Fight or flight? Barriers hinder paramedics from using best CPR practices

ANN ARBOR, Mich. - Local laws, insurance reimbursement and public misperceptions impede emergency medical services workers from using best resuscitation practices, according to a University of Michigan led 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, say 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) was physicians; 66.7 percent were EMS directors at a wide variety of practice settings. Almost one-third of the EMS systems represented by participants do not currently have termination of resuscitation protocols.
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:
  • Medicare and private insurers who don't incent EMS agencies because they only reimburse for transporting patients to the hospital;
  • state legislation that requires transport to hospitals and restricts the ability of responders to follow do-not-resuscitate 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," says  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, give lifesaving medications such as epinephrine and shock the heart to try to re-establish a normal heart rhythm. After this 20- to 30-minute process, paramedics should stop if they find no viable heart rhythm.
"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," says 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.
Additional authors: 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., Ph.D.
Funding: Robert Wood Johnson Foundation Clinical Scholars Program

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