March 26, 1999
To:Emergency and Protective Services Committee
From:Commissioner of Works and Emergency Services
Subject:Cardiac Arrest Care and Emergency Medical Services
Purpose:
To provide information to the Emergency and Protective Services Committee on the report from the Institute for Clinical
and Evaluative Studies on Cardiovascular Health and Services in Ontario.
Funding Sources, Financial Implications and Impact Statement:
There are no immediate financial implications or requirements related to this report.
Recommendations:
It is recommended that this report be received for information.
Council Reference/Background/History:
The Institute for Clinical and Evaluative Studies (ICES) is a provincial resource for the study of health care in the Province
of Ontario which has released a number of widely recognized studies. Their most recent publication, Cardiovascular Health
and Services in Ontario includes a chapter on Cardiac Arrest and Emergency Medical Services. Their review analyzed data
on sudden cardiac death, cardiac arrest, the chain of survival, resuscitation and the relationship to Emergency Medical
Services.
"Sudden cardiac death is a major contributor to premature mortality in Canada. The precise number of sudden cardiac
deaths is unknown, but this condition has been estimated to account for about 11% of all deaths in Canada annually.
Sudden cardiac death occurs as a direct consequence of cardiac arrest. Cardiac arrest has been described as a clinical
disorder in which the normal rhythmic pumping capabilities of the heart are disrupted, compromising normal circulation
and resulting in loss of consciousness and certain death if not treated. The disruption in the pumping capacity of the heart is
often due to changes in the electrical activity of the heart, the most common of which is ventricular fibrillation (VF). Other
irregularities include asystole, where electrical activity stops altogether, pulseless electrical activity (PEA) in which the
electrical beat of the heart continues without any cardiac output, and ventricular tachycardia (VT)."
The chain of survival as described by the Heart and Stroke Foundation includes early access to emergency services, early
CPR, early defibrillation and early advanced life support. Survival is dependant on the timely application of each of the
elements of the chain of survival. The ICES report referenced research which projected a 0% survival rate if there was no
bystander, if the emergency medical services (EMS) start cardiopulmonary resuscitation (CPR) at five minutes and if there
is no defibrillation or advanced life support (ALS) until 20 minutes later at a hospital. In contrast, a 34% survival rate is
projected if 50% of bystanders can initiate CPR, if CPR is started within three minutes of cardiac arrest, if the EMS provide
defibrillation at five minutes, and if paramedics can perform ALS in the field starting 10 minutes after the patient collapses.
ICES analyzed data from 23 communities across the province including Toronto Ambulance data and data from the
communities currently involved in the Ontario Prehospital Advanced Life Support (OPALS) study. Toronto data compared
favourably with data from across the province.
Comments and/or Discussion and/or Justification:
In each of the links in the chain of survival the City of Toronto has made significant strides in overcoming obstacles to
creating a truly cardiac safe city.
In the first link, early access, the well established 911 system links the caller quickly to emergency medical services.
Improvements in the computer aided dispatch system at Toronto Ambulance has assisted in further expediting access to the
system and the dispatch of appropriate resources.
Improvements in the second link, early CPR, has included education programs available to the public from a number of
agencies. Additional support for community CPR training would further enhance this process. All EMS providers are
trained in the performance of CPR as are firefighters and police officers. Toronto Ambulance has been utilizing telephone
CPR instruction since 1992 for patients suspected of having suffered cardiac arrest based on information supplied by
callers. This initiates CPR before any responding emergency service can arrive at the scene, effectively creating first
responders from the calling public. As approximately 80% of all cardiac arrests in Toronto occur in the home, family
members are typically the callers and are more likely to participate in resuscitation without concern for the unfortunately
inaccurate perceptions in the community of the risk of infectious disease exposure.
The defibrillation program of Toronto Ambulance has ensured that the third link of the chain of survival, early
defibrillation, has been further strengthened. All paramedics are trained and certified to provide defibrillation. The
successful outcome of defibrillation is time dependant and efforts have been directed to early identification of patients upon
receipt of the request for ambulance response ensuring the earliest possible notification of paramedics. Firefighters have
been trained to provide early defibrillation with automatic defibrillators. The Public Access Defibrillation (PAD) program
will expand first responder defibrillation by enabling security guards, health and safety personnel, health club staff and
others to use automatic defibrillators.
Toronto Ambulance is progressing towards a full advanced life support (ALS) system to ensure availability of early ALS,
the fourth link in the chain of survival. Toronto advanced life support paramedics have extensive training and highly
developed clinical skills to enable them to provide state of the art pre-hospital care including advanced airway management
and intubation, intravenous access and the administration of required resuscitative medications. Involvement of paramedics
in advanced life support research studies has further enhanced their skills and knowledge base. As well, Toronto
paramedics and training staff have been instrumental in the education and training of advanced level paramedics across the
Province of Ontario. The ALS and Defibrillation programs are under the medical control of the Sunnybrook Base Hospital
Program for the delegation of controlled medical acts.
Conclusions:
The City of Toronto and Toronto Ambulance have been pro-active in implementing improvements to the chain of survival
and the delivery of pre-hospital care. Further enhancements such as strengthening training in CPR, Public Access
Defibrillation and the completion of advanced life support training for paramedics should result in further improvement in
patient outcome from sudden cardiac death and cardiac arrest in the City of Toronto.
Contact Name:
Ronald L. Kelusky, General Manager
Phone 397-9240
Fax: 392-2115
R.L. KeluskyBarry H.Gutteridge
General ManagerCommissioner
Toronto AmbulanceWorks and Emergency Services
