May 30, 2012 | by

Enabling Citizen Heroes

This article is reprinted with permission from EMS Insider

Add a mobile app to your CPR program

EMS InsiderWhen it comes to cardiac arrests, a few well-known facts exist: Time is muscle; the window of opportunity to save a patient whose heart has stopped is excruciatingly small; and getting responders who know CPR to the patient as soon as possible provides the best chance for survival. The third fact was brought home to San Ramon Valley (Calif.) Fire Protection District (SRVFPD) Fire Chief Richard Price during lunch one day. While he was eating at a local deli, he heard sirens in the distance. Then he watched as the engine eventually stopped in front of the restaurant. Because he does not receive pages for medical emergencies, he was unaware that someone had collapsed in cardiac arrest just next door. Had he known, he could have been there in seconds to start CPR and use the AED in his vehicle before the crews arrived. This incident gave Price an idea. With the current cell phone technology and GPS, there must be a way to alert staff who may be in the area of a cardiac arrest, he thought. “It was very conceptual at that time. The idea grew out of that,” Price says. The “idea” evolved into a CPR mobile app for the iPhone and Android, that eventually became known as PulsePoint. Price expanded on his original idea to include citizens trained in CPR, who have indicated they’re willing to assist in case of an emergency. The app uses the GPS feature on the phone to locate citizens who have signed up for the program and are in the vicinity of a cardiac arrest patient. Notifications are sent only if the victim is in a public place and only to potential rescuers within walking distance of the emergency. The application also directs rescuers to the exact location of the closest AED. “We crowd source good Samaritans,” Price says. Price knew he needed help to develop the mobile app, so the district partnered with interns from the College of Informatics at Northern Kentucky University. While they worked out the technical details, Price attended to other issues. Initially, some concern was expressed about sending too many rescuers to what can often be a chaotic scene. However, Price says that this seldom happens. “We can always make the notification circle smaller, if we get to that problem,” he says. Even in the limited cases where extra rescuers respond, it hasn’t been an issue, Price says. On one occasion, a person suffered a cardiac arrest at a coffee shop and a large number of rescuers responded. But instead of causing confusion or getting in the way, they did a good job assigning tasks, and those who weren’t directly involved in the rescue attempt helped by clapping to the beat of the chest compressions.

Privacy issues
Price notes that the chain of survival depends on training people in CPR and sending them out into their communities to respond when needed. “The app doesn’t really change that very much. It just takes some of the fate out of it,” he says. Still, certain privacy precautions had to be considered. To protect the rescuer’s information, the app doesn’t know the identity of the responders—it simply locates a “device” by accessing the unique identification number, which is required for the PulsePoint server to locate and send alert messages to a specific device. Price says the app doesn’t access any other information on the responder’s device. “No personal information is ever collected or retained,” he says. Because the activation occurs within an exceptionally limited radius—within walking distance—the app only alerts people to emergencies in their immediate vicinity. “It makes you more aware of what’s happening nearby you,” he says. He says they were also careful to consider possible Health Insurance Portability and Accountability Act (HIPAA) violations when designing the app. No patient information is ever broadcast or known by PulsePoint. Because PulsePoint doesn’t know who responded, the citizen rescuers are not informed of outcomes. “Occasionally circumstances allow the citizen rescuers to come together with survivors, but it’s a careful, respectful process,” Price says. The issue only becomes problematic if there’s an infectious disease concern.

Where’s the AED?
The biggest hurdle for a seamless citizen CPR response is locating public AEDs. Price says that the district has done a good job of promoting the use of AEDs, but locating them and ensuring they’re properly maintained has been a challenge. “When you’re dispatching people to them, the standard is higher,” he says. “You need to know one is there.” Despite a vigorous awareness program in San Ramon Valley, the use rates of AEDs among citizens are low. Price believes the area for which emergency responders should commit additional resources. “AEDs need to rise to the importance of fire extinguishers,” he says. Some communities are starting to include AED location information in their computer-aided design (CAD) system so dispatchers can provide not only CPR instructions, but also the location of a nearby AED.

PulsePoint foundation
Once the district developed the app, they wanted to share it—and not just with their neighbors. “We want to be around the globe,” Price says. To do so, they created the PulsePoint Foundation, a 501(c)3 nonprofit organization that provides and supports the app free of charge. Supporting services are also provided at no charge to public safety agencies that offer the CPR app in their community. However, charges from the CAD system vendor may occur, which interface with the app. The foundation is working with the CAD vendors to moderate these costs. Currently, the PulsePoint Foundation is working with more than 150 organizations in the deployment of the app.

Community outreach
To launch a successful CPR mobile app program, community outreach is critical. Price recommends a multi-pronged marketing program to encourage citizen awareness and ongoing involvement. The district started with a public service announcement in movie theaters and other venues to raise awareness of both the app and the importance of citizen CPR. SRVFPD used university interns to help develop the PSA. “It was a low-cost way to create tremendous
value,” Price says. The district spent very little public money, and the students received real-world experience. “It gave meaning to their studies,” Price says. “It’s a win-win.” The district continues to promote CPR at all community events, and is working to provide CPR training to all seventh graders in the local school district. It also established a program to manage the maintenance of the approximately 200 public AEDs in the community. “We know where every single one is and have hands on them every six months,” Price says.

Upgrades added
A number of upgrades have been added to the program since the original application launched. A streaming radio function allows citizens to listen to emergency calls anywhere in the world. Most recently, a Twitter feature began broadcasting PulsePoint app CPR activations in real time. The tweet includes the time of activation, the general location and the number of citizen rescuers notified. The goal is to increase awareness of the app and the role it plays in saving lives. The Twitter feed can be found at @1000livesaday, a reference to the number of people who die daily in the U.S. from sudden cardiac arrest. Price says the number of activations is around one per day. On average, 3-4 citizens respond per incident. “I’ve seen as many as 22,” he says. The next release of the app will include a survey tool sent one hour after app users were notified of a need for CPR. The goal is to collect data on the responses to the notifications and create a clearer picture of what happens during the response before the professionals arrive. It will attempt to find out whether a person responded to the notification and if not, why. If they did respond, they’ll be asked whether they performed CPR, if an AED was available, and if so, whether it was used. The optional survey will continue to allow the citizen responder to remain anonymous, if desired. Price says the survey is being developed by Bentley J. Bobrow, MD, medical director of the Bureau of Emergency Services Arizona Department of Health Services; and Steven C. Brooks, MD, MHSc FRCPC, emergency physician and scientist at Sunnybrook Health Sciences Centre and assistant professor at the University of Toronto.

Summary
Because CPR has been around for 50 years, Price says sometimes it can be hard to find something exciting about it. But the process of developing the app and sharing it with others has been just that. “We were right at the time in history when it was all possible. Six months earlier, and it would not have been possible,” he says. Through this process, SRVFPD learned something about human beings that they probably already knew—people really want to help others. “This is a way, at no cost, you can make a significant difference in [out-of-hospital cardiac arrest] survivability,” Price says. “Think about the force multiplier—it’s a huge deal.” However, he warns, the app isn’t a panacea. “It works best in systems that are already good,” he says. That means good citizen CPR programs, an active AED strategy and a strong activation policy for ST-elevation myocardial infarction patients. “It ties a lot of things together and makes good systems pay off bigger,” he says. Although good work can often go unrewarded, this isn’t the case for Price. In February, the Danville Area Chamber of Commerce and the San Ramon Valley Times named Price “Citizen of the Year” for his innovative efforts to protect the lives of the citizens in his jurisdiction and beyond.