Sudden Cardiac Arrest Survival is a Wicked Mess

Likely influenced by the recent death from sudden cardiac arrest of Tim Russert, host of NBC’s “Meet the Press,” the US House and Senate by unanimous consent passed a resolution making October National Sudden Cardiac Arrest (SCA) Awareness Month. In addition, from October 17 - 19, the Sudden Cardiac Arrest Association, a prevention advocate group, held its annual meeting in Center City Philadelphia. The resolution and meeting were designed to help raise awareness that SCA can strike persons of any age, gender, or race including those who seem in good health. Similar to Tim Russert, approximately 450 people each day in the US do not survive when they experience SCA.

Last month, a report in the Journal of the American Medical Association (JAMA)
presented a 2006-2007 review of more that 20,000 cardiac arrests that occurred - mostly in homes and public areas - in nine US and Canadian cities. The results showed that the overall average survival rate was a dismal 4.4%. Some cities, such as Seattle, showed a remarkably higher rate – nearly 40% - but only if the victim experienced a certain category of heart problem, ventricular
fibrillation. If a person has a cardiac arrest at home or on the streets of Philadelphia, the survival rate, unfortunately, averages approximately 7%.

Why despite the best efforts by everyone from lay person to professional responder do 93% of those who experience SCA in Philadelphia not survive? Is a 40% survival the best that can be expected? What are all the forces that contribute to survival and how do they interact? For several months, our research group has been discussing these and similar questions in the Russell
L. Ackoff Systems Thinking Library at the University of Pennsylvania. We believe that the current state of SCA survival in Philadelphia and across the US is a mess.

Mess - also called wicked - is a management science term used since the 1970’s to describe a special category of complex problems. A wicked mess is characterized by strongly interacting events that co-produce confusions, conflicts, and failures within large organizations, communities, and environments that prevent the main goal – in this case, survival - from being
adequately accomplished. A wicked mess cannot be solved by following the common strategy of dividing the problem into smaller parts or sections and trying to solve each individually. This is because in a wicked mess the causes of the problem are found in the interactions between the needs and interests of the people and groups involved in the problem. To effectively understand
and manage a wicked mess such as SCA survival, a “systems” framework and a systems methodology must be used. We believe that borrowing these frameworks and methodologies from management science and applying them to SCA survival is a creative and worthwhile pathway to save more lives.

The chain of events traditionally thought to save a life begin when a person’s heart suddenly stops beating. They include calling 911, starting CPR, shocking the heart with a defibrillator, providing EMS, and hospital emergency department care. Indeed, the authors of the JAMA report noted, “it seems likely that the differences (in survival) reflect, in part, regional differences in the availability of…bystander CPR…lay responder defibrillation programs…EMS
factors…or treatments available at receiving hospitals…but, no analysis (has been able to detect) the independent contributions of these factors.” We believe this is because the traditional mindset of only trying to improve individual links in the chain of events, i.e., the parts, will not solve a wicked mess problem. SCA survival is the kind of problem where even a significant change in a single event will not fix the overall system.

Our approach is different. If bystanders, EMS responders, and healthcare professionals are components of a single system, we ask how communications including feedback and learning should be coordinated between people before, during and following an emergency. Since in every organizational system, each individual has personal interests that can conflict with job performance, we ask how stress reactions, personality, organization and family culture, and other
characteristics and obstructions influence performance and SCA survival. Also, because all organization systems are influenced by the social, economic, and regulatory environment, we ask how economic and financial forces, technology, politics, and a host of other events affect overall patient survival.

The first step required to understand a wicked mess problem such as SCA survival is to perform a system diagnosis. This provides a detailed description of how the entire system currently operates. It identifies which characteristics and properties of the system promote and which interfere with survival. We show the relationships in “diagrams” and in “story” form to allow one to see and understand how and why the people, groups, and events in the entire system
operate both successfully and unsuccessfully.

Systems diagnoses have been effectively used for decades to understand complex organizational systems within healthcare, government, military, and global corporate enterprises. Once understood, systems methodologies have been effectively used to change direction, realign interests, and improve outcomes. This time we hope our approach will help to save more lives.

We feel that applying this approach to SCA survival is innovative, practical, and essential if we are to make significant and sustainable impact. We encourage community leaders to visit our website to contribute to our efforts by leaving
constructive comments – positive or negative – and to suggest if their city should be our diagnostic test site.

Visit our website for more information.

October 23, 2008