Francisco remains on par in comparison to similarly-monitored communities.

In order to be optimally effective, all links in the “chain-of-survival” need to be functioning properly.  This requires bystander CPR, effective use of automatic external devices (AED’s) when available, rapid and appropriate dispatch, quick response, rapid assessment and appropriate pre-hospital & hospital medical treatment.


Measuring Outcomes

In March 2009, the San Francisco Fire Department began participating in an important public health registry called CARES (Cardiac Arrest Registry to Enhance Survival). Developed by the Centers for Disease Control and Prevention (CDC), American Heart Association (AHA), and Emory University Department of Emergency Medicine, the registry collects data from participating EMS systems and hospitals to track cardiac arrest cases and identify opportunities for improvement in the treatment of cardiac arrest.
Sudden cardiac arrest results from an abrupt loss of heart function and is the leading cause of death among adults in the Unites States.  Survival rates in the event of sudden cardiac arrest are low, but victims' chances of survival increase with early activation of the 911 system, early bystander CPR, rapid defibrillation, and early access to definitive care.  CARES is designed to allow local EMS systems to measure each link in their "chain-of-survival" and use this information to save more lives.
CARES consolidates all essential data elements of a pre-hospital cardiac arrest event and utilizes an internet database system to register events, record response times associated with First Responder/EMS dispatches, and track patient outcomes with hospitals.
By participating in CARES, the San Francisco Fire Department aims to improve the delivery of EMS care to cardiac arrest victims, and to improve the survival rate of victims of sudden cardiac arrest.


Bystander CPR Rates

In sudden cardiac arrest, bystander CPR doubles a person’s chance of survival.  Our community’s relatively low rate of bystander CPR may be one significant cause of our “average” survivor rates.  With the objective of improving rates of bystander CPR, SFFD is involved in the following:

  • SFFD has explored partnerships with the SF Emergency Medical Services Agency, HeartSafe Cities, and SF Fire Fighters Union, Local 798 to provide community training in bystander CPR.  We hope to expand these groups of volunteers with others to increase the training opportunities for our citizens.
  • SFFD has developed a working relationship with iRescue, a novel smart phone application, that will notify capable persons trained in CPR about the presence of a nearby cardiac arrest and the location of the closest Automatic External Defibrillator (AED).

Automatic External Defibrillators

Early AED use by citizens also significantly improves the chances of survival for persons suffering from sudden cardiac arrest.  The AED Program initiated at the San Francisco International Airport (SFO) is SFFD’s most successful AED Program, with over 150 AED units placed throughout the airport terminals; one AED is available within 150 feet of any passenger.

  • Almost all sudden cardiac arrests are witnessed at SFO, with over 90% having an AED placed on the patient.
  • Sudden cardiac arrest patients at SFO currently have twice the return of spontaneous circulation as compared to cardiac arrests occurring in the City of San Francisco.
  • SFFD continues to act as the Medical Director for over 200 AED’s located within the City of San Francisco.
  • SFFD will continue our work with iRescue to optimally geo-locate all AED’s within San Francisco to assist our dispatchers and citizen volunteers.

Dispatcher-Assisted CPR

The dispatchers at the Department of Emergency Management (DEM), Division of Emergency Communications, have been trained to provide instruction on how to perform CPR when someone calls 911 for help.  As part of the ongoing quality improvement process at DEM, all calls that could have benefited from dispatcher-assisted CPR are reviewed and individual feedback is given to the dispatcher.


SFFD Performance of Advance Cardiac Life Support

All 1,400 members of SFFD have been trained in updated CPR and Advanced Cardiac Life Support (ACLS) in early 2011.  Our new protocols, based on recent changes made by the American Heart Association, emphasize the importance of initiating effective chest compressions within the first few minutes of CPR.  We also moved toward using the King Tube as the primary airway adjunct, a device that is easier to apply and thus reduces the interruption of chest compressions. 
SFFD also purchased new E series ZOLL monitors that provide real time visual feedback to the person performing chest compressions; it lets rescuers know the effectiveness of the chest compressions they are performing.  We also plan to review chest compressions and other aspects of the cardiac arrest event with the members involved in a resuscitation team, providing valuable performance feedback and suggestions for improvement.
In the near future, SFFD will be implementing new protocols that will start hypothermia in the field for post resuscitation patients.  Initiating hypothermia is another procedure which has recently been proven to be effective in increasing the chances of survival for victims of sudden cardiac arrest.


Resuscitation Academy

In October 2010, Dr. Karl Sporer, the EMS Medical Director for San Francisco Fire Department, attended a prestigious one week Resuscitation Academy at the University of Seattle, Medic One Foundation.   Seattle has long been a world leader in improving cardiac arrest survival; this one week academy exposes medical directors and EMS personnel to the proven techniques used in Seattle.  Dr. Sporer will be applying these techniques to SFFD, with the goal of improving overall survival rates of sudden cardiac arrest patients.


Ventricular Fibrillation Case Quality Improvement

In 2010, all of the SFFD-response cases of cardiac arrest that were witnessed and had an initial shockable rhythm were subjected to an in depth analysis of all links in the “chain-of-survival”.  The presence of bystander CPR or AED, review of the 911 call for appropriate instructions in CPR, timing of arrival of the first responders (SFFD), ambulance medics, and Rescue Captains were all assessed.  The medical care that was rendered by the EMT’s and medics on scene, as well as the care given in the hospital, were also reviewed.   This sort of analysis can often expose areas of previously unrecognized system failure, and consequently reveal opportunities for future improvement.  Results of the reviews are still being analyzed.


Post Resuscitation Hospital Care

One of the more promising treatments recently seen in cardiac care is inducing mild hypothermia in patients who have regained a pulse after being resuscitated, but are still unconscious.  Patients who have received this treatment have demonstrated remarkable improvements in full neurological recovery.
SFFD is working closely with the SF Emergency Medical Services Agency on the development of STAR (STEMI and Resuscitation) centers.  The development of these centers will improve our care of patients with sudden cardiac arrest, ST segment elevation myocardial infarction (STEMI), or post resuscitation, and will incorporate the latest improvements in cardiac care, including the use of hypothermia and emergent cardiac catheterization.  We hope to see the establishment of the STAR system in late 2011 or early 2012.


For more information regarding the Sudden Cardiac Arrest Improvement Plan for San Francisco, the CARES Program, or other issues related to cardiac arrest care, please contact the SFFD Medical Director at: (415) 558-3645.  You can also visit the CARES website.

If you are interested in obtaining certified CPR or First Aid training, please try contacting the following organizations:

 Learn this simple two-step method for performing CPR, presented by the American Heart Association: