Strategies to improve cardiac arrest survival: a time to act

The Institute of Medicine (IOM) released a new report, Strategies to Improve Survival from Cardiac Arrest: A Time to Act, on June 30, 2015. The new report presents a comprehensive system‐wide approach for improving cardiac arrest (CA) survival throughout the USA1 with eight evidence‐based recommendations. In this communication, we wish to highlight this new report and briefly describe differences in approaches to improving survival for CA patients between Japan and the USA. In the weeks following the report, many organizations like the American Heart Association (AHA), American Red Cross, foundations, and others, have amplified many of the recommendations. For example, the AHA has committed $5million of funding to support the recommendations.2

By way of background for Japanese readers, the IOM/National Academy of Medicine (NAM) is one of the most influential organizations in the promotion of new health care policy within the US. With a mission to “improve the health of the nation”, the IOM/NAM has been described by the New York Times as “The most esteemed and authoritative adviser on issues of health and medicine, and its reports can transform medical thinking around the world.” One of the most influential prior reports from the IOM is “To Err is Human”.3 As resuscitation experts, we have high hopes that this recently released IOM report will help elevate survival of CA both within the USA and globally because the system level recommendations call for tangible actions that could save thousands of lives. We particularly want to inform Japanese readers about the IOM report, and to provide a perspective from the Japan Resuscitation Council (JRC) and the Japanese Association of Acute Medicine (JAAM) in response to the recommendations. In addition, we highlight areas where the Japanese nation has been working actively (Table 1). Our most important message is to encourage everyone to read and consider the value of these recommendations. We agree that now is the “time to act”.

Table 1.

Commitments of the Japanese nation related to the 2015 Institute of Medicine report on cardiac arrest

Recommendations		1. OHCA National Registry	1. IHCA National Registry	2. Culture of Action	3. Dispatch and EMS	4. National Accreditation	5. CQI	6. Discovery Science	7. Implementation Science	8. National Collaborative
Acts	Year
FDMA BLS training for public	1994			✓
JAAM ICLS course for in‐hospital HCP	2002				✓	✓
Public Access AED in Japan	2004			✓
FDMA national data registry and analysis	2005	✓						✓	✓
JCS AHA‐ITC for BLS and ACLS training for all HCP	2007				✓	✓
JCS CPR guidelines for cardiologists	2009			✓		✓
JRC CPR guidelines for all HCP	2010	✓		✓	✓	✓	✓		✓	✓
FDMA BLS and ACLS implementation	2012a				✓

All acts are currently available.

^aProtocol updated based on JRC CPR guidelines 2010. ACLS, advanced cardiac life support; AED, automated external defibrillator; AHA, American Heart Association; BLS, basic life support; CPR, cardiopulmonary resuscitation; CQI, continuous quality improvement; EMS, emergency medical system; FDMA, Fire and Disaster Management Agency; HCP, health care provider; ICLS, immediate cardiac life support; IHCA, in‐hospital cardiac arrest; ITC, International Training Center; JAAM, Japanese Association for Acute Medicine; JCS, Japanese Circulation Society; JRC, Japan Resuscitation Council; OHCA, out‐of‐hospital cardiac arrest.

1. Establish a National Cardiac Arrest Registry: Because the USA does not have a national CA registry, as we have in Japan, the first recommendation addresses the need for this vital national data. The Japanese nation is proud of its existing national registry of out‐of‐hospital CA (OHCA) that was established in 2005 thanks to the broad support from the Japanese emergency medical system (EMS). According to the latest data,4 the 1‐month survival rate of OHCA patients in 2013, whose arrest was witnessed, with presumed cardiac origin, and initially shockable rhythms, was 31.6%. Nichol et al.5 reported survival rates of shockable rhythms ranged from 7.7% to 39.9% in 10 communities in North America. These data tell us that Japan's overall survival rates are increasing significantly but have not yet achieved the maximum possible. The AHA has the aspirational goal to double survival rates2 in the USA by the year 2020.

2. Foster a Culture of Action through Public Awareness and Training: CA demands immediate responses from laypersons, to rapidly begin bystander cardio pulmonary resuscitation (CPR) and bystander use of an automated external defibrillator (AED).6, 7 The Fire and Disaster Management Agency has trained over 1.4 million people in more than 70,000 public training courses during the last two decades in Japan. The AHA is planning to increase the number of trained laypersons by 50%. Since Japan's adoption of AEDs by the public,8 training courses for AED plus CPR have been widespread. Over 500,000 AEDs have been placed throughout the country.9

3. Enhance the Capabilities and Performance of EMS Systems: Standardized training for EMS personnel promotes more rapid adoption of best practices and allows for better quality of CA care. Since Japanese CPR guidelines were released in 2010 by the JRC,10 progress in uniform adoption and quality assurance has been accelerated for all health care providers.

4. Set National Accreditation Standards Related to Cardiac Arrest for Hospitals and Health Care Systems: The AHA's BLS, Heart saver, and ACLS provider courses have contributed to improve quality control for the provision of CPR in health care systems for the last several decades in Japan. These efforts were enhanced in 2007 with the establishment of the Japanese Circulation Society's International Training Center, which was done in partnership with the AHA. The Japanese Circulation Society initiated CPR consensus for cardiologists in 2009.11 In the meantime, JAAM organized a new training course called Immediate Cardiac Life Support for non‐cardiology residents and physicians. The course is typically attended by doctors, nurses, and EMS personnel working together in a local area so that it builds important personal relationships between team members.

5. Adopt Continuous Quality Improvement Programs: Quality improvement programs for CA need to include specific CA outcomes and process measures. However, Japan faces challenges similar to those faced in the USA because there are too few personnel available who have the responsibility, authority, and accountability to ensure quality measures and process improvements. Additional personnel are needed to be responsible for data entry, reporting of events, follow‐up for outcomes, generating reports, and ongoing assessments of the quality of CPR.

6. Accelerate Research on Pathophysiology, New Therapies, and Translation of Science for Cardiac Arrest; 7. Accelerate Research on the Evaluation and Adoption of Cardiac Arrest Therapies: Japanese resuscitation investigators have published many key papers using the national database; these papers have provided new insights into social and environmental risk factors.6, 7, 12 However, the funding support for basic science and translational science is relatively small in the area of resuscitation science. Building a more robust infrastructure to support fundamental and basic science, discovering the fundamental mechanism of physiology that underlie CA, and development of new human therapies need substantial additional support in Japan.

7. Create a National Cardiac Arrest Collaborative: To accomplish all these tasks and to create a better national infrastructure for improving survival, the collaboration between the Japanese Ministry of Health in synergy and many other stakeholder organizations should be strengthened to advocate for these goals. Implementation of the IOM/NAM's eight recommendations will help advance collaborative efforts in resuscitation and serve to improve patient outcomes from CA globally.

Conflict of Interest

K.S. is currently working for Northwell Health System and previously had a visiting position at the University of Pennsylvania and the Children's Hospital of Philadelphia. K.S. has a patent royalty right of the device for metabolic measurement in resuscitation. K.N. and H.N. have no disclosures on potential conflict of interests. L.B.B. has employment/leadership/advisory appointments at Northwell Health System, Scientific Advisory Committee at Nihon Kohden, and previously served as the director of the Center for Resuscitation Science at the University of Pennsylvania. L.B.B. holds inventor's equity and royalties from Helar, a company started by the University of Pennsylvania. L.B.B. has a patent royalty right of hypothermia induction and reperfusion therapies and the device for metabolic measurement in resuscitation. L.B.B. received honoraria from Philips Medical Systems, NIH Data Safety Monitoring Board, NIH Resuscitation Outcomes Consortium, NIH K12 Training Grant and Nihon Kohden. L.B.B. is funded in his research as a principal investigator by NIH, NIH/NHLBI, Medtronic Foundation, Benechill, Zoll Medical, Philips Medical, and Nihon Kohden.