Local laws, insurance reimbursement and public misperceptions impede emergency medical services (EMS) workers from using best resuscitation practices, according to a 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, said 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) were physicians, and 66.7 percent were EMS directors at a wide variety of practice settings.
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:
- private insurers and Medicare who provide higher reimbursement to EMS for patient transport, regardless of whether the cardiac arrest victim is successfully resuscitated in the field or not;
- state legislation that requires transport to hospitals and restricts the ability of responders to follow do-not-resuscitate (DNR) 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," said 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, shock the heart to try to re-establish a normal heart rhythm and provide appropriate advanced cardiovascular life support. The final decision to stop resuscitation efforts must be based on clinical judgment and respect for human dignity. Cessation of efforts in the out-of-hospital setting, following system-specific criteria and under direct medical control, should be standard practice in all EMS systems.
"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," said 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.
Co-authors are: 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. Individual author disclosures are available on the manuscript.
The Robert Wood Johnson Foundation Clinical Scholars Program funded the study.
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NR09 – 1077 (Circ/Sasson)