Formula for Survival: Stuck on Implementation

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Cardiac arrest is a complex, high-stakes condition.  Nearly 1,000 times each day across the United States, communities respond to reports of unconscious, not breathing persons.  On average, as little as 9% of cardiac arrest victims survive.  Many more could survive if communities implemented what’s been shown to work in cities like Seattle – where survival exceeds 50%.

There are tremendous disparities in survival when comparing cities.  Where one decides to live shouldn’t determine if they’ll live.  Sadly, that is the case.

The Formula for Survival framework illustrates three important factors that determine the outcome of cardiac arrest.  Survival = Medical Science X Educational Efficiency X Local Implementation.

Many communities struggle to organize the optimal response to reverse this life-threatening state.  The challenge isn’t that we don’t what works – quite the contrary.   High-quality scientific evidence is readily available and interpreted by expert reviewers.

Dismal survival from cardiac arrest is a crisis of local implementation.  Translating the science into actionable tasks is easier than it sounds.  The difficulty is compounded by many factors – three of which include:

  1. Unclear ownership and authority to make an impact.
  2. Lack of accountability to measure and improve performance across the Chain of Survival.
  3. Too little emphasis on continuous and rigorous training.

Ownership and Authority to Make and Impact – Cardiac arrest incidents require urgent and flawless response from multiple agencies within the community.  911 Communications, Law Enforcement, Fire Department, and EMS all have a role in the response.  Bystander engagement is critical as well.  Few communities assign over-arching ownership, with decision-making authority, to an individual capable of architecting a truly efficient and impactful survival chain.  Quality is difficult to attain and maintain when the assets within a response chain are controlled in different silos.


Understanding and Optimizing the Chain of Survival – The Chain of Survival is a model to describe several links within the response to cardiac arrest.  Weakness in any link lessons the likelihood of resuscitating the patient.   Upon collapse, the optimal response includes nearly immediate CPR from bystanders, followed by quick assumption of CPR by police, or other first responders, and timely defibrillation.  Too often, community leaders believe cardiac arrest is an EMS incident.  False.  It is a public safety incident.  Within each link reside critical performances that must be executed flawlessly.  Too often the bar is set too low with respect to monitoring quality.  Deep understanding of the Chain of Survival is usually lacking – this means performance gaps remain unidentified.  With best in class cities achieving 50% survival, and most other communities performing well under 12%, refinements to the Chain must be ongoing.  What works in one community may not translate well to another community – there is not a one size fits all solution.

Emphasis on Continuous and Rigorous Training – The training requirements for public safety officials are substantial.  There are numerous mandates, guidelines and priorities all competing for time and resources.  Few communities engage in ongoing, multi-agency training.  With the rise of active-shooter incidents, more communities are conducting drills involving dispatch, law enforcement, fire and EMS departments.  This is encouraging and perhaps a model to build on.  Like active-shooting incidents, there is an enormous requirement on timely, definitive response to achieve an optimal outcome.  Also like active-shooter events, the frequency of cardiac arrest is low.  Most public safety officials respond to less than 3 cardiac arrest per year.  This is too infrequent to maintain competence.

With unclear ownership, sub-optimal chains of survival, and infrequent training, we are unlikely to see improved survival from cardiac arrest.  Better outcomes, however, may be attained.

How might a community improve survival?  Here’s a starter list:

  • Determine the current survival from cardiac arrest in your community.
  • Create a sense of urgency and get buy-in from sister-agencies within the community.
  • Commit to improving.    Assign accountability and authority to a single individual.  Joint accountability might be an option so long as both individuals are held equally responsible for success.
  • Measure performance at each link of the Chain.  Identify gaps.  Set goals.  Start small.  Build on early success.
  • Provide ongoing and clear feedback to everyone within the survival chain.
  • Train as if lives are depending on your competence.  Because they do.

Improving survival from cardiac arrest requires high-level commitment to understand the current results and implement a culture of continuous cross-functional leadership.  Only through this approach may we improve the survival prospects for future cardiac arrest victims.

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