30-minute CPR protocol raises issues

The Department of Health protocol requiring emergency response personnel to conduct 30 minutes of onsite CPR on those whose who have ceased breathing because of a heart attack has the director of Kent Hospital concerned – Warwick Mayor Scott Avedisian fearing the public won’t understand and Johnston Fire Chief Timothy McLaughlin critical of how the department has handled the new directive.

According to the Health Department, the new protocol along with revised protocols on stroke victims and the use of backboards for transporting patients take effect March 1. Jason Rhodes, chief of the Rhode Island Department of Health Center for Emergency Medical Services, described Warwick Fire as a “leader in the state.” The department started using the 30-minute CPR protocol on Nov. 1. According to Warwick Fire Chief James McLaughlin, the practice has already produced positive results with the resuscitation of two people suffering from cardiac arrest.

Dr. Michael Dacey, chief operating officer at Kent Hospital, doesn’t dispute the value of CPR, but he questions the long range outcomes of those not moved to a hospital sooner rather than later.

He said restoration of a heart beat may be viewed as a “win” when, in fact, because of the prolonged lack of blood flow to the brain, the patient could face lasting neurological damage. He said Kent has had “good neurological outcomes” with the use of Targeted Temperature Management (TTM) or therapeutic hypothermia, where the body is cooled down to as low as 93 degrees and then slowly raised. Time following resuscitation is critical to the therapy.

Dacey, who has worked the emergency department, said he had no knowledge of the new protocol until reading a story about Warwick’s use of 30-minute CPR in last Thursday’s Beacon. He said he knows of no consultation over the protocols with the hospital community and has asked for a meeting with the state.

He said his concern is that the initial care of cardiac arrest cases – there are 90 licensed ambulance and rescue units serving the state’s 39 cities and towns – is being given to people who may deal with two cases a year instead of those who may handle 30 cases. According to the protocol, the distance to a hospital makes no difference to the directive of 30 minutes of onsite CPR.

The protocol reads, “Regardless of proximity to a receiving facility, absent concern for provider safety or a traumatic etiology for cardiac arrest, resuscitation should occur at the location the patient is found. Resuscitative efforts should continue for a minimum of 30 minutes prior to moving the patient to the ambulance or transporting the patient.”

Rhodes said a 25-member advisory board that included four physicians and a representative from the Hospital Association of Rhode Island developed the protocols over 18 months. Additionally, he said the protocol is based on recommendations of the American Heart Association (AHA).

“You can’t do quality CPR in the back of a rescue,” Rhodes said.

AHA guidelines do not specify how long CPR should be administered. In an email, Michelle Karn, director of communications for the Rhode Island AHA, wrote, “The American Heart Association’s guidelines are treated like a road map when states such as Rhode Island decide to look at their own EMS protocols for improvement. The states ultimately make their own final decisions based on their resources and geography.”

Karn added that the Rhode Island Metro EMS Association sponsored a resuscitation academy to improve the quality of CPR being provided by the state’s EMS personnel.

“It was designed based on best practices from other states and the AHA’s 2015 guidelines,” she said.

John Potvin, from the East Providence Fire Department, who worked with the Rhode Island American Heart Association on the protocols, could not be reached for comment.

What if rescue personnel don’t follow the policy?

“If they choose not to follow they would be subject to discipline,” Rhodes said.

It’s not that Johnston Fire Chief Timothy McLaughlin doesn’t want to follow protocol; he feels the Health Department has done a poor job of communicating how the program is to work and training for it.

He said his 88-member department has started training, “but the roll out with the hospitals is horrible.” He said a half hour of CPR is a long time and he doubted many on the department could do it (Rhodes suggests responders tradeoff).

“They didn’t explain it and we’re stuck with it,” he said.

Chief McLaughlin (no relation to Warwick Fire Chief James McLaughlin) also shares the concern of Mayor Avedisian that family members and friends at the scene of a cardiac arrest wouldn’t understand why the patient isn’t being rushed from the scene. Avedisian imagines situations where anxious friends and family could interfere and even provoke an incident. He said Warwick Police are being informed of the protocol and are prepared to deal with such an adverse situation.

Warwick Fire Chief McLaughlin reports positive results using the 30-minute protocol. Department personnel have been trained. The Warwick department responds to about 16,000 incidents annually, of which about 12,000 are rescue related, he said.

Rhodes said Department of Health data shows an average of 700 cardiac arrest cases a year. He didn’t have data on how many of those cases survived.

“Besides having a hospital interest, I have a professional interest in this, too,” Dacey said. “We want to do the right thing for the patient.”

Dacey questions the directive that stroke patients be transported to a comprehensive stroke center. Rhode Island Hospital offers the only comprehensive center, whereas Kent has a primary center.

“We treat 200 [stroke] patients a year with great outcomes,” said Dacey.

Rhodes said a third new protocol discourages the use of backboards for transporting patients. As practiced now, EMTs will outfit a patient with a neck brace and strap them to a board for transport to a hospital. Rhodes said boards can be used for moving patients, but patients are more comfortable on a gurney than a board for transport.

In reference to CPR, Karn said the AHA emphasizes the importance of high quality CPR (bystander and provider CPR) to improve survival rates. She listed the following key statistics relative to cardiac arrests;

l Each year, over 326,000 out-of-hospital cardiac arrests occur in the United States.

l When a person has a cardiac arrest, survival depends on immediately getting CPR from someone nearby.

l According to the American Heart Association, 90 percent of people who suffer out-of-hospital cardiac arrests die. CPR, especially if performed immediately, can double or triple a cardiac arrest victim’s chance of survival.

l Most Americans (70 percent) feel helpless to act during a cardiac emergency because they don’t know how to administer CPR or they’re afraid of hurting the victim.

l 70 percent of out-of-hospital cardiac arrests happen in homes and residential settings.

l Unfortunately, only about 39 percent of people who experience an out-of-hospital cardiac arrest get the immediate help that they need before professional help arrives.