The Division for Heart Disease and Stroke Prevention developed policy and system outcome indicators across the priority areas of
the National Heart Disease and Stroke Prevention Program. The indicators are specific, observable, and measureable characteristics
that show the progress being made toward achieving outcomes. This comprehensive set of indicators can be used for program
planning and evaluation by state Heart Disease and Stroke Prevention programs as well as their partners.
Outcome Indicators for
Policy and Systems Change
IMPROVING EMERGENCY RESPONSE
Centers for Disease Control and Prevention
National Center for Chronic Disease Prevention and Health Promotion
Division for Heart Disease & Stroke Prevention
Mail Stop K–47 • 4770 Buford Highway, NE • Atlanta, Georgia 30341
770 488 2424 • Fax 770 488 8151 • www.cdc.gov/DHDSP
Outcome Indicators for
Policy and Systems Change:
Improving Emergency
Response
Centers for Disease Control and Prevention
Division for Heart Disease and Stroke
Prevention
September 2010
ACKNOWLEDGMENTS
We would like to extend special thanks to the following individuals for their
assistance in preparing and reviewing this publication.
Expert Review Panel Members
See Appendix I
Indicator Workgroup (alphabetical order)
Anita Berwanger, Missouri Department of Health and Senior Services
Ian Brissette, New York State Department of Health
Margaret Casey, National Association of Chronic Disease Directors
Eric Cook-Wiens, Kansas Department of Health and Environment
Vance Farrow, District of Columbia Department of Health
Farooq Ghouri, Kansas Department of Health and Environment
Daniel Kim, Virginia Department of Health
Deborah Pearlman, Rhode Island Department of Health
Dale Rogoff Greer, Massachusetts Department of Public Health
Zahid Samad, Tennessee Department of Health
Velma Thiesen, Michigan Department of Community Health
Deb Wigand, Maine Department of Health and Human Services
Becky Wright, Oregon Public Health Division
Centers for Disease Control and Prevention (alphabetical order)
Eileen Chappelle
Mary George
Yuling Hong
Natasha Jamison
Darwin Labarthe
Rashon Lane
Dyann Matson Koffman
Robert Merritt
Belinda Minta
Michael Schooley
Hylan Shoob
Amy Valderrama
Nancy Watkins
Ishmael Williams
We also give thanks to:
Catalina Ramirez, RTI International
Amy Roussel, RTI International
Emily Warmoth, RTI International
Suggested Citation
Wall HK, Ladd S, Rogers T, Fulmer E, Lim S, Leeks K, Jernigan J. Outcome Indicators for
Policy and Systems Change: Improving Emergency Response. Atlanta, GA: Centers for
Disease Control and Prevention; 2010.
ii
CONTENTS
Section
Page
1. Introduction .............................................................................................1
1.1 Purpose ....................................................................................... 1
1.2 Methods ....................................................................................... 3
1.3 Use ............................................................................................. 4
2. Expert Panel Indicator Rating Tables .......................................................6
3. Indicator Profiles ...................................................................................20
LOGIC MODEL BOX 1: Worksite Changes ............................................. 22
LOGIC MODEL BOX 2: Community Changes .......................................... 38
LOGIC MODEL BOX 3: Emergency Response Systems Changes ................ 53
LOGIC MODEL BOX 4: Individual Changes............................................. 59
LOGIC MODEL BOX 5: Emergency Medical Provider Changes ................... 69
LOGIC MODEL BOX 6: Increased Individual Adoption of Emergency
Response Actions .......................................................................... 76
Logic Model Box 7: Reduced Time from Symptom Onset to
Emergency Department Arrival ....................................................... 83
LOGIC MODEL BOX 8: Reduced Morbidity and Mortality Due to Heart
Disease and Stroke ....................................................................... 92
LOGIC MODEL BOX 9: Reduced Levels of Disparities in Heart Disease
and Stroke ................................................................................. 114
LOGIC MODEL BOX 10: Reduced Costs Associated with Heart Disease
and Stroke ................................................................................. 122
4. Appendices ...........................................................................................130
Appendix I: Expert Review Panel Members ......................................... 131
Appendix II: Logic Model for Improving Emergency Response .............. 133
Appendix III: Data Source Descriptions ............................................. 134
Appendix IV: Acronyms ................................................................... 140
iii
FIGURES AND TABLES
Number
Page
Figure 1. Improving Emergency Response Logic Model .................................4
Table 1. Expert Panel Indicator Rating Tables ..............................................8
Figure 2. Indicator Number Designation .....................................................21
iv
1. INTRODUCTION
1.1 Purpose
The Centers for Disease Control and Prevention (CDC) Division for Heart Disease and Stroke
Prevention (DHDSP) developed policy and systems change outcome indicators for state
Heart Disease and Stroke Prevention (HDSP) programs and partners across program
priorities. Program Managers, Evaluators, and DHDSP are the primary intended users of the
indicators and supporting materials. State HDSP programs are funded to support policy and
systems change that will lead to improvements in six priority areas to address heart disease
and stroke prevention and control:
•
Increase control of high blood pressure
•
Increase control of high blood cholesterol
•
Increase knowledge of signs and symptoms for heart attack and stroke and the
importance of calling 9-1-1
•
Improve emergency response
•
Improve quality of heart disease and stroke care
•
Eliminate disparities in terms of race, ethnicity, gender, geography, or
socioeconomic status
State work focuses on controlling high blood pressure or high blood cholesterol in adults
with emphasis on health care and worksite settings; however, because heart disease and
stroke are the first and third leading causes of death in the U.S., many adults will
experience acute cardiovascular events. Therefore, it is important to address emergency
response and recognition of heart attack and stroke.
Indicators are specific, observable, and measureable characteristics that show the progress
a program is making toward achieving outcomes. This document provides outcome
indicators for improving emergency response for adults experiencing acute cardiovascular
events. Each indicator includes a scaled rating based on existing science, expert opinion,
and state practices. The work is intended to assist with program planning and evaluation
to:
•
Provide a solid evidence base for public health decision making
•
Describe outcome indicators for evaluation of state HDSP programs and suggest
appropriate data sources and measures for these indicators
•
Encourage states to use valid and reliable measurement methods and
comparable data sources
•
Help DHDSP determine evaluation criteria, assess best practices, and provide
consistent surveillance and evaluation technical assistance to states
Section 1―Introduction
This indicator book includes:
•
A logic model to identify causal pathways across the outcome components
(Appendix II)
•
A brief summary of the state of the science for each logic model component and
how it relates to downstream components
•
Indicator rating tables that list all of the indicators associated with each
component of the logic model and the synthesized expert reviewer ratings for
each indicator
•
Indicator profiles that include detailed information for each indicator
•
Data source descriptions (Appendix III) to provide background information on
suggested data sources
Throughout the Improving Emergency Response Indicators book, the following terms are
used:
•
Emergency response refers to all aspects of the response system for acute
cardiovascular events including bystander recognition and response, 9-1-1,
emergency medical dispatch (EMD), emergency medical services (EMS), and
some aspects of emergency department care. Additional aspects of emergency
department care for acute cardiovascular events can be found in “Outcome
Indicators for Policy and Systems Changes: Improving Quality of Care”.
•
Acute cardiovascular events include heart attack, stroke, and out-of-hospital
cardiac arrest (OHCA).
•
Heart attack, where blood flow to the muscle of the heart is impaired, may also
be referred to as myocardial infarction. ST-elevation myocardial infarction
(STEMI) is a specific type of heart attack that is detected by a 12-lead
electrocardiography (ECG) and should be cared for at a hospital that has the
capability of performing percutaneous coronary intervention (PCI), also known as
coronary angioplasty, a procedure used to open blocked or narrowed coronary
arteries.
•
Cardiac arrest occurs when the heart’s mechanical activity of blood circulation
stops. This results in the loss of a pulse. Heart attack, abnormal heart rhythms
like ventricular fibrillation, and trauma are some known causes of cardiac arrest.
•
There are two major stroke types, ischemic and hemorrhagic. Ischemic strokes
occur as a result of an obstruction within a blood vessel supplying blood to the
brain. Hemorrhagic strokes are caused by a weakened blood vessel that ruptures
and bleeds into the surrounding brain. Ischemic strokes are more common than
hemorrhagic. In this document, the term ‘acute stroke’ may refer to either type
of stroke.
As outlined above, increasing knowledge of signs and symptoms for heart attack and stroke
and the importance of calling 9-1-1 and improving emergency response are two priority
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September 2010
Section 1―Introduction
areas for state HDSP programs. Because of the close interaction between identifying an
acute cardiovascular event and subsequently initiating the emergency response system,
these two distinct HDSP priority areas have been included in this indicator document. A
separate indicator document for Improving Quality of Care indicators addresses actions
taken in the hospital setting once an individual has experienced an acute heart attack or
stroke event. The two sets of indicators complement one another and may be used in
tandem for program planning and evaluation. Please note that it is assumed individual
HDSP programs will choose to focus on one part or subset of the emergency response
system and that this work will be done in coordination with community partners and
emergency response personnel. There is no expectation that a program will capture and
analyze information across all system of care elements.
1.2 Methods
The Social-Ecological Model (SEM) of health, first described by McLeroy, Bibeau, Steckler, &
Glanz (1988), provides a framework in which to develop, implement, and evaluate
comprehensive health promotion interventions. The model describes society as
interconnected elements – individual, interpersonal, organizational, community, and social –
that affect one another. The model supports the premise that in order to change individual
behavior, a comprehensive intervention should consider how all these levels of influence can
be addressed to support long-term, healthful lifestyle choices. The SEM informed the logic
model for Improving Emergency Response and the indicators that span these dimensions.
State HDSP programs are charged with working at the societal and community levels of the
SEM through policy and systems changes.
Because working at these higher levels is intended to ultimately impact individual
knowledge, awareness, and behavior change, outcomes that reflect these
individual-level changes have been included in the indicators, though working
directly with individuals is not within the scope of HDSP Programs.
The indicators were identified through an extensive review of the literature that supported
the development of a logic model for policy and systems change to improve emergency
response. Each outcome indicator is nested within a component of the logic model (Exhibit
1 and Appendix 1). Indicators were linked across the logic model to downstream
outcomes based on published findings.
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September 2010
Section 1―Introduction
Figure 1. Improving Emergency Response Logic Model
In pu ts
S ho r t- te rm
O ut co m es
Ac tivit ies
O u tpu ts
Bo x 1 Wor ksite Cha nge s:
• Pol ic ies/ Prot ocols/To ols
• Env iro nme ntal Chan ges
Bo x 2 C ommu ni ty Chan ges :
• Env iro nme ntal Chan ges
• Pol ic y/Le gisl ativ e C han ges
In te r me d ia t e
Ou t co me s
Box 4 I ndi vid ual
Ch ang e:
• K no wle dge of S ign s
and S ym ptom s
• K no wle dge of
Ap pro pri ate E merg ency
Resp onse
• In ten tion to A ct
in R espon se to a
Car di ovascul ar E vent
Box 6 Increa se d
Ind ivi dua l A do pti on
of Eme rgen cy
Res p onse/ Acti ons
Box 7 Red uced
Tim e from
Sym pto m Ons et to
Hospi tal A rr ival
Bo x 3 Em erge nc y R espon se
S ystem Chan ge:
• Aw are ness
• Pol ic ies/ Prot ocols/To ols
• Env iro nme ntal Chan ges
Box 5 Emer gen cy
Med ical Prov ide r
Ch ang es
L o ng - te r m
O ut co m es
Bo x 8 Reduce d
M orb idi ty an d
M orta lit y Due t o
Hea rt Di se ase and
S trok e
Bo x 9 Reduce d
Lev els of Disp ari ties
in Hear t Disea se and
S trok e
Bo x 10 Re duced
Costs Associa ted
Wi th He art Di sease
A nd S tr oke:
•Hea lthcar e
•Em plo yer
•S oc iet al
Cont ex tua l F act o rs
• S ocio -econ omi c and dem ogra phi c ch aracte risti cs o f the ta rge t pop ula tio n
• Pa rti ci pat ing org ani zati ons’ pol icies a nd p racti ce s
• He alt hcare i nd ustry p racti ce tren ds an d po lici es
• Pa rtn ershi ps amo ng p ati ents, p rovi der s, h eal thcare org ani zati ons, an d wo rksit es
Candidate indicators were then reviewed and rated by an expert panel that included content
area experts, CDC experts, and state health department program managers, evaluators,
and epidemiologists. See Section 2 Expert Panel Indicator Rating Tables below for more
information on the rating criteria and methods.
1.3 Use
The outcome indicators are intended to assist in planning and outcome evaluation of state
HDSP activities. To facilitate use, the indicators and supporting materials were written to
allow flexibility to tailor measurement to the specific strategies and needs of programs.
State HDSP programs may use the indicators to support the development of an evaluation
plan as described in Evaluation Guide: Developing an Evaluation Plan published by CDC
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September 2010
Section 1―Introduction
DHDSP, available at
http://www.cdc.gov/dhdsp/state_program/evaluation_guides/pdfs/evaluation_plan.pdf.
The HDSP Evaluation Guide identifies eight steps in developing an evaluation plan:
1. Develop evaluation questions (what do you want to know?)
2. Determine indicators (What will you measure? What type of data will you
need to answer the evaluation question?)
3. Identify data sources (Where can you find these data?)
4. Determine the data collection method (How will you gather the data?)
5. Specify the time frame for data collection (When will you collect the data?)
6. Plan the data analysis (How will data be analyzed and interpreted?)
7. Communicate results (With whom and how will results be shared?)
8. Designate staff responsibility (Who will oversee the completion of this
evaluation?)
State HDSP programs can use the logic model, indicator ratings, and profiles to select a set
of outcome indicators to include in their evaluation plan:
•
Logic model box summaries provide a very brief overview summarizing the state
of the science for the given outcome component and identify how it relates to
downstream components. As HDSP programs consider evaluation needs,
reviewing this information will identify critical causal pathways across the
outcome components that should be measured. Once these causal pathways are
identified, HDSP programs may want to select one or more indicators from each
identified outcome component to ensure a strong evaluation plan.
•
Indicator rating tables list all of the indicators associated with the outcome
component of the logic model and the synthesized expert reviewer ratings for
each indicator by criterion. HDSP programs may want to select criteria most
suited to the context of the program and most important to stakeholders. Once
the criteria are prioritized, programs can apply the criteria to the full list of
indicators within each outcome component to select relevant outcome indicators.
•
Indicator profiles include detailed information for each indicator including more
specific definitions, potential data sources, and pertinent references. This
information may provide a starting point for addressing Step 3 in the Evaluation
Plan development, “Identify data sources.” HDSP programs, however, will need
to carefully consider a number of relevant issues before final selection of
measures can occur, including at what level data should be collected; whether
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September 2010
Section 1―Introduction
the data source to be used is valid, reliable, and feasible given the context; and
the periodicity of data collection.
2. EXPERT PANEL INDICATOR RATING TABLES
The rating table lists the indicators by logic model box and summarizes the expert panel
ratings for each indicator. The indicators were rated on criteria that describe five important
characteristics of a “good” indicator and overall quality of the indicator. Availability of an
existing data source was not a criterion for selection of the indicators or a rated criterion.
Rating tables can be used to quickly review the indicators to identify those with specific
criteria, e.g. indicators with the highest scientific validity, or as a quick reference to review
all the indicators and their relationships. The expert panel rating summaries below reflect
the median values across reviewers on each rated criterion.
The criteria are:
Overall Quality
•
Reflects expert reviewer opinion of the overall quality of the indicator
•
Rated on a scale from 1-10. Reviewers are determined to have low agreement
when less than 75% of all valid ratings are within two points of the median.
Resources Needed
•
Reflects the amount of funds, time, and effort needed to collect reliable and
precise data on the indicator and to analyze primary or secondary data.
•
Rated on a scale of 1-4. The greater the number of dollar signs, the greater the
resources needed. Reviewers are determined to have low agreement when less
than 75% of all valid ratings are within one point of the median.
•
Dollar signs do not represent a specific amount or range of costs but are instead
a relative measure of expert reviewer ratings regarding resources required to
collect and analyze data to measure the indicator.
Strength of the Scientific Evidence
•
The extent to which the literature supports the use of the indicator for HDSP
program evaluation, with the assumption that implementing interventions to
modify an upstream indicator will result in measurable downstream effect.
•
Rated on a scale of 1-5. Reviewers are determined to have low agreement when
less than 75% of all valid ratings are within one point of the median.
Face Validity
•
Expert reviewer estimation of the extent to which judgments about and
measurement of the indicator would appear valid and relevant to policy makers
and other decision makers who use the results of an evaluation to justify
continued support of policy and program approaches.
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September 2010
Section 1―Introduction
•
Rated on a scale of 1-5. Reviewers are determined to have low agreement when
less than 75% of all valid ratings are within one point of the median.
•
The extent to which expert reviewers believe that the indicator would help to
answer key HDSP program evaluation questions.
•
Rated on a scale of 1-5. Reviewers are determined to have low agreement when
less than 75% of all valid ratings are within one point of the median.
Utility
Conformity with Accepted Practice
•
Expert reviewer opinion of the degree to which use of the indicator is consistent
with currently accepted HDSP practice
•
Rated on a scale of 1-5. Reviewers are determined to have low agreement when
less than 75% of all valid ratings are within one point of the median.
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Section 2 – Expert Panel Indicator Rating Tables
Table 1. Expert Panel Indicator Rating Tables
Indicator Name
and Number
Resources
Needed
Overall Quality
low ← → high
Scientific
Evidence
Face
Validity
Accepted
Practice
→ better
←
3.1.1 Proportion of worksites
with an emergency response
plan that addresses acute
cardiovascular events
Utility
$$$
3.1.2 Proportion of worksites
with AED programs
$$$†
††
3.1.3 Proportion of worksites
that provide access to CPR
instruction that includes
guidance on the use of an AED
3.1.4 Proportion of worksites
that provide information about
their AED program to
community Emergency
Medical Service providers
3.1.5 Proportion of worksites
that provide access to
educational information
addressing signs and
symptoms and the importance
of emergency response for
acute cardiovascular events
†
$$
††
††
††
$$†
$$$†
†
†
†
†
†
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September 2010
Section 2 – Expert Panel Indicator Rating Tables
Indicator Name
and Number
Overall Quality
Resources
Needed
low ← → high
3.1.6 Proportion of worksites
with environmental supports
that facilitate emergency
response for acute
cardiovascular events
Scientific
Evidence
Face
Validity
←
Utility
Accepted
Practice
→ better
$$
††
†
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within one point of the median for this
criterion.
††
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within two points of the median for
overall quality of the indicator.
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September 2010
Section 2 – Expert Panel Indicator Rating Tables
Indicator Name
and Number
Resources
Needed
Overall Quality
Scientific
Evidence
low ← → high
←
3.2.1 Number of community
interventions to improve
knowledge of signs and
symptoms and emergency
response for acute
cardiovascular events
Utility
→ better
$$$
3.2.2 Number of evidenceinformed policies adopted to
improve emergency response
for acute cardiovascular
events
††
$$
3.2.3 Number of community
environmental supports to
improve emergency response
for acute cardiovascular
events
††
$$$
3.2.4 Proportion of
communities served by
telephone dispatchers certified
to provide CPR instructions
according to standardized
emergency medical dispatch
protocols◊
$$
3.2.5 Proportion of
communities that provide
access to CPR training for
community members
$$
◊
Face
Validity
†
To improve clarity, the language of this indicator has significantly changed since the expert panel review
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September 2010
Accepted
Practice
Section 2 – Expert Panel Indicator Rating Tables
Indicator Name
and Number
Resources
Needed
Overall Quality
low ← → high
3.3.1 Proportion of nonhospital health care settings
that establish systems for
emergency response to acute
cardiovascular events
3.3.2 Proportion of
ambulances with equipment to
facilitate optimal emergency
response for acute
cardiovascular events
††
Scientific
Evidence
Face
Validity
←
Utility
Accepted
Practice
→ better
$$
††
$$
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within two points of the median for
overall quality of the indicator.
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September 2010
Section 2 – Expert Panel Indicator Rating Tables
Indicator Name
and Number
Overall Quality
Resources
Needed
Scientific
Evidence
low ← → high
←
3.4.1 Proportion of individuals
who are aware of the signs
and symptoms for acute
cardiovascular events
$$$
3.4.2 Proportion of individuals
with knowledge of the
appropriate emergency
response actions for acute
cardiovascular events
$$$
3.4.3 Disparity in knowledge
of the signs and symptoms for
acute cardiovascular events
between general and priority
populations
$$
3.4.4 Disparity in knowledge
of appropriate emergency
response actions for acute
cardiovascular events between
general and priority
populations
$$
†
Face
Validity
Utility
Accepted
Practice
→ better
†
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within one point of the median for this
criterion.
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September 2010
Section 2 – Expert Panel Indicator Rating Tables
Indicator Name
and Number
Resources
Needed
Overall Quality
Scientific
Evidence
low ← → high
3.5.1 Proportion of acute
cardiovascular events in nonhospital settings where health
care providers use AEDs
3.5.2 Proportion of acute
cardiovascular events where
emergency response
personnel provide appropriate
pharmacologic treatment prior
to hospital arrival
3.5.3 Proportion of acute
cardiovascular events with
documented use of
appropriate emergency
response equipment
Face
Validity
←
Utility
Accepted
Practice
→ better
†
$$$$
††
$$
††
$$
†
†
††
†
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within one point of the median for this
criterion.
††
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within two points of the median for
overall quality of the indicator.
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September 2010
Section 2 – Expert Panel Indicator Rating Tables
Indicator Name
and Number
Resources
Needed
Overall Quality
low ← → high
Scientific
Evidence
Face
Validity
←
3.6.1 Proportion of acute
cardiovascular events in which
the emergency response
system is activated
$$†
3.6.2 Proportion of acute
cardiovascular events where
bystanders use an AED
$$
††
3.6.3 Proportion of acute
cardiovascular events in which
bystanders administer CPR
††
Utility
Accepted
Practice
→ better
†
†
$$
†
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within one point of the median for this
criterion.
††
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within two points of the median for
overall quality of the indicator.
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September 2010
Section 2 – Expert Panel Indicator Rating Tables
Indicator Name
and Number
Overall Quality
Resources
Needed
Scientific
Evidence
low ← → high
3.7.1 Median time between
symptom onset and call to
9-1-1
3.7.2 Median time between
symptom onset and
emergency department arrival
Face
Validity
Utility
Accepted
Practice
→ better
←
$$$
3.7.3 Proportion of acute
cardiovascular events utilizing
the emergency response
system where emergency
response professionals provide
pre-arrival notification to the
receiving hospital
Denotes no available expert reviewer rating.
$$$
Indicator was added post-expert panel review.
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September 2010
Section 2 – Expert Panel Indicator Rating Tables
Indicator Name
and Number
Resources
Needed
Overall Quality
low ← → high
3.8.1 Proportion of adults who
show a return of spontaneous
circulation after a cardiac
arrest
3.8.2 Proportion of adults who
survive to emergency
department arrival after an
acute cardiovascular event
Utility
Accepted
Practice
→ better
$$†
††
$$
††
$$
3.8.4 Proportion of adults who
survive to hospital
discharge after an acute
cardiovascular event where
pre-hospital CPR or
an AED was employed
3.8.6 Death rate at 30 days
after hospital discharge among
adults with acute
cardiovascular events who are
transported to a hospital with
a specialized cardiac care unit
Face
Validity
←
3.8.3 Inpatient death rate
after an acute cardiovascular
event
3.8.5 Proportion of individuals
with poor functional status
after acute cardiovascular
events
Scientific
Evidence
$$$
$$$
††
$$
††
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September 2010
†
Section 2 – Expert Panel Indicator Rating Tables
Indicator Name
and Number
Overall Quality
Resources
Needed
low ← → high
3.8.7 Death rate at 30 days
after hospital discharge among
adults with acute stroke who
are transported to a hospital
with a specialized stroke care
unit
3.8.10 Death rate at one year
after hospital discharge for
adults with acute
cardiovascular events
Face
Validity
←
Utility
Accepted
Practice
→ better
$$
††
3.8.8 Death rate at 30 days
after hospital discharge for
adults with acute
cardiovascular events
3.8.9 Death rate at six months
after hospital discharge for
adults with acute
cardiovascular events
Scientific
Evidence
$$$
$$$
††
$$$
†
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within one point of the median for this
criterion.
††
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within two points of the median for
overall quality of the indicator.
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September 2010
Section 2 – Expert Panel Indicator Rating Tables
Indicator Name
and Number
Overall Quality
Resources
Needed
low ← → high
Face
Validity
←
3.9.1 Disparity in time to
treatment for an acute
cardiovascular event between
general and priority
populations
$$$
3.9.2 Disparity in treatment for
acute cardiovascular events
between general and priority
populations
$$$
3.9.3 Disparity in
cardiovascular mortality
between general and priority
populations
Scientific
Evidence
Utility
→ better
$$
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September 2010
Accepted
Practice
Section 2 – Expert Panel Indicator Rating Tables
Indicator Name
and Number
Resources
Needed
Overall Quality
low ← → high
3.10.3 Average annual
outpatient costs attributable
to acute cardiovascular events
††
Face
Validity
←
3.10.1 Average annual
inpatient costs attributable to
acute cardiovascular events
3.10.2 Average annual
emergency department costs
attributable to acute
cardiovascular events
Scientific
Evidence
Utility
Accepted
Practice
→ better
$$$
$$$
††
$$$$
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within two points of the median for
overall quality of the indicator
19
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September 2010
Section 3―Indicator Profiles
3. INDICATOR PROFILES
Indicators are organized and presented by short-term, intermediate, and long-term logic
model boxes. For each logic model box, a brief summary of the science supporting the
indicators is provided followed by a profile of each indicator. The indicator profiles provide
detailed information about each indicator.
The profiles include:
Indicator Name and Number ― Each indicator has been assigned a unique three-part
number (see Figure 2)
•
The first number identifies the priority area (3 = Improving Emergency
Response)
•
The second number identifies the outcome component of the logic model
•
The third number identifies the specific indicator within the component
Rating ― Summary ratings provided by the expert reviewers. The symbols used correspond
to median reviewer ratings for each criterion
Priority Area ― The title of the priority area
Logic Model Component ― The title of the associated outcome component
What to Measure ― A description of what to measure when employing the indicator for
outcome evaluation
Why This Indicator is Useful ― A brief rationale statement is provided for using the
indicator as a measure of the outcome component
How to Measure ― Example data sources, surveys, or methodologies for collecting
information relevant to the indicator are provided. Although some of the proposed data
sources and measures are able to provide pertinent information at the state level, others
are not. Additionally, depending on the context and scope of state strategies, evaluation of
state program activities may require using a given measure or data collection methodology
in a more targeted way, for example, within a single county or health care system. The
example data sources, surveys, and measures information are provided as an initial
suggestion. Appendix 2, Data Source Descriptions, contains a brief summary of each data
source or survey listed.
Population Group ― The population group for which data relevant to the indicator are
most commonly collected, if applicable
20
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September 2010
Section 3―Indicator Profiles
Comments ― Additional information pertinent to measuring the indicator or the example
data source; at times, suggestions regarding collecting, analyzing, and reporting data are
noted
Other Information ― As needed, illustrative examples of elements included under the
pertinent indicator
References ― A small subset of citations relevant to the indicator
Figure 2. Indicator Number Designation
Priority Area
1 = Controlling High
Blood Pressure
2 = Controlling High
Cholesterol
3 = Improving Emergency
Response
3.2.4
Specific Indicator
within the Logic
Model Box
Logic Model Box
Worksite Changes
Community Changes
Emergency Response System Changes
Individual Changes
Emergency Medical Provider Changes
Increased Individual Adoption
Reduced Time from Symptom Onset
to Hospital Arrival
8 = Reduced Morbidity and Mortality
9 = Reduced Levels of Disparities
10 = Reduced Costs
1
2
3
4
5
6
7
=
=
=
=
=
=
=
The above example is the fourth indicator in Box 2 of the logic model outcomes for
Improving Emergency Response, Community Changes.
21
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September 2010
Section 3―Indicator Profiles
LOGIC MODEL BOX 1:
Worksite Changes
Worksite efforts to improve emergency response to acute cardiovascular events are
multifaceted and include providing cardiopulmonary resuscitation (CPR) training; educating
employees on the relevant signs, symptoms, and steps for emergency response actions;
and making automated external defibrillators (AED) available. These strategies have been
shown to increase use of emergency response actions and systems (Andre, 2004; Wright,
2001) and increase emergency department patient visits for acute cardiovascular events
outside the workplace (Eppler, 1994; Gaspoz, 1996; Herlitz, 1991; Wright, 2001). Thus, it
is anticipated that these efforts can help improve outcomes for acute cardiovascular events
that occur in the workplace.
The American Heart Association (AHA) strongly recommends that public access defibrillation
(PAD) programs be established to provide a quick response to individuals experiencing
cardiac arrest (AHA, 2010). PAD programs increase accessibility of AEDs in places where
large numbers of people gather. AEDs are small, lightweight devices used to assess and
restore a person’s heart rhythm through electric shock in the event of sudden cardiac
arrest. They can be placed throughout the community for quick access when needed, with
worksites being high-value locations for PAD programs. Although few studies have
examined the effectiveness of AEDs in worksites (Fogle, 2004), there is a great potential for
improving health outcomes especially at worksites with many employees and/or a high
volume of patrons.
In addition to providing AEDs as part of a worksite emergency response program, the
Occupational Safety and Health Administration (OSHA) also recommends that worksites
provide frequent training and retraining in CPR and instructions to address acute
cardiovascular events (OSHA, 2006). OSHA does not provide CPR training, but other
organizations, such as the AHA, American Red Cross, and National Safety Council, provide
trainings that can be individualized to the needs of a worksite. Additionally, many national
organizations, such as the AHA and the American College of Occupational and
Environmental Medicine (ACOEM), provide guidance for the implementation of emergency
response programs including AEDs within the workplace. Recommendations include:
•
Training designated rescuers in CPR and how to use an AED
•
Having physician oversight of the program
•
Integrating with the local EMS system
•
Using and maintaining the AED according to the manufacturer’s instructions (AHA,
2010)
Additionally, ACOEM advocates that all worksite AED programs should include:
•
A centralized management system
22
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September 2010
Section 3―Indicator Profiles
•
Compliance with federal and state regulations
•
A written AED program description at each location
•
An overall emergency response plan for the worksite
•
A scheduled maintenance and replacement plan
•
An AED quality assurance program
•
Well-designed placement of the AED and supplies (ACOEM, 2006)
Listed below are the indicators associated with this outcome box:
3.1.1 Proportion of worksites with an emergency response plan that addresses acute
cardiovascular events
3.1.2 Proportion of worksites with AED programs
3.1.3 Proportion of worksites that provide access to CPR instruction that includes guidance
on the use of an AED
3.1.4 Proportion of worksites that provide information about their AED program to
community Emergency Medical Service providers
3.1.5 Proportion of worksites that provide access to educational information addressing
signs and symptoms and the importance of emergency response for acute cardiovascular
events
3.1.6 Proportion of worksites with environmental supports that facilitate emergency
response for acute cardiovascular events
References
American College of Occupational and Environmental Medicine. Automated External
Defibrillation in the Occupational Setting Position Statement (reaffirmed May 2006).
Available at http://www.acoem.org/guidelines.aspx?id=564.
American Heart Association. Automated External Defibrillation Implementation Guide.
Available at http://www.americanheart.org/downloadable/heart/1102621921707702272%20AED%20ImplementGuide.pdf.
Andre AD, Jorgenson DB, Froman JA, Snyder DE, Poole JE. Automated external defibrillator
use by untrained bystanders: Can the public-use model work? Prehospital Emergency
Care 2002;8(3):284–291.
Eppler E, Eisenberg MS, et al. 911 and emergency department use for chest pain: Results of
a media campaign. Annals of Emergency Medicine 1994;24(2):202–208.
Fogle CC, Oser CS, Blades LL, Harwell TS, Helgerson SD, Gohdes D, et al. Increasing
employee awareness of the signs and symptoms of heart attack and the need to use
911 in a state health department. Preventing Chronic Disease 2004;1(3):1–8.
Gaspoz JM, Unger PF, et al. Impact of a public campaign on prehospital delay in patients
reporting chest pain. Heart 1996;76(2):150–155.
23
Not for dissemination. This document is for internal use of State HDSP Programs.
September 2010
Section 3―Indicator Profiles
Herlitz J, Blohm M, Hartford M, Karlson BW, Luepker R, Holmberg S, et al. Follow-up of a 1year media campaign on delay times and ambulance use in suspected acute
myocardial infarction. European Heart Journal 1992;13(2):171–177.
U.S. Department of Labor. Best practices guide: fundamentals of a workplace first aid
program. Occupational Safety and Health Administration. 2006. Available at
http://www.osha.gov/Publications/OSHA3317first-aid.pdf
Wright RS, Kopecky SL, Timm M, Pflaum DD, Carr C, Evers K, et al. Impact of communitybased education on health care evaluation in patients with acute chest pain
syndromes: The Wabasha Heart Attack Team (WHAT) project. Family Practice
2001;18(5):537–539.
24
Not for dissemination. This document is for internal use of State HDSP Programs.
September 2010
Section 3―Indicator Profiles
Indicator
Proportion of worksites with an emergency response plan that
addresses acute cardiovascular events (3.1.1)
Rating
$$$
Overall Quality
Resources
Needed
low ← → high
Scientific
Evidence
Face
Accepted
Utility
Validity
Practice
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Short-term Outcomes Box 1 – Worksite Changes
What to Measure
The proportion of worksites with an established, written, medical
emergency response plan to address acute cardiovascular events. For
elements of an emergency response plan, see “Comments” below.
Why This Indicator Past research notes the importance of worksites implementing medical
is Useful
emergency response plans and outlines the essential components and
practical considerations of such plans (Hernandez & Christensen, 2001;
Starr, 2002; U.S. Department of Labor, 2006).
How to Measure
CDC Worksite Health ScoreCard: An assessment tool to prevent
heart disease, stroke, and related conditions
•
During the past 12 months, did your worksite have an emergency
response plan that addresses acute heart attack and stroke
events?
Massachusetts Worksite Health Improvement Survey, 2008
•
Does your organization have a written emergency procedures plan
for medical emergencies?
Georgia Worksite Health Promotion Policies and Practices Survey,
2008
•
Does your worksite have a formal, written disaster plan or
emergency response plan?
Community Health Assessment aNd Group Evaluation (CHANGE)
Tool
•
To what extent does your worksite adopt an emergency response
plan (e.g., appropriate equipment such as Automatic External
Defibrillator [AED] or instructions for employee action)?
25
Not for dissemination. This document is for internal use of State HDSP Programs.
September 2010
Section 3―Indicator Profiles
Population Group
Worksites
Comments
The medical emergency response plan should include written policies
identifying potential workplace risks, guidelines for educational materials
and training related to signs and symptoms of heart attack and stroke as
well as the provision of CPR, a comprehensive AED program the meets
the standards identified by the American College of Occupational and
Environmental Medicine (ACOEM), and instructions on activating and
facilitating emergency response via 9-1-1.
References
Hernandez B, Christensen J. Automatic external defibrillator intervention
in the workplace. A comprehensive approach to program
development. Official Journal of the American Association of
Occupational Health Nurses 2001;49(2):96–106.
Nichol G, Hallstrom AP, Ornato JP, Riegel B, Stiell IG, Valenzuela T, et al.
Potential cost-effectiveness of public access defibrillation in the
United States. Circulation 1998;97(13):1315-20.
Reed DB, Birnbaum A, Brown LH, O'Connor RE, Fleg JL, Peberdy MA, et
al. Location of cardiac arrests in the public access defibrillation
trial. Prehospital Emergency Care 2006;10(1):61-76.
Starr LM. Automated external defibrillation in the occupational setting:
ACOEM position statement. Journal of Occupational and
Environmental Medicine 2002;44(1):2–7.
U.S. Department of Labor. Best practices guide: Fundamentals of a
workplace first aid program. Occupational Safety and Health
Administration 2006. Available at
http://www.osha.gov/Publications/OSHA3317first-aid.pdf.
Zerwic JJ, Prasun MA. Acute myocardial infarction in the workplace.
Official Journal of the American Association of Occupational Health
Nurses 1998;46(4):195-202.
26
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September 2010
Section 3―Indicator Profiles
Indicator
Proportion of worksites with AED programs (3.1.2)
Rating
$$$†
††
Overall Quality
Resources Scientific
Face
Accepted
Utility
Needed
Evidence Validity
Practice
low ← → high
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Short-term Outcomes Box 1 – Worksite Changes
What to Measure
The proportion of worksites that have an AED program. The AED
program should follow the guidelines outlined in the ACOEM Position
statement referenced in “Comments” below.
Why This Indicator Studies recommend implementing worksite AED programs. In particular,
OSHA notes that worksites are potential candidates for AED programs
is Useful
because of the possibility of sudden cardiac arrest and the need for
timely defibrillation. Each worksite should asses its own requirements for
an AED program as part of its first aid response (Hernandez &
Christensen, 2001; Starr, 2002; U.S. Department of Labor, 2006).
How to Measure
CDC Worksite Health ScoreCard: An assessment tool to prevent
heart disease, stroke, and related conditions
During the past 12 months:
•
Did your worksite offer access to a nationally-recognized training
course on Cardiopulmonary Resuscitation (CPR) that includes
training on Automated External Defibrillator (AED) usage?
•
Did your worksite have one or more functioning AEDs in place?
•
Did your worksite identify the location of AEDs with posters,
signs, markers, or other forms of communication?
•
Did your worksite perform maintenance or testing on all the
AEDs?
•
Did your worksite provide information to your local community
Emergency Medical Service providers so they are aware that your
worksite has an AED in place to facilitate emergency response?
Missouri Worksite Inventory Secondary Prevention Assessment,
2005
•
Does your worksite have at least one AED on site?
•
Are there trainings available for all employees to learn how to use
27
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September 2010
Section 3―Indicator Profiles
the AED?
•
Does the worksite have trained, designated employees who will
assist a person in need with an AED?
•
Does the worksite require that somebody with AED training be onsite at all times?
•
Who is responsible for maintenance of the AED(s) at your
worksite?
Massachusetts Worksite Health Improvement Survey, 2008
•
Does your organization offer emergency medical response training
to employees? If yes, which of the following are offered?
o
•
Automated External Defibrillator (AED)
Does your organization have at least one Automated External
Defibrillator (AED) prominently located at your worksite?
Georgia Worksite Health Promotion Policies and Practices Survey,
2008
•
Is there at least one Automated External Defibrillator (AED)
present at your worksite?
•
Does your company provide training to your employees on how to
use AED?
•
How often is/are the AED(s) serviced?
Population Group
Worksites
Comments
The American College of Occupational and Environmental Medicine
(ACOEM) recommends that employer-sponsored programs for the use of
AEDs in worksites and public settings, include all of the following
elements:
1. Establishment of a centralized management system for the AED
program
2. Medical direction and control of the worksite AED program
3. Awareness of and compliance with federal and state regulations
4. Development of written AED program description for each location
5. Coordination with local emergency medical services
6. Integration with an overall emergency response plan for the worksite
7. Selection and technical consideration of AEDs
8. Ancillary medical equipment and supplies for the worksite AED
program
9. Assessment of the proper number and placement of AEDs and
supplies
10. Scheduled maintenance and replacement of AED and ancillary
equipment
11. Establishment of an AED quality assurance program
12. Periodic review and modification of the worksite AED program
protocols
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September 2010
Section 3―Indicator Profiles
References
American Heart Association. Automated external defibrillation:
Implementation guide 2004.Available at
http://www.americanheart.org/downloadable/heart/11026219217
0770-2272%20AED%20ImplementGuide.pdf.
Hernandez B, Christensen J. Automatic external defibrillator intervention
in the workplace. A comprehensive approach to program
development. Official Journal of the American Association of
Occupational Health Nurses 2001;49(2):96–106; quiz 107–108.
Review.
Nichol G, Hallstrom AP, Ornato JP, Riegel B, Stiell IG, Valenzuela T, et al.
Potential cost-effectiveness of public access defibrillation in the
United States. Circulation 1998;97(13):1315-1320. Review.
Reed DB, Birnbaum A, Brown LH, O'Connor RE, Fleg JL, Peberdy MA, et
al. PAD trial investigators. Location of cardiac arrests in the public
access defibrillation trial. Prehospital Emergency Care
2006;10(1):61-76
Starr, L. M. Automated external defibrillation in the occupational setting:
ACOEM position statement. Journal of Occupational and
Environmental Medicine 2002;44(1):2–7.
U.S. Department of Labor. Best practices guide: Fundamentals of a
workplace first aid program. Occupational Safety and Health
Administration 2006. Available at
http://www.osha.gov/Publications/OSHA3317first-aid.pdf
†
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within one
point of the median for this criterion.
††
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within two
points of the median for overall quality of the indicator.
29
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September 2010
Section 3―Indicator Profiles
Indicator
Proportion of worksites that provide access to CPR instruction
that includes guidance on the use of an AED (3.1.3)
Rating
†
$$
††
Overall Quality
Resources Scientific Face
Accepted
Utility
Needed Evidence Validity
Practice
low ← → high
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Short-term Outcomes Box 1 – Worksite Changes
What to Measure
The proportion of worksites that provide employees with access to CPR
instruction that teaches how to use of an AED.
Why This Indicator
is Useful
Out-of-hospital cardiac arrest survival rates are very low. These rates
plummet if there is a delay in the provision of CPR and defibrillation
(Vukmir, 2006). The American College of Occupational and
Environmental Medicine recommends that employer-sponsored
programs in the worksite include recognized and standardized training
on CPR and use of the AED (U.S. Department of Labor, 2006). The
training should be integrated with other first aid responder programs
(Starr, 2002).
How to measure
CDC Worksite Health ScoreCard: An assessment tool to prevent
heart disease, stroke, and related conditions
•
During the past 12 months, did your worksite offer access to a
nationally recognized training course on Cardiopulmonary
Resuscitation (CPR) that includes training on Automated
External Defibrillator (AED) usage?
Missouri Worksite Inventory Secondary Prevention Assessment,
2005
•
Does your worksite offer a course in CPR, also called Basic Life
Support?
•
Are there trainings available for all employees to learn how to
use the AED?
Massachusetts Worksite Health Improvement Survey, 2008
•
Does your organization offer emergency medical responses
training to employees?
30
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September 2010
Section 3―Indicator Profiles
o
Cardiopulmonary Resuscitation (CPR)
o
Automated External Defibrillator (AED)
Georgia Worksite Health Promotion Policies and Practices
Survey, 2008
•
Does your company offer training to employees on
cardiopulmonary resuscitation (CPR)?
•
Does your company provide training to employees on how to
use the AED?
Population Group
Worksites
References
American Heart Association. Automated external defibrillation:
Implementation guide. 2004. Available at
http://www.americanheart.org/downloadable/heart/1102621921
70770-2272%20AED%20ImplementGuide.pdf.
Hernandez B, Christensen J. Automatic external defibrillator
intervention in the workplace. A comprehensive approach to
program development. American Association of Occupational
Health Nurses Journal 2001;49(2):96–106. Review.
Larsen MP, Eisenberg MS, Cummins RO, Hallstrom AP. Predicting
survival from out-of-hospital cardiac arrest: a graphic model.
Annals of Emergency Medicine 1993;22:1652–1658.
Starr, L. M. Automated external defibrillation in the occupational
setting: ACOEM position statement. Journal of Occupational and
Environmental Medicine 2002;44(1):2–7.
Vukmir RB. Survival from prehospital cardiac arrest is critically
dependent upon response time. Resuscitation 2006;69(2):229–
234.
Wilson MG, DeJoy DM, Jorgensen CM, Crump CJ. Health promotion
programs in small worksites: results of a national survey.
American Journal of Health Promotion 1999;13(6):358–365.
†
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within one
point of the median for this criterion.
††
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within two
points of the median for overall quality of the indicator.
31
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September 2010
Section 3―Indicator Profiles
Indicator
Proportion of worksites that provide information about their AED
program to community Emergency Medical Service providers
(3.1.4)
Rating
$$†
†
†
†
††
Overall Quality
Resources Scientific Face
Accepted
Utility
Needed
Evidence Validity
Practice
low ← → high
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Short-term Outcomes Box 1 – Worksite Changes
What to Measure
The proportion of worksites that report the availability of their AEDs to
community emergency response planners to enhance community AED
registries. For more detailed information and description, see
“Comments” below.
Why This Indicator
is Useful
Out-of-hospital cardiac arrest survival rates are very low. For every
minute that passes between collapse and defibrillation, survival rates
decrease 7% to 10% if no CPR is provided (Larsen et al., 1993). Recent
efforts to build AED registries and link the information with 9-1-1
services are intended to provide emergency dispatch personnel with
more complete information about AED locations in the community. This
information can be provided to bystanders during 9-1-1 calls to
facilitate resuscitation efforts. As increasing numbers of worksites install
AEDs, sharing this information to supplement AED community registries
can improve timely access to defibrillation.
How to Measure
CDC Worksite Health ScoreCard: An assessment tool to prevent
heart disease, stroke, and related conditions
•
During the past 12 months, did your worksite provide
information to your local community Emergency Medical Service
providers so they are aware that your worksite has an AED in
place to facilitate emergency response?
Missouri Worksite Inventory Secondary Prevention Assessment,
2005
•
Population Group
Has your worksite registered the AED(s) with your local
emergency medical service (EMS) and/or other entities required
by ordinance, such as a local city AED registry?
Worksites
32
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September 2010
Section 3―Indicator Profiles
Comments
The Sudden Cardiac Arrest Association is working to develop a national
AED registry and link this information to 9-1-1 services. The intent of
this registry is to reduce response times so AEDs can be accessed and
used as quickly as possible in response to cardiac arrest. The registry
and linkage with 9-1-1 allows dispatchers to have expanded visibility
into the location of community-based AEDs. The utility of such registries
improves as availability of community-based AEDs (including those in
worksites) is provided for inclusion.
References
American Heart Association. Automated external defibrillation:
Implementation guide 2004. Available at
http://www.americanheart.org/downloadable/heart/1102621921
70770-2272%20AED%20ImplementGuide.pdf.
Hernandez B, Christensen J. Automatic external defibrillator
intervention in the workplace. A comprehensive approach to
program development. AAOHN Journal 2001;49(2):96–106.
Review.
Larsen MP, Eisenberg MS, Cummins RO, Hallstrom AP. Predicting
survival from out-of-hospital cardiac arrest: a graphic model.
Annals of Emergency Medicine 1993;22:1652–1658.
Starr LM. Automated external defibrillation in the occupational setting:
ACOEM position statement. Journal of Occupational and
Environmental Medicine 2002;44(1):2–7.
U.S. Department of Labor. Best practices guide: Fundamentals of a
workplace first aid program. Occupational Safety and Health
Administration 2006. Available at
http://www.osha.gov/Publications/OSHA3317first-aid.pdf.
†
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within one
point of the median for this criterion.
††
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within two
points of the median for overall quality of the indicator.
33
Not for dissemination. This document is for internal use of State HDSP Programs.
September 2010
Section 3―Indicator Profiles
Indicator
Proportion of worksites that provide access to educational
information addressing signs and symptoms and the
importance of emergency response for acute cardiovascular
events (3.1.5)
Rating
$$$†
†
†
††
Overall Quality
Resources Scientific Face
Accepted
Utility
Needed Evidence Validity
Practice
low ← → high
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Short-term Outcomes Box 1 – Worksite Changes
What to Measure
The proportion of worksites that provide access to information to their
employees regarding the signs and symptoms of and the importance
of emergency response for acute cardiovascular events.
Why This Indicator
is Useful
Early recognition of the signs and symptoms of a heart attack and
stroke can lead to reduced morbidity and mortality. Research
demonstrates that worksite interventions can be effective in increasing
employee awareness of the signs and symptoms of acute
cardiovascular events and the importance of using 9-1-1 (Fogle,
2004).
How to Measure
CDC Worksite Health ScoreCard: An assessment tool to prevent
heart disease, stroke, and related conditions
•
During the past 12 months, did your worksite have posters or
flyers in the common areas of your worksite (such as bulletin
boards, kiosks, and break rooms) that identify the signs and
symptoms of a stroke and also convey that strokes are to be
treated in emergencies?
•
During the past 12 months, did your worksite have posters or
flyers in the common areas of your worksite (such as bulletin
boards, kiosks, break rooms) that identify the signs and
symptoms of a heart attack and also convey that heart
attacks are to be treated as emergencies?
•
During the past 12 months, did your worksite provide any other
information on the signs and symptoms of stroke through
emails, newsletters, management communications, websites,
seminars or classes, or other materials?
•
During the past 12 months, did your worksite provide any other
34
Not for dissemination. This document is for internal use of State HDSP Programs.
September 2010
Section 3―Indicator Profiles
information on the signs and symptoms of heart attack
through emails, newsletters, management communications,
websites, seminars or classes, or other materials?
Missouri Worksite Inventory Secondary Prevention
Assessment, 2005
•
Does your worksite offer training in how to recognize the signs
and symptoms of heart attack?
•
Does your worksite offer training in how to recognize the signs
and symptoms of stroke?
Population Group
Worksites
Reference
Fogle CC, Oser CS, Blades LL, Harwell TS, Helgerson SD, Gohdes D, et
al. Increasing employee awareness of the signs and symptoms
of heart attack and the need to use 911 in a state health
department. Preventing Chronic Disease 2004;1(3):1–8.
Wilson MG, DeJoy DM, Jorgensen CM, Crump CJ. Health promotion
programs in small worksites: results of a national survey.
American Journal of Health Promotion 1999;13(6):358-365.
Zerwic JJ, Ennen K, DeVon HA. Stroke. Risks, recognition, and return
to work. AAOHN Journal 2002;50(8):354-359.
†
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within one
point of the median for this criterion.
††
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within two
points of the median for overall quality of the indicator.
35
Not for dissemination. This document is for internal use of State HDSP Programs.
September 2010
Section 3―Indicator Profiles
Indicator
Proportion of worksites with environmental supports that
facilitate emergency response for acute cardiovascular events
(3.1.6)
Rating
$$
††
Overall Quality
Resources Scientific Face
Accepted
Utility
Needed Evidence Validity
Practice
low ← → high
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Short-term Outcomes Box 1 – Worksite Changes
What to Measure
The proportion of worksites that have implemented environmental
changes to facilitate emergency response to acute cardiovascular
events. An example of a relevant environmental change is making AEDs
available in designated spots in the worksite and/or hanging posters
listing the signs and symptoms of an acute cardiovascular event and
appropriate emergency response actions.
Why This Indicator
is Useful
Ensuring immediate response to out-of-hospital cardiac arrest is critical
to increasing survival (Vukmir, 2006). AHA recommends placing AEDs
within the worksite to facilitate a 3-minute response time (AHA, 2004).
Additionally, improving knowledge of signs and symptoms of heart
attack and stroke may help to increase timely activation of the
emergency response system in worksites (Fogle et al., 2004). Posting
informational materials, in coordination with worksite training and
educational activities, can improve applicable employee awareness and
knowledge.
How to Measure
CDC Worksite Health ScoreCard: An assessment tool to prevent
heart disease, stroke, and related conditions
•
During the past 12 months, did your worksite have one or more
functioning AEDs in place?
•
During the past 12 months, did your worksite identify the
location of AEDs with posters, signs, markers, or other forms of
communication?
•
During the past 12 months, did your worksite provide have
posters or flyers in the common areas of your worksite (such as
bulletin boards, kiosks, break rooms) that identify the signs and
symptoms of a heart attack and also convey that heart attacks
are to be treated as emergencies?
•
During the past 12 months, did your worksite have posters or
36
Not for dissemination. This document is for internal use of State HDSP Programs.
September 2010
Section 3―Indicator Profiles
flyers in the common areas of your worksite (such as bulletin
boards, kiosks, and break rooms) that identify the signs and
symptoms of a stroke and also convey that strokes are to be
treated as emergencies?
Missouri Worksite Inventory Secondary Prevention Assessment,
2005
•
Does your worksite have at least one AED on site?
•
Does your worksite have trained, designated employees who will
assist a person in need with an AED?
•
Does your worksite require that somebody with AED training be
on-site at all times?
Massachusetts Worksite Health Improvement Survey, 2008
•
Does your organization have at least one Automated External
Defibrillator (AED) prominently located at your worksite?
Georgia Worksite Health Promotion Policies and Practices
Survey, 2008
•
Is there at least one automated external defibrillator (AED)
present at your worksite?
Population Group
Worksites
References
American Heart Association. Automated external defibrillation:
Implementation guide 2004. Available at
http://www.americanheart.org/downloadable/heart/1102621921
70770-2272%20AED%20ImplementGuide.pdf.
Fogle CC, Oser CS, Blades LL, Harwell TS, Helgerson SD, Gohdes D, et
al. Increasing employee awareness of the signs and symptoms
of heart attack and the need to use 911 in a state health
department. Preventing Chronic Disease 2004;1(3):1–8.
Hernandez B, Christensen J. Automatic external defibrillator
intervention in the workplace. A comprehensive approach to
program development. Official Journal of the American
Association of Occupational Health Nurses 2001;49(2):96–106;
Starr LM. Automated external defibrillation in the occupational setting:
ACOEM position statement. Journal of Occupational and
Environmental Medicine 2002;44(1):2–7.
Vukmir RB. Survival from prehospital cardiac arrest is critically
dependent upon response time. Resuscitation 2006;69(2):229–
234.
††
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within two
points of the median for overall quality of the indicator.
37
Not for dissemination. This document is for internal use of State HDSP Programs.
September 2010
Section 3―Indicator Profiles
LOGIC MODEL BOX 2:
Community Changes
An important component to improving health outcomes for heart attack and stroke is to
ensure that patients seek and receive care as soon as possible after symptom onset. For
this to happen, a bystander witness must be able to recognize the signs and symptoms of a
heart attack and stroke and the need to take emergency actions in response to acute
cardiovascular events. Numerous community-based media campaigns have been
implemented to educate the public on acute cardiovascular event signs and symptoms and
the appropriate actions to take upon recognition. In one study, Silver and colleagues
increased public knowledge for the five warning signs of stroke through a television
advertising campaign in Ontario (Silver et al., 2003). Other investigators implemented a
community education program that reduced the average treatment delay time among
patients with confirmed AMI from 10 hours to 6 hours 27 minutes (Herlitz et al., 1992).
Similarly, Eppler and colleagues provided community education that resulted in an increased
volume of 9-1-1 calls in response to an acute cardiovascular event (Eppler et al., 1994).
In addition to educating the public through mass media, many communities are making
environmental changes that support emergency response for acute cardiovascular events.
In some communities, telephone 9-1-1 dispatchers have been trained to provide CPR
instructions to bystanders witnessing acute cardiovascular events (Bång et al., 1999;
Hallstrom et al., 2000, Bohm et al., 2009). In other communities, 9-1-1 dispatchers are
provided training and education on the use of emergency response techniques including
AEDs (Culley et al., 2004; Hallstrom et al., 2004; Hedges et al., 2006; Swor et al., 2005).
Findings from the Public Access Defibrillation (PAD) Trial showed that twice as many
patients in the CPR-plus AED group as in the CPR-only group survived after a definite
cardiac arrest, yielding a twofold difference in survival (Hallstrom et al., 2004). Additionally,
Culley et al. (2004) have shown that survival from a heart attack was similar across the
AED operator groups included in the study; 54% for medically trained operators, 50% for
lay operators, and 50% for police. Environmental change initiatives include creating new
emergency response systems and making them available in public gathering places such as
efforts to train likely first-responders on AED use (Colquhoun et al., 2000) in casinos
(Valenzuela et al., 2000) and airplanes (Page et al., 2000). However, studies assessing
these efforts have had mixed results (Page et al., 2000; Sweeney et al., 1998).
The Centers for Disease Control and Prevention (CDC) is also urging communities to adopt
policies to support emergency response (Ford Lattimore et al., 2008). It is suggested that
policies be developed at the community level to gain local support that can then spread
throughout a state.
38
Not for dissemination. This document is for internal use of State HDSP Programs.
September 2010
Section 3―Indicator Profiles
Community changes provide a context and support system for individuals to increase their
knowledge of signs and symptoms and appropriate emergency actions to be taken in
response to acute cardiovascular events. The intent of these community changes –
interventions, community environmental supports, and community education efforts – is to
increase the use and adoption of emergency response actions, with the hope that these will
ultimately decrease the time between symptom onset and treatment. While some initial
findings have shown increases in adoption of emergency response actions, they have also
shown that these changes can be hard to sustain over time (DeLemos et al., 2003; Eppler
et al., 1994). Nonetheless, the importance of addressing community-level changes remains,
because of the potential for widespread reach of environmental changes and educational
efforts impacting community members.
Listed below are the indicators associated with this outcome box:
3.2.1 Number of community interventions to improve knowledge of signs and symptoms
and emergency response for acute cardiovascular events
3.2.2 Number of evidence-informed policies adopted to improve emergency response for
acute cardiovascular events
3.2.3 Number of community environmental supports to improve emergency response for
acute cardiovascular events
3.2.4 Proportion of communities served by telephone dispatchers certified to provide CPR
instructions according to standardized emergency medical dispatch protocols
3.2.5 Proportion of communities that provide access to CPR training for community
members
References
Bång A, Biber B, Isaksson L, Lindqvist J, Herlitz J. Evaluation of dispatcher-assisted
cardiopulmonary resuscitation. European Journal of Emergency Medicine
1999;6(3):175–183.
Bohm K, Stålhandske B, Rosenqvist M, Ulfvarson J, Hollenberg J, Svensson L. Tuition of
emergency medical dispatchers in the recognition of agonal respiration increases the
use of telephone assisted CPR. Resuscitation 2009;80:1025-28.
Colquhoun MC. Defibrillation by general practitioners. Resuscitation 2002;52(2):143–148.
Culley LL, Rea TD, Murray JA, Welles B, Fahrenbruch CE, Olsufka M, et al. Public access
defibrillation in out-of-hospital cardiac arrest: A community-based study. Circulation
2004;109:1859–1863.
Eppler E, Eisenberg MS, et al. 911 and emergency department use for chest pain: Results of
a media campaign. Annals of Emergency Medicine 1994;24(2):202–208.
Ford Lattimore B, O’Neil S, Besculides M. Tools for developing, implementing, and
evaluating state policy. Prevention of Chronic Disease 2008;5(2):A58
39
Not for dissemination. This document is for internal use of State HDSP Programs.
September 2010
Section 3―Indicator Profiles
Hallstrom A, Cobb L, Johnson E, Copass M. Cardiopulmonary resuscitation by chest
compression alone or with mouth-to-mouth ventilation. The New England Journal of
Medicine, 2000;342(21), 1546–1553.
Hallstrom A, Ornato JP. Public access defibrillation and survival after out-of-hospital cardiac
arrest. JAMA, 2004;351:637–646.
Hedges JR, Sehra R, Van Zile JW, Anton AR, Bosken LA, O’Conner RE, et al. Automated
external defibrillator program does not impair cardiopulmonary resuscitation
initiation in the public access defibrillation trial. Academic Emergency Medicine
2006;13:659–665.
Herlitz J, Blohm M, Hartford M, Karlson BW, Luepker R, Holmberg S, et al. Follow-up of a
1-year media campaign on delay times and ambulance use in suspected acute
myocardial infarction. European Heart Journal 1992;13(2):171–177.
Page RL, Joglar JA, Kowal RC, Zagrodzky JD, Nelson LL, Ramaswarmy K, et al. Use of
automated external defibrillators by a U.S. airline. The New England Journal of
Medicine 2000;343:1210–1216.
Silver FL, Rubini F, et al. Advertising strategies to increase public knowledge of the warning
signs of stroke. Stroke 2003;34(8):1965–1968.
Swor R, Fahoome G, Compton S. Potential impact of a targeted cardiopulmonary
resuscitation program for older adults on survival from private-residence cardiac
arrest. Academic Emergency Medicine, 2005;12(1):7–12.
Valenzuela TD, Roe DJ, Nichol G, Clark LL, Spaite DW, Hardman RG. Outcomes of rapid
defibrillation by security officers after cardiac arrest in casinos. The New England
Journal of Medicine 2000;343(17):1206–1209.
40
Not for dissemination. This document is for internal use of State HDSP Programs.
September 2010
Section 3―Indicator Profiles
Indicator
Number of community interventions to improve knowledge of
signs and symptoms and emergency response for acute
cardiovascular events (3.2.1)
Rating
$$$
Overall Quality
Resources Scientific Face
Accepted
Utility
Needed Evidence Validity
Practice
low ← → high
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Short-term Outcomes Box 2 – Community Changes
What to Measure
Number of community interventions intended to improve recognition
of the signs and symptoms of heart attack and stroke and enhance
emergency response for cardiovascular events. More information
regarding types of activities that typify these interventions is
included in “Comments” below.
Why This Indicator
is Useful
Prompt treatment for heart attack and stroke enhances improves
patient outcomes (Jollis et al., 2007). Community interventions that
shorten patient response time to seek medical treatment and
initiatives designed to improve communication and coordination
across regional, organized systems of care have been shown to
decrease treatment delays (Jollis et al., 2007; National Institute of
Neurological Disorders and Stroke, 1997).
How to Measure
Community Health Assessment aNd Group Evaluation
(CHANGE) Tool
•
To what extent does the community institution/organization:
o
Adopt curricula or training to raise awareness of the
signs and symptoms of heart attacks and strokes?
o
Adopt curricula or training to raise awareness of the
importance of calling 9-1-1 immediately when
someone is having a heart attack or stroke?
Texas State Department of State Health Services: Heart and
Stroke Healthy City Recognition Program: Heart and Stroke
Healthy Indicators
Indicator # 7: Training programs are in place to improve the rate of
bystander CPR and use of AEDs
•
Public awareness programs are place to educate the public about
41
Not for dissemination. This document is for internal use of State HDSP Programs.
September 2010
Section 3―Indicator Profiles
the signs and symptoms of heart attack and the importance of
calling 911:
o
Name of program(s)
o
Number of times programs have been available in the past
year
Population Group
Not applicable. Indicator measures community interventions.
Comments
Examples of community interventions include the establishment of
community coalitions to identify gaps in CV services, regional
coordination to shorten emergency response times to acute
cardiovascular events, and culturally and linguistically appropriate
community-based education campaigns to increase knowledge of
signs and symptoms, CPR implementation, and emergency response
activation.
Evaluators should consider monitoring type of intervention and
associated dose as well as overall number of interventions within a
community.
References
Barnhart JM, Cohen O, Kramer HM, Wilkins CM, Wylie-Rosett J.
Awareness of heart attack symptoms and lifesaving actions
among New York City area residents. Journal of Urban Health
2005;82(2): 207–215.
DeLemos CD, Atkinson RP, Croopnick SL, Wentworth DA, Atkins PT.
How effective are “community” stroke screening programs at
improving stroke knowledge and prevention practices? Stroke
2004; 34:e247–e249.
Eppler E, Eisenberg MS, Schaeffer S, Meischke H, Larson MP. 911
and emergency department use for chest pain: Results of a
media campaign. Annals of Emergency Medicine
1994;24(2):202–208.
Herlitz J, Blohm M, Hartford M, Karlson BW, Luepker R, Holmberg S,
et al. Follow-up of a 1-year media campaign on delay times
and ambulance use in suspected acute myocardial infarction.
European Heart Journal 1992;13(2):171–177.
Jollis JG, Roettig ML, Aluko AO, Anstrom KJ, Applegate RJ, Babb JD,
et al. Implementation of a statewide system for coronary
reperfusion for ST-segment elevation myocardial infarction.
The Journal of the American Medical Association
2007;298(20):E1–E6.
National Institute of Neurological Disorders and Stroke (NINDS) rtPA Stroke Study Group. A systems approach to immediate
evaluations and management of hyperacute stroke 1997.
AHA, 28, 1530–1540.
42
Not for dissemination. This document is for internal use of State HDSP Programs.
September 2010
Section 3―Indicator Profiles
Quain DA, Parsons MW, Loudfoot AR, Spratt NJ, Evans MK, Russell
ML, et al. Improving access to acute stroke therapies: a
controlled trial of organised pre-hospital and emergency care.
Medical Journal of Australia 2009;189(8):429-33.
43
Not for dissemination. This document is for internal use of State HDSP Programs.
September 2010
Section 3―Indicator Profiles
Indicator
Number of evidence-informed policies adopted to improve
emergency response for acute cardiovascular events (3.2.2)
Rating
††
Overall Quality
$$
†
Resources Scientific Face
Accepted
Utility
Needed Evidence Validity
Practice
low ← → high
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Short-term Outcomes Box 2 – Community Changes
What to Measure
The number of legislative and regulatory policy changes established
at the state, local, or national levels that support emergency
response for acute cardiovascular events. Additional detail regarding
types of policies is included in “Comments” below.
Why This Indicator
is Useful
Legislative and regulatory policies are important in speeding time to
treatment and enhancing the quality of prehospital care by creating
and supporting systems to support timely emergency response by
the public and emergency medical personnel. Research
demonstrates that survival rates improve as time to treatment
decreases (Vukmir, 2006).
How to Measure
Heart Disease and Stroke Prevention Legislative Database is a
centralized database for state HDSP policies
Survey of Policies and Programs Related to Health For Cities
and Towns in Massachusetts, 2007
•
•
Does your city or town have automatic external defibrillators
(AEDs) in the following facilities?
o
Schools
o
Other recreational facilities
o
Other municipal buildings
Is placement of the AEDs in the following facilities mandated?
o
Schools
o
Other recreational facilities
o
Other municipal buildings
44
Not for dissemination. This document is for internal use of State HDSP Programs.
September 2010
Section 3―Indicator Profiles
Population Group
Not applicable. Indicator measures policies.
Comments
Examples of legislative and regulatory policies to improve emergency
response include regional efforts to ensure routing to certified
cardiac or stroke centers; mandated education, certification, and
licensure for emergency medical dispatchers; mandated AED
placement in municipal buildings; and support of statewide
surveillance pertaining to emergency response for cardiovascular
events. States may also want to consider tracking related
regulations as well.
Reference
Emergency medical dispatching: rapid identification and treatment of
acute myocardial infarction. National Heart Attack Alert
Program Coordinating Committee Access to Care
Subcommittee. American Journal of Emergency Medicine
1995;13(1):67-73.
Evenson KR, Brice JH, Rosamond WD, Lellis JC, Christian JB, Morris
DL. Statewide survey of 911 communication centers on acute
stroke and myocardial infarction. Prehospital Emergency Care
2007;11(2):186-191
Ford Lattimore B, O’Neil S, Besculides M. Tools for developing,
implementing, and evaluating state policy. Preventing Chronic
Disease, 5(2). 2008. Available at
http://www.cdc.gov/pcd/issues/2008/apr/07_0210.htm.
Vukmir RB. Survival from prehospital cardiac arrest is critically
dependent upon response time. Resuscitation 200;69(2):22934.
†
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within one
point of the median for this criterion.
††
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within two
points of the median for overall quality of the indicator.
45
Not for dissemination. This document is for internal use of State HDSP Programs.
September 2010
Section 3―Indicator Profiles
Indicator
Number of community environmental supports to improve
emergency response for acute cardiovascular events (3.2.3)
Rating
††
Overall Quality
$$$
Resources Scientific Face
Accepted
Utility
Needed Evidence Validity
Practice
low ← → high
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Short-term Outcomes Box 2 – Community Changes
What to Measure
The number of communities that implement environmental changes
that support emergency response for acute cardiovascular events.
Additional detail regarding types of environmental changes is
included in “Comments” below.
Why This Indicator
is Useful
Environmental changes that support access to timely, high-quality
cardiovascular care improves patient outcomes. A comprehensive
approach that addresses the environment, social, and cultural
aspects of health, and individual lifestyles and behaviors, offers the
greatest opportunity for success (Veazie et al., 2005).
How to Measure
Texas State Department of State Health Services: Heart and
Stroke Healthy City Recognition Program: Heart and Stroke
Healthy Indicators
Indicator # 8: Defibrillators (Manual and/or Automated External) are
available to first responders and the emergency system of care
maintains a rapid response time for cardiac events.
•
•
Emergency Personnel Response units are adequately equipped
with defibrillators. Indicate below how your community is
meeting this criterion:
o
EMS vehicles are equipped with AEDs
o
Fire Vehicles are equipped with AED’s (first responders)
o
Police Vehicles are equipped with AED’s (first responders)
The EMS System (Prehospital to Emergency Center) is equipped
to manage patients with ST elevation myocardial infarction
(STEMI). Indicate below how your community is meeting this
criterion:
o
Advanced Life Support capable EMS vehicles are equipped
46
Not for dissemination. This document is for internal use of State HDSP Programs.
September 2010
Section 3―Indicator Profiles
with 12 lead ECGs
o
The EMS System measures the proportion of STEMI
patients who receive a prehospital 12 lead ECG
Missouri Community Policy and Environmental Change
Program Packet
•
Do MOST businesses or public buildings in the community
have easily accessible AEDs?
•
Do you have access to public trainings on the signs and
symptoms of stroke?
•
Do you have access to public trainings on the signs and
symptoms of heart attack?
•
Do you have 9-1-1 access in your community?
•
Does your community have affordable, convenient CPR
courses for all age groups?
Population Group
Not applicable. Indicator measures environmental supports.
Comments
Examples of environmental changes to improve recognition of signs
and symptoms of heart attack and stroke and enhance emergency
response include those that:
•
Place AEDs within community-based organizations
•
Decrease barriers to access emergency response systems such
as having 9-1-1 available within the community
•
Increase access to emergency medical dispatch
•
Increase capacity for coordinated emergency response
Note that from a public health perspective, community interventions
and environmental changes may be similar. Brownson et al. (2006)
describe the growing interest in interventions to change the physical
and sociopolitical environments to reduce chronic disease. Such
environmental and policy change approaches are often more
permanent than interventions focused on individual-level behavioral
change.
References
Bång A, Biber B, Isaksson L, Lindqvist J, Herlitz J. Evaluation of
dispatcher-assisted cardiopulmonary resuscitation. European
Journal of Emergency Medicine. 1999;6(3):175–183.
Brownson RC, Haire-Joshu D, Luke DA. Shaping the context of
health: a review of environmental and policy approaches in
the prevention of chronic diseases. Annual Review of Public
Health. 2006;27:341-70.
Culley LL, Rea TD, Murray JA, Welles B, Fahrenbruch CE, Olsufka M,
et al. Public access defibrillation in out-of-hospital cardiac
47
Not for dissemination. This document is for internal use of State HDSP Programs.
September 2010
Section 3―Indicator Profiles
arrest: A community-based study. Circulation
2004;109:1859–1863.
Hallstrom A, Ornato JP. Public access defibrillation and survival after
out-of-hospital cardiac arrest. The Journal of the American
Medical Association 2004;351:637–646.
Page RL, Joglar JA, Kowal RC, Zagrodzky JD, Nelson LL,
Ramaswarmy K, et al. Use of automated external
defibrillators by a U.S. airline. The New England Journal of
Medicine 2000;343:1210–1216.
Veazie MA, Galloway JM, Matson-Koffman D, LaBarthe DR,
Brownstein JN, Emr M, et al. Taking the initiative:
Implementing the American Heart Association Guide for
Improving Cardiovascular Health at the Community Level:
Healthy People 2010 Heart Disease and Stroke Partnership
Community Guideline Implementation and Best Practices
Workgroup. Circulation 2005;112(16), 2538–2554.
††
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within two
points of the median for overall quality of the indicator.
48
Not for dissemination. This document is for internal use of State HDSP Programs.
September 2010
Section 3―Indicator Profiles
Indicator
Proportion of communities served by telephone dispatchers
certified to provide CPR instructions according to standardized
emergency medical dispatch protocols (3.2.4)
Rating◊
$$
Overall Quality
Resources Scientific Face
Accepted
Utility
Needed Evidence Validity
Practice
low ← → high
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Short-term Outcomes Box 2 – Community Changes
What to Measure
The proportion of communities that have telephone dispatchers
trained, certified, and available to provide CPR instructions to
bystanders who call 9-1-1.
Why This Indicator A Public Safety Answering Point (PSAP) is a call center responsible for
is Useful
answering calls to 9-1-1 for police, firefighting, and ambulance
services. A PSAP may serve one or more communities. PSAP
dispatchers can be trained and certified to deliver Emergency Medical
Dispatch (EMD), protocols that help standardize the response to 9-11 medical calls and provide pre-arrival instructions for various
medical emergencies including acute cardiovascular events.
Research shows that despite extensive CPR training, bystanders do
not perform CPR in more than half of witnessed cardiac arrests
(Hallstrom et al., 2000). High-quality CPR instruction provided by
telephone emergency medical dispatchers increases bystander CPR
rates and has been linked to improved survival rates (Bång et al.,
2002; Hauff et al., 2003; Vaillancourt et al., 2007, Bohm et al.,
2009). Trained dispatchers can also recognize acute strokes and
agonal breathing that may accompany cardiac arrest (Bohm et al.,
2009).
How to Measure
Population Group
National Institute of Neurological Disorders and Stroke
(NINDS) Emergency Response Evaluation Form
•
Do you require your dispatchers to be trained in Emergency
Medical Dispatching (EMD)?
•
If someone calls 911 for a cardiac arrest victim, will the
dispatcher provide him CPR and AED instructions over the phone?
Communities
49
Not for dissemination. This document is for internal use of State HDSP Programs.
September 2010
Section 3―Indicator Profiles
Comments
The National Academies of Emergency Dispatch provide standards for
certification. There are several major EMD providers in the United
States including APCO, PowerPhone, and Priority Dispatch.
Evaluators are encouraged to assess this indicator based on official
certification standards; dispatchers with personal CPR certifications
should not be counted.
Reference
Bång A, Ortgren PO, Herlitz J, Währborg P. Dispatcher-assisted
telephone CPR: a qualitative study exploring how dispatchers
perceive their experiences. Resuscitation 2002;53(2):135-151
Bohm K, Stålhandske B, Rosenqvist M, Ulfvarson J, Hollenberg J,
Svensson L. Tuition of emergency medical dispatchers in the
recognition of agonal respiration increases the use of
telephone assisted CPR. Resuscitation 2009;80:1025-28.
Emergency medical dispatching: rapid identification and treatment of
acute myocardial infarction. National Heart Attack Alert
Program Coordinating Committee Access to Care
Subcommittee. The American Journal of Emergency Medicine
1995;13(1):67-73.
Evenson KR, Brice JH, Rosamond WD, Lellis JC, Christian JB, Morris
DL. Statewide survey of 911 communication centers on acute
stroke and myocardial infarction. Prehospital Emergency Care
2007;11(2):186-191
Hallstrom A, Cobb L, Johnson E, Copass M. Cardiopulmonary
resuscitation by chest compression alone or with mouth-tomouth ventilation. The New England Journal of Medicine
2000;342(21):1546–1553.
Hauff SR, Rea TD, Culley LL, Kerry F, Becker L, Eisenberg MS.
Factors impeding dispatcher-assisted telephone
cardiopulmonary resuscitation. Annals of Emergency Medicine
2003;42(6):731-737.
Vaillancourt C, Stiell IG, Wells GA. Understanding and improving low
bystander CPR rates: a systematic review of the literature.
Canadian Journal of Emergency Medicine 2008;10(1):51-65.
Vaillancourt C, Verma A, Trickett J, Crete D, Beaudoin T, Nesbitt L, et
al. Evaluating the effectiveness of dispatch-assisted
cardiopulmonary resuscitation instructions. Academic
Emergency Medicine 2007;14(10):877-883.
◊
To improve clarity, the language of this indicator has significantly changed since the
expert panel review
50
Not for dissemination. This document is for internal use of State HDSP Programs.
September 2010
Section 3―Indicator Profiles
Indicator
Proportion of communities that provide access to CPR
training for community members (3.2.5)
Rating
$$
Overall Quality
Resources Scientific Face
Accepted
Utility
Needed Evidence Validity
Practice
low ← → high
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Short-term Outcomes Box 2 – Community Changes
What to Measure
The proportion of communities that provide access to education or
training on the use of emergency response techniques and relevant
equipment to its citizens.
Why This Indicator
is Useful
The survival rate for out-of-hospital cardiac arrest is low. CPR
training has been shown to increase bystander CPR and
subsequently the proportion of individuals who survive to hospital
discharge (Andresen et al., 2008; Hallstrom and Ornato, 2004;
Hedges et al., 2006).
How to Measure
Missouri Community Policy and Environmental Change
Program Packet
•
Does your community have affordable, convenient CPR courses
for all age groups?
Texas State Department of State Health Services: Heart and
Stroke Healthy City Recognition Program: Heart and Stroke
Healthy Indicators
Indicator # 7: Training programs are in place to improve the rate of
bystander CPR and use of AEDs.
•
Nationally recognized training programs are in placed for CPR and
AED. Indicate below how your community is meeting this
criterion:
o
Nationally recognized CPR classes are in the area
o
Number of CPR/AED trainings held in the community in
the past year
o
Total number of people trained in CPR/AED in the past
year
51
Not for dissemination. This document is for internal use of State HDSP Programs.
September 2010
Section 3―Indicator Profiles
Population Group
Communities
References
Andresen D, Arntz HR, Gräfling W, Hoffmann S, Hofmann D,
Kraemer R, et al. Public access resuscitation program
including defibrillator training for laypersons: a randomized
trial to evaluate the impact of training course duration.
Resuscitation 2008;76(3):419-424.
Bång A, Biber B, Isaksson L, Lindqvist J, Herlitz J. Evaluation of
dispatcher-assisted cardiopulmonary resuscitation. European
Journal of Emergency Medicine 1999;6(3):175–183.
Culley LL, Rea TD, Murray JA, Welles B, Fahrenbruch CE, Olsufka M,
et al. Public access defibrillation in out-of-hospital cardiac
arrest: A community-based study. Circulation
2004;109:1859–1863. Review.
Hallstrom A, Ornato JP. Public access defibrillation and survival after
out-of-hospital cardiac arrest. The Journal of the American
Medical Association 2004;351:637–646.
Hedges JR, Sehra R, Van Zile JW, Anton AR, Bosken LA, O’Conner
RE, et al. Automated external defibrillator program does not
impair cardiopulmonary resuscitation initiation in the public
access defibrillation trial. Academic Emergency Medicine
2006;13:659–665.
Swor R, Fahoome G, Compton S. Potential impact of a targeted
cardiopulmonary resuscitation program for older adults on
survival from private-residence cardiac arrest. Academic
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September 2010
Section 3―Indicator Profiles
LOGIC MODEL BOX 3:
Emergency Response Systems Changes
The American Heart Association has estimated that 295,000 out-of-hospital cardiac arrests
occur annually in the United States, thus illustrating the critical need for emergency
response systems that can adequately respond to and treat these patients (Lloyd-Jones et
al, 2010). Many public safety systems have begun ensuring that emergency response
vehicles (e.g., ambulances and fire trucks) are appropriately equipped with an AED to treat
individuals experiencing acute cardiovascular events (Kellerman et al., 1993; Mols et al.,
1994; Richless et al., 1993; Sedgwick et al., 1993; Shuster & Keller, 1993; Stotz et al.,
2003). Additionally, many local public health systems have encouraged access to AEDs and
training for first responders in traditional and nontraditional settings including non-hospital
health care locations, long-term care facilities, casinos, sporting arenas, and airplanes.
(Becker et al., 1998 ; Colquhoun et al., 2000; Page et al., 2000; Valenzuela et al., 2000).
Studies have demonstrated mixed findings for these efforts; in particular, Sweeney et al.
(1998) noted that survival to hospital discharge was not statistically different among
patients treated by AED-equipped first-responders compared with those performing CPR
only.
Health care organizations have enhanced their emergency response system by establishing
pre-arrival notification procedures to allow sufficient time to prepare and organize the
treatment team (Belvis et al., 2005; Vaught et al., 2006). Other examples of changes to the
public safety system to enhance emergency response include establishing mobile
emergency care units staffed with specialists (Koefoed-Nielsen et al., 2002; Willich et al.,
2000) and equipping and training basic and advanced life support providers in the use of
impedance threshold devices, which are designed to maximize circulation of blood to the
vital organs during CPR (Thayne et al., 2005).
Making these changes to the emergency response system allows for a more rapid response
to acute cardiovascular events, thus providing patients with necessary treatment as soon as
possible. Decreasing the time to treatment has the potential to improve survival and longterm outcomes (Sedgwick, 1993).
Listed below are the indicators associated with this outcome box:
3.3.1 Proportion of non-hospital health care settings that establish systems for emergency
response to acute cardiovascular events
3.3.2 Proportion of ambulances with equipment to facilitate optimal emergency response for
acute cardiovascular events
References
Becker L, Eisenberg M, Fahrenbruch C, Cobb L. Circulation 1998;97:2106-2109.
53
Not for dissemination. This document is for internal use of State HDSP Programs.
September 2010
Section 3―Indicator Profiles
Belvis R, Cocho D, Marti-Fabregas J, Pagonabarraga J, Aleu A, Garcia-Bargo MD, et al.
Benefits of a prehospital stroke code system. Cerebrovascular Diseases 2005;19(2):
96–101.
Colquhoun MC. Defibrillation by general practitioners. Resuscitation 2002:52(2)143–148.
Kellerman AL, Hackman BB, Somes G, Kreth TK, Nail L, Dobyns P. Impact of first-responder
defibrillation in an urban emergency medical services system. Journal of the
American Medical Association 1993;270(14):1708–1713.
Koefoed-Nielsen J, Christensen EF, Melchiorsen H, Foldspang A. Acute myocardial infarction:
Does prehospital treatment increase survival? European Journal of Emergency
Medicine 2002;9(3):210–216.
Lloyd-Jones D, Adams RJ, Brown TM, Carnethon M, Dai S, et al. Heart disease and stroke
statistics 2010 update: a report from the American Heart Association. Circulation
2010;121:e46–e215.
Mols, P., Beaucarne, E., Bruyninx, J., Labruyere, J. P., De Myttenaere, L., Naeije, N., et al.
Early defibrillation by EMTs: The Brussels experience. Resuscitation 1994;27(2):129–
136.
Page RL, Joglar JA, Kowal RC, Zagrodzky JD, Nelson LL, Ramaswarmy K, et al. Use of
automated external defibrillators by a U.S. airline. The New England Journal of
Medicine 2000;343:1210–1216.
Richless LK, Schrading WA, Polana J, Hess DR, Ogden CS. Early defibrillation program:
Problems encountered in a rural/suburban EMS system. The Journal of Emergency
Medicine 1993;11:127–134.
Rosamund W, Flegal K, Furie K, Go A, Greenlund K, Haase N. Heart disease and stroke
statistics – 2008 update. Circulation 2008;117:e25–e146.
Sedgwick ML, Dalziel K, Watson J, Carrington DJ, Cobbe SM. Performance of an established
system of first responder out-of-hospital defibrillation. The results of the second year
of the Heartstart Scotland Project in the “Utstein Style.” Resuscitation
1993;26(1):75–88.
Shuster M, Keller JL. Effect of fire department first-responder automated defibrillation.
Annals of Emergency Medicine 1993;22(4):721–727.
Stotz M, Albrecht R, Zwicker G, Drewe J, Ummenhofer W. EMS defibrillation-first policy may
not improve outcome in out-of-hospital cardiac arrest. Resuscitation
2003;58(3):277–282.
Sweeney TA, Runge JW, Gibbs MA, Raymond JM, Schafermeyer RW, Norton, HJ, et al. EMT
defibrillation does not increase survival from sudden cardiac death in a two-tiered
urban-suburban EMS system. Annals of Emergency Medicine 1998;31(2):234–240.
Thayne RC, Thomas DC, Neville JD, Van Dellen A. Use of an impedance threshold device
improves short-term outcomes following out-of-hospital cardiac arrest. Resuscitation
2005;67(1):103–108.
Valenzuela TD, Roe DJ, Nichol G, Clark LL, Spaite DW, Hardman RG. Outcomes of rapid
defibrillation by security officers after cardiac arrest in casinos. The New England
Journal of Medicine 2000;343(17):1206–1209.
54
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September 2010
Section 3―Indicator Profiles
Vaught C, Young DR, Bell SJ, Maynard C, Gentry M, Jacubowitz S, et al. The failure of years
of experience with electrocardiographic transmission from paramedics to the hospital
emergency department to reduce the delay from door to primary coronary
intervention below the 90-minute threshold during acute myocardial infarction.
Journal of Electrocardiology 2006;39(2):136–141.
Willich SN, Kulig M, Scholz RD, Arntz HR. Long-term prognosis of cardiovascular patients
following mobile emergency care. European Journal of Emergency Medicine
2000;7(3):201–205.
55
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September 2010
Section 3―Indicator Profiles
Indicator
Proportion of non-hospital health care settings that establish
systems for emergency response to acute cardiovascular
events (3.3.1)
Rating
††
Overall Quality
$$
Resources Scientific Face
Accepted
Utility
Needed Evidence Validity
Practice
low ← → high
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Short-term Outcomes Box 3 – Emergency Response Systems
Changes
What to Measure
The proportion of non-hospital health care settings, such as nursing
homes, assisted living facilities, Federally Qualified Healthcare
Centers, and physician offices , that have systems to provide
emergency response for acute cardiovascular events. Additional
detail regarding systems to provide emergency response is included
in “Comments” below.
Why This Indicator
is Useful
The proportion of patients suffering cardiac arrest in nonhospital
health care settings who receive CPR and defibrillation prior to EMS
arrival is low (Sha, Fairbanks, and Lemer, 2007). The more quickly
patients receive CPR, the greater the survival rate to hospital
discharge.
How to Measure
TO BE DETERMINED
Population Group
Not applicable. This indicator is best measured by tracking and
monitoring non-health care settings with systems to provide
emergency response to acute cardiovascular events.
Comments
Systems to provide emergency response in non-hospital health care
settings include policies addressing roles and responsibilities for
health care facility staff as well as equipment to facilitate the
provision of CPR prior to EMS arrival, Equipment may include AED
access spots, impedance threshold devices, and oxygen.
References
Colquhoun MC. Defibrillation by general practitioners. Resuscitation
2002;52(2):143–148.
Domanovits H, Meron G, Sterz F, Kofler J, Oschatz E, Holzer M, et
al. Successful automatic external defibrillator operation by
people trained only in basic life support in a simulated
56
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September 2010
Section 3―Indicator Profiles
cardiac arrest situation. Resuscitation 1998;39:47–50.
Richless LK, Schrading WA, Polana J, Hess DR, Ogden CS. Early
defibrillation program: Problems encountered in a
rural/suburban EMS system. The Journal of Emergency
Medicine 1993;11:127–134.
Shah MN, Fairbanks RJ, Lerner EB. Cardiac arrests in skilled nursing
facilities: continuing room for improvement? Journal of the
American Medical Directors Association 2007;8(3 Suppl
2):e27-31.
††
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within two
points of the median for overall quality of the indicator.
57
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September 2010
Section 3―Indicator Profiles
Indicator
Proportion of ambulances with equipment to facilitate optimal
emergency response for acute cardiovascular events (3.3.2)
Rating
$$
Overall Quality
Resources Scientific Face
Accepted
Utility
Needed Evidence Validity
Practice
low ← → high
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Short-term Outcomes Box 3 – Emergency Response Systems
Changes
What to Measure
The proportion of ambulances equipped with AEDs, 12-lead ECGs,
and devices that allow for transmission of clinical data and the ability
to get real-time medical support from the hospital.
Why This Indicator Prompt treatment for heart attack and stroke enhances quality of
is Useful
care and improves patient outcomes (Jollis et al., 2007). Although
evidence to date has been mixed, equipping ambulances to facilitate
early care for heart attack and stroke appears to shorten time to
treatment and may lead to improved patient outcomes (McLean et
al., 2008; Sejersten, 2008).
How to Measure
TO BE DETERMINED
Population Group
Not applicable. The indicator is best measured by tracking and
monitoring whether ambulances have equipment to facilitate optimal
emergency response and coordination with hospitals when
responding to acute cardiovascular events.
References
Faxon DP, Jacobs AK. Strategies to improve early reperfusion in STelevation myocardial infarction. Reviews in Cardiovascular
Medicine 2007;8(3):127-134.
Jollis JG, Roettig ML, Aluko AO, Anstrom KJ, Applegate RJ, Babb JD,
et al. Implementation of a statewide system for coronary
reperfusion for ST-segment elevation myocardial infarction.
The Journal of the American Medical Association
2007;298(20):E1–E6.
McLean S, Egan G, Connor P, Flapan AD. Collaborative decisionmaking between paramedics and CCU nurses based on 12lead ECG telemetry expedites the delivery of thrombolysis in
ST elevation myocardial infarction. Emergency Medicine
Journal 2008;25(6):370–374
58
Not for dissemination. This document is for internal use of State HDSP Programs.
September 2010
Section 3―Indicator Profiles
Sedgwick ML, Dalziel K, Watson J, Carrington DJ, Cobbe SM.
Performance of an established system of first responder outof-hospital defibrillation. The results of the second year of the
Heartstart Scotland Project in the “Utstein Style.”
Resuscitation 1993;26(1):75–88.
Sejersten M, Sillesen M, Hansen PR, Nielsen SL, Nielsen H, Trautner
S, et al. Effect on treatment delay of prehospital
teletransmission of 12-lead electrocardiogram to a cardiologist
for immediate triage and direct referral of patients with STsegment elevation acute myocardial infarction to primary
percutaneous coronary intervention. American Journal of
Cardiology 2008;101(7):941–946.
Stotz M, Albrecht R, Zwicker G, Drewe J, Ummenhofer W. EMS
defibrillation-first policy may not improve outcome in out-ofhospital cardiac arrest. Resuscitation 2003;58(3):277–282.
Vaught C, Young DR, Bell SJ, Maynard C, Gentry M, Jacubowitz S, et
al. The failure of years of experience with electrocardiographic
transmission from paramedics to the hospital emergency
department to reduce the delay from door to primary
coronary intervention below the 90-minute threshold during
acute myocardial infarction. Journal of Electrocardiology
2006;39(2):136–141.
LOGIC MODEL BOX 4:
Individual Changes
Improving individual awareness of the signs and symptoms of heart attack and stroke and
enhancing knowledge of appropriate emergency response actions has the potential to
increase the likelihood that individuals will take emergency actions in the event of an acute
cardiovascular event. A number of studies have assessed the effects of education efforts in
various settings including worksites (Fogle, 2004), whole communities (Goff, 2004), and
individual community efforts (Meischke, 2004; Morgenstern, 2003; Wright, 2001);
unfortunately, these studies have demonstrated mixed results. Meischke (2004), for
example, found no significant difference between intervention subjects and controls in
knowledge of acute myocardial infarction symptoms, whereas others have demonstrated
that certain interventions do increase recognition of symptoms (Goff, 2004). Enhancing
knowledge of signs and symptoms and understanding of appropriate emergency response
action has been shown to increase use of emergency response actions (e.g. CPR, AED
usage) and systems (e.g. 9-1-1, EMS) (Andre, 2004; Eppler, 1994; Gaspoz, 1996; Herlitz,
1991; Wright, 2001).
Listed below are the indicators associated with this outcome component:
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Not for dissemination. This document is for internal use of State HDSP Programs.
September 2010
Section 3―Indicator Profiles
3.4.1 Proportion of individuals who are aware of the signs and symptoms for acute
cardiovascular events
3.4.2 Proportion of individuals with knowledge of the appropriate emergency response
actions for acute cardiovascular events
3.4.3 Disparity in knowledge of the signs and symptoms for acute cardiovascular events
between general and priority populations
3.4.4 Disparity in knowledge of appropriate emergency response actions for acute
cardiovascular events between general and priority populations
References
Andre AD, Jorgenson DB, Froman JA, Snyder DE, Poole JE. Automated external defibrillator
use by untrained bystanders: Can the public-use model work? Prehospital Emergency
Care 2004;8(3):284–291.
Eppler E, Eisenberg MS, Schaeffer S, Meischke H, Larson MP. 911 and emergency
department use for chest pain: Results of a media campaign. Annals of Emergency
Medicine 1994;24(2):202–208.
Fogle CC, Oser CS, Blades LL, Harwell TS, Helgerson SD, Gohdes D, et al. Increasing
employee awareness of the signs and symptoms of heart attack and the need to use
911 in a state health department. Preventing Chronic Disease 2004;1(3):1–8.
Gaspoz JM, Unger PF, Urban P, Chevrolet JC, Rutishauser W, Lovis C, et al. Impact of a
public campaign on prehospital delay in patients reporting chest pain. Heart
1996;76(2):150–155.
Goff DC, Mitchell P, Finnegan J, Pandey D, Bittner V, Feldman H, et al. Knowledge of heart
attack symptoms in 20 US communities. Results from the rapid early action for
coronary treatment community trial. Preventive Medicine 2004;38(1):85–93.
Herlitz J, Blohm M, Hartford M, Karlson BW, Luepker R, Holmberg S, et al. Follow-up of a 1year media campaign on delay times and ambulance use in suspected acute
myocardial infarction. European Heart Journal 1992;13(2):171–177
Meischke H, Diehr P, Rowe S, Cagle A, Eisenberg M. Evaluation of a public education
program delivered by firefighters on early recognition of a heart attack. Evaluation &
the Health Professions 2004;27(1):3–21.
Morgenstern LB, Bartholomew LK, Grotta JC, Staub L, King M, Chan W. Sustained benefit of
a community and professional intervention to increase acute stroke therapy. Archives
of Internal Medicine 2003;163(18):2198–2202.
Wright RS, Kopecky SL, Timm M, Pflaum DD, Carr C, Evers K, et al. Impact of communitybased education on health care evaluation in patients with acute chest pain
syndromes: The Wabasha Heart Attack Team (WHAT) project. Family Practice
2001;18(5):537–539.
60
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September 2010
Section 3―Indicator Profiles
Indicator
Proportion of individuals who are aware of signs and
symptoms for acute cardiovascular events (3.4.1)
Rating
$$$
Overall Quality
†
Resources Scientific Face
Accepted
Utility
Needed Evidence Validity
Practice
low ← → high
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Short-term Outcomes Box 4 – Individual Changes
What to Measure
The proportion of individuals with knowledge of the signs and
symptoms of acute cardiovascular events.
Why This Indicator Effective, sustained education programs have been shown to increase
is Useful
risk recognition and knowledge of signs and symptoms, which may
prompt individuals to activate the emergency response system
(Delemos et al., 2003; Fogle et al., 2004; Goff et al., 2004; Moses et
al., 1991).
How to Measure
Behavioral Risk Factor Surveillance System (BRFSS) Heart
Attack and Stroke Module
Heart Attack and Stroke, Optional Module
•
Do you think pain or discomfort in the jaw, neck, or back are
symptoms of a heart attack?
•
Do you think feeling weak, lightheaded, or faint are symptoms of
a heart attack?
•
Do you think chest pain or discomfort are symptoms of a heart
attack?
•
Do you think sudden trouble seeing in one or both eyes is a
symptom of a heart attack?
•
Do you think pain or discomfort in the arms or shoulders are
symptoms of a heart attack?
•
Do you think shortness of breath is a symptom of a heart attack?
•
Do you think sudden confusion or trouble speaking are symptoms
of a stroke?
•
Do you think sudden numbness or weakness of face, arm, or leg,
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September 2010
Section 3―Indicator Profiles
especially on one side are symptoms of a stroke?
•
Do you think sudden trouble seeing in one or both eyes is a
symptom of a stroke?
•
Do you think sudden chest pain or discomfort are symptoms of a
stroke?
•
Do you think sudden trouble walking, dizziness, or loss of balance
are symptoms of a stroke?)
•
Do you think severe headache with no known cause is a symptom
of a stroke?
Population Group
Adults 18 or older
References
Barnhart JM, Cohen O, Kramer HM, Wilkins CM, Wylie-Rosett J.
Awareness of heart attack symptoms and lifesaving actions
among New York City area residents. Journal of Urban Health
2005;82(2): 207–215.
Blohm M, Hartford M, Karlson BW, Karlsson T, Herlitz J. A media
campaign aiming at reducing delay times and increasing the
use of ambulance in AMI. American Journal of Emergency
Medicine 1994;12(3):315–318.
DeLemos CD, Atkinson RP, Croopnick SL, Wentworth DA, Atkins PT.
How effective are “community” stroke screening programs at
improving stroke knowledge and prevention practices? Stroke
2004;34:e247–e249.
Fogle CC, Oser CS, Blades LL, Harwell TS, Helgerson SD, Gohdes D,
et al. Increasing employee awareness of the signs and
symptoms of heart attack and the need to use 911 in a state
health department. Preventing Chronic Disease 2004;1(3):1–
8.
Goff DC, Mitchell P, Finnegan J, Pandey D, Bittner V, Feldman H, et
al. Knowledge of heart attack symptoms in 20 US
communities. Results from the rapid early action for coronary
treatment community trial. Preventive Medicine
2004;38(1):85–93.
Wein TH, Staub L, Felberg R, Hickenbottom SL, Chan W, Grotta JC, et
al. Activation of emergency medical services for acute stroke
in a nonurban population: The T.L.L. Temple Foundation
Stroke Project. Stroke 2000;31(8):1925–1928.
Wright RS, Kopecky SL, Timm M, Pflaum DD, Carr C, Evers K, et al.
Impact of community-based education on health care
evaluation in patients with acute chest pain syndromes: The
Wabasha Heart Attack Team (WHAT) project. Family Practice
2001;18(5):537–539.
†
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within one
point of the median for this criterion.
62
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September 2010
Section 3―Indicator Profiles
Indicator
Proportion of individuals with knowledge of the appropriate
emergency response actions for acute cardiovascular events
(3.4.2)
Rating
$$$
Overall Quality
Resources Scientific Face
Accepted
Utility
Needed Evidence Validity
Practice
low ← → high
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Short-term Outcomes Box 4 – Individual Changes
What to Measure
The proportion of individuals with knowledge of the appropriate
emergency response actions for acute cardiovascular events. These
actions include activating the emergency response system by calling
9-1-1, potentially administering CPR, and/or using an AED.
Why This Indicator Rates of bystander CPR are low (Vadeboncoeur et al., 2007).
is Useful
Campaigns to enhance knowledge of CPR techniques and proper use
of AED equipment has been shown to increase awareness of
appropriate emergency response actions and activation of the
emergency response system (Fogle et al., 2004; Meischke and
Finnegan, 1999; Andre et al., 2004).
How to Measure
Behavioral Risk Factor Surveillance System (BRFSS)
•
If you thought someone was having a heart attack or a stroke,
what is the first thing you would do?
o
Take them to the hospital
o
Tell them to call their doctor
o
Call 9-1-1
o
Call their spouse or a family member
National Health Interview Survey (NHIS)
•
If you thought someone was having a stroke, what is the BEST
thing to do right away?
o
Advise them to drive to the hospital
o
Advise them to call their physician
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September 2010
Section 3―Indicator Profiles
o
Call 9-1-1 (or another emergency number)
o
Call spouse or family member
o
Other
o
Refused
o
Don't know
Population Group
Adults 18 or older
References
Andre AD, Jorgenson DB, Froman JA, Snyder DE, Poole JE.
Automated external defibrillator use by untrained bystanders:
Can the public-use model work? Prehospital Emergency Care
2004;8(3):284–291.
Barnhart JM, Cohen O, Kramer HM, Wilkins CM, Wylie-Rosett J.
Awareness of heart attack symptoms and lifesaving actions
among New York City area residents. Journal of Urban Health
2005;82(2): 207–215.
Blohm M, Hartford M, Karlson BW, Karlsson T, Herlitz J. A media
campaign aiming at reducing delay times and increasing the
use of ambulance in AMI. American Journal of Emergency
Medicine 1994;12(3):315–318.
Fogle CC, Oser CS, Blades LL, Harwell TS, Helgerson SD, Gohdes D,
et al. Increasing employee awareness of the signs and
symptoms of heart attack and the need to use 911 in a state
health department. Preventing Chronic Disease 2004;1(3):1–
8.
Osganian SK, Zapka JG, Feldman HA, Goldberg RJ, Hedges JR,
Eisenberg MS, et al.REACT Study Group. Rapid Early Action
for Coronary Treatment. Use of emergency medical services
for suspected acute cardiac ischemia among demographic and
clinical patient subgroups: the REACT trial. Rapid Early Action
for Coronary Treatment. Prehospital Emergency Care
2002;6(2):175-85.
Travis LH, Flemming KD, Brown RD Jr, Meissner I, McClelland RL,
Weigand SD. Awareness of stroke risk factors, symptoms, and
treatment is poor in people at highest risk. Journal of Stroke &
Cerebrovascular Diseases 2003;12(5):221-227.
Vadeboncoeur T, Bobrow BJ, Clark L, Kern KB, Sanders AB, Berg RA,
et al. The Save Hearts in Arizona Registry and Education
(SHARE) program: who is performing CPR and where are they
doing it? Resuscitation 2007;75(1):68-75.
64
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September 2010
Section 3―Indicator Profiles
Indicator
Disparity in knowledge of signs and symptoms for acute
cardiovascular events between general and priority
populations (3.4.3)
Rating
$$
Overall Quality
Resources Scientific Face
Accepted
Utility
Needed Evidence Validity
Practice
low ← → high
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Short-term Outcomes Box 4 – Individual Changes
What to Measure
Disparity in knowledge of signs and symptoms of acute
cardiovascular events between individuals in the general population
and those within priority groups.
Why This Indicator Research has identified racial/ethnic and gender disparities in the
is Useful
awareness of signs and symptoms of heart attack and stroke and in
subsequent emergency response actions (Barnhart et al., 2005; Fang
et al., 2008; McGruder et al., 2008). These disparities may be
reduced through innovative CPR outreach programs that target
priority populations and aim to increase signs and symptoms
recognition (Barnhart et al., 2005; Goff et al., 2004; Ratner et al.,
2006).
How to
Measure
Behavioral Risk Factor Surveillance System (BRFSS)
•
Demographic information
Heart Attack and Stroke, Optional Module
•
Do you think pain or discomfort in the jaw, neck, or back are
symptoms of a heart attack?
•
Do you think feeling weak, lightheaded, or faint are symptoms of
a heart attack?
•
Do you think chest pain or discomfort are symptoms of a heart
attack?
•
Do you think sudden trouble seeing in one or both eyes is a
symptom of a heart attack?
•
Do you think pain or discomfort in the arms or shoulders are
symptoms of a heart attack?
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September 2010
Section 3―Indicator Profiles
•
Do you think shortness of breath is a symptom of a heart attack?
•
Do you think sudden confusion or trouble speaking are symptoms
of a stroke?
•
Do you think sudden numbness or weakness of face, arm, or leg,
especially on one side are symptoms of a stroke?
•
Do you think sudden trouble seeing in one or both eyes is a
symptom of a stroke?
•
Do you think sudden chest pain or discomfort are symptoms of a
stroke?
•
Do you think sudden trouble walking, dizziness, or loss of balance
are symptoms of a stroke?)
•
Do you think severe headache with no known cause is a symptom
of a stroke?
Population Group
Adults 18 or older
References
Barnhart JM, Cohen O, Kramer HM, Wilkins CM, Wylie-Rosett J.
Awareness of heart attack symptoms and lifesaving actions
among New York City area residents. Journal of Urban Health
2005;82(2): 207–215.
Fang J, Keenan N, Dai S, Denny C. Disparities in Adult Awareness of
Heart Attack Warning Signs and Symptoms --- 14 States,
2005. MMWR 2008;57(07):175-179
Goff DC, Mitchell P, Finnegan J, Pandey D, Bittner V, Feldman H, et
al. Knowledge of heart attack symptoms in 20 US
communities. Results from the rapid early action for coronary
treatment community trial. Preventive Medicine
2004;38(1):85–93.
McGruder HE, Greenlund KJ, Malarcher AM, Antoine TL, Croft JB,
Zheng ZJ. Racial and ethnic disparities associated with
knowledge of symptoms of heart attack and use of 911:
National Health Interview Survey 2001. Ethnicity & Disease
2008;18(2):192-197.
Ratner PA, Tzianetas R, Tu AW, Johnson JL, Mackay M, Buller CE, et
al. Myocardial infarction symptom recognition by the lay
public: The role of gender and ethnicity. Journal of
Epidemiological Community Health 2006;60:606–615.
66
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September 2010
Section 3―Indicator Profiles
Indicator
Disparity in knowledge of appropriate emergency response
actions for acute cardiovascular events between general and
priority populations (3.4.4)
Rating
$$
Overall Quality
Resources Scientific Face
Accepted
Utility
Needed Evidence Validity
Practice
low ← → high
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Short-term Outcomes Box 4 – Individual Changes
What to Measure
Disparity in knowledge of appropriate emergency response actions
for acute cardiovascular events between individuals in the general
population and those within priority groups. These actions include
activating the emergency response system by calling 9-1-1,
potentially administering CPR, and/or using an AED.
Why This Indicator Racial/ethnic disparities exist in knowledge of the need to call 9-1-1
is Useful
(Fang et al., 2008; McGruder et al., 2008). These disparities may be
reduced through innovative CPR outreach programs that target
priority populations and aim to increase appropriate emergency
response actions for heart attack and stroke (Barnhart et al., 2005;
Goff et al., 2004; Ratner et al., 2006).
How to Measure
Behavioral Risk Factor Surveillance System (BRFSS)
•
Pertinent demographic information
•
If you thought someone was having a heart attack or a stroke,
what is the first thing you would do?
o
Take them to the hospital
o
Tell them to call their doctor
o
Call 9-1-1
o
Call their spouse or a family member
National Health Interview Survey (NHIS)
•
Pertinent demographic information
•
If you thought someone was having a stroke, what is the BEST
thing to do right away?
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Section 3―Indicator Profiles
o
Advise them to drive to the hospital
o
Advise them to call their physician
o
Call 9-1-1 (or another emergency number)
o
Call spouse or family member
o
Other
o
Refused
o
Don't know
Population Group
Adults 18 or older
References
Barnhart JM, Cohen O, Kramer HM, Wilkins CM, Wylie-Rosett J.
Awareness of heart attack symptoms and lifesaving actions
among New York City area residents. Journal of Urban Health
2005;82(2): 207–215.
Fang J, Keenan N, Dai S, Denny C. Disparities in Adult Awareness of
Heart Attack Warning Signs and Symptoms --- 14 States,
2005. MMWR 2008;57(07):175-179
Goff DC, Mitchell P, Finnegan J, Pandey D, Bittner V, Feldman H, et
al. Knowledge of heart attack symptoms in 20 US
communities. Results from the rapid early action for coronary
treatment community trial. Preventive Medicine
2004;38(1):85–93.
McGruder HE, Greenlund KJ, Malarcher AM, Antoine TL, Croft JB,
Zheng ZJ. Racial and ethnic disparities associated with
knowledge of symptoms of heart attack and use of 911:
National Health Interview Survey 2001. Ethnicity & Disease
2008;18(2):192-197.
Ratner PA, Tzianetas R, Tu AW, Johnson JL, Mackay M, Buller CE, et
al. Myocardial infarction symptom recognition by the lay
public: The role of gender and ethnicity. Journal of
Epidemiological Community Health 2006;60:606–615.
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Section 3―Indicator Profiles
LOGIC MODEL BOX 5:
Emergency Medical Provider Changes
Emergency medical providers play a critical role in initiating treatment among individuals
experiencing heart attack or stroke. With adequate training and equipment, these
personnel can provide appropriate treatment that can alter the course of the acute
cardiovascular event. Colquhoun (2002), for example, recognized this opportunity by
equipping health care providers with AEDs with which to provide immediate medical
response for those experiencing cardiac arrest. Similarly, emergency medical responders
trained and equipped with appropriate medication and treatment options can provide early,
pre-hospital assistance to victims of acute cardiovascular events to decrease the time from
symptom onset to treatment. The combination of efforts offers the potential to reduce timeto-treatment and improve outcomes for individuals suffering acute cardiovascular events.
Listed below are the indicators associated with this outcome box:
3.5.1 Proportion of acute cardiovascular events in non-hospital settings where health care
providers use AEDs
3.5.2 Proportion of acute cardiovascular events where emergency response personnel
provide appropriate pharmacologic treatment prior to hospital arrival
3.5.3 Proportion of acute cardiovascular events with documented use of appropriate
emergency response equipment
References
Colquhoun MC. Defibrillation by general practitioners. Resuscitation 2002;52(2):143–148.
Hanefeld C, Lichte C, Mentges-Schroter I, Sirtl C, Mugge A. Hospital-wide first-responder
automated external defibrillator programme: 1 year experience. Resuscitation
2005;66:167–170.
Kellerman AL, Hackman BB, Somes G, Kreth TK, Nail L, Dobyns P. Impact of first-responder
defibrillation in an urban emergency medical services system. Journal of the
American Medical Association 1993;270(14):1708–1713.
Page RL, Joglar JA, Kowal RC, Zagrodzky JD, Nelson LL, Ramaswarmy K, et al. Use of
automated external defibrillators by a U.S. airline. The New England Journal of
Medicine 2000;343:1210–1216.
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Section 3―Indicator Profiles
Indicator
Proportion of acute cardiovascular events in non-hospital
settings where health care providers use AEDs (3.5.1)
Rating
†
$$$$
††
Overall Quality
Resources Scientific Face
Accepted
Utility
Needed Evidence Validity
Practice
low ← → high
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Intermediate Outcomes Box 5 – Emergency Medical Provider
Changes
What to Measure
Proportion of acute cardiovascular events in non-hospital settings
where health care providers use AEDs appropriately.
Why This Indicator Studies have shown that providing training and availability of AEDs to
is Useful
nonhospital health care providers (Boyd et al., 2006; Colquhoun,
2002; Fisher, 2007) can increase the timeliness and quality of care to
patients suffering cardiac arrest.
How to Measure
EMS Trip Reports or Run Sheets can be used for data abstraction
if electronic systems are not in place
National EMS Informational System (NEMSIS)
•
Condition code number E07_35
•
Providers Primary Impression E09_15
•
Providers Secondary Impression E09_16
•
Incident Location Type E08_07
o
Residential Institution (Nursing Home, jail/prison)
o
Healthcare facility (clinic, hospital, nursing home)
•
Prior Aid E09_01
•
Prior Aid Performed By E09_02
o
•
Other Healthcare Provider
Procedures D04_04
Cardiac Arrest Registry to Enhance Survival (CARES)
•
Location type
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September 2010
Section 3―Indicator Profiles
•
o
Nursing Home
o
Physician Office/Clinic
Was an AED used during resuscitation?
o
Yes
o
No
o
AED present but not used
o
AED malfunctioned
Population Group
Non-hospital health care settings
References
Boyd BC, Fantuzzo JJ, Votta T. The role of automated external
defibrillators in dental practice. New York State Dental Journal
2006;72(4):20-23.
Colquhoun MC. Defibrillation by general practitioners. Resuscitation
2002;52(2):143–148.
Fisher J, Anzalone B, McGhee J, Sylvia B, Ullman EA. Lack of early
defibrillation capability and automated external defibrillators
in nursing homes. Journal of the American Medical Directors
Association 2007;8(6):413-415.
Shah MN, Fairbanks RJ, Lerner EB. Cardiac arrests in skilled nursing
facilities: continuing room for improvement? Journal of the
American Medical Directors Association 2007;8(3 Suppl
2):e27-31.
White RD. AED (automated external defibrillators). A physician's
responsibility. Journal of Emergency Medical Services 1992;
17(4):8-9.
†
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within one
point of the median for this criterion.
††
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within two
points of the median for overall quality of the indicator.
71
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September 2010
Section 3―Indicator Profiles
Indicator
Proportion of acute cardiovascular events where emergency
response personnel provide appropriate pharmacologic
treatment prior to hospital arrival (3.5.2)
Rating
$$
††
Overall Quality
Resources Scientific Face
Accepted
Utility
Needed Evidence Validity
Practice
low ← → high
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Intermediate Outcomes Box 5 – Emergency Medical Provider
Changes
What to Measure
Proportion of acute cardiovascular events where emergency response
personnel provide appropriate pharmacologic treatment prior to
hospital arrival. Examples of potential pharmacologic treatments
included in “Comments” below.
Why This Indicator Grijseels et al. (1995) have found that pre-hospital pharmacologic
is Useful
treatment is feasible, safe, and provides significant time gains for
patients with chest pain for more than 30 minutes. A meta-analysis
by Morrison et al. (2000) shows that pre-hospital pharmacologic
treatment significantly decreases time to thrombolysis and mortality
for patients suffering an acute myocardial infarction.
How to Measure
EMS Trip Reports or Run Sheets can be used for data abstraction
if electronic systems are not in place
National EMS Information System (NEMSIS)
•
Providers Primary Impression E09_15
•
Providers Secondary Impression E09_16
•
Medication Given E18_03
•
Medications D04_06
•
Prior Aid E09_01
•
Prior Aid Performed By E09_02
o
EMS Provider
Population Group
Emergency response personnel
Comments
Pharmacologic treatment may include administering initial
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September 2010
Section 3―Indicator Profiles
thrombolytic therapy, nitroglycerin tablets or spray, morphine, or
nonenteric aspirin.
Evaluators should consider analyzing EMS data for specific diagnosis
codes and related pharmacologic treatment of interest.
References
Grijseels EWM, Bouten MJM, Lenderink T, Deckers JW, Hoes AW,
Hartman JAM, et al. Prehospital thrombolytic therapy with
either alteplase or streptokinase. European Heart Journal
1995;16:1833–1838.
Morrison LJ, Verbeck PR, McDonald AC, Sawadsky BV, Cook DJ.
Mortality and prehospital thrombolysis for acute myocardial
infarction: A meta-analysis. The Journal of the American
Medical Association 2000;283(20):2686–2692.
Rittenberger JC, Beck PW, Paris PM. Errors of omission in the
treatment of prehospital chest pain patients. Prehospital
Emergency Care 2005;9(1):2–7.
††
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within two
points of the median for overall quality of the indicator.
73
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September 2010
Section 3―Indicator Profiles
Indicator
Proportion of acute cardiovascular events with documented
use of appropriate emergency response equipment (3.5.3)
Rating
$$
†
†
††
Overall Quality
Resources Scientific Face
Accepted
Utility
Needed Evidence Validity
Practice
low ← → high
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Intermediate Outcomes Box 5 – Emergency Medical Provider
Changes
What to Measure
Proportion of acute cardiovascular events with documented use of
appropriate emergency response equipment. Response equipment
may include items such as AEDs and ECG devices.
Why This Indicator
is Useful
Survival rates for those suffering out-of-hospital cardiac arrest are
low and further plummet if there is a delay in the provision of CPR
and defibrillation (Vukmir, 2006). For every minute that passes
between collapse and defibrillation, survival rates decrease 7% to
10% if no CPR is provided (Larsen et al., 1993).
How to Measure
EMS Trip Reports or Run Sheets can be used for data
abstraction if electronic systems are not in place
National EMS Information System (NEMSIS)
•
Providers Primary Impression E09_15
•
Providers Secondary Impression E09_16
•
Medical Device Name or ID D09_02
•
Procedures D04_04
•
Prior Aid E09_01
•
Prior Aid Performed By E09_02
o
•
Other Healthcare Provider
Procedures D04_04
Cardiac Arrest Registry to Enhance Survival (CARES)
•
Was an AED used during Resuscitation
o
Yes
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September 2010
Section 3―Indicator Profiles
o
No
o
AED present but not used
o
AED malfunctioned
Population Group
Adults 18 and over
Comments
Evaluators should consider analyzing EMS data for specific
diagnosis codes and related emergency response equipment of
interest, e.g. STEMI and 12-lead ECG, cardiac arrest and AED.
References
Davis EA, Mosesso VN, Jr. Performance of police first responders in
utilizing automated external defibrillation on victims of
sudden cardiac arrest. Prehospital Emergency Care
1998;2(2):101–107.
Larsen MP, Eisenberg MS, Cummins RO, Hallstrom AP. Predicting
survival from out-of-hospital cardiac arrest: a graphic
model. Annals of Emergency Medicine 1993;22:1652–1658.
MacDonald RD, Swanson JM, Mottley JL, Weinstein C. Performance
and error analysis of automated external defibrillator use in
the out-of-hospital setting. Annals of Emergency Medicine
2001;38(3):262–267.
Page RL, Joglar JA, Kowal RC, Zagrodzky JD, Nelson LL,
Ramaswarmy K, et al. Use of automated external
defibrillators by a U.S. airline. The New England Journal of
Medicine 2000;343:1210–1216.
Richless LK, Schrading WA, Polana J, Hess DR, Ogden CS. Early
defibrillation program: Problems encountered in a
rural/suburban EMS system. The Journal of Emergency
Medicine 1993;11:127–134.
Shah S, Garcia M, Rea TD. Increasing first responder CPR during
resuscitation of out-of-hospital cardiac arrest using
automated external defibrillators. Resuscitation
2006;71(1):29-33.
Vukmir RB. Survival from prehospital cardiac arrest is critically
dependent upon response time. Resuscitation
2006;69(2):229–234.
†
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within one
point of the median for this criterion.
††
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within two
points of the median for overall quality of the indicator.
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Section 3―Indicator Profiles
LOGIC MODEL BOX 6:
Increased Individual Adoption of Emergency Response Actions
Swift action on the part of individuals who experience, witness, or respond to acute
cardiovascular events can increase the likelihood of positive outcomes and reduce mortality.
In response to relevant signs and symptoms, bystanders can initiate emergency response
by calling 9-1-1 and/or beginning CPR. Increasing the use of the 9-1-1 emergency
notification has been shown to reduce time from symptom onset to hospital arrival (Barsan,
1994). Indeed, activating EMS is the most important factor in reducing delay times to
hospital arrival for stroke patients (Wein, 2000). Similarly, bystanders appropriately
performing CPR before the arrival of emergency medical providers may help improve
survival; for example, one study demonstrated that 86% of cardiac arrest survivors had
received bystander-initiated CPR within four minutes of collapse (Colquhoun, 2002).
Listed below are the indicators associated with this outcome box:
3.6.1 Proportion of acute cardiovascular events in which the emergency response system is
activated
3.6.2 Proportion of acute cardiovascular events where bystanders use an AED
3.6.3 Proportion of acute cardiovascular events in which bystanders administer CPR
References
Abella B, Aufderheide T, Eigel B, Hickey R, Longstreth WT, Nadkarni V, et al. Reducing
barriers for implementation of bystander-initiated cardiopulmonary resuscitation: A
scientific statement from the American Heart Association for healthcare providers,
policymakers, and community leaders regarding the effectiveness of
cardiopulmonary resuscitation. Circulation 2008;117:704–709.
American Heart Association. Aspirin in Heart Attack and Stroke Prevention. Available at
http://www.americanheart.org/presenter.jhtml?identifier=4456.
Barsan WG, Brott TG, Broderick JP, Haley Jr. EC, Levy DE, Marler JR. Urgent therapy for
acute stroke. Effects of a stroke trial on untreated patients. Stroke
1994;25(11):2132–2137.
Colquhoun MC. Defibrillation by general practitioners. Resuscitation 2002;52(2):143–148.
Sedgwick ML, Dalziel K, Watson J, Carrington DJ, Cobbe SM. Performance of an established
system of first responder out-of-hospital defibrillation. The results of the second year
of the Heartstart Scotland Project in the “Utstein Style.” Resuscitation
1993;26(1):75–88.
Wein TH, Staub L, Felberg R, Hickenbottom SL, Chan W, Grotta JC, et al. Activation of
emergency medical services for acute stroke in a nonurban population: The T.L.L.
Temple Foundation Stroke Project. Stroke 2000;31(8):1925–1928.
76
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September 2010
Section 3―Indicator Profiles
Indicator
Proportion of acute cardiovascular events in which the
emergency response system is activated (3.6.1)
Rating
$$†
Overall Quality
Resources Scientific Face
Accepted
Utility
Needed Evidence Validity
Practice
low ← → high
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Intermediate Outcomes Box 6 – Increased Individual Adoption of
Emergency Response/Actions
What to Measure
The proportion of acute cardiovascular events in which individuals
activate the emergency response system by calling 9-1-1. The call to
9-1-1 may be placed by the individual experiencing the acute
cardiovascular event or by a family member, friend, or bystander.
Why This Indicator Mortality related to acute MI and stroke is reduced when individuals
is Useful
activate the emergency response system, the first step in the system
of care (Eppler et al., 1994; Herlitz et al., 1992; Wein et al., 2000;
Wright et al., 2001).
How to Measure
Emergency Department Administrative Data
•
Diagnosis code
•
Method of transportation to hospital
State Emergency Department Databases (SEDD) contain clinical
and nonclinical variables such as:
•
Diagnosis code
•
Method of transportation to hospital
Paul Coverdell National Acute Stroke Registry measures, tracks,
and improves the delivery and quality of stroke care. Variables
include:
•
Arrival mode
•
IDC9-CM Diagnosis
American College of Cardiology Foundation and American
Heart Association’s ACTION Registry® -- GWTG™
•
Cardiac Diagnosis
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September 2010
Section 3―Indicator Profiles
•
Point of Origin for Admission or Visit
Population Group
Adults 18 or older
Comments
Evaluators should consider analyzing EMS data for specific diagnosis
codes of interest.
References
Eppler E, Eisenberg MS, Schaeffer S, Meischke H, Larson MP. 911
and emergency department use for chest pain: Results of a
media campaign. Annals of Emergency Medicine
1994;24(2):202–208.
Herlitz J, Blohm M, Hartford M, Karlson BW, Luepker R, Holmberg S,
et al. Follow-up of a 1-year media campaign on delay times
and ambulance use in suspected acute myocardial infarction.
European Heart Journal 1992;13(2):171–177
Koefoed-Nielsen J, Christensen EF, Melchiorsen H, Foldspang A.
Acute myocardial infarction: Does prehospital treatment
increase survival? European Journal of Emergency Medicine
2002;9(3):210–216.
Osganian SK, Zapka JG, Feldman HA, Goldberg RJ, Hedges JR,
Eisenberg MS, et al.REACT Study Group. Rapid Early Action
for Coronary Treatment. Use of emergency medical services
for suspected acute cardiac ischemia among demographic and
clinical patient subgroups: the REACT trial. Rapid Early Action
for Coronary Treatment. Prehospital Emergency Care
2002;6(2):175-85.
Wein TH, Staub L, Felberg R, Hickenbottom SL, Chan W, Grotta JC, et
al. Activation of emergency medical services for acute stroke
in a nonurban population: The T.L.L. Temple Foundation
Stroke Project. Stroke 2000;31(8):1925–1928.
Wright RS, Kopecky SL, Timm M, Pflaum DD, Carr C, Evers K, et al.
Impact of community-based education on health care
evaluation in patients with acute chest pain syndromes: The
Wabasha Heart Attack Team (WHAT) project. Family Practice
2001;18(5):537–539.
†
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within one
point of the median for this criterion.
78
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September 2010
Section 3―Indicator Profiles
Indicator
Proportion of acute cardiovascular events where bystanders
use an AED (3.6.2)
Rating
†
$$
†
††
Overall Quality
Resources Scientific Face
Accepted
Utility
Needed Evidence Validity
Practice
low ← → high
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Intermediate Outcomes Box 6 – Increased Individual Adoption of
Emergency Response/Actions
What to Measure
Proportion of acute cardiovascular events where bystanders
appropriately use emergency medical response equipment such as an
AED.
Why This Indicator Survival rate after a cardiac arrest remains low even in the hospital
is Useful
setting (Dichtwald et al., 2009). These rates plummet if there is a
delay in the provision of CPR and defibrillation (Vukmir, 2006). For
every minute that passes between collapse and defibrillation, survival
rates decrease 7% to 10% if no CPR is provided (Larsen et al.,
1993). Recent research, although mixed, suggests that bystander
use of medical response equipment such as AEDs may positively
impact survival rates (Culley et al., 2004; Rea et al., 2006).
How to Measure
EMS Trip Reports or Run Sheets can be used for data abstraction
if electronic systems are not in place
National EMS Informational System (NEMSIS)
•
Prior Aid E09_01
•
Prior Aid Performed By E09_02
o
•
Lay Person
Procedures D04_04
Cardiac Arrest Registry to Enhance Survival (CARES) is an
Internet database system that reduces time involved in registering
events, tracking patient outcomes with hospitals, and response
intervals associated with First Responder and EMS response.
Variables include:
•
Was an AED used during resuscitation?
o
Yes
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September 2010
Section 3―Indicator Profiles
o
No
o
AED present but not used
o
AED malfunctioned
Population Group
Adults 18 or older
References
Blohm M, Hartford M, Karlson BW, Karlsson T, Herlitz J. A media
campaign aiming at reducing delay times and increasing the
use of ambulance in AMI. American Journal of Emergency
Medicine 1994;12(3):315–318.
Culley LL, Rea TD, Murray JA, Welles B, Fahrenbruch CE, Olsufka M,
et al. Public access defibrillation in out-of-hospital cardiac
arrest: A community-based study. Circulation
2004;109:1859–1863.
Hazinski MF, Idris AH, Kerber RE, Epstein A, Atkins D, Tang W, Lurie
K; Lay rescuer automated external defibrillator ("public access
defibrillation") programs; Lessons learned from an
international multicenter trial: Advisory statement from the
American Heart Association Emergency Cardiovascular
Committee; the Council on Cardiopulmonary, Perioperative,
and Critical Care; and the Council on Clinical Cardiology.
Circulation 2005;111(24):3336-40.
Larsen MP, Eisenberg MS, Cummins RO, Hallstrom AP. Predicting
survival from out-of-hospital cardiac arrest: a graphic model.
Annals of Emergency Medicine 1993;22:1652–1658.
Page RL, Joglar JA, Kowal RC, Zagrodzky JD, Nelson LL,
Ramaswarmy K, et al. Use of automated external defibrillators
by a U.S. airline. The New England Journal of Medicine
2000;343:1210–1216.
Rea TD, Helbock M, Perry S, Garcia M, Cloyd D, Becker L, et al.
Increasing use of cardiopulmonary resuscitation during out-ofhospital ventricular fibrillation arrest: survival implications of
guideline hanges. Circulation 2006;114(25):2760-2765. Epub
2006 Dec 11.
Thayne RC, Thomas DC, Neville JD, Van Dellen A. Use of an
impedance threshold device improves short-term outcomes
following out-of-hospital cardiac arrest. Resuscitation
2005;67(1):103–108.
Vukmir RB. Survival from prehospital cardiac arrest is critically
dependent upon response time. Resuscitation
2006;69(2):229–234.
†
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within one
point of the median for this criterion.
††
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within two
points of the median for overall quality of the indicator.
80
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September 2010
Section 3―Indicator Profiles
Indicator
Proportion of acute cardiovascular events in which bystanders
administer CPR (3.6.3)
Rating
$$
††
Overall Quality
Resources Scientific Face
Accepted
Utility
Needed Evidence Validity
Practice
low ← → high
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Intermediate Outcomes Box 6 – Increased Individual Adoption of
Emergency Response/Actions
What to Measure
The proportion of acute cardiovascular events in which bystanders
administer CPR.
Why This Indicator Although survival rates in out-of-hospital cardiac arrest are
significantly higher when bystanders perform CPR, research shows
is Useful
that bystander CPR rate is less than fifty percent of witnessed cardiac
arrests (Coons and Guy, 2009; Hallstrom, et al., 2000). Efforts to
improve the quality of CPR through CPR certification and telephone
emergency dispatcher CPR instruction increase these rates (Bång, et
al., 2002).
How to Measure
EMS Trip Reports or Run Sheets can be used for data abstraction if
electronic systems are not in place
National EMS Informational System (NEMSIS)
•
Prior Aid E09_01
•
Prior Aid Performed By E09_02
o
•
Lay Person
Procedures D04_04
Cardiac Arrest Registry to Enhance Survival (CARES) is an
Internet database system that reduces time involved in registering
events, tracking patient outcomes with hospitals, and response
intervals associated with First Responder and EMS response. Variables
include:
•
Who initiated CPR?
o
Bystander
o
Bystander family member
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September 2010
Section 3―Indicator Profiles
o
First responder fire/police
o
Responding EMS personnel
o
Medical provider
o
Other
Population Group
Adults 18 or older
References
Bång A, Biber B, Isaksson L, Lindqvist J, Herlitz J. Evaluation of
dispatcher-assisted cardiopulmonary resuscitation. European
Journal of Emergency Medicine 1999;6(3):175–183.
Becker L, Vath J, Eisenberg M, Meischke H. The impact of television
public service announcements on the rate of bystander CPR.
Prehospital Emergency Care 1999;3(4):353–356.
Christenson J, Nafziger S, Compton S, Vijayaraghavan K, Slater B,
Ledingham R, et al. The effect of time on CPR and automated
external defibrillator skills in the Public Access Defibrillation
Trial. Resuscitation 2007;74(1):52-62. Epub 2007 Feb 14.
Coons SJ, Guy MC. Performing bystander CPR for sudden cardiac
arrest: behavioral intentions among the general adult
population in Arizona. Resuscitation 2009;80(3):334-40. Epub
2009 Jan 20.
Culley LL, Rea TD, Murray JA, Welles B, Fahrenbruch CE, Olsufka M, et
al. Public access defibrillation in out-of-hospital cardiac arrest:
A community-based study. Circulation 2004;109:1859–1863.
Hallstrom A, Cobb L, Johnson E, Copass M. Cardiopulmonary
resuscitation by chest compression alone or with mouth-tomouth ventilation. The New England Journal of Medicine
2000;342(21):1546–1553.
Richless LK, Schrading WA, Polana J, Hess DR, Ogden CS. Early
defibrillation program: Problems encountered in a
rural/suburban EMS system. The Journal of Emergency
Medicine 1993;11:127–134.
††
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within two
points of the median for overall quality of the indicator.
82
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September 2010
Section 3―Indicator Profiles
LOGIC MODEL BOX 7:
Reduced Time from Symptom Onset to Emergency Department Arrival
Medical technology to address and respond to acute cardiovascular events has greatly
improved in recent years. Treatment procedures, such as use of thrombolytic therapy,
improve both patient outcomes (The National Institute of Neurological Disorders and Stroke
rt-PA Stroke Study Group, 1995; Kwiatkowski et al., 1999) and myocardial function
(Simoons et al., 1986; Serruys et al., 1986), thus reducing cardiovascular mortality;
however, for these technologies to provide the maximum benefit to patient health,
treatment must occur quickly. Emergency medical services are essential for timely response
and transport for individuals experiencing an out-of-hospital acute cardiovascular event.
EMS can also provide immediate treatment through the use of thrombolytics, early
defibrillation with an automated external defibrillator (AED), and through impedance
threshold devices (ITD), as well as by following diversion plans to regional high-level
treatment centers.
EMS services provide a more rapid transport to the receiving hospital than private
transportation, thus reducing the time from symptom onset to treatment (Hutchings, 2004).
In fact, the median time to treatment with private transport was approximately five times
longer than the time necessary for EMS to initiate treatment on-scene after the initial 9-1-1
call (Hutchings, 2004). Reducing time from symptom onset to treatment for conditions such
as ST-segment myocardial infarction (STEMI) and stroke reduces morbidity and mortality.
Additionally, studies demonstrate the improved rate of survival among cardiac arrest
patients treated with an AED by EMS providers (Eisenberg et al., 1980, 1984; Stults et al.,
1984, 1986; Weaver et al., 1984, 1988). Immediate treatment by EMS services using ITDs
have also resulted in significantly higher return rates of spontaneous circulation (Thayne,
2005).
Listed below are the indicators associated with this outcome box:
3.7.1 Median time between symptom onset and call to 9-1-1
3.7.2 Median time between symptom onset and emergency department arrival
3.7.3 Proportion of acute cardiovascular events utilizing the emergency response system
where emergency response professionals provide pre-arrival notification to the receiving
hospital
References
Eisenberg MS, Copass MK, Hallstrom AP, et al. Treatment of out-of-hospital cardiac arrests
with rapid defibrillation by emergency medical technicians. New England Journal of
Medicine 1980;302:1379–1383.
Eisenberg MS, Hallstrom AP, Copass MK, et al. Treatment of ventricular fibrillation:
Emergency medical technician defibrillation and paramedic services. Journal of the
American Medical Association 1984;251:1723–1726.
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Section 3―Indicator Profiles
Hutchings CB, Mann NC, Daya M, Jui J, Goldberg R, Cooper L, et al. Patients with chest pain
calling 9-1-1 or self-transporting to reach definitive care: which mode is quicker?
American Heart Journal 2004;147(1):35–41.
Kwiatkowski TG, Libman RB, Frankel M, Tilley BC, Morgenstern LB, Lu M, et al; National
Institute of Neurological Disorders and Stroke Recombinant Tissue Plasminogen
Activator Stroke Study Group. Effects of tissue plasminogen activator for acute
ischemic stroke at one year. New England Journal of Medicine 1999;340:1781–1787.
The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group.
Tissue plasminogen activator for acute ischemic stroke. New England Journal of
Medicine 1995;333:1581–1587.
Serruys PW, Simoons ML, Suryapranata H, et al. Preservation of global and regional left
ventricular function after early thrombolysis in acute myocardial infarction. Journal of
the American Medical College of Cardiology 1986;7:729–742.
Simoons ML, Serruys PW, van den Brand M, et al. Early thrombolysis in acute myocardial
infarction: Limitation of infarct size and improved survival. Journal of the American
Medical College of Cardiology 1986;7:717–728.
Stults KR, Brown DD, Kerber RE. Efficacy of an automated external defibrillator in the
management of out-of-hospital cardiac arrest: Validation of the diagnostic algorithm
and initial clinical experience in a rural environment. Circulation 1986;73:701–709.
Stults KR, Brown DD, Schug VL, et al. Prehospital defibrillation performed by emergency
medical technicians in rural communities. New England Journal of Medicine
1984;310:219–223.
Thayne RC, Thomas DC, Neville JD, Van Dellen A. Use of an impedance threshold device
improves short-term outcomes following out-of-hospital cardiac arrest. Resuscitation
2005;67(1):103–108.
Weaver WD, Copass MK, Bufi D, et al. Improved neurological recovery and survival after
early defibrillation. Circulation 1984;69:943–948.
Weaver WD, Hill D, Fahrenbrugh CE, et al. Use of the automatic external defibrillator in the
management of out-of-hospital cardiac arrest. New England Journal of Medicine
1988;319:661–666.
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Section 3―Indicator Profiles
Indicator
Median time between symptom onset and call to 9-1-1 (3.7.1)
Rating
$$$
Overall Quality
Resources Scientific Face
Accepted
Utility
Needed Evidence Validity
Practice
low ← → high
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Intermediate Outcomes Box 7 – Reduced Time from Symptom Onset
to Hospital Arrival
What to Measure
Median time from the onset of symptoms, also known as last known
well, of acute cardiovascular event and the activation of emergency
response via a telephone call to 9-1-1. The call to 9-1-1 may be
made by the individual experiencing the acute cardiovascular event
or a friend, family member, or bystander.
Why This Indicator Survival rates for cardiac arrest events are significantly greater when
is Useful
patients receive CPR or defibrillation soon after experiencing
symptoms. For example, Sedgwick et al. (1993) found those who
were defibrillated within 4 minutes of symptom onset had a 43%
survival rate. Moreover, thrombolytic therapies and other treatments
for acute heart attacks (Simoons, 1986) and ischemic strokes (The
National Institute of Neurological Disorders and Stroke rt-PA Stroke
Study Group, 1995) must be given within a small window of time in
order to be effective. A critical factor influencing time intervals
between symptom onset and calls for help is awareness of symptoms
of an acute cardiovascular event (Goff et al., 2004).
How to Measure
EMS Trip Reports or Run Sheets can be used for data abstraction
if electronic systems are not in place
National EMS Information System (NEMSIS)
•
Incident or Onset Date/Time (defined as the date/time the
injury occurred or symptoms began)
•
Cardiac Arrest E11_01
•
Estimated Time of Arrest Prior to EMS Arrival E11_08
•
PSAP Call Date/Time (is the date/time the call requesting EMS
services was placed)
Paul Coverdell National Acute Stroke Registry
•
When was the patient last known to be well (i.e., in their
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Section 3―Indicator Profiles
usual state of health or at their baseline), prior to the
beginning of the current stroke or stroke-like symptoms?
Population Group
Reference
•
When was the patient first discovered to have the current
stroke or stroke-like symptoms?
•
Date and time call received by EMS
Not applicable. This indicator is best measured by tracking time
intervals and events leading to activation of the emergency response
system.
Barnhart JM, Cohen O, Kramer HM, Wilkins CM, Wylie-Rosett J.
Awareness of heart attack symptoms and lifesaving actions
among New York City area residents. Journal of Urban Health
2005;82(2): 207–215. Epub 2005 May 11.
Barsan WG, Brott TG, Broderick JP, Haley Jr. EC, Levy DE, Marler JR.
Urgent therapy for acute stroke. Effects of a stroke trial on
untreated patients. Stroke 1994;25(11):2132–2137.
Blohm M, Hartford M, Karlson BW, Karlsson T, Herlitz J. A media
campaign aiming at reducing delay times and increasing the
use of ambulance in AMI. American Journal of Emergency
Medicine 1994;12(3):315–318.
Goff DC, Mitchell P, Finnegan J, Pandey D, Bittner V, Feldman H, et
al. Knowledge of heart attack symptoms in 20 US
communities. Results from the rapid early action for coronary
treatment community trial. Preventive Medicine
2004;38(1):85–93.
Herlitz J, Blohm M, Hartford M, Karlson BW, Luepker R, Holmberg S,
et al. Follow-up of a 1-year media campaign on delay times
and ambulance use in suspected acute myocardial infarction.
European Heart Journal 1992;13(2):171–177.
The National Institute of Neurological Disorders and Stroke rt-PA
Stroke Study Group. Tissue plasminogen activator for acute
ischemic stroke. New England Journal of Medicine
1995;333:1581–1587.
Sedgwick ML, Dalziel K, Watson J, Carrington DJ, Cobbe SM.
Performance of an established system of first responder outof-hospital defibrillation. The results of the second year of the
Heartstart Scotland Project in the “Utstein Style.”
Resuscitation 1993;26(1):75–88.
Simoons ML, Serruys PW, van den Brand M, et al. Early thrombolysis
in acute myocardial infarction: Limitation of infarct size and
improved survival. Journal of the American Medical College of
Cardiology 1986;7:717–728.
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Section 3―Indicator Profiles
Indicator
Median time between symptom onset and emergency
department arrival (3.7.2)
Rating
Overall
Quality
Resources
Needed
Scientific
Evidence
Face
Validity
Utility
Accepted
Practice
low ← →
high
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Intermediate Outcomes Box 7 – Reduced Time from Symptom Onset
to Hospital Arrival
What to Measure
Time between the onset of symptoms, also known as last known
well, of an acute cardiovascular event and arrival at emergency
department.
Why This Indicator Time to treatment is critical after an acute cardiovascular event.
is Useful
Some treatments such as thromboytic therapy must be initiated
within a strictly specified time frame (in the case of thrombolytic
therapy, within three hours of symptom onset for acute ischemic
stroke) (Lattimore, et al., 2003). Campaigns aimed at increasing
knowledge and awareness in communities have been shown to be
successful in increasing use of 9-1-1 which speeds time to treatment
(Barsan et al., 1994; Herlitz et al., 1992). It is important to note that
while time interval from symptom onset to hospital may be shorter in
some cases when using private transportation, time to treatment and
patient outcomes are improved with EMS (Hutchings et al., 2004).
How to Measure
EMS Trip Reports or Run Sheets can be used for data abstraction
if electronic systems are not in place
Emergency Department Administrative Data
•
Diagnosis code
•
Time of symptom onset
•
Time of arrival to ED
National EMS Information System (NEMSIS)
•
Condition code number E07_35
•
ICD-9 Code for the Condition Code Number E07_36
•
Providers Primary Impression E09_15
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•
Providers Secondary Impression E09_16
•
Incident or Onset Date/Time E05_01
•
Cardiac Arrest E11_01
•
Estimated Time of Arrest Prior to EMS Arrival E11_08
•
Patient Arrived at Destination Date/Time E05_10
Paul Coverdell National Acute Stroke Registry
•
When was the patient last known to be well (i.e., in their
usual state of health or at their baseline), prior to the
beginning of the current stroke or stroke-like symptoms?
•
When was the patient first discovered to have the current
stroke or stroke-like symptoms?
•
What is the earliest documented time the patient arrived at
the hospital?
Population Group
Not applicable. This indicator is best measured by tracking time
intervals and events leading to hospital arrival.
Comments
It is important to note that shorter time intervals between symptom
onset and hospital arrival, while extremely important, may not
always indicate quality of care.
Depending on need, evaluators may want to assess interim time
periods such as between activation of EMS and first responder
arrival, first responder arrival and emergency department arrival,
etc.
The American Heart Association’s Get with the Guidelines – Stroke
has similar data elements and performance measures as the Paul
Coverdell National Acute Stroke Registry and can be used for
evaluation of this indicator for acute stroke patients.
References
Barsan WG, Brott TG, Broderick JP, Haley Jr. EC, Levy DE, Marler JR.
Urgent therapy for acute stroke. Effects of a stroke trial on
untreated patients. Stroke 1994;25(11):2132–2137.
Herlitz J, Blohm M, Hartford M, Karlson BW, Luepker R, Holmberg S,
et al. Follow-up of a 1-year media campaign on delay times
and ambulance use in suspected acute myocardial infarction.
European Heart Journal 1992;13(2):171–177.
Hutchings CB, Mann NC, Daya M, Jui J, Goldberg R, Cooper L, et al.
Patients with chest pain calling 9-1-1 or self-transporting to
reach definitive care: which mode is quicker? American Heart
Journal 2004;147(1):35–41.
Kaila KS, Bhagirath KM, Kass M, Avery L, Hall L, Chochinov AH, et al.
Reperfusion times for ST elevation myocardial infarction: a
prospective audit. Mcgill Journal of Medicine 2007;10(2):75–
88
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Section 3―Indicator Profiles
80.
Kleindorfer DO, Lindsell CJ, Broderick JP, Flaherty ML, Woo D, Ewing
I, et al. Community socioeconomic status and prehospital
times in acute stroke and transient ischemic attack: Do poorer
patients have longer delays from 911 call to the emergency
department? Stroke 2006;37:1508–1513.
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Section 3―Indicator Profiles
Indicator
Proportion of acute cardiovascular events utilizing the
emergency response system where emergency response
professionals provide pre-arrival notification to receiving
hospital (3.7.3)
Rating
$$$
Overall Quality
Resources Scientific Face
Accepted
Utility
Needed Evidence Validity
Practice
low ← → high
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Intermediate Outcomes Box 7 – Reduced Time from Symptom Onset
to Hospital Arrival
What to Measure
Proportion of acute cardiovascular events using the emergency
response system where emergency response professionals provide
pre-arrival notification of the patient’s arrival and condition to the
receiving hospital.
Why This Indicator The ability of EMS to provide notification to the hospital prior to
is Useful
arrival has been shown to decrease the time in which a patient
receives appropriate assessment and tests (Belvis et al., 2005),
increase the proportion of patients receiving appropriate
pharmacologic treatment (Lattimore et al., 2003), and ultimately
decrease mortality (Douglas et al., 2005).
How to Measure
Paul Coverdell National Acute Stroke Registry
•
Advanced notification by EMS?
American Heart Association/American Stroke Association
Get With The Guidelines® – Stroke
•
Advanced notification by EMS?
Population Group
Adults 18 or older
References
Abdullah AR, Smith EE, Biddinger PD, Kalenderian D, Schwamm LH.
Advance hospital notification by EMS in acute stroke is
associated with shorter door-to-computed tomography time
and increased likelihood of administration of tissueplasminogen activator. Prehospital Emergency Care
2008;12(4):426-31.
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Section 3―Indicator Profiles
Belvis R, Cocho D, Marti-Fabregas J, Pagonabarraga J, Aleu A,
Garcia-Bargo MD, et al. Benefits of a prehospital stroke code
system. Cerebrovascular Diseases 2005;19(2):96–101.
Douglas VC, Tong DC, Gillum LA, Zhao S, Brass LM, Dostal J, et al.
Do the Brain Attack Coalition’s criteria for stroke centers
improve care for ischemic stroke? Neurology 2005;64:422–
427.
Faxon DP, Jacobs AK. Strategies to improve early reperfusion in STelevation myocardial infarction. Reviews in Cardiovascular
Medicine 2007;8(3):127-134.
Lattimore SU, Chalela J, Davis L, DeGraba T, Ezzeddine M, Haymore
J, et al. Impact of establishing a primary stroke center at a
community hospital on the use of thrombolytic therapy: The
NINDS Suburban Hospital Stroke Center experience. Stroke
2003;34:55–57.
Sekulic M, Hassunizadeh B, McGraw S, David S. Feasibility of early
emergency room notification to improve door-to-balloon times
for patients with acute ST segment elevation myocardial
infarction. Catheterization and Cardiovascular Interventions
2005;66(3):316-319.
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Section 3―Indicator Profiles
LOGIC MODEL BOX 8:
Reduced Morbidity and Mortality Due to Heart Disease and Stroke
Educating the public regarding signs and symptoms of heart attack and stroke helps victims
and bystanders react quickly when faced with an acute cardiovascular event. When
combined with systems-level changes to enhance emergency response, this allows patients
to receive appropriate treatment more quickly. A growing body of evidence demonstrates
that timely care by EMS responders and faster emergency treatment for acute
cardiovascular events reduces mortality and improves health outcomes (Koefoed-Nielsen et
al., 2002; Thayne et al., 2005; Valenzuela et al., 2000; Wolcke et al., 2003).
Tracking the key indicators of cardiovascular morbidity and mortality will assist in assessing
the effectiveness of efforts to improve emergency response. The Working Group of the
American Heart Association/American College of Cardiology First Scientific Forum on
Assessment of Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke
recommends monitoring outcomes such as mortality, readmission rates, resource
consumption, and health status over time as important measures of patient care (Quality of
Care and Outcomes Research in CVD and Stroke Working Group, 2000).
Listed below are the indicators associated with this outcome box:
3.8.1 Proportion of adults who show a return of spontaneous circulation after a cardiac
arrest
3.8.2 Proportion of adults who survive to emergency department arrival after an acute
cardiovascular event
3.8.3 Inpatient death rate after an acute cardiovascular event
3.8.4 Proportion of adults who survive to hospital discharge after an acute cardiovascular
event where pre-hospital CPR or an AED was employed
3.8.5 Proportion of individuals with poor functional status after acute cardiovascular events
3.8.6 Death rate at 30 days after hospital discharge among adults with acute cardiovascular
events who are transported to a hospital with a specialized cardiac care unit
3.8.7 Death rate at 30 days after hospital discharge among adults with acute stroke who are
transported to a hospital with a specialized stroke care unit
3.8.8 Death rate at 30 days after hospital discharge for adults with acute cardiovascular
events
3.8.9 Death rate at six months after hospital discharge for adults with acute cardiovascular
events
3.8.10 Death rate at one year after hospital discharge for adults with acute cardiovascular
events
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References
Koefoed-Nielsen J, Christensen EF, Melchiorsen H, Foldspang A. Acute myocardial infarction:
Does prehospital treatment increase survival? European Journal of Emergency
Medicine 2002;9(3):210–216.
Quality of Care and Outcomes Research in CVD and Stroke Working Group. Measuring and
improving quality of care: A report from the American Heart Association/American
College of Cardiology First Scientific Forum on Assessment of Healthcare Quality in
Cardiovascular Disease and Stroke. Circulation 2000;101:1483–1493.
Thayne RC, Thomas DC, Neville JD, Van Dellen A. Use of an impedance threshold device
improves short-term outcomes following out-of-hospital cardiac arrest. Resuscitation
2005;67(1):103–108.
Valenzuela TD, Roe DJ, Nichol G, Clark LL, Spaite DW, Hardman RG. Outcomes of rapid
defibrillation by security officers after cardiac arrest in casinos. The New England
Journal of Medicine 2000;343(17):1206–1209.
Wolcke BB, Mauer DK, Schoefmann MF, Teichmann H, Provo TA, Linder KH, et al.
Comparison of standard cardiopulmonary resuscitation versus the combination of
active compression-decompression cardiopulmonary resuscitation and an inspiratory
impedance threshold device for out-of-hospital cardiac arrest. Circulation
2003;108(18):2201–2205. Epub October 20, 2003.
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Section 3―Indicator Profiles
Indicator
Proportion of individuals who show a return of spontaneous
circulation after a cardiac arrest (3.8.1)
Rating
$$†
†
††
Overall Quality
Resources Scientific Face
Accepted
Utility
Needed
Evidence Validity
Practice
low ← → high
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Long-term Outcomes Box 8 – Reduced Morbidity and Mortality
What to Measure
Proportion of individuals suffering cardiac arrest who subsequently show
a return of spontaneous circulation (ROSC). ROSC may occur in a
hospital setting or under the supervision of emergency medical service
providers.
Why This Indicator Survival rate after a cardiac arrest remains low even in the hospital
is Useful
setting (Dichtwald et al., 2009). These rates plummet if there is a delay
in the provision of CPR, making efforts to increase bystander CPR, the
availability of defibrillation, and timely treatment by emergency
responders critical (Vukmir, 2006).
How to Measure
National EMS Information System (NEMSIS)
•
Cardiac Arrest E11_01
•
Providers Primary Impression E09_15
o
•
Cardiac arrest
Any Return of Spontaneous Circulation E11_06
Cardiac Arrest Registry to Enhance Survival (CARES)
•
Return of Spontaneous Circulation (ROSC)
•
Sustained Return of Spontaneous Circulation
Population Group
Adults 18 or over
Comments
Evaluators should consider linking this indicator with the long-term
functional outcome of the patient.
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References
Dichtwald S, Matot I, Einav S. Improving the Outcome of In-Hospital
Cardiac Arrest: The Importance of Being EARNEST. Seminars in
Cardiothoracic and Vascular Anesthesia 2009; Feb 16.
Hanefeld C, Lichte C, Mentges-Schroter I, Sirtl C, Mugge A. Hospitalwide first-responder automated external defibrillator
programme: 1 year experience. Resuscitation 2005;66:167–170.
Nichol G, Stiell IG, Laupacis A, Pham B, De Maio VJ, Wells GA. A
cumulative meta-analysis of the effectiveness of defibrillatorcapable emergency medical services for victims of out-of-hospital
cardiac arrest. Annals of Emergency Medicine 1999;34:517-25.
Nichol G, Thomas E, Callaway CW, Hedges J, Powell JL, Aufderheide TP,
et al. Regional Variation in Out-of-Hospital Cardiac Arrest
Indicidence and Outcome. The Journal of the American Medical
Association 2008;300:1423-1431.
Richless LK, Schrading WA, Polana J, Hess DR, Ogden CS. Early
defibrillation program: Problems encountered in a rural/suburban
EMS system. The Journal of Emergency Medicine 1993;11:127–
134.
Vukmir RB. Survival from prehospital cardiac arrest is critically
dependent upon response time. Resuscitation 2006;69(2):229–
234.
†
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within one point
of the median for this criterion.
††
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within two points
of the median for overall quality of the indicator.
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Section 3―Indicator Profiles
Indicator
Proportion of adults who survive to emergency department
arrival after an acute cardiovascular event (3.8.2)
Rating
$$
††
Overall Quality
Resources Scientific Face
Accepted
Utility
Needed
Evidence Validity
Practice
low ← → high
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Long-term Outcomes Box 8 – Reduced Morbidity and Mortality
What to Measure
Survival to hospital arrival following an acute cardiovascular event.
Individuals may arrive at the hospital via emergency medical services
transportation or by private transportation.
Why This Indicator Timely provision of CPR and defibrillation has been shown to decrease
is Useful
short-term survival rates for out of hospital cardiac arrest (Casner,
Andersen, and Isaacs, 2005; Perina and Braithwaite, 2001; Vukmir et
al., 2006).
How to Measure
Emergency Department Administrative Data
•
Diagnosis code
•
Patient disposition
State Emergency Department Database
•
Diagnosis code
•
Disposition of patient, as received from source
•
Died during hospitalization
National EMS Information System (NEMSIS)
•
Providers Primary Impression E09_15
•
Providers Secondary Impression E09_16
•
Cardiac Arrest E11_01
•
Destination Type E04_15
•
o
Hospital
o
Morgue
Emergency Department Disposition E22_01
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Section 3―Indicator Profiles
o
Death
Cardiac Arrest Registry to Enhance Survival (CARES)
•
End of Event
o
Dead in field
o
Pronounced dead in ED
o
Ongoing resuscitation in ED
Population Group
Adults 18 or over
Comments
Evaluators should consider analyzing EMS data for specific diagnosis
codes of interest.
References
Casner M, Andersen D, Isaacs SM. The impact of a new CPR assist
device on rate of return of spontaneous circulation in out-ofhospital cardiac arrest. Prehosptial Emergency Care
2005;9(1):61-7.
Perina D, Braithwaite S. Acute myocardial infarction in the prehospital
setting. Emergency Medicine Clinics of North America
2001;19(2):483-92.
Richless LK, Schrading WA, Polana J, Hess DR, Ogden CS. Early
defibrillation program: Problems encountered in a rural/suburban
EMS system. The Journal of Emergency Medicine 1993;11:127–
134.
Sedgwick ML, Dalziel K, Watson J, Carrington DJ, Cobbe SM.
Performance of an established system of first responder out-ofhospital defibrillation. The results of the second year of the
Heartstart Scotland Project in the “Utstein Style.” Resuscitation
1993;26(1):75–88.
††
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within two
points of the median for overall quality of the indicator.
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Section 3―Indicator Profiles
Indicator
Inpatient death rate after an acute cardiovascular event (3.8.3)
Rating
$$
Overall Quality
Resources
Needed
Scientific
Face
Accepted
Utility
Evidence Validity
Practice
low ← → high
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Long-term Outcomes Box 8 – Reduced Morbidity and Mortality
What to Measure
Inpatient mortality rate associated with heart disease/stroke.
Why This Indicator Shortened time to treatment has been shown to correlate with
is Useful
decreased mortality among patients experiencing an acute
cardiovascular event (Henry et al., 2007; Jollis, et al., 2007).
Interventions that shorten patient response time to seek medical
treatment and initiatives designed to improve communication and
coordination across regional, organized systems of care have been
shown to decrease treatment delays and increase survival rates to
hospital discharge (Jollis et al., 2007).
How to Measure
State Inpatient Databases (SID)
•
Principal and secondary diagnosis
•
Admission and discharge status
Cardiac Arrest Registry to Enhance Survival (CARES)
•
•
Emergency Department Outcome
o
Resuscitation terminated in ED
o
Admitted to ICU/CC
o
Admitted to floor
o
Transferred to another acute care facility from the
emergency department
Hospital Outcome
o
Died in the Hospital
o
Discharged Alive
o
Transferred to another acute care hospital
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Section 3―Indicator Profiles
o
Patient has not been disposed
o
Unknown
Paul Coverdell National Acute Stroke Registry
•
Admission diagnosis
•
Discharge status
Population Group
Adults 18 or older
Comments
Evaluators should consider issues of risk adjustment when using this
indicator and stratifying by type of event.
References
Henry TD, Sharkey SW, Burke MN, Chavez IJ, Graham KJ, Henry CR, et
al. A regional system to provide timely access to percutaneous
coronary intervention for ST-elevation myocardial infarction.
Circulation 2007;116: 721-728.
Jollis JG, Roettig ML, Aluko AO, Anstrom KJ, Applegate RJ, Babb JD, et
al. Implementation of a statewide system for coronary
reperfusion for ST-segment elevation myocardial infarction. The
Journal of the American Medical Association 2007;298(20):E1–
E6.
Nichol G, Thomas E, Callaway CW, Hedges J, Powell JL, Aufderheide TP,
et al. Regional Variation in Out-of-Hospital Cardiac Arrest
Indicidence and Outcome. The Journal of the American Medical
Association 2008;300:1423-1431.
Ting HH, Rihal CS, Gersh BJ, Haro LH, Bjerke CM, Lennon RJ, et al.
Regional systems of care to optimize timeliness of reperfusion
therapy for ST-elevation myocardial infarction: The Mayo Clinic
STEMI Protocol. Circulation, 2007;116: 729-736.
Wang HE, Marroquin OC, Smith KJ. Direct paramedic transport of acute
myocardial infarction patients to percutaneous coronary
intervention centers: a decision analysis. Annals of Emergency
Medicine 2009;53(2):233-240.
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Section 3―Indicator Profiles
Indicator
Proportion of adults who survive to hospital discharge after an
acute cardiovascular event where pre-hospital CPR or an AED
was employed (3.8.4)
Rating
$$$
Overall Quality
Resources
Needed
Scientific
Face
Accepted
Utility
Evidence Validity
Practice
low ← → high
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Long-term Outcomes Box 8 – Reduced Morbidity and Mortality
What to Measure
Survival to hospital discharge following CPR or the use of emergency
response equipment such as an impedance threshold device or
defibrillation after out-of-hospital cardiac arrest.
Why This Indicator Timely provision of CPR and defibrillation increases the likelihood of
is Useful
surviving out of hospital cardiac arrest (Perina and Braithwaite, 2001;
Vukmir et al., 2006). Recent research demonstrates that CPR in
conjunction with the use of an impedance threshold device significantly
improved short-term survival rates (Wolcke et al., 2003).
How to Measure
National EMS Information System (NEMSIS)
•
Providers Primary Impression E09_15
•
Providers Secondary Impression E09_16
•
Cardiac Arrest E11_01
•
Procedure E19_03
•
Procedures D04_04
•
Reason CPR Discontinued E11_10
•
Emergency Department Disposition E22_01
Cardiac Arrest Registry to Enhance Survival (CARES)
•
Who Initiated CPR
•
End of Event
o
Dead in field
o
Pronounced dead in ED
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Section 3―Indicator Profiles
o
•
•
Ongoing resuscitation in ED
Emergency Department Outcome
o
Resuscitation terminated in ED
o
Admitted to ICU/CCU
o
Admitted to floor
o
Transferred to another acute care facility from the
emergency department
Hospital Outcome
o
Died in the Hospital
o
Discharged Alive
o
Transferred to another acute care hospital
State Inpatient Databases (SID)
•
Principal and secondary diagnosis
•
Discharge status
Population Group
Adults 18 or over
References
Destro A, Marzalona M, Sermasi S, Rossi F. Automatic external
defibrillators in the hospital as well? Resuscitation 1996;31: 39–
44.
Nichol G, Thomas E, Callaway CW, Hedges J, Powell JL, Aufderheide TP,
et al. Regional Variation in Out-of-Hospital Cardiac Arrest
Indicidence and Outcome. The Journal of the American Medical
Association 2008;300:1423-1431.
Perina D, Braithwaite S. Acute myocardial infarction in the prehospital
setting. Emergency Medicine Clinics of North America
2001;19(2):483-92.
Vukmir RB. Survival from prehospital cardiac arrest is critically
dependent upon response time. Resuscitation 2006;69(2):229–
234.
Wang HE, Min A, Hostler D, Chang CC, Callaway CW. Differential effects
of out-of-hospital interventions on short- and long-term survival
after cardiopulmonary arrest. Resuscitation 2005; 67(1):69-74.
Wolcke BB, Mauer DK, Schoefmann MF, Teichmann H, Provo TA, Linder
KH, et al. Comparison of standard cardiopulmonary resuscitation
versus the combination of active compression-decompression
cardiopulmonary resuscitation and an inspiratory impedance
threshold device for out-of-hospital cardiac arrest. Circulation
2003;108(18):2201–2205. Epub 2003 October 20.
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Section 3―Indicator Profiles
Indicator
Proportion of individuals with poor functional status after an
acute cardiovascular event (3.8.5)
Rating
$$$
††
Overall Quality
Resources Scientific Face
Accepted
Utility
Needed
Evidence Validity
Practice
low ← → high
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Long-term Outcomes Box 8 – Reduced Morbidity and Mortality
What to Measure
Proportion of individuals who have been hospitalized for an
acute/significant heart disease or stroke-related event with consequent
poor functional status.
Why This Indicator Patients suffering acute cardiovascular events including heart attack and
is Useful
stroke are particularly vulnerable to impaired functional status. Some
studies demonstrate that individuals achieving high functional status
one year after event can expect to maintain it over time (Harve et al.,
2007).
How to Measure
Paul Coverdell National Acute Stroke Registry
•
Ambulation status before and after stroke
American Heart Association/ American Stroke Association’s Get
With The Guidelines® – Stroke
•
Ambulatory status prior to current event
Population Group
Adults 18 or older
References
Agewall S, Berglund M, Henareh L. Reduced quality of life after
myocardial infarction in women compared with men. Clinical
Cardiology 2004;27, 271–274.
Harve H, Tiainen M, Poutiainen E, Maunu M, Kajaste S, Roine RO, et al.
The functional status and perceived quality of life in long-term
survivors of out-of-hospital cardiac arrest. Acta
Anaesthesiologica Scandinavica 2007;51(2):206-209.
Nau DP, Ellis JJ, Kline-Rogers EM, Mallya U, Eagle KA, Erickson SR.
Gender and perceived severity of cardiac disease: Evidence that
women are “tougher.” American Journal of Medicine
102
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September 2010
Section 3―Indicator Profiles
2005;118:1256–1261.
Wingate S. Quality of life for women after a myocardial infarction. Heart
and Lung 2005;24:467–473.
††
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within two
points of the median for overall quality of the indicator.
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Section 3―Indicator Profiles
Indicator
Death rate at 30 days after hospital discharge among adults
with acute cardiovascular events who are transported to a
hospital with a specialized cardiac care unit (3.8.6)
Rating
$$
††
Overall Quality
Resources Scientific Face
Accepted
Utility
Needed Evidence Validity
Practice
low ← → high
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Long-term Outcomes Box 8 – Reduced Morbidity and Mortality
What to Measure
Mortality rate at 30 days post-discharge among individuals with an
acute cardiovascular event who are transported to a hospital that has a
specialized heart disease unit, such as those providing percutaneous
coronary intervention (PCI) for STEMI.
Why This Indicator
is Useful
Shortened time to treatment has been shown to correlate with
decreased mortality among patients experiencing an acute CV event
(Henry et al., 2007; Jollis et al., 2007). Interventions that improve
communication and coordination across regional, organized systems of
care have been shown to decrease treatment delays and increase
survival rates (Jollis et al., 2007).
How to Measure
Medicare Provider Analysis and Review (MEDPAR) File
•
MEDPAR Diagnosis Code
•
MEDPAR Discharge Date
•
Beneficiary Death Date
Population Group
Adults 18 or older
Comments
Evaluators should consider issues of risk adjustment when using this
indicator and stratifying by type of event.
Reference
Henry TD, Sharkey SW, Burke MN, Chavez IJ, Graham KJ, Henry CR, et
al. A regional system to provide timely access to percutaneous
coronary intervention for ST-elevation myocardial infarction.
Circulation 2007;116: 721-728.
Jollis JG, Roettig ML, Aluko AO, Anstrom KJ, Applegate RJ, Babb JD, et
al. Implementation of a statewide system for coronary
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Section 3―Indicator Profiles
reperfusion for ST-segment elevation myocardial infarction. The
Journal of the American Medical Association 2007;298(20):E1–
E6.
Ting HH, Rihal CS, Gersh BJ, Haro LH, Bjerke CM, Lennon RJ, et al.
Regional systems of care to optimize timeliness of reperfusion
therapy for ST-elevation myocardial infarction: The Mayo Clinic
STEMI Protocol. Circulation, 2007;116: 729-736.
Wang HE, Marroquin OC, Smith KJ. Direct paramedic transport of acute
myocardial infarction patients to percutaneous coronary
intervention centers: a decision analysis. Annals of Emergency
Medicine 2009;53(2):233-240.
††
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within two
points of the median for overall quality of the indicator.
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Section 3―Indicator Profiles
Indicator
Death rate at 30 days after hospital discharge among adults with
acute stroke who are transported to a hospital with a specialized
stroke care unit (3.8.7)
Rating
$$
††
Overall Quality
Resources Scientific Face
Accepted
Utility
Needed
Evidence Validity
Practice
low ← → high
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Long-term Outcomes Box 8 – Reduced Morbidity and Mortality
What to Measure
Mortality rate at 30 days post-discharge among individuals with an
acute cardiovascular event who are transported to a hospital with a
specialized stroke care unit. For more information regarding key
elements of a specialized stroke care center, refer to “Comments”
below.
Why This Indicator Stroke-related mortality is lower when patients have access to
is Useful
specialized stroke care units (Camilo and Goldstein, 2005; Lattimore et
al., 2003; Stroke Unit Trialists’ Collaboration, 1997).
How to Measure
Medicare Provider Analysis and Review (MEDPAR) File
•
MEDPAR Diagnosis Code
•
MEDPAR Discharge Date
•
Beneficiary Death Date
Population Group
Adults 18 and older who have been transported to a hospital with a
specialized stroke care unit.
Comments
Key elements of specialized stroke care center include acute stroke
teams, stroke units, written care protocols, and an integrated
emergency response system. Important support services include
availability and interpretation of computed tomography scans 24 hours
every day and rapid laboratory testing (Alberts et al., 2000)
Evaluators should consider issues of risk adjustment when using this
indicator and stratifying by type of stroke
References
Alberts M J, Hademenos G, Latchaw RE, Jagoda A, Marler JR, Mayberg
MR, et al. Recommendations for the establishment of primary
106
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September 2010
Section 3―Indicator Profiles
stroke centers. The Journal of the American Medical Association
2000; 283(23):3102–3109.
Camilo O,Goldstein L. Lower stroke-related mortality in counties with
stroke centers: North Carolina Stroke Facilities Survey.
Neurology 2005;64(4):762–763.
Douglas VC, Tong DC, Gillum LA, Zhao S, Brass LM, Dostal J, et al. Do
the Brain Attack Coalition’s criteria for stroke centers improve
care for ischemic stroke? Neurology 2005;64: 422–427.
Lattimore SU, Chalela J, Davis L, DeGraba T, Ezzeddine M, Haymore J,
et al. Impact of establishing a primary stroke center at a
community hospital on the use of thrombolytic therapy: The
NINDS Suburban Hospital Stroke Center experience. Stroke
2003;34:55–57.
Stroke Unit Trialists’ Collaboration. Collaborative systematic review of
the randomised trials of organised inpatient (stroke unit) care
after stroke. British Medical Journal 1997;314:1151–1159.
††
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within two
points of the median for overall quality of the indicator.
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Section 3―Indicator Profiles
Indicator
Death rate at 30 days after hospital discharge for adults with
acute cardiovascular events (3.8.8)
Rating
$$$
Overall Quality
Resources Scientific
Face
Accepted
Utility
Needed
Evidence Validity
Practice
low ← → high
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Long-term Outcomes Box 8 – Reduced Morbidity and Mortality
What to Measure
Mortality rate measured 30 days after being discharged from a hospital
following an acute cardiovascular event.
Why This Indicator
is Useful
Timely, high-quality emergency response decreases mortality rates at
30 days post-discharge (Bång et al., 2007; Brodie et al., 2001; Wang
et al., 2009).
How to Measure
Medicare Provider Analysis and Review (MEDPAR) File
•
MEDPAR Diagnosis Code
•
MEDPAR Discharge Date
•
Beneficiary Death Date
Population Group
Adults 18 or older
Comments
Evaluators should consider issues of risk adjustment and type of event
when using this indicator.
References
Bång A, Grip L, Herlitz J, Kihlgren S, Karlsson T, Caidahl K, et al.
Lower mortality after prehospital recognition and treatment
followed by fast tracking to coronary care compared with
admittance via emergency department in patients with STelevation myocardial infarction. International Journal of
Cardiology 2008;129(3):325-32.
Galea S, Blaney S, Nandi A, Silverman R, Vlahov D, Foltin G, et al.
Explaining racial disparities in incidence of and survival from
out-of-hospital cardiac arrest. American Journal of
Epidemiology 2007; 166(5):534-43.
108
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September 2010
Section 3―Indicator Profiles
Wang HE, Marroquin OC, Smith KJ. Direct paramedic transport of acute
myocardial infarction patients to percutaneous coronary
intervention centers: a decision analysis. Annals of Emergency
Medicine 2009;53(2):233-240.
109
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September 2010
Section 3―Indicator Profiles
Indicator
Death rate at six months after hospital discharge for adults
with acute cardiovascular events (3.8.9)
Rating
$$$
††
Overall Quality
Resources Scientific Face
Accepted
Utility
Needed Evidence Validity
Practice
low ← → high
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Long-term Outcomes Box 8 – Reduced Morbidity and Mortality
What to Measure
Mortality rate measured six months after being discharged from a
hospital following an acute cardiovascular event.
Why This Indicator
is Useful
Lower mortality rates at six months have been linked with timely
treatment and guideline-based care (Brodie et al., 2001; Garot, et al.,
2007; Goldberg et al., 2004). However, as the length of time from
acute event increases, long-term survival is more closely associated
with quality of patient care rather than initial emergency response.
How to Measure
Medicare Provider Analysis and Review (MEDPAR) File
•
MEDPAR Diagnosis Code
•
MEDPAR Discharge Date
•
Beneficiary Death Date
Population Group
Adults 18 or older
Comments
Evaluators should consider issues of risk adjustment and type of event
when using this indicator.
References
Garot P, Lefevre T, Eltchaninoff H, Morice MC, Tamion F, Abry B, et al.
Six-month outcome of emergency percutaneous coronary
intervention in resuscitated patients after cardiac arrest
complicating ST-elevation myocardial infarction. Circulation
2007; 115:1354–1362.
Goldberg RJ, Currie K, White K, Briefer D, Steg PG, Goodman SG, et
al. Six-month outcomes in a multinational registry of patients
hospitalized with an acute coronary syndrome (The Global
Registry of Acute Coronary Events [GRACE]). The American
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Section 3―Indicator Profiles
Journal of Cardiology 2004;93:288–293.
van Alem AP, Marcel GW, Dijkgraaf J, Tijssen GP, Koster RW. Health
system costs of out-of-hospital cardiac arrest in relation to time
to shock. Circulation 2004;110:1967–1973.
††
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within two
points of the median for overall quality of the indicator.
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Section 3―Indicator Profiles
Indicator
Death rate at one year after hospital discharge for adults with
acute cardiovascular events (3.8.10)
Rating∆
$$$
Overall Quality
Resources Scientific
Face
Accepted
Utility
Needed
Evidence Validity
Practice
low ← → high
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Long-term Outcomes Box 8: Reduced Morbidity and Mortality
What to Measure
Mortality rate measured one year after being discharged from a
hospital following an acute cardiovascular event.
Why This Indicator
is Useful
Increased emergency response time increases both short-term and
long-term mortality rates (Guglin et al., 2004); however, as the length
of time from acute event increases, long-term survival is more closely
associated with quality of patient care rather than initial emergency
response.
How to Measure
Medicare Provider Analysis and Review (MEDPAR)
•
MEDPAR Diagnosis Code
•
MEDPAR Discharge Date
•
Beneficiary Death Date
Population Group
Adults 18 or older
Comments
Evaluators should consider issues of risk adjustment and type of event
when using this indicator.
References
Garot P, Lefevre T, Eltchaninoff H, Morice MC, Tamion F, Abry B, et al.
Six-month outcome of emergency percutaneous coronary
intervention in resuscitated patients after cardiac arrest
complicating ST-elevation myocardial infarction. Circulation
2007; 115:1354–1362.
Goldberg RJ, Currie K, White K, Briefer D, Steg PG, Goodman SG, et al.
Six-month outcomes in a multinational registry of patients
hospitalized with an acute coronary syndrome (The Global
Registry of Acute Coronary Events [GRACE]). The American
Journal of Cardiology 2004;93:288–293.
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September 2010
Section 3―Indicator Profiles
Guglin ME, Wilson A, Kostis JB, Parrillo JE, White MC, Gessman LJ.
Immediate and 1-year survival of out-of-hospital cardiac arrest
victims in southern New Jersey: 1995-2000. Pacing and Clinical
Electrophysiology 2004;27(8):1072-1076.
Persse DE, Key CB, Bradley RN, Miller CC, Dhingra A. Cardiac arrest
survival as a function of ambulance deployment strategy in a
large urban emergency medical services system. Resuscitation
2003; 59(1):97-104.
Shah MN, Fairbanks RJ, Lerner EB. Cardiac arrests in skilled nursing
facilities: continuing room for improvement? Journal of the
American Medical Directors Association 2007;8(3 Suppl 2):e2731.
van Alem AP, Marcel GW, Dijkgraaf J, Tijssen GP, Koster RW. Health
system costs of out-of-hospital cardiac arrest in relation to time
to shock. Circulation 2004;110:1967–1973.
∆
Mortality rate at one year was added to the priority area based on expert feedback. Ratings included are from a
similar indicator rated under the Policy and Systems Change Indicators for Heart Disease and Stroke Prevention:
Improving Quality of Care.
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September 2010
Section 3―Indicator Profiles
LOGIC MODEL BOX 9:
Reduced Levels of Disparities in Heart Disease and Stroke
Major disparities in morbidity and mortality exist among differing racial and ethnic groups
within the United States. The rate of premature deaths caused by cardiovascular diseases is
greater among African Americans than among any other racial/ethnic groups in the United
States (cf. Sekikawa & Kuller, 2000). These differences have numerous contributing factors.
Ethnicity, education, and income are associated with the recognition of AMI symptoms
(Ratner et al., 2008), with whites having above-average confidence in MI recognition and
more awareness of the public availability of AEDs compared with nonwhites (Barnhart et al.,
2005).
Reduced ability to recognize the signs and symptoms of heart attack and stroke may extend
the delay time between symptom onset and seeking treatment. Various studies have shown
that symptom onset for AMI to Emergency Department presentation and door-to-needle
times were significantly longer in African Americans (Bradley et al., 2004; Syed et al., 2000)
and for Hispanic and Asian/Pacific Islanders (Bradley et al., 2004) compared with whites.
Door-to-balloon times are also significantly longer for African American and Hispanic
patients than for white patients, and a notable portion of this disparity in time to treatment
is related to the specific hospitals where patients presented (Bradley et al., 2004).
Interestingly, despite reporting delays in time to treatment for blacks compared with whites,
studies have shown no significant differences in in-hospital mortality rates for black and
white patients (Syed et al., 2000; Taylor et al., 1998). Nonetheless, reducing levels of
disparities by increasing awareness of signs and symptoms of heart attack and stroke, and
reducing time delays to treatment, offers the potential to improve health outcomes and
reduce mortality across gender, age, and race/ethnicity groups.
Listed below are the indicators associated with this outcome box:
3.9.1 Disparity in time to treatment for an acute cardiovascular event between general and
priority populations
3.9.2 Disparity in treatment for acute cardiovascular events between general and priority
populations
3.9.3 Disparity in cardiovascular mortality between general and priority populations
References
Barnhart, J. M., Cohen, O., Kramer, H. M., Wilkins, C., & Wylie-Rosett, J. (2005). Awareness
of heart attack symptoms and lifesaving actions among New York City area
residents. Journal of Urban Health, 82(2), 207–215.
Bradley, E. H., Jerrin, J., Wang, Y., et al. (2004). Racial and ethnic differences in time to
acute reperfusion therapy for patients hospitalized with myocardial infarction. JAMA,
202(13), 1563–1572.
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September 2010
Section 3―Indicator Profiles
Ratner, P. A., Tzianetas, R., Tu, A. W., Johnson, J. L., Mackay, M., Buller, C. E., Rowlands,
M., Reime, B. (2006). Myocardial infarction symptom recognition by the lay public:
The role of gender and ethnicity. Journal of Epidemiological Community Health. 60,
606–615.
Sekikawa, A., & Kuller, L. H. (2000). Striking variation in coronary heart disease mortality in
the United States among black and white women aged 45–54 by state. Journal of
Women’s Health and Gender-Based Medicine, 9(5), 545–558.
Syed, M., Khaja, F., Rybicki, B. A., Wulbrecht, N., Alam, M., Sabbad, H. N., Goldstein, S., &
Borzak, S. (2000). Effect of delay on racial differences in thrombolysis for acute
myocardial infarction. American Heart Journal, 140, 643–650.
Taylor, H. A., Canto, J. G., Sanderson, B., Rogers, W. J., & Hilbe, J. (1998). Management
and outcomes for black patients with acute myocardial infarction in the reperfusion
era. American Journal of Cardiology, 82, 1019–1023.
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September 2010
Section 3―Indicator Profiles
Indicator
Disparity in time to treatment for an acute cardiovascular event
between general and priority populations (3.9.1)
Rating
$$$
Overall Quality
Resources
Needed
Scientific
Face
Accepted
Utility
Evidence Validity
Practice
low ← → high
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Long-term Outcomes Box 9 – Reduced Levels of Disparities
What to Measure
Disparity in the median time to treatment for an acute cardiovascular
event for individuals in the general population compared to those within
priority groups. Examples of time critical treatments are included in
“Comments” below.
Why This Indicator Reducing time from the onset of acute cardiovascular event symptoms
to treatment can reduce morbidity and mortality; however the extent to
is Useful
which this varies by racial and ethnic groups is not clear. Some
researchers suggest that time to treatment may vary for ethnic and
racial groups (Syed, 2000) while others identify variables such as the
receipt of CPR and/or hospital characteristics as being responsible for
noted differences (Bradley, 2004; Galea, 2007).
How to Measure
Paul Coverdell National Acute Stroke Registry
•
Final clinical diagnosis related to stroke
•
Date/Time patient last known to be well
•
IV tPA initiated at this hospital?
•
Date/Time IV t-PA initiated
Population Group
Adults 18 or over
Comments
Time critical treatments include reperfusion, thrombolysis, or
angioplasty for acute heart disease and stroke events
Please note that in treating acute cardiovascular events, the emergency
medical system and hospital/physician responses are closely linked.
Recent guidelines define time to treatment as “first medical contact” to
treatment. Program evaluators are encouraged to consider related
indicators in “Outcome Indicators for Policy and Systems Change:
Improving Quality of Care” to assess fully the median time to treatment.
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The American Heart Association’s Get with the Guidelines – Stroke has
similar data elements and performance measures as the Paul Coverdell
National Acute Stroke Registry and can be used for evaluation of this
indicator for acute stroke patients.
References
Bradley EH, Wang Y, Herrin J, Webster T, Blaney M, Krumholz H. Racial
and ethnic differences in time to acute reperfusion therapy for
patients hospitalized with myocardial infarction. The Journal of
the American Medical Association 2004;202(13):1563–1572.
Galea S, Blaney S, Nandi A, Silverman R, Vlahov D, Foltin G, et al.
Explaining racial disparities in incidence of and survival from outof-hospital cardiac arrest. American Journal of Epidemiology
2007; 166(5):534-43.
Syed M, Khaja F, Rybicki BA, Wulbrecht N, Alam M, Sabbad HN, et al.
Effect of delay on racial differences in thrombolysis for acute
myocardial infarction. American Heart Journal 2000;140:643–
650.
Taylor HA, Canto JG, Sanderson B, Rogers WJ, Hilbe J. Management and
outcomes for black patients with acute myocardial infarction in
the reperfusion era. American Journal of Cardiology
1998;82:1019–1023.
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Section 3―Indicator Profiles
Indicator
Disparity in treatment for acute cardiovascular events between
general and priority populations (3.9.2)
Rating
$$$
Overall Quality
Resources Scientific Face
Accepted
Utility
Needed Evidence Validity
Practice
low ← → high
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Long-term Outcomes Box 9 – Reduced Levels of Disparities
What to Measure
Disparity in treatment received by patients presenting to the
emergency department or hospital with an acute myocardial infarction
or stroke with differing insurance coverage between individuals in the
general population and those within priority groups. See “Comments”
below for additional information.
Why This Indicator
is Useful
Reducing health disparities remains a major public health challenge in
the United States. While demographics, clinical factors, and hospital
characteristics may impact some of these disparities, findings suggest
that utilization of appropriate treatments for an acute cardiovascular
event may differ by payer status as well (Canto, 2000; Hiestand,
2004; Philbin, 2001).
How to Measure
Paul Coverdell National Acute Stroke Registry
•
Demographics
•
Date/Time IV t-PA Initiated
•
DVT prophylaxis
•
Dysphagia screening
•
Antithrombotic medication within 48 hours of hospitalization
•
Lipid profile
•
Antithrombotic medications on discharge
•
Smoking cessation
•
Stroke education
•
Anticoagulation for atrial fibrillation
•
Rehabilitation considered
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Section 3―Indicator Profiles
American College of Cardiology Foundation and American Heart
Association’s ACTION Registry® -- GWTG™
•
Demographic data
•
Procedures
•
Received fibrinolytic therapy
•
Primary PCI date/time
•
DVT prophylaxis initiated by end of hospital day 2
•
Discharge medications
Population Group
Adults 18 or over
Comments
Evaluators may want to assess individual measures or an aggregate
measure of defect-free care across all aspects of recommended care
for a given acute cardiovascular event. Clinical performance measures
exist for acute stroke care (Reeves, et al. 2010) and STEMI/NSTEMI
care (Krumholz, et al., 2006).
The American Heart Association’s Get with the Guidelines – Stroke has
similar data elements and performance measures as the Paul
Coverdell National Acute Stroke Registry and can be used for
evaluation of this indicator for acute stroke patients.
References
Canto JG, Rogers WJ, French WJ, Gore JM, Chandra NC, Barron HV.
Payer status and the utilization of hospital resources in acute
myocardial infarction. Archives of Internal Medicine
2000;160:817–823.
Hiestand BC, Prall DM, Lindsell CJ, Hoekstra JW, Pollack C, Hollander
JE, et al. Insurance status and the treatment of myocardial
infarction at academic centers. Academic Emergency Medicine
2004;11:343–348.
Krumholz HM, Anderson JL, Brooks NH, Fesmire FM, Lambrew CT,
Landrum MB, et al. ACC/AHA Clinical Performance Measures for
Adults With ST-Elevation and Non–ST-Elevation Myocardial
Infarction: A Report of the American College of Cardiology/
American Heart Association Task Force on Performance
Measures. Journal of the American College of Cardiology
2006;47;236-265.
Philbin EF, McCullough PA, DiSalvo TG, Dec GW, Jenkins PL, Weaver
WD. Underuse of invasive procedures among Medicaid patients
with myocardial infarction. American Journal of Public Health
2001;91: 1082–1088.
Reeves MJ, Parker C, Fonarow GC, Smith EE, Schwamm LH.
Development of Stroke Performance Measures. Definitions,
Methods, and Current Measures. Stroke 2010; e-published
ahead of print.
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September 2010
Section 3―Indicator Profiles
Indicator
Disparity in cardiovascular mortality between general and
priority populations (3.9.3)
Rating
$$
Overall Quality
Resources
Needed
low high
Scientific Face
Accepted
Utility
Practice
Evidence Validity
better
Priority Area
Improving Emergency Response
Logic Model
Component
Long-term Outcomes Box 9 – Reduced Levels of Disparities
What to Measure
Disparity in cardiovascular mortality between individuals in the
general population and those in priority populations.
Why This Indicator Reducing health disparities remains a major public health challenge
is Useful
in the United States. Although disparities exist across a number of
domains, age-specific death rates for cardiovascular disease suggest
that black adults have higher death rates at all ages compared with
other ethnic/racial groups (Mensah et al., 2005). Some researchers
suggest that time to treatment may be one variable contributing to
mortality disparities (Syed, 2000).
How to Measure
National Vital Statistics System
•
Primary and secondary causes of death
•
Demographics
Population Group
Adults 18 or older
Comments
Trends related to heart disease and stroke are important to capture
and analyze across specific populations. Evaluators should consider
issues of risk adjustment when using this indicator.
References
Galea S, Blaney S, Nandi A, Silverman R, Vlahov D, Foltin G, et al.
Explaining racial disparities in incidence of and survival from
out-of-hospital cardiac arrest. American Journal of
Epidemiology 2007; 166(5):534-43.
Mensah GA, Brown DW. An overview of cardiovascular disease
burden in the United States. Health Affairs (Millwood)2007;
26(1):38-48.
Mensah GA, Mokdad AH, Ford ES, Greenlund KJ, Croft JB. State of
disparities in cardiovascular health in the United States.
Circulation 2005;111(10):1233-41.
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Section 3―Indicator Profiles
Schneider E, Zaslavsky A, Epstein A. Racial disparities in the quality
of care for enrollees in Medicare managed care. The Journal of
the American Medical Association 2002;287:1288 1294.
Syed M, Khaja F, Rybicki BA, Wulbrecht N, Alam M, Sabbad HN, et al.
Effect of delay on racial differences in thrombolysis for acute
myocardial infarction. American Heart Journal 2000;140:643–
650.
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Section 3―Indicator Profiles
LOGIC MODEL BOX 10:
Reduced Costs Associated with Heart Disease and Stroke
The economic cost of heart disease and stroke is substantial. Cardiovascular disease (CVD)
imposes an economic burden on the nation, both in the direct cost of health care services
and the indirect cost of lost productivity because of morbidity and mortality. The estimated
direct and indirect cost of CVD for 2010 is $503.2 billion (Lloyd-Jones et al, 2010). Certain
emergency response strategies may provide cost-effective treatment; for example,
defibrillation by nontraditional responders could be cost-effective in locations where cardiac
arrest is frequent, devices and trained users are available, and response times are short
(Nichol et al., 2003). Others have shown that AED deployment is a cost-effective strategy
across a range of public locations, with a cost per quality-adjusted life year (QALY) of
$30,000 for AED deployment compared with situations in which cardiac arrest victims
receive treatment by AED-equipped emergency medical services (Cram et al., 2003).
Identifying how the costs of treatment are distributed across payers is critical because costs
falling to individuals, especially those who are uninsured, may present barriers to receiving
timely treatment (Ayanian et al., 2000). Delay in being treated or failure to comply with
recommended therapies could consequently result in higher costs for heart disease and
stroke treatment.
Listed below are the indicators associated with this outcome box:
3.10.1 Average annual inpatient costs attributable to acute cardiovascular events
3.10.2 Average annual emergency department costs attributable to acute cardiovascular
events
3.10.3 Average annual outpatient costs attributable to acute cardiovascular events
References
Ayanian JZ, Weissman JS, Schneider EC, Ginsburg JA, Zaslavsky AM. Unmet health needs of
uninsured adults in the United States. The Journal of the American Medical
Association 2000;284(16):2061–2069.
Cram P, Vijan S, Fendrick AM. Cost-effectiveness of automated external defibrillator
deployment in selected public locations. Journal of General Internal Medicine
2003;18:745–754.
Cutler DM, Long G, Berndt ER, Royer J, Fournier AA, Sasser A, et al. The value of
antihypertensive drugs: A perspective on medical innovation. Health Affairs
(Millwood) 2007;26(1):97–110.
Lloyd-Jones D, Adams RJ, Brown TM, Carnethon M, Dai S, et al. Heart disease and stroke
statistics 2010 update: a report from the American Heart Association. Circulation
2010;121:e46–e215.
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Section 3―Indicator Profiles
Nichol G, Valenzuela T, Roe D, Clark L, Huszti E, Wells GA. Cost effectiveness of
defibrillation by targeted responders in public settings. Circulation 2003;108:697–
703.
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Section 3―Indicator Profiles
Indicator
Average annual inpatient costs attributable to acute
cardiovascular events (3.10.1)
Rating
$$$
Overall Quality
Resources
Needed
low ← → high
Scientific
Face
Accepted
Utility
Evidence Validity
Practice
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Long-term Outcomes Box 10 – Reduced Costs
What to Measure
Average per capita inpatient costs on an annual basis related to heart
attack and stroke. Tracking costs separately by payer (private
insurance, Medicare, Medicaid, and the overall total) may be useful for
evaluating program effects.
Why This Indicator Providing evidence-based, timely cardiovascular care has been shown to
is Useful
reduce inpatient costs (Mahoney et al., 2002; Roberts et al., 1997).
Monitoring average annual inpatient costs captures major distribution of
direct medical costs. Over time, may capture shifts in where and how
services are provided.
How to Measure
State Inpatient Databases
•
Principal and secondary diagnoses
•
Total charges
Healthcare Cost and Utilization Project (HCUP) Nationwide
Inpatient Sampling
•
Diagnosis information
•
Total charges
MarketScan Databases capture person-specific inpatient clinical
utilization expenditures and enrollment across inpatient, outpatient,
prescription drug, and carve-out services from a selection of large
employers, health plans, and government and public organizations.
Population Group
Adults 18 or older
Comments
Recommend estimating this econometrically from survey or claims data.
“Costs” usually represents payment amounts; true resource cost
estimates are difficult to obtain, and charges are often not recorded on
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September 2010
Section 3―Indicator Profiles
available data.
State HDSP programs may find it useful to break out data by different
cardiovascular diseases from the International Classification of Diseases,
Ninth Revision, Clinical Modification (ICD-9-CM).
References
Mahoney EM, Jurkovitz CT, Haitao C, Becker ER, Culler S, Kosinski, AS.
Treat angina with aggrastat and determine cost of therapy with
an invasive or conservative strategy—thrombolysis in myocardial
infarction. Cost and cost-effectiveness of an early invasive versus
conservative strategy for the treatment of unstable angina and
non-ST-segment elevation myocardial infarction. The Journal of
the American Medical Association 2002;288(15):1851–1858.
Roberts RR, Zalenski RJ, Mensah EK, Rydman RJ, Ciavarella G, Gussow
L, et al. Costs of an emergency department-based accelerated
diagnostic protocol vs. hospitalization in patients with chest pain:
A randomized controlled trial. The Journal of the American
Medical Association 1997;278(20):1670–1676.
Rosen AB, Cutler DM, Norton DM, Hu HM, Vijan S. The value of coronary
heart disease care for the elderly 1987–2002. Health Affairs
(Millwood) 2007;26(1):111–123.
Tung CY. Effects of stroke on medical resource use and costs in acute
myocardial infarction. GUSTO I Investigators. Global utilization of
streptokinase and tissue plasminogen activator for occluded
coronary arteries study. Circulation 1999;99(3):370–376.
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Section 3―Indicator Profiles
Indicator
Average annual emergency department costs attributable to
acute cardiovascular events (3.10.2)
Rating
$$$
††
Overall Quality
Resources Scientific Face
Accepted
Utility
Needed
Evidence Validity
Practice
low ← → high
←
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Long-term Outcomes Box 10 – Reduced Costs
What to Measure
Average annual per capita costs for emergency department use related
to heart attack and stroke. Tracking costs separately by payer (private
insurance, Medicare, Medicaid, and the overall total) may be useful for
evaluating program effects.
Why This Indicator There are substantial costs associated with heart disease and stroke
treatment (Etemad and McCollam, 2005). Emergency department
is Useful
services, one element of these costs, may be classified as inpatient or
outpatient claims. Over time, monitoring changes in average per capita
ED services may indicate improved treatment or management of
cardiovascular disease risks to prevent recurrent heart attack/stroke.
How to Measure
State Emergency Department Databases (SEDD)
•
Principal and secondary diagnoses
•
Total charges
MarketScan Databases capture person-specific inpatient clinical
utilization expenditures and enrollment across inpatient, outpatient,
prescription drug, and carve-out services from a selection of large
employers, health plans, and government and public organizations.
Population Group
Adults 18 or older
Comments
Recommend estimating this econometrically from survey or claims data.
“Costs” usually represents payment amounts; true resource cost
estimates are difficult to obtain, and charges are often not recorded on
available data.
State HDSP programs may find it useful to break out data by different
cardiovascular diseases using the International Classification of
Diseases, Ninth Revision, Clinical Modification (ICD-9-CM).
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Section 3―Indicator Profiles
Reference
Etemad LR, McCollam PL. Total first-year costs of acute coronary
syndrome in a managed care setting. Journal of Managed Care
Pharmaceuticals 2005;11(4):300–306.
Roberts RR, Zalenski RJ, Mensah EK, Rydman RJ, Ciavarella G, Gussow
L. Costs of an emergency department-based accelerated
diagnostic protocol versus hospitalization in patients with chest
pain: A randomized controlled trial. The Journal of American
Medical Association 1997;278(20):1670–1676.
††
Denotes low agreement among expert reviewers. Less than 75% of valid ratings are within two
points of the median for overall quality of the indicator.
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Section 3―Indicator Profiles
Indicator
Average annual outpatient costs attributable to acute
cardiovascular events (3.10.3)
Rating
$$$$
Overall Quality
Resources
Needed
low ← → high
Scientific
Evidence
←
Face
Utility
Validity
Accepted
Practice
→ better
Priority Area
Improving Emergency Response
Logic Model
Component
Long-term Outcomes Box 10 – Reduced Costs
What to Measure
Average annual per-capita costs of outpatient services (physician visits,
ambulatory services) attributable to heart attack and stroke. Tracking
costs separately by payer (private insurance, Medicare, Medicaid, and
the overall total) may be useful for evaluating program effects.
Why This Indicator Examination of annual outpatient costs versus inpatient costs may serve
is Useful
as a marker for improvements in secondary preventive care and
treatment.
How to Measure
Claims Data
MarketScan Databases capture person-specific inpatient clinical
utilization expenditures and enrollment across inpatient, outpatient,
prescription drug, and carve-out services from a selection of large
employers, health plans, and government and public organizations.
Population Group
Adults 18 or older
Comments
Recommend estimating this econometrically from survey or claims data.
“Costs” usually represents payment amounts; true resource cost
estimates are difficult to obtain, and charges are often not recorded on
available data.
State HDSP programs may find it useful to break out data by different
cardiovascular diseases using the International Classification of
Diseases, Ninth Revision, Clinical Modification (ICD-9-CM).
References
Etemad LR, McCollam PL. Total first-year costs of acute coronary
syndrome in a managed care setting. Journal of Managed Care
Pharmaceuticals 2005;11(4):300–306.
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September 2010
Section 3―Indicator Profiles
Margolis J, Barron JJ, Grochulski WD. Health care resources and costs
for treating peripheral artery disease in a managed care
population: Results from analysis of administrative claims data.
Journal of Managed Care and Pharmacy 2005;11(9):727–734.
Rosen AB, Cutler DM, Norton DM, Hu HM, Vijan S. The value of coronary
heart disease care for the elderly 1987–2002. Health Affairs
(Millwood) 2007;26(1):111–123.
Xuan J, Duong PT, Russo PA, Lacey MJ, Wong B. The economic burden
of congestive heart failure in a managed care population.
American Journal of Managed Care 2000;6(6):693–700.
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Section 4―Appendices
4. APPENDICES
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Section 4―Appendices
Appendix I: Expert Review Panel Members (alphabetical order)
We thank the following panel of expert reviewers who rated the indicators.
Without their generosity in sharing their expertise and time, this publication
would not have been possible.
James M. Atkins, MD, FACC
Medical Director
Emergency Medicine Education
St. Paul Hospital
Jim DeTienne
Supervisor
EMS and Trauma Systems Section
Montana Department of Public Health and Human Services
Michael Greenwell
Vice President
Health Marketing and Communications
Danya International, Inc.
Kim Kelley, MSW
Systems of Care Improvement Coordinator
Heart Disease and Stroke Prevention Program
Washington State Department of Health
Dawn Kleindorfer, MD
Associate Professor
Department of Neurology
University of Cincinnati College of Medicine
Lazette Lawton, MS, CHES
Team Lead
Program Services Team
Division for Heart Disease and Stroke Prevention
Centers for Disease Control and Prevention
Kevin McGinnis, MPS, EMT-P
Communications Technology Advisor
Joint National EMS Leadership Conference
Matthew McKenna, MD, MPH
Director
Office of Smoking and Health
Centers for Disease Control and Prevention
Greg Mears, MD, FACEP
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Section 4―Appendices
North Carolina EMS Medical Director
Department of Emergency Medicine
University of North Carolina-Chapel Hill
Graham Nichol, MD, MPH
Director and Chair,
Medic One Foundation,
Harborview Center for Prehospital Emergency Care
Barbara Pryor, MS, RD, LD
Program Director
Heart Disease and Stroke Prevention Program
Ohio Department of Health
Andrew Riesenberg, MS
Health Communications Specialist
Division for Heart Disease and Stroke Prevention
Centers for Disease Control and Prevention
Hilary Wall, MPH
Senior Epidemiologist/Program Evaluator
Heart Disease and Stroke Prevention and Control Program
Massachusetts Department of Public Health
G. Ishmael Williams, MA
Statistician
Division for Heart Disease and Stroke Prevention
Centers for Disease Control and Prevention
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Section 4―Appendices
Appendix II: Logic Model for Improving Emergency Response
S h o r t- te rm
O ut co m es
I n p u ts
A c ti vi t i es
O u tp u ts
B o x 1 W or ks ite C ha nge s:
• Pol ic ies / Prot oc ols /To ols
• Env iro nm e ntal C han ges
B o x 2 C om m u ni ty C han ges :
• Env iro nm e ntal C han ges
• Pol ic y/L e gis l ativ e C han ges
I n te r me d ia t e
Ou t co me s
B ox 4 I ndi vid ual
Ch ang e:
• K no wle dge of S ign s
and S ym ptom s
• K no wle dge of
Ap pro pri ate E m erg enc y
Res p ons e
• In ten tion to A c t
in R es pon s e to a
Car di ovas c ul ar E vent
B ox 6 Inc rea se d
Ind ivi dua l A do pti on
of Em e rgen c y
Res p ons e/ Ac ti ons
B ox 7 Red uc ed
Tim e from
Sym pto m O ns et to
H os pi tal A rr ival
B o x 3 Em erge nc y R es pon se
S ys tem C han ge:
• Aw are nes s
• Pol ic ies / Prot oc ols /To ols
• Env iro nm e ntal C han ges
B ox 5 Em er gen cy
Med ic al Prov ide r
Ch ang es
L o ng - te r m
O ut co m es
B o x 8 R educ e d
M orb idi ty an d
M orta lit y D ue t o
H ea rt D i se as e and
S trok e
B o x 9 R educ e d
L ev els of D is p ari ties
in H ear t D is ea se and
S trok e
B o x 1 0 Re duc ed
C os ts As s oc ia ted
W i th H e art D i s eas e
A nd S tr oke:
• H ea lthc ar e
• Em plo yer
• S oc iet al
C on t ex tu a l F act o rs
•
•
•
•
S oc io -ec on om i c and dem ogra phi c ch arac te ris ti cs o f the ta rge t pop ula tio n
Pa rti ci pat ing org ani z ati ons ’ pol ic ies a nd p rac ti ce s
H e alt hc are i nd us try p rac ti ce tren ds an d po lic i es
Pa rtn ers hi ps am o ng p ati ents , p rovi der s, h eal thc are org ani z ati ons , an d wo rks it es
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Section 4―Appendices
Appendix III: Data Source Descriptions
There are many data sources and tools that can be used collect data for more than one indictor. Data sources and tools are
listed below in alphabetical order along with a brief description of each. Specific questions or data elements from the sources for
measuring indicators are provided in each indicator profile.
Data Source/Tool
Description
American College of
Cardiology Foundation
and American Heart
Association’s ACTION
Registry® – GWTG™
American College of Cardiology Foundation and American Heart
Association’s ACTION Registry® – GWTG™ empowers health
care provider teams to consistently treat heart attack patients
according to the most current, science-based guidelines.
American Heart
Association/American
Stroke Association’s Get
With The Guidelines®
(GWTG) – Stroke
Get With The Guidelines – Stroke is the American Heart
Association’s collaborative performance improvement program,
demonstrated to improve adherence to evidence-based care of
patients hospitalized with stroke. The program provides
hospitals with a Web-based Patient Management Tool™,
decision support, a robust registry, real-time benchmarking
capabilities and other performance improvement methodologies
toward the goal of enhancing patient outcomes and saving
lives.
Behavioral Risk Factor
Surveillance System
(BRFSS)
The Behavioral Risk Factor Surveillance System is a state-based
system of health surveys that generate information about
health risk behaviors, clinical preventive practices, and health
care access and use primarily related to chronic diseases and
injury.
For More Information
http://www.ncdr.com/webncdr/ACTIO
N/default.aspx
http://www.americanheart.org/getwith
theguidelines
Telephone: (800) 257-4737
Email: [email protected]
http://www.cdc.gov/brfss/
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Section 4―Appendices
Data Source/Tool
Description
Cardiac Arrest Registry
to Enhance Survival
(CARES)
The Cardiac Arrest Registry to Enhance Survival program was
initiated in October 2004 as a cooperative agreement between
the Center for Disease Control and Prevention (CDC) and the
Department of Emergency Medicine at Emory University School
of Medicine to identify incidents of pre-hospital cardiac arrest.
CARES is designed to consolidate all essential data elements of
a pre-hospital cardiac arrest event in an efficient manner.
Participants can track ongoing system performance in several
tailored reports. As of June 2009, CARES included 28
participating communities in 17 states and the District of
Columbia.
CDC Worksite Health
ScoreCard: An
Assessment Tool to
Prevent Heart Disease,
Stroke, and Related
Conditions
The CDC Worksite Health ScoreCard: An Assessment Tool to
Prevent Heart Disease, Stroke, and Related Conditions can be
used as a planning guide and to assess if a worksite has
incorporated services, programs, and interventions to prevent
heart disease, stroke, and related risk factors such as high
blood pressure and high cholesterol.
Community Health
Assessment aNd Group
Evaluation Tool
(CHANGE)
The Community Health Assessment aNd Group Evaluation Tool
is a community assessment tool developed by CDC’s Healthy
Communities Program (formerly the Steps Program) within the
Division of Adult and Community Health. The purpose of
CHANGE is to conduct an assessment of community assets and
potential areas for improvement.
Georgia Worksite Health
Promotion Policies and
Practices Survey
The Georgia Worksite Health Promotion Policies and Practices
Survey was conducted for the first time in 2002 and again in
2008. This cross-sectional survey was adapted from the 1999
National Worksite Health Promotion Survey. It consists of
questions relating to worksite policies and environments
affecting health practices of Georgia workers.
For More Information
https://mycares.net/
Dyann Matson-Koffman
[email protected]
http://www.cdc.gov/healthycommuniti
esprogram/tools/change.htm
[email protected]
[email protected]
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Section 4―Appendices
Data Source/Tool
Description
For More Information
Heart Disease and
Stroke Prevention
Legislative Database
The Heart Disease and Stroke Prevention Legislative Database
is a centralized location for state heart disease and stroke
prevention and control policies. Additionally, a mapping
application was created so users of the database can map
policies based on selected criteria. This function allows the user
to see a visual representation of the policies nationwide with the
ability to copy or print maps for other uses.
http://apps.nccd.cdc.gov/DHDSPLeg/
MarketScan Databases
The MarketScan Databases capture person-specific clinical
utilization, expenditures, and enrollment across inpatient,
outpatient, prescription drug, and carve-out services from a
selection of large employers, health plans, and government and
public organizations. The annual medical databases include
private sector health data from approximately 100 payers.
Historically, more than 500 million claim records are available in
the MarketScan Databases. These data represent insured
employees and their dependents for active employees, early
retirees, COBRA continues, and Medicare-eligible retirees with
employer-provided Medicare Supplemental plans.
http://home.thomsonhealthcare.com/P
roducts/view/?id=71
Massachusetts Worksite
Health Improvement
Survey
The Massachusetts Worksite Health Improvement Survey was
developed in 2008, with input from experts in health promotion
and occupational health, to assess workplace practices with
regard to promoting and protecting employee health and wellbeing.
[email protected]
Medicare Provider
Analysis and Review
(MEDPAR) File
The Medicare Provider Analysis and Review File contains data
from claims for services provided to beneficiaries admitted to
Medicare certified inpatient hospitals and skilled nursing
facilities (SNF). MEDPAR File allows researchers to track
inpatient history and patterns/outcomes of care over time. Data
of death information is appended up to three years after date of
discharge.
http://www.cms.hhs.gov/IdentifiableD
ataFiles/05_MedicareProviderAnalysisa
ndReviewFile.asp
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Section 4―Appendices
Data Source/Tool
Description
For More Information
Missouri Community
Policy and
Environmental Change
Program Packet
The Missouri Community Policy and Environmental Change
Program helps assess what types of policy and environmental
barriers exist in the community and what type of changes the
community wants.
Missouri Worksite
Inventory Secondary
Prevention Assessment
The Missouri Worksite Inventory Secondary Prevention
Assessment is a tool used to conduct policy and environmental
inventory to assess needs for community-wide change. This
includes an inventory assessment and strategies for identifying
and implementing change.
National EMS
Information System
(NEMSIS)
The National Emergency Medical Service Information System is
the national repository that is used to potentially store EMS
data from every state in the nation. It was developed to help
states collect more standardized elements and eventually
submit the data to a national EMS database.
http://www.nemsis.org/
National Health
Interview Survey
(NHIS)
The National Health Interview Survey is a nationally
representative, cross-sectional survey that has been a source of
information on the health of the civilian non-institutionalized
population of the United States since 1957. NHIS data are
collected through personal household interviews. Blacks,
Asians, and Hispanics are oversampled.
http://www.cdc.gov/nchs/nhis.htm
National Institute of
Neurological Disorders
and Stroke Emergency
Response Evaluation
Form from the Acute
Stroke Treatment
Program
The Emergency Response Evaluation Form from the Acute
Stroke Treatment Program was disseminated by the National
Institute of Neurological Disorders and Stroke to act as a
resource for evaluating an emergency response system.
http://www.ninds.nih.gov/news_and_e
vents/proceedings/stroke_2002/acute_
stroke_template_appndx_c.pdf
Telephone: 537-522-2860
Email: [email protected]
Telephone: 537-522-2860
Email: [email protected]
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Section 4―Appendices
Data Source/Tool
Description
For More Information
National Vital Statistics
System
The National Vital Statistics System is legally responsible for the
registration of vital events—births, deaths, marriages, divorces,
and fetal deaths.
http://www.cdc.gov/nchs/nvss.htm
Nationwide Inpatient
Sampling (NIS)
The Healthcare Cost and Utilization Project (HCUP) Nationwide
Inpatient Sample is an annually generated database of hospital
inpatient stays that has been collected from 1988 to present.
Researchers and policymakers use the NIS to identify, track,
and analyze national trends in health care utilization, access,
charges, quality, and outcomes.
http://www.hcupus.ahrq.gov/db/nation/nis/NIS_2007_I
NTRODUCTION.pdf
Paul Coverdell National
Acute Stroke Registry
The Paul Coverdell National Acute Registry measures, tracks,
and improves the quality of care and access to care for stroke
patients from onset of stroke symptoms through rehabilitation
and recovery; decreases rate of premature death and disability
from acute stroke; eliminates disparities in care; supports
development of stroke systems of care that emphasize quality
of care; improves access to rehabilitation and opportunities for
recovery after stroke; and increases the workforce capacity and
scientific knowledge for stroke surveillance within stroke
systems of care. The six states that currently have funding for
this registry are Georgia, Massachusetts, Michigan, Minnesota,
North Carolina, and Ohio.
http://www.cdc.gov/dhdsp/stroke_regi
stry.htm
State Emergency
Department Databases
(SEDD)
The State Emergency Department Databases are a set of
databases from participating states that capture discharge
information on all emergency department visits that do not
result in an admission. Information on patients initially seen in
the emergency room and then admitted to the hospital is
included in the State Inpatient Databases (SID). SEDD data
files beginning in data year 1999 are available through the
Healthcare Cost and Utilization Project (HCUP).
http://www.hcupus.ahrq.gov/db/state/sedddbdocument
ation.jsp
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Section 4―Appendices
Data Source/Tool
Description
For More Information
State Inpatient
Databases (SID)
The State Inpatient Databases contain inpatient discharge
abstracts in participating states, translated into a uniform
format to facilitate multi-state comparisons and analyses.
Together, the SID encompass about 90 percent of all U.S.
community hospital discharges. SID data files beginning in
data year 1990 are available through HCUP.
http://www.hcupus.ahrq.gov/sidoverview.jsp
Survey of Policies and
Programs Related to
Health For Cities and
Towns in
Massachusetts, 2007
The Survey of Policies and Programs Related to Health For
Cities and Towns in Massachusetts was created in 2007 to
assess municipal policies and programs related to health as well
as measure the impact of land use and community design,
identify community partnerships responsible for being catalysts
to plan new structures and redesign existing ones, and evaluate
the availability of policies or programs aimed at ensuring
protection from toxins, access to healthy food outlets, places to
walk and recreate, and other health-promoting environments.
[email protected]
Texas State Department
of State Health
Services: Heart and
Stroke Healthy City
Recognition Program:
Heart and Stroke
Healthy Indicators
The Texas State Department of State Health Services: Heart
and Stroke Healthy City Recognition Program: Heart and Stroke
Healthy Indicators contains a set of 10 community indicators
that are most important actions in the settings of emergency
response, health care, worksite, school and restaurant that
have the largest impact on the community as a whole.
http://www.dshs.state.tx.us/wellness/i
ndicators.shtm
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Not for dissemination. This document is for internal use of State HDSP Programs.
September 2010
Section 4―Appendices
Appendix IV: Acronyms
ACOEM
AED
AHA
AMI
CDC
CPR
CVD
DHDSP
ECG
EMD
EMS
HDSP
ICD-9-CM
ITD
MI
NSTEMI
OHCA
OSHA
PAD
PCI
PSAP
ROSC
SEM
STEMI
tPA
American College of Occupational and Environmental Medicine
Automated external defibrillator
American Heart Association
Acute myocardial infarction
Centers for Disease Control and Prevention
Cardiopulmonary resuscitation
Cardiovascular disease
Division for Heart Disease and Stroke Prevention
Electrocardiography
Emergency medical dispatch
Emergency medical services
Heart Disease and Stroke Prevention
International Classification of Diseases, Ninth Revision, Clinical
Modification
Impedance threshold device
Myocardial infarction
Non-ST-elevation myocardial infarction
Out-of-hospital cardiac arrest
Occupational Safety and Health Administration
Public access defibrillation
Percutaneous coronary intervention
Public Safety Answering Point
Return of spontaneous circulation
Social-ecological model
ST-elevation myocardial infarction
Tissue plasminogen activator
Data source acronyms are defined in Appendix III Data Source Descriptions.
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September 2010
The Division for Heart Disease and Stroke Prevention developed outcome indicators for policy and systems change across the
priority areas of the National Heart Disease and Stroke Prevention Program. The indicators are specific, observable, and
measureable characteristics that show the progress being made toward achieving outcomes. This comprehensive set of indicators can
be used for program planning and evaluation by state Heart Disease and Stroke Prevention programs as well as their partners.
Outcome Indicators for
Policy and Systems Change
CONTROLLING HIGH BLOOD PRESSURE
Centers for Disease Control and Prevention
National Center for Chronic Disease Prevention and Health Promotion
Division for Heart Disease & Stroke Prevention
Mail Stop K–47 • 4770 Buford Highway, NE • Atlanta, Georgia 30341
770 488 2424 • Fax 770 488 8151 • www.cdc.gov/DHDSP