Achieving the Best Possible Outcomes for Cardiovascular Emergencies - Part 3 of 3

What could be accomplished with Two Dollars?

In Ontario roughly 20% of the population is age 55 or older. In a typical LHIN (Local Health Integration Network) with a population of 1,000,000 this represents about 200,000 people. A budget line based on $2.00 per age 55+ resident dedicated to raising awareness amongst older adults of how to recognize and respond to cardiovascular emergencies would represent an annual expenditure of $400,000 of the best money ever spent on healthcare.  Provincially that’s about $6.4 million out of the $49 billion healthcare budget.

Managing the care and rehabilitation of patients that have experienced Heart Attack and Stroke represents a multi-million dollar cost to any healthcare system. Due to the extremely high cost of treating patients that have experienced the worst possible outcomes every healthcare jurisdiction invests heavily in developing facilities and teams of specialists that are tasked with achieving the best possible outcomes. The tools and the techniques that these interventional teams use are at the leading edge of medical technology representing the culmination of billions of dollars of worldwide research and development costs. The programs are so expensive and highly specialized that in Ontario only one in eleven (15 of 165) hospitals are set-up to perform the cardiac procedures.

What I find fascinating is that the same billions of dollars of research has shown conclusively that the independent variable with the strongest association to good outcomes for Heart Attack and Stroke victims is time, specifically the time from symptom onset to definitive treatment. In-hospital improvements to programs may result in incremental improvements in time to treatment but the potential for quantum improvement lies entirely in the pre-hospital realm and specifically with the lay public - the patients, their families, coworkers and friends.

The gold standard treatment times of 90 minutes for Heart Attack (STEMI) and 180 minutes for Stroke will only be achieved consistently when the majority of the adult population is knowledgeable around recognizing and responding to observed symptoms. Every time the gold standard time to treatment is achieved the healthcare systems saves tens perhaps even hundreds of thousands of dollars. We should also pause to consider the human cost of missing the 90 or 180 minute window.

Every month I teach CPR to between 50 and 100 older adults across Ontario and we typically spend up to an hour discussing Heart Attack and Stroke recognition and response.  The vast majority of the adults I meet are somewhat aware of the symptoms, totally unaware of how to respond when symptoms are observed, unaware of the importance of a timely response and most importantly unaware of the life altering difference in patient (and family) outcomes for those that are treated within the gold standard timeframes.  Especially with adult learners explaining the why of things, in this case significantly better patient outcomes,  is the most effective way to deliver the message.

If every LHIN in Ontario hired one fulltime Health Promoter, with an appropriate program budget, dedicated to raising awareness amongst older adults of how to recognize and respond to cardiovascular emergencies measuring the impact of their efforts, in both economic and human terms, would likely be the best news story that many LHIN’s would have to report on each year.  Through stakeholder networking to create opportunities for workshops and presentations and effective use of both traditional and social media a little money could go a long way to disseminating the “time is of the essence” message.  Realizing the economic benefit of increasing the number of Heart Attack and Stroke patients that arrive at Ontario’s world class facilities within the target time from symptom onset is some of the lowest hanging fruit in the healthcare system

Note: The task of educating the public on Heart Attack and Stroke Recognition and Response is entirely separate and distinct from promoting lifestyles that contribute to good cardiovascular health.  Programs aimed at lifestyle modification will have little or no effect on “symptom onset to definitive therapy times” for patients experiencing a cardiovascular emergency.

Achieving the Best Possible Outcomes for Cardiovascular Emergencies - Part 2 of 3

What does the best possible outcome for Heart Attack or Stroke look like?

I was at The Cottage Life Show in Toronto last weekend, promoting CPR and AED’s (Automated External Defibrillator) for the family cottage.  A couple stopped by the booth to ask a few questions. Both were healthy and happy and I would have never guessed that less than a year ago he had suffered a significant myocardial infarction. The reason he looked and felt so good – immediately upon the onset of symptoms 911 was called and he was taken directly to the cardiac catheterization lab at Sunnybrook Hospital and emergency angioplasty was performed well within the 90 minute target time.

Over the past six years I have met many patients that have been treated within the 90 minute door to balloon time (DTB) window that is the target for all STEMI (ST Elevated Myocardial Infarction) programs and it would be impossible to tell that any of them had recently had a significant MI.  Most patients that make the 90 minute DTB window have suffered little or no loss of heart function and little or no permanent damage to the heart muscle. Return to a good quality of life often takes only a few weeks and return to work often occurs even sooner than many patients would have hoped for.  Many STEMI patients have told me that they “feel better now than they have in a couple of years.”

Last summer I met a neighbour walking his dog.  As he approached I didn’t even notice his slight limp and wouldn’t have guessed he had recently suffered a stroke unless he had told me. His story was similar to the stories of most stroke patients that are home within a few weeks with little or no noticeable deficit – both he and his wife instantly recognized what was happening and wasted no time in calling 9-1-1.  The Paramedics transported him directly to the Regional Stroke Centre where he received thrombolytic therapy within two hours of the onset of symptoms.

These two real world examples are what I would define as “the best possible outcome” for Heart Attack and Stroke. After a short stay in hospital both patients were home, physically and neurologically intact, enjoying a very good quality of life and quite willing to buy green bananas.  

What does it mean for patients, families and taxpayers when the best possible outcome is achieved?

For spouses, children, grandchildren, friends and co-workers to have a person they care about come through an acute cardiovascular event with little or no permanent deficit and able to return quickly to a pre-event quality of life is priceless.

For our overburdened healthcare system the price of not consistently achieving the best possible outcome for heart attack and stroke is one that we can no longer afford to pay. When Heart Attack and Stroke are allowed to run their course and visit the maximum damage upon the patient the result is lengthy hospital stays including many days or weeks in intensive care, the costliest level of care.  Many patients are unable to go directly home but must go to a rehabilitation facility where they re-acquire simple skills needed to manage daily living. Return to anything like their pre-event quality of life, including return to work, may take months or years or may never happen.  Many patients will have an intimate and costly relationship with the healthcare system for the rest of their life. 

The investment required to educate older adults (and for that matter everyone) how to recognize and respond to significant cardiovascular emergencies is miniscule by comparison. In a world where communication and knowledge sharing is omnipotent and omnipresent it astounds me how few of the adults that attend my classes have even a rudimentary knowledge of heart attack and stroke recognition and management. I do know that for two dollars for every adult over age 50 we could go a long way toward providing each of them with the knowledge and tools to achieve the best possible outcome for Heart Attack and Stroke.

Friends don’t take Friends to the Hospital

Never self-transport friend or family to the hospital if you suspect Heart Attack or Stroke.  Never.

Paramedics know which Hospitals specialize in treating specific medical conditions and symptoms. 

In Ontario, and most other places, Paramedics are highly trained and well equipped to assess the presence and severity of heart attack and stroke. Based on the patient presentation during their initial assessment the Paramedics will decide which hospital is the appropriate facility to treat the specific symptoms they are observing.  At the start of every shift and updated throughout each shift as changes occur, Paramedics are informed which hospitals in the region are receiving patients with specific symptoms.  A wide range of factors from off load delays, too broken equipment, to Doctors being away on vacation can effect which hospitals are receiving which patients. It would be impractical, perhaps impossible to keep the public updated on this information. The message to the public has to be when symptoms are observed Call 911 and let the Paramedics decide which hospital is best for your situation.

For two of the most common and most devastating medical emergencies, Stroke and Heart Attack, the most significant factor in determining patient outcome is time, specifically the time from the onset of symptoms to the time when blood flow to the affected part of the body is restored. When human tissue is denied blood due to a blockage in an artery it is denied oxygen and without oxygen tissue begins dying. In the case of heart muscle after 90 minutes some tissue will be dead and there will be permanent damage to the heart and loss of some heart function. In the case of Stroke, brain cells may last 150 minutes in a low oxygen environment but beyond that damage is typically permanent and full restoration of all function is unlikely.

In Ontario 15 of 165 hospitals have fully equipped and staffed Cardiac Catheterization Labs that operate around the clock every day.  At these facilities Cardiac Intervention Teams perform the procedure that is most effective for restoring blood flow to affected heart muscle, emergency angioplasty or PPCI – Primary Percutaneous Coronary Intervention.  Nearly 12 million of Ontario’s 13 million residents live close enough to one of these hospitals to make the 90 minute window if 911 is called as soon as definitive symptoms are recognized.  If you self-transport a family member to the wrong hospital by the time you get inside and the staff identifies the problem and calls for an ambulance to transport the patient to the appropriate facility it is almost assured that the 90 minute window will be closed.

For Stroke the target is a moving one and the local hospital that is receiving Stroke patients may change throughout the day as the availability of a CT Scan machine and trained technicians is considered. Clot busting TPA Therapy – tissue plasminogen activator – can only be started after a CT Scan to confirm if the stroke is in fact being caused by a blocked (not ruptured) artery.  Again, getting to the right hospital, with the right equipment in the right timeframe is the only way to achieve the best possible outcome for Stroke.

What does the best possible outcome for Heart Attack or Stroke look like? What does it mean for patients, families and taxpayers when the best possible outcome is achieved? Stay tuned for the next blog in this three part series.

Canada is Relying on you to Sue .... for the lack of an AED

If you have lost a loved one to Sudden Cardiac Arrest anywhere in Canada, anytime in the last two years and the event occurred at a location where common sense dictates it would have been reasonable to place an Automated External Defibrillator (AED), please speak to a lawyer about the possibility of a lawsuit. I am asking this as favour on behalf of all Canadians especially the thousands of families that will lose a loved one in preventable circumstances this year and next year and every year until we maximize the potential of Public Access Defibrillation (PAD) programs.

Momentum for effective PAD programs has built so slowly across Canada that for nearly a decade I’ve been hoping for a good cathartic lawsuit, one that would cleanse the blockage that is preventing so many senior decision makers in so many areas of Canadian life from committing to placing AED’s in all of the locations over which they have influence.  The excuses I’ve heard range from liability (arising from improper or unsuccessful deployment), to cost, to simply denying any corporate responsibility for responding to people in distress.  The only way Canadian communities are going to realize the full life saving potential of PAD programs is if families that have lost a loved one to Sudden Cardiac Arrest, in locations where an AED should reasonably have been placed, sue the property owner and stick with the lawsuit right through to a court ordered settlement. There have been out of court settlements, but typically these come with a gag order and the real story is never told in a public forum.

If you are a member of the enormous cohort of Canadians that have lost a loved one that could realistically have been saved by a well-placed AED winning a lawsuit will not make you whole. Hopefully a large settlement provides some level of comfort and financial security for your family. Hopefully the size of your settlement causes corporate and government decision makers to consider that it may be more cost effective to buy a handful of $1,400 AED’s as opposed to facing the alternative, defending a multi-million dollar lawsuit. Hopefully your family will take great comfort in knowing that your tragic loss  paved the way for families that follow to celebrate a life saved.

In 1999 I sold my first AED to a private golf club near Toronto. The event was newsworthy enough that it made the front page of Canada’s largest newspaper – above the fold. I naively thought that within five or six years AED’s would become as ubiquitous as coffee shops named after hockey players. Nearly 15 years on we are still fighting to get AED’s placed in the obvious frontline locations such as schools, shopping centres, big box stores, fitness clubs and golf courses. Building deeply rooted community cardiovascular emergency response programs and achieving thirty to forty per cent improvement in survival rates, is still just a vision on the far horizon. This despite the overwhelming evidence that AED’s, combined with new CPR protocols, do nothing but save lives and dramatically improve survival rates for out-of-hospital cardiac arrest and despite the fact that AED’s have come down in price from $5,600 in 1999 to $1,400 in 2014. Organizations that have implemented effective PAD programs already have done it because their moral compass guided them in the right direction. Those organizations that have not committed to preventing sudden cardiac death on their properties , including dozens of school boards, might benefit from a good cathartic lawsuit.

What's in Name ?

Will Hamilton Wentworth District School Board choose Style over Substance ?

 

Dear HWDSB Trustees, I am  sure you are all aware that at this time the School Council at George R. Allan Elementary School is diligently exploring every possible funding option to raise the $150,000 required to replace the school playground which will be lost during the upcoming construction. In fact the Council is considering a $10,000 purchase of architectural drawings a requirement of a number of grant applications including the AVIVA grant. HWDSB has it made clear to School Council that there is no money in the construction budget to pay for replacing the playground and that cost must be borne by the school community.

The lack of available funds for playground equipment begs the question - If there is no money for playground equipment, where is the money coming from to pay for a name change? The obvious follow-up question is - What will the name change cost? The third question would be - Is an expensive and unnecessary name change an appropriate use of scarce dollars?

It is hard to imagine that a name change will cost less than $100,000 by the time legal costs, document costs, clerical expenses, signage and construction (including defacing the facade of one of west Hamilton’s most venerable buildings) and a myriad of other incurred costs and expenses are added up - name changes tend to be a little bit like renovating an old house, full of hidden and unexpected costs. 

 

In the current tight economic climate, where School Boards spend a preponderance of time contemplating resource allocation, it seems irresponsible to even consider taking on this unnecessary expense.  An old shipping container with a cardboard sign proclaiming “School” can be a wonderful place of learning but absent play, physical activity and physical wellbeing effective learning cannot take place - the evidence that supports this simple truth is unequivocal.  It is an interesting coincidence that internationally recognized research into the linkages between physical activity and learning is being led by a parent that has three children attending G.R. Allan.

Perhaps HWDSB would consider forgoing the optional name change of G.R. Allan Elementary School and commit the funds that would have been spent on a name change to the fundraising initiative for the new playground. Given that money is not available to pay for all of the items on everyone's wish list this option represents the best possible outcome for our children. Realizing the full potential of every child must remain of primary importance in all of our efforts. Prioritizing the funding for renaming a school versus providing appropriate and safe play space should be a straightforward decision for duly elected Trustees. 

Should you have any questions, comments or concerns please feel free to contact me directly by e-mail

Best Regards, Blake

Blake Hurst

Hamilton ON

blake.hurst@cogeco.ca

 

Until our Leaders Buy-In .......

 Survival Rates for Cardiac Arrest will continue to founder

Public Access Defibrillation (PAD) programs should be one of the most effective lifesaving initiatives in human history.  We won’t scratch the surface of the lifesaving potential of PAD - CPR/AED - programs until leaders at every level of society wholeheartedly buy-in.  I am continually disappointed by how few individuals in leadership positions attend CPR /AED training.  When the message from the top is “this is something we are doing as an organization but it’s not important enough for me to get personally involved” that attitude trickles down through the entire organization or community.  Of the over 100 CPR/AED classes I teach each year it would be safe to say that the most senior person(s) on staff attends less than 25 per cent of the time.

The difference in the attitude of everyone in the room is palpable when the Principal or the Owner or the Director or the Minister is down on his or her knees performing chest compressions alongside the rank and file.  Learning how perform effective CPR and deploy an AED to save another human beings life is not beneath the lofty station of  Government and Private Sector CEO’s, Elected Officials, School Board Directors, School Principals, Minor Sport Executives or Church Leaders.  A commitment to the well-being of the individual, demonstrated through grassroots participation, makes a powerful statement.  Think of a Corporate CEO or the Mayor of a large city pledging a dollar amount to mental health versus lacing up her shoes and running a half marathon to help raise money and awareness and then giving a talk at the award ceremonies.

The spread of effective community based cardiovascular emergency response programs is dependent on the hands-on involvement of leaders in every sector.  When leaders attend the training and learn firsthand how easy it is to perform effective chest compressions, deploy an AED and achieve a life changing outcome for a cardiac arrest victim the conversion from sceptical adult learner to PAD champion is instantaneous.  Once converted these influencers use their new found knowledge and passion to affect change in their own organizations as well as in other organizations that they influence.

Having leaders with hands on knowledge of resusciation is a critical factor in clearing the risk aversion hurdle that bogs down program implementation in many organizations and communities. I’ve sat in dozens of Board meetings listening to untrained Board Members engage in long winded debate about the risk associated with purchasing an AED and training staff in CPR. I’ve also seen one person that has recently taken a CPR course put the whole issue to bed with a brief testimonial of what they learned and experienced during their training. An enlightened leader can and will find a way to clear all of the hurdles - cost, training schedules, ongoing program maintenance, risk management – and move directly to the ultimate objective of being prepared to respond to cardiovascular emergencies.

When leaders do attend my classes I stress the role of the leader in a real life resuscitation scenario, which is not necessarily to get down on their hands and knees and perform compressions or attach defibrillation pads.  A good leader should take command of the situation and provide clear direction to the team – “Can you please go and Call 911” – “Can you please go out to the road to meet the Paramedics and show them where we are” – “Can you run and get the AED” – “Can you start chest compressions and can you two stay here to switch off when he gets tired”  - “Can you please keep everyone that doesn’t need to be here far far away” – “Can you go to the office and bring the copy of Jim’s medical information sheet for the Paramedics”.  Of course if the leader hasn't taken the training they have no idea what tasks need to be completed in order to save the victims life.  Either a corporation or  taxpayers are paying these individuals good money to lead and they should not be allowed to abdicate their responsibilities at the most critical times.  I have investigated many PAD saves where the successful outcome could be attributed in large part to a trained responder with innate leadership skills taking a step back from the patient in order to take effective command of the entire situation.

Nothing kills more people than cardiac arrest, 40,000 a year in Canada.  Until very recently survival rates for out-of-hospital cardiac arrest have been dismal, less than 5% in most communities. Automated External Defibrillators and simplified CPR protocols are now at the centre of programs that are routinely achieving save rates north of 65 per cent.  Despite the proven game changing, life giving potential of the new protocols they have struggled to gain a meaningful foothold, particularly in Canada. Only when our leaders and influencers buy-in to community based resuscitation programs at both a micro and a macro level will we begin to realize their potential which is measured in lives saved.

Idiot is a word derived from the Greek - idiōtēs - Person Lacking Professional Skill

 

Recently I’ve been reading too many articles where community leaders, resuscitation experts (?) and advocates for cardiac response programs are trumpeting the fact an untrained responder, even an “idiot” (their word, not mine), can deploy an AED, not make the situation worse and maybe even make it better. While this simplistic idea may seem true on its face, there is a logical argument, supported by strong evidence, that untrained responders do in fact make things much worse. In his research Peter Ko showed that survival in a group of patients that received a shock from an AED but poor CPR was 8%, while survival in the group that received a shock plus quality CPR was 53%.

 

The goal of having dead people remain dead is being achieved with overwhelming efficiency, in the 85% to 95% range, in most communities. If the primary goal of a resuscitation program is not to make dead people worse off the untrained responder model is perfect. If the goal is to improve survival rates for cardiac arrest then every time untrained responders are the only people on scene it reduces the chance of saving a life and the patient  is made worse off by virtue of the fact that she is being given a smaller chance at survival.  The entire community is also worse off, family and friends remain dead while tax dollars are squandered on an ineffective program.

 

This is far more than an issue of semantics. When advocates for resuscitation programs present their case to funders - municipal councils, provincial or state governments, corporate executives, school boards -  and the funders push back on cost, as they are programmed to do, the first cost cutting measure put forward is to cut back on training.  

“The machine is idiot proof, even if an untrained responder applies the machine improperly or fails to deploy the machine at all the patient can’t be made worse off.” explains the advocate proudly displaying his advanced knowledge of defibrillation science

“Well by that logic” says the funder “why pay for any training at all. If the machine is so simple an idiot can use it we should just buy a dozen machines, hang them in our buildings and call it a done deal.”

The advocate, anxious to walk out of the meeting with something, accepts the offer of 12 AED and no budget for training and another ineffective PAD program is born. What funders need to know is that to build an effective program that maximizes the number of lives saved investment must be made in every link in the chain of survival. The evidence is clear and unequivocal, most patients that survive cardiac arrest benefit from the proper use of multiple links in the chain.  Funders can take comfort in the fact that if the trained responder model breaks down and an untrained person attempts the resuscitation they can’t make things worse, but it is far from ideal when that happens.

If your are an “expert” trumpeting the “idiot proof” operation of AED’s please reconsider your words or at the very least downplay this aspect of the machine. If you are an advocate for effective resuscitation programs in your organization or community please push for more training opportunities for all stakeholders and potential responders.

In Memory of Brock

http://globalnews.ca/news/939093/alberta-mother-raises-defibrillator-awareness-in-sons-memory/