Georgia - When Atlanta's emergency medical system needed rescuing,
Mayor Shirley Franklin started performing CPR in more ways than one.
In 2003, she started issuing orders that have resulted in lifesaving
changes to Atlanta's emergency system. She began looking for ways to
hold emergency crews more accountable, and last year she ordered all
8,000 city employees -- including herself -- to be trained in
"All you need to do is save one life and it's worth it," Franklin
says. "It's miraculous."
Thanks to those efforts and a program created in Atlanta by Emory
University and the Centers for Disease Control and Prevention, the
city is saving more residents who collapse of sudden cardiac arrest.
Since September 2005, the survival rate for such patients in Atlanta
has jumped from less than 3% to 15%. That's well above the 6% to 10%
survival rate for most cities that was identified in a 2003 analysis
by USA TODAY.
Atlanta's success has made it, and the program it's following, a
template for cities trying to improve cardiac-arrest survival rates,
an often murky set of figures complicated by communication problems
among government agencies.
Several cities -- including Houston, Anchorage, Austin, Cincinnati,
Kansas City, Mo., Raleigh, N.C., and Tucson -- are following in
Atlanta's footsteps by signing up for the Emory/CDC program. It
allows cities to use its Internet database to combine data from 911
dispatch centers, paramedic run reports and hospital discharge
records to reveal more about the performance of EMS units -- widely
viewed as a key step in improving cardiac survival rates. Many
cities have no system to effectively track such rates.
A few cities in the program or planning to join it were identified
in the USA TODAY report four years ago as having particularly good
systems for tracking emergency crews' performance. Those include
Houston, Kansas City, Tucson, Boston, Nashville and San Francisco.
Other cities taking part or planning to -- such as Atlanta, Austin
and Columbus, Ohio -- were identified as having less-than-stellar
systems for tracking cardiac survival rates.
The program -- known as Cardiac Arrest Registry to Enhance Survival,
or CARES -- is a five-year, $1.5 million CDC project launched three
years ago. It was partly inspired by the USA TODAY investigation,
which found that emergency medical systems in most of the nation's
50 largest cities were fragmented, inconsistent and slow.
Why the focus on cardiac arrest survival rates and not those from
something else, such as car accidents or cancer? Cities use cardiac
arrest survival rates as a key measure of EMS performance because
such victims typically live or die depending on the care they get in
the first minutes after collapse, unlike other emergencies in which
survival hinges more on hospital care.
"The system has to deliver in order to save a cardiac arrest
victim," says Arthur Kellermann, an emergency physician at Emory
University School of Medicine. "If it can deliver in a consistent
manner for cardiac arrest victims, there is every reason to expect
that it will deliver for trauma victims, asthma victims, women in
More than 250,000 people die outside of hospitals each year when
their hearts stop beating. Many are reaching the natural end to
battles with disease, but others are healthy when struck by an
electrical short circuit of the heart called ventricular
fibrillation. "V-fib" can be caused by anything from a blocked
coronary artery, to a ball striking the chest, to changes in the
heart muscle from an infection.
In 2003, USA TODAY found disparities in emergency medical care
across the nation, and said cities that carefully track their EMS
performance save many more lives. In most cases, such cities also
make a point of teaching residents CPR by, among other things,
sending firefighters into homes, churches or businesses to train
The reason: If a bystander or acquaintance can quickly perform CPR
when a person is stricken with cardiac arrest, they can buy the
victim precious time before emergency personnel arrive. Businesses
also are encouraged to have defibrillators and people trained to use
them so victims can be shocked if rescue crews can't arrive quickly.
Bryan McNally, the emergency physician from Emory Healthcare who
heads CARES, told an EMS conference in February that the impetus for
the program included USA TODAY's finding that a lack of data
regarding EMS responses to cardiac arrest victims is a "major
obstacle to improving pre-hospital emergency cardiac care."
Atlanta's huge challenge
Franklin says she learned from USA TODAY's report that Atlanta was
losing more than 10 times as many cardiac arrest victims as cities
such as Boston, Seattle and Rochester, Minn. The newspaper's
analysis ranked cities' EMS efforts in three tiers, with Atlanta's
in the bottom tier of cities that had no idea how many lives their
rescue units were -- or were not -- saving.
"Shirley Franklin was furious to see Atlanta as a 'Class C' city,"
Kellermann says. "She felt it should be in the first tier."
When Franklin took a closer look, what she saw was grim.
From August 2005 through March 2006, her city saved only one person
considered by doctors to be among the "most saveable" victims of
sudden cardiac arrest. They were deemed saveable because people saw
them collapse, and what the victims needed was to be treated quickly
with a defibrillator shock to restore their heart's rhythm.
USA TODAY found that in such cases, life and death usually is
decided within six minutes of an attack. If the heart is not
restarted by then, brain damage can be so severe that the victim is
not likely to wake up, even if he or she survives.
"It became really clear to us when we looked at the statistics that
the availability of trained personnel close by when somebody is
experiencing cardiac arrest can save a life," Franklin says.
She vowed to do more to help the city improve, including enrollment
It's paying off. From September 2005 through July 2007, months in
which the city has tracked its performance using CARES, 10 of 66
cardiac arrest victims in the "most saveable" category survived with
normal brain function.
Atlanta's 15% survival rate is a dramatic improvement, but still
well behind leading cities such as Boston, where the survival rate
for such cardiac patients is 38%.
One patient's good fortune
The response to save 69-year-old Ronald Williams on May 21 shows how
the Atlanta area's system is still moving too slowly to save a life
without help from bystanders.
Williams, of Tucker, Ga., was undergoing a stress test in his
cardiologist's office when his heart went into V-fib. The medical
staff called for help, began CPR and delivered a shock with a
The call for help went first to a 911 center, then to fire
department rescuers from Sandy Springs, an Atlanta suburb. By the
time paramedics reached Williams and delivered a second shock with
their defibrillator, nine minutes had passed since he had gone into
Williams says he's lucky he was in his doctor's office. "It could
have happened anyplace," says the retired aerospace technician,
whose blocked arteries were cleared in a hospital after he was
Jing Fang, a physician and researcher in CDC's Division for Heart
Disease and Stroke Prevention who is technical director for CARES,
says the program ultimately should help save more people like
Using the system's database, city leaders can track how many cardiac
arrest victims their crews tried to save, how many of the victims
had their hearts restarted in the field, and how many went home from
the hospital with good brain function. The leaders also can see how
many victims got help before rescuers arrive. By seeing how each
part of the system performed, EMS leaders say they can determine
what improvements are needed.
The CARES program allows cities to tell how their crews are
performing compared with others in their region and, soon, to the
other cities participating nationally.
Some cities that are struggling to determine their cardiac arrest
survival rates are not in CARES. In Dallas, officials see CARES
as "valuable and laudable," but they are creating their own system
to track cardiac arrest survival, says Marshal Isaacs, medical
director for the city's fire and rescue units. He says the system
could be in place next year.
In Chicago, Philadelphia, El Paso and San Diego, medical directors
report having problems getting hospitals to share data on patient
survival rates. Jim Dunford, medical director for San Diego's EMS,
says a law is needed to force cooperation.
"How can it be that the No. 1 killer of Americans remains heart
disease and we still can't accurately measure outcome from cardiac
arrest?" he asks.
El Paso's EMS medical director, James "Randy" Loflin, says his city
is unable to track survival rates because "hospitals tell us they
can't share survival data due to HIPAA," a federal law that protects
patient privacy. CARES was designed to share data while complying
with the law, McNally says.
'Community response' is key
When Atlanta started crunching its cardiac arrest survival numbers,
it became clear that when rescue crews reached a patient, there
often were people standing around, unsure how to help.
Only 7% of the city's cardiac arrest victims were getting CPR from
bystanders when the CARES program was introduced. Houston, Tucson
and other cities that save the most lives in such situations have
raised their CPR rates for bystanders through training programs and
by having 911 dispatchers give simplified CPR instructions over the
phone. Chest compressions alone -- even without mouth-to-mouth
breathing -- can buy minutes for a cardiac arrest victim until
"It's not just about streamlining or improving the professional
response, it's also about the community response," McNally
says. "What is happening before the ambulance or first responders
get there? Are people doing CPR?"
When Franklin told city employees to get CPR training, she
says, "each of us took a pledge that we would train others."
Atlanta's bystander CPR rate has more than doubled to more than 17%.
To give an idea of how far Atlanta has to go to catch up with cities
that save the most lives, McNally cites bystander CPR rates of 30%
to 40% and higher in places such as Seattle and Boston.
"A lot of us think ... the only solution is a doctor," Franklin
says. "Having a trained workforce is part of the solution."
Written by USA Today