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A Heart Safe Community
July 2008
A HEART SAFE COMMUNITY:
THE GOAL, OUTCOMES, & OUTPUTS
By Chris D. Evans
July 2008
Contact Information:
Chris D. Evans, Fire Chief
South Jordan City
(801) 254-0948 ext 1601
[email protected]
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A Heart Safe Community
July 2008
Table of Contents
Introduction ............................................................................................................................................... 3
Background................................................................................................................................................ 3
Program Goal............................................................................................................................................. 4
Desired Outcomes ..................................................................................................................................... 4
Component Outputs .................................................................................................................................. 5
Community Awareness.......................................................................................................................... 5
Community Education ........................................................................................................................... 5
Public Access AED .................................................................................................................................. 6
Link to Local Emergency Medical Dispatch Services ............................................................................. 7
Basic Life Support with Heart Safe Enhancements ............................................................................... 8
Advanced Life Support with Heart Safe Enhancements ........................................................................ 9
Definitive Care ..................................................................................................................................... 10
Modern Cardiac Survival Laws & Ordinances...................................................................................... 11
Quality Assurance/Improvement Program ......................................................................................... 12
Sustainability Plan ............................................................................................................................... 12
Summary.................................................................................................................................................. 13
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A Heart Safe Community
July 2008
Introduction
Despite major advances in medical technology and emergency medical care, coronary heart
disease continues to be the nation’s leading cause of death.1 It claims more lives each year
than lung cancer, breast cancer, prostate cancer, fires, firearms, and AIDS combined. It knows
no boundaries and as such impacts individuals of all ages, gender, race and social status.
While no community is exempt from this problem, every community has the ability to do
something about it.
This guide includes a description of the comprehensive heart safe program developed and
implemented by the City of South Jordan (“City”). While it is not meant to be all inclusive, it
is intended to provide the reader with an overview of the entire program. Adjustments will
continue to be made as needed to address the needs of the City, availability of resources, and
advancements in technology.
Background
The numbers are staggering; in 2007, approximately 1.2 million Americans suffered a heart
attack, of those about 425,000 died; more than 325,000 died from Sudden Cardiac Arrest
(SCA) before they ever reached the hospital or while in the emergency room and of the
estimated 700,000 people who had a stroke, about 150,000 did not survive.2
Over the past few decades Americans have invested billions of dollars in fire prevention and as
result, the death toll from fire in the U.S. has been reduced to less than 6,000 people each year.
Today, cardiovascular disease claims more lives in a few days than fires do in an entire year.3
In fact, only about 5% of people who experience a SCA survive.4 Fortunately, with the
implementation of a few key strategies, we can have a significant impact on this problem
within our community. With widespread implementation of public access defibrillators alone,
more than 50,000 lives can be saved in the United States each year.5 Imagine the impact
communities will have when they complete the implementation of a public access defibrillator
program along with the other key strategies as described herein.
The South Jordan City Heart Safe Initiative includes:

An on-going community awareness campaign

Widespread community training

A Public Access Defibrillator (PAD) program

A link to the local emergency medical dispatch system

First responders with heart safe enhancements

Advanced life support with heart safe enhancements

Definitive care that includes pre-hospital providers in the cardiovascular & stroke
response team and includes STEMI and stroke protocols
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A Heart Safe Community

Modern cardiac survival laws and ordinances

A quality assurance program

A sustainability plan
July 2008
Over the past eight to ten years dozens of communities throughout the United States have
implemented very successful PAD programs. Many of these use the term “Heart Safe” to
describe their efforts. While a PAD program is a critical component of a Heart Safe
Community, it is only one piece of a larger more comprehensive solution. PAD programs
generally focus strictly on SCA and do not include many of the elements needed to address
prevention and intervention of a heart attack or stroke.
Whereas heart attack is the leading cause of SCA and stroke is the third leading cause of death
in the United States, such efforts will have minimal impact on the problem as a whole until we
develop and implement a solution that provides for the widespread implementation of a
program that addresses all cardiovascular emergencies and stroke. Simply defining a Heart
Safe Community is not sufficient, we must provide businesses and residents with the tools,
resources, and other assistance necessary to implement a comprehensive, cost effective and
sustainable solution.
Program Goal
Reduce heart damage, improve the quality of life, and increase survivability of individuals who
experience a heart attack, sudden cardiac arrest or stroke while in South Jordan City.
Desired Outcomes
The following outcomes are intended to support the goal as outlined above:
 At least 90% of the time, residents activate the 911 system for cardiovascular related
problems in lieu of going to the hospital by a privately owned vehicle.
 At least 80% of the time, on a witness cardiac arrest, CPR is initiated in less than two
minutes.
 When medically indicated, call-to-shock time for a witnessed SCA is five minutes or
less at least 80% of the time.
 On-scene time of emergency responders is less than fifteen minutes at least 90% of the
time for ST Elevated Myocardial Infarction (STEMI) and stroke patients.
 When medically indicated, call-to-drug time for thrombolytic therapy is within the
AHA standard at least 90% of the time.
 When medically indicated, call-to-balloon time is within the AHA standard at least
90% of the time.
 The survival rate for witnessed SCA patients is 30% or greater community wide.
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A Heart Safe Community
July 2008
Component Outputs
The following information is offered to provide you with a brief overview of each section of
the program and examples of outputs that will be used to assist the City with meeting the stated
goal and desired outcomes.
Community Awareness
Most people wait two hours or more to seek medical assistance after experiencing symptoms of
a heart attack.6 Further, countless people travel to the emergency room by privately owned
vehicle. Both of these issues are contributing factors to the high mortality rate associated with
heart attacks.
An ongoing community awareness campaign will not only include information on how a
person can reduce their risk of having a heart attack, sudden cardiac arrest, or stroke, but also
information on what to do should it occur. Outputs for this section will include the following:

Develop and implement a unique marketing campaign that includes information on the
following:
o Cardiovascular disease risk factors & prevention techniques
o Signs & symptoms of a cardiovascular emergency
o Importance of early activation of 911
o Benefits of bystander CPR
o Public access AEDs
o Heart Safe Initiative
o The Chain of Survival

Develop and implement a system to track and evaluate the effectiveness of various
marketing tools and methods.
While prevention is the preferred method of reducing the loss of life from a cardiovascular
emergency, history has shown if we focus on this alone we will have little impact on the
problem.
Community Education
As is the case in South Jordan, many fire departments and other emergency medical service
providers strive to maintain a response time of four minutes or less, it should be noted that
“response time” as defined by the National Fire Protection Association only includes the travel
time. It does not include the time it takes for a person to recognize the problem, notify 911, for
the dispatch center to notify a response team (dispatch time), or the time from notification until
wheels begin turning on response vehicles (turn-out time). Taking this into consideration, in
most cases an emergency responder will not arrive within the first five minutes of the event
occurring.
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A Heart Safe Community
July 2008
If CPR is not performed brain death will start to occur in four to six minutes after someone
experiences a SCA.7 CPR buys time by maintaining some blood flow to the heart & brain
during cardiac arrest. A SCA victim’s chances of survival fall seven to ten percent for every
minute of delay.8
A critical aspect of this program lies in our ability to engage the community and ensure they
learn how to perform CPR and how to use an AED. Essentially they must become a part of our
response team. Without this our efforts will have minimal impact. While integrated CPR and
AED training is a priority, healthy lifestyle training will also be included. Outputs will
include:

Acquire nationally recognized instructional curriculum for risk reduction and integrated
CPR and AED training.

Acquire a sufficient quantity of training manikins, AED trainers and other related
supplies.

Develop a strong cadre of qualified instructors including volunteer instructors.

Develop and implement an on-line course registration process.

Provide integrated CPR and AED training to high risk groups, State/County/City
employees, employees of local businesses, teachers, residents, etc.

Implement an e-learning CPR/AED initial and refresher training solution.

Implement other unique training solutions such as CPR Anytime, CPR Saturday, etc.

Establish a relationship with the community center, local health club, or other local
qualified individual to offer nutritional, stress management and fitness related classes.
Public Access AED
Early on, defibrillators were only used in medical facilities and by personnel trained in
advanced life support. Over the years these devices have been refined to the point that they are
small, portable, very affordable, and extremely reliable, safe, and easy to use. The American
Heart Association reports that sudden cardiac arrest victims who receive immediate CPR and a
shock from an AED within three to five minutes have survival rates as high as forty-eight to
seventy-four percent.9 Whereas communities cannot afford to place enough EMS personnel in
the field to ensure responders arrive within three to five minutes of the event occurring, it is
very important that members of the community are encouraged to receive training in the use of
an AED, and that AEDs are readily available throughout the community.
As a part of this program public access AEDs will be placed in target areas throughout the
community. Consideration will be given to deploying AEDs with the following individuals
and/or sites:

Police cars & other public safety vehicles
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A Heart Safe Community

State, County, and City owned facilities

Public, private, and charter schools

Health clubs

Nursing homes

Churches

Businesses

Homes of high risk individuals

Locations with large public gatherings
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Outputs for the PAD section will include the following:

Establish medical oversight.

Develop draft PAD protocols for governmental agencies, local businesses, schools, and
residents.

Develop and release a request for proposal (RFP) for the purchase of AEDs, other
related supplies, and to evaluate the potential of establishing a public-private
partnership.

Place a minimum of one AED in all State, County, and City owned facilities, all police
and fire first responder vehicles, City parks, areas of large public gatherings, and all
public, charter and private schools.

Train “PAD Specialists” to assist local businesses with developing and implementing a
PAD program.

Implement a comprehensive web based PAD management software solution that allows
the program manager to access all information community wide and site managers to
manage all information for their site.
By removing the obstacles to establishing a site specific PAD program, more entities and
individuals will participate in the program.
Link to Local Emergency Medical Dispatch Services
The local emergency medical dispatch center has an important role in the heart safe program.
If dispatchers do not understand the importance of rapidly dispatching the appropriate
resources, are not trained to provide pre-arrival instructions to callers, or cannot tell callers
where the closest AED is, the PAD program may have little success.
Today you will find most modern emergency medical dispatch centers already include a few
key components such as enhanced 911, a computer-aided dispatch system, and a priority
medical dispatch system. While some solutions are very costly and as such may be difficult to
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A Heart Safe Community
July 2008
implement, there are several other outputs that are of little expense and are relatively easy to
implement. The desired outputs include the following:

Heart safe awareness training provided to all dispatchers

All dispatchers trained and certified to a nationally recognized Emergency Medical
Dispatcher standard

Integrated CPR and AED training for all dispatchers

Nationally recognized priority dispatch system that includes procedures for instructing
a caller how to perform CPR and use an AED

A system to receive, record, and update AED location information reported by AED
acquirers

Ability to immediately report the location of an AED to callers reporting a potential
sudden cardiac arrest emergency

Computer aided dispatch system

An E911 system with wireless/GPS capability
Basic Life Support with Heart Safe Enhancements
Advanced Life Support (ALS) is critical for cardiovascular emergencies. Industry standards
indicate that the ALS should maintain a travel time of eight minutes or less to emergencies.
Due to the cost associated with this service, most organizations strategically place ALS
response teams throughout the community to maximize the response area of each unit.
Paramedics are well trained, well equipped, and provide an outstanding service to the
community; however, due to the cost of this service they generally are not as readily available
as first responders who are trained in Basic Life Support (BLS).
Many fire departments staff quick or first response units, typically a fire engine, with
individuals who are trained in BLS. These units are generally located throughout the
community to maintain a travel time of four minutes or less to a fire or medical emergency.
The EMT-Basic is a BLS training and certification program that can be obtained in as little as
four weeks; however, these individuals are limited in their ability to provide advanced
interventions during a cardiovascular emergency. Fortunately there is a cost effective solution
that can have a significant impact on a patient who experiences a heart attack or sudden cardiac
arrest patient.
An EMT-Intermediate can provide several important interventions during a cardiac related
emergency. An upgrade from EMT-Basic to EMT-Intermediate will only require
approximately sixty to eighty hours of additional training. Additionally, we can use our own
paramedics to provide the training for our EMT’s. Once certified, authorized, and equipped,
an EMT-Intermediate can provide several interventions that can be critical to a cardiac patient.
These include the following:
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A Heart Safe Community

ECG interpretation

IV therapy

Administration of specific cardiac medications

Endotracheal intubation
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Considering the minimal investment required to upgrade to this service, it will become the
minimum level of service offered by the South Jordan Fire Department. This will provide for
greater flexibility, improved care of all patients, and ensure that cardiac patients receive
appropriate advanced interventions regardless of the status of the ALS unit. This program is
intended to supplement our existing advanced life support response system not replace it.
Outputs include but are not limited to the following:

Train & certify EMT-Basic’s to the EMT-Intermediate level.

Acquire necessary equipment & supplies to upgrade response units to EMTIntermediate.

In cooperation with your off-line medical director, develop and implement protocols for
the additional interventions.

Develop and implement an in-service training program to maintain knowledge, skills,
and abilities.

Upgrade response designation with the State licensing agency as required.
Advanced Life Support with Heart Safe Enhancements
The ALS curriculum already includes advanced interventions for cardiovascular emergencies.
With recent advancements in technology there are several heart safe enhancements that can and
will be made within South Jordan City. This includes but is not limited to specialized
equipment & training to verify proper placement of the endotracheal tube, alternatives for a
failed airway, alternatives to standard IV therapy, and technology to ensure patients receive
consistent, uninterrupted high-quality chest compressions that deliver improved blood flow to
the heart and brain. Desired outputs include the following:

Provide heart safe awareness training to staff.

Utilize technology to assist with improving outcomes:
o Non-invasive cardiac support pump
o End-tidal CO2
o Failed airway adjunct
o EZ IO Infusion System

Develop and implement protocols to support the use of the technology.
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Additionally, the pre-hospital 12-lead Electrocardiogram (ECG) program is an effective
strategy to ensure patients with an acute myocardial infarction are treated in a cardiac
catheterization laboratory (cath lab) quick enough to minimize or prevent permanent loss of
cardiac muscle and the potential development of a number of other complications such as
lethal cardiac arrhythmias, congestive heart failure, and cardiogenic shock.
In South Jordan all paramedics and EMT’s will have the ability to rapidly acquire, interpret,
and transmit a diagnostic quality 12-lead ECG to the hospital within minutes of making contact
with the patient. The desired outcome includes decreasing the amount of time required to
diagnose an acute myocardial infarction (AMI) and ensuring definitive therapy is provided
within ninety minutes of the patient activating 911. Outputs include the following:

Develop a heart care team that includes knowledgeable and influential representatives
from the EMS provider, emergency room, and cath lab.

Develop protocols for field personnel, ER staff, and the cath lab.

Acquire necessary equipment & supplies for both the pre-hospital setting as well as for
the ER and Cath Lab.

Develop & provide training for paramedics, EMT’s, ER Staff, and Cardiologist.
While considered by some to be controversial, the following advanced interventions will be
thoroughly researched and implemented as appropriate:

Use of an external non-invasive cardiac support pump to sustain life while a SCA
patient is treated in the catheterization lab

Pre-hospital induced hypothermia

Administration of a thrombolytic by field paramedics
Definitive Care
As it relates to treating a patient with a cardiovascular emergency or stroke, hospitals are not
all created equal. It is important to assess the capabilities of area hospitals and identify those
that are capable of rapidly assessing and providing appropriate interventions for a STEMI or
Stroke patient. The ideal situation is one in which the staff demonstrates an understanding of
heart safe strategies, are trained and equipped to respond to the emergency, recognize and
accept their limitations, quickly divert field units to the closest appropriate facility, and include
the pre-hospital provider as a member of their response team.
In our program a definitive care link must be added to the cardiovascular chain of survival.
Our patients will pay the ultimate price if the link between ALS and definitive care is damaged
or non-existent. A significant change in the outcome of STEMI and stroke patients will not
occur until emergency room physicians & cardiologists include pre-hospital emergency
responders in the STEMI & Stroke Team. As such, outputs include but are not limited to the
following:
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
Establish a focus group to include representation from the ED physicians group,
cardiologist, stroke team, pre-hospital ALS and BLS, and the community heart safe
program manager or his/her designee.

Provide awareness training to ED, Cath Lab, and local Insta-Care staff.

Identify and designate stroke centers and heart centers.

Establish and implement protocols that allow pre-hospital providers to divert to the
closest appropriate hospital.

Develop and implement STEMI, SCA, and stroke protocols for ED and Cath Lab.
Modern Cardiac Survival Laws & Ordinances
All 50 States have adopted Good Samaritan laws which are intended to provide immunity from
civil liability for the user of an AED;10 however, most have serious gaps. Due to the conditions
included in many of these laws some may actually increase liability instead of decreasing it.
Further, many do not provide protection from civil immunity for the trainer, acquirer of the
device, the physician who issues the prescription, the individual who provides medical
direction, or the PAD program manager. While there are no known lawsuits against lay
rescuers for performing CPR or using an AED,11 due to a perceived liability concern, to
support the widespread implementation of public access defibrillator programs the gaps in the
existing Good Samaritan laws must be addressed. Further, it is important to eliminate many of
the conditions which have been included in most state CPR and AED laws.
The City will take the lead with drafting new laws and ordinances that consolidate, modernize
and simplify the CPR and AED in the State of Utah. This will include the following:

Absent gross negligence and willful misconduct, and without other conditions, provide
immunity from civil liability to a Good Samaritan who performs CPR or uses an AED
and all others as described above.

Require reporting of AED location to the local emergency medical dispatch center.

Require the dispatch center to implement a solution that allows the dispatcher to
immediately tell the caller when an AED is located within a facility.

Encourage training while ensuring it does not require a license, certificate, or other
certification to perform CPR or use an AED.

Consider specific training mandates for certain professionals who work in high risk
locations.

Provide general AED mandates.

Establish an AED fund to support the placement and maintenance of AEDs in State
facilities and all K-12 public and private schools.

Adopt a local resolution to support heart safe community initiative.
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Adopt local ordinances to support and/or strengthen the program goal and federal and
state regulations.
Quality Assurance/Improvement Program
Essentially this is a system similar to what many in the fire service have come to know as sizeup. It is an on-going process that involves gathering and evaluating information, developing
and implementing appropriate strategies and tactics, developing contingency plans, and
adjusting the plan as needed to meet the established goal. Further, our program must include
methods that allow all participants including volunteer responders to receive appropriate
training, support and feedback. Outputs may include the following:

Develop performance measures for all sections of the program.

Establish an electronic data collection system that allows for sharing of information
from time of 911 call through discharge from the hospital.

Develop and implement after-incident review and feedback procedures.

Ensure quality assurance team meets regularly to review incidents, progress or lack
thereof, and make recommendations for improvement.
Sustainability Plan
Prior to or early into the implementation of our program it is important that a written
sustainability plan is developed. This plan will provide a road map to guide our program today
and in the future. The process of creating a sustainability plan can also strengthen community
partners' buy-in and understanding of the efforts needed to keep your program operating and
improving. We will use the plan to market our program to potential corporate sponsors as well
serve as a guide for the ongoing management of the program and its sustainability.
Components of our sustainability plan will include the following:

Implement a comprehensive web-based software solution that provides for the ongoing
maintenance of the PAD program by the community program manager as well as site
specific program managers.

Establish a public-private partnership with an AED manufacturer and/or other
appropriate corporate sponsors.

Implement a mechanism to seek and receive donations from corporate sponsors,
community groups, and other members of the community.

Develop a replacement schedule for equipment and supplies.

Establish a dedicated fund that includes a dedicated revenue stream to support the
ongoing maintenance of the program.
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Summary
There are a number of very successful PAD programs across the United States. Some of these
programs are seeing survival rates for a witnessed SCA of greater than fifty percent.
Considering this, we will see greater results through the implementation of not only a PAD
program but a comprehensive heart safe initiative that includes key strategies for heart attack,
sudden cardiac arrest and stroke.
While the strategies may seem to be extensive and possibly overwhelming to some, with a
design-build concept similar to what one might use for a construction project, we are likely to
enjoy greater success much sooner than with a traditional approach. It is not necessary to
implement the entire program all at one time. In fact, I generally would not recommend it. We
will prioritize the program, take advantage of opportunities such as grants and donations when
they present themselves, and design and implement it one strategy at a time if necessary. With
this approach we will begin to see results almost immediately. As a result our staff and
community will embrace the program and it will gain support and momentum very quickly.
1
Kung, Hoyert, Xu, Murphy. “Deaths: Final Data for 2005.” Hyattsville, MD: U.S. Department of Health and
Human Services, Centers for Disease Control and Prevention. National Vital Statistics Reports, Volume 56,
Number 10, April 24, 2008.
2
American Heart Association, American Stroke Association. “Know the Facts, Get the Stats 2007”. 55-1041,
December 2006.
3
Lazar, Richard. “Legislative Strategies for Modernizing U.S. AED Laws.” December 2006.
4
Heart Rhythm Foundation. “Sudden Cardiac Arrest Key Stats.”
http://www.heartrhythmfoundation/org/facts/scd.asp (accessed June 2008).
5
Gillespie, Bonnie Jean. “New Study Results Underscore Need for AEDs in Public Places.” American RedCross.
www.redcross.org/news/hs/cpraed/021022aed.html (accessed July 2007).
6
National Institutes of Health, National Heart, Lung, and Blood Institute. “Act in Time to Heart Attack Signs.”
NIH Publication No. 01-3313, September 2001.
7
American Heart Association. “CPR facts and statistics.”
http://www.americanheart.org/presenter.jhtml?identifier=3034352 (accessed May 2008).
8
Hazinski, Idris, Kerber, Epstein, Atkins, Tang, Lurie. “Lay Rescuer Automated External Defibrillator 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.” Dallas, Texas: American Heart Association, 21 June 2005.
Circulation 2005:111:3336-3340.
9
Hazinski, Nadkarni, Hickey, O’Conner, Becker, Zaritsky. “Major Changes in the 2005 AHA Guidelines for CPR and
ECC: Reaching the Tipping Point for Change”. Dallas, Texas: American Heart Association, 28 November 2005.
Circulation 2005;112;IV-206-IV-211.
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10
American Heart Association. “PAD Program Legal Issues.”
http://www.americanheart.org/downloadable/heartsmart/10957148343644Dpadlegal/pdf (accessed July 2007).
11
National Conference of State Legislatures. “State Laws on Heat Attack, Cardiac Arrest & Defibrillators.”
http://www.ncsl.org/programs/health/aed.htm (accessed July 2007).
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