RACE-CARS DCC 2/2

Project Abstract
Approximately 350,000 people suffer out-of-hospital cardiac arrest (OHCA) each year, with an average survival
rate with good neurological function of only 9.0%. In response to the clear public health imperative signaled by
these statistics, the Institute of Medicine in 2015 called for studies on implementation of interventions for
OHCA at the community, emergency medical services (EMS), and hospital levels. The lack of consistent use of
effective interventions across the country is largely due to the lack of high quality evidence from randomized
trials on how to implement these interventions at the systems (community) level. The proposed Regional
Approaches to Cardiovascular Emergencies- Cardiac ARreSt (RACE-CARS) cluster-randomized trial has been
designed to develop new systems-based high quality clinical trial evidence on how to improve outcomes for
OHCA. The premise for RACE-CARS is based on prior observations showing substantial regional
heterogeneity in care correlated with variations in outcomes. In 11 North Carolina counties, we observed
improved rates of bystander CPR and first responder defibrillation, associated with a 37% increase in survival
with good neurologic outcome over a 4-year period.
RACE-CARS, a 7-year pragmatic, cluster randomized (1:1) trial of 50 counties in NC, will test whether
implementation of a customized set of strategically targeted community-based interventions can improve
survival to hospital discharge with good neurologic function in OHCA relative to control/standard care. Our
intervention program will consist of 4 main elements: (1) optimized medical 911-dispatch performance with
rapid recognition of cardiac arrest and dispatch of emergency response, (2) enhanced 911-dispatch telephone
coaching of bystander CPR, (3) improved first responder performance with AED use, and (4) comprehensive
public training of CPR and AED use. Quality of life and neurological functional status will be assessed at 6 and
12 months. RACE-CARS will leverage our statewide emergency care network, which has successfully
collaborated on improving quality of emergency cardiovascular care over the past 14 years, and ongoing data
collection of the majority of cardiac arrests in NC using the CARES registry. We will enroll ~20,000 patients
with cardiac arrest over the study period, to give us >90% power to detect a 30% increase in bystander CPR,
and 50% increase in bystander or first responder defibrillation, and > 85% power to detect a 33% increase in
survival with good neurologic outcome. While all the intervention approaches have evidence for improved
outcomes in prior observational studies, RACE CARS is unique in combining these efforts into a pragmatic
randomized systems-based implementation trial that can be adjusted to the needs and abilities/resources of
regions that vary according to population density, demographic and socioeconomic status.
1