Constructing a community cardiac health risk profile ...nfa.usfa.fema.gov/pdf/efop/efo48512.pdfHeart Association (AHA) a projected 40.8 % of the Unites States population will have

Running head: CONSTRUCTING A CARDIAC HEALTH RISK PROFILE 1

Constructing a cardiac health risk profile: Building the foundation for a community cardiac

wellness program for the City of Twinsburg, Ohio

Gina DeVito-Staub

Twinsburg Fire Department, Twinsburg, Ohio

March 01, 2014

CONSTRUCTING A COMMUNITY CARDIAC HEALTH RISK 2

Certification Statement

I hereby certify that this paper constitutes my own product, that where the language of others is

set forth, quotation marks so indicate, and that appropriate credit is given where I have used the

language, idea, expression, or writings of another.

Signed: ______________________________________________________________________


Abstract

Eighty-two percent of Twinsburg Fire Department responses were emergency medical

calls yet only ten percent of TFD prevention activities focus on non-fire risk reduction. There is a

disproportionate demand of EMS risk reduction programs in comparison to fire prevention

programs. The problem is that TFD is a fire-based EMS Department that does not have an

emergency medical prevention presence in the City of Twinsburg. The purpose of this research is

to reduce the number of emergency cardiac responses and development of a community cardiac

risk profile. This community cardiac risk profile will provide the foundation to construct a

cardiac risk reduction program for Twinsburg, Ohio. Action research was utilized and the

following questions were addressed: 1. Who is requesting emergency medical responses for

cardiac emergencies in the City of Twinsburg? 2. What are the pre-existing cardiac conditions of

the TFD emergency cardiac patients? 3. Where are the TFD emergency cardiac patients located?

4. What are the locations or population groups that should be the focus of a community cardiac

risk reduction program? 5. What are the components of a community cardiac risk reduction

program? Procedures for this research included a literature review, interviews, and data analysis.

This research generated a cardiac risk profile for Twinsburg, Ohio. Coordination of Twinsburg

resources and collaborative partnerships will aid in reaching the target audiences identified in the

cardiac risk profile.

.


Table of Contents

Certification Statement ................................................................................................................... 2

Abstract ........................................................................................................................................... 3

Introduction ..................................................................................................................................... 5

Background and Significance ......................................................................................................... 6

Literature Review............................................................................................................................ 8

Procedures ..................................................................................................................................... 15

Results ........................................................................................................................................... 21

Discussion ..................................................................................................................................... 29

References ..................................................................................................................................... 32

Appendix A ................................................................................................................................... 37

Appendix B ................................................................................................................................... 40

Appendix C ................................................................................................................................... 42

Appendix D ................................................................................................................................... 43

Appendix E ................................................................................................................................... 45

Appendix F.................................................................................................................................... 46

Appendix G ................................................................................................................................... 47

Appendix H ................................................................................................................................... 48

Appendix I .................................................................................................................................... 49


Constructing a community cardiac health risk profile: Building the groundwork for a community

cardiac wellness program for the City of Twinsburg, Ohio

Introduction

Chronic disease mortality rates are expected to increase twenty percent between 2002 and

2030 (Freudenberg & Olden, 2010). Every thirty-four seconds an American will suffer some

type of a cardiac event (Go et al., 2013, p. e186). The cost of cardiac disease in the United States

is approximately $108.9 billion dollars each year causing considerable health and economic

burdens stemming from lost productivity, acute illness, health care demands, disability, and

premature death (Zeng et al., 2013). According to Taniguchi et al. eighty percent of risk factors

attributed to cardiac disease are modifiable risks (Taniguchi, Baernstein, & Nichol, 2012).

The demands of the Twinsburg Fire Department (TFD) emergency medical services

(EMS) impact the entire community and TFD capacity to protect and serve the community. The

problem is that Twinsburg Fire Department is a fire-based emergency medical service that does

not have an emergency medical prevention presence in the City of Twinsburg. The purpose of

this research is to reduce the number of cardiac emergency responses the development of a

community cardiac risk profile.

The expectations of TFD paramedics are to contact social services, welfare agencies and

document the environment of the patient if needed which falls within the sphere of public health.

Recognizing EMS leverage to access target audience who experience increased health risk is the

next logical step for TFD paramedics to enter into the realm of public health (Chubb, 2001). To

uphold the TFD expectations a proactive approach is necessary to encourage health risk

reduction strategies specifically cardiac health and incorporate them into daily responses of the


fire department, within the fire prevention bureau and extend into the Community. The

prevalence of heart disease coupled with modifiable risk factors opens a door for TFD

paramedics to positively influence not only their patients but an entire community.

The research utilized action research methodology to answer the following questions:

1. Who is requesting emergency medical responses for cardiac emergencies in the

City of Twinsburg?

2. What are the pre-existing conditions of the Twinsburg Fire Department

emergency cardiac patients?

3. Where are the Twinsburg Fire Department emergency cardiac patients located?

4. What are the locations or population groups that should be the focus of a

community cardiac risk reduction program?

5. What are the components of a community cardiac risk reduction program?

Background and Significance

The Twinsburg Fire Department (TFD) provides fire, rescue and emergency medical

services (EMS) to the City of Twinsburg and Twinsburg Township forming a protection district

that is situated between Cleveland and Akron, Ohio. The TFD protects approximately 21 square

miles and is a Class 4 Insurance Service Organization (ISO) rated department. The majority of

the district is considered suburban and serves a residential population of 22,000 (R. Racine,

personal communication, April 25, 2012). The fire district includes industrial facilities and large

commercial buildings that contain high quantities of hazards materials (DeVito-Staub, 2012).

The Department is composed of thirty-two full time employees and twelve part-time employees

all of which are paramedics excluding two full time Captains. In 2013 Twinsburg Fire


Department responded to 2,232 calls; eighty-two percent were EMS responses (D. Simon,

personal communication, April 15, 2014).

The Twinsburg Fire Department has evolved from a strict fire department to a fire-based

EMS department. The functions of TFD continue to expand. The TFD Fire Prevention Bureau

was designed to save lives through education, enforcement and lessen the demand of fire and

emergency services. Currently eighty-two percent of TFD responses are EMS calls yet only ten

percent of TFD prevention activities focus on non-fire risk reduction (L. Racine, personal

communication, April 15, 2014). There is a disproportionate demand of EMS risk reduction

programs in comparison to fire prevention programs. A cultural shift within TFD is necessary to

expand prevention activities into non-fire risk reduction strategies for the future and

sustainability of operations and prevention. Planning and implementing an EMS risk reduction

strategy will positively impact EMS demand similar to early fire prevention programs within the

City of Twinsburg (L. Racine, personal communication, March 4, 2014).

Construction of a community cardiac risk profile entails a description of the cardiac risks

and demographic characteristics of those affected by cardiac events. The importance of local

data analysis in prevention planning by the TFD will provide the groundwork to analyze the

community risk, identify hazards and causal factors, assess vulnerability, establish priorities

based on cardiac risk, create cardiac risk reduction objectives and recommend cardiac

intervention strategies (United States Fire Administration [USFA], 2012, p. SM1-8). The greatest

advantage to the community is improved cardiac health, cardiac risk reduction, extending life,

providing options for education and a decrease healthcare cost all of which were goals expressed

by Mayor Katy Procop of Twinsburg, Ohio (K. Procop, personal communication, June 2013).


The fire service has become the principal contractor of EMS (Chubb, 2001). The

increasing demand for EMS generates expenses for TFD including but not limited to staffing,

equipment, and training s impacting the Community coffers. Innovative approaches for cost

containment, improving health outcomes, and reduce EMS demand are vital to sustain, expand,

and tailor the continuum of care for the Twinsburg Community (Zeng et al., 2013). The

traditional role of the fire department has not been involved in non-fire prevention programs

(Bigham, Kennedy, Drennen, & Morrison, 2013).

This applied research project is associated with the goals and objectives of the United

States Fire Administration (USFA) operational objectives to reduce risk at the local level through

prevention and mitigation, improve local planning and preparedness while improving the fire and

emergency professional status (United States Fire Administration [USFA], 2014) The model

utilized for this applied research project was presented in the Executive Analysis of Community

Risk Reduction Course (USFA, 2012).

Literature Review

The literature review focused on understanding cardiac risk, assessing community risk,

intervention strategies and implementing an action plan to reduce community cardiac risk

(USFA, 2012, p. SM1-8).

The leading cause of death for men and women is cardiac disease. One in every four

deaths is attributed to cardiac disease (CDC, n.d.). Risk reduction is critical to decrease acute

illness, disability, lost productivity, premature death, cost containment, and demand on

Twinsburg Fire Department resulting from cardiac etiologies (Zeng et al., 2013). The cost of

healthcare continues to increase with chronic diseases, liable for seventy-five percent of the

national annual health care expenditures (Milani & Lavie, 2009). According to the American


Heart Association (AHA) a projected 40.8 % of the Unites States population will have some

form of cardiac disease by 2030. In turn, the medical costs are expected to increase one hundred

percent between 2013 and 2030 (Go et al., 2013)

As a consequence of higher health care demands Bigham et al. forecast that EMS demand

will increase as much as eight percent annually producing a noticeable effect on allied health

care professionals (2013). Currently, the roles traditionally performed by physicians are being

extended by allied health professionals through community paramedics and home healthcare

(Bigham et al., 2013). The scope of healthcare is broadening beyond hospital-centered to a

community based approach focusing on diversification, cost containment and interdisciplinary

coordination of services (McAllister et al., 2013). Prevention of illness and injury is one of the

most advantageous tactics to control the rising public and private cost of healthcare (Chubb,

2001). Community health care methodologies involve health activities to safeguard and enhance

the health of the population or community through validation of new approaches, analysis of

issues at hand, expansion of the health care field, implementation and treatment of community

health programs (Ashengrau & Seage, 2014) The most valuable approach for health risk

reduction strategies are debatable according to Pennant et al (2010). Pennant et al. denotes that

targeting the entire community is alluring and will affect widespread community behavior to

promote health risk reduction (Pennant et al., 2010).

A paradigm shift is introduced by Sun et al to reshape the community’s perception of

public health as a collective rather than solely personal responsibility. This reframing of public

health will motivate community involvement, encompass allied health care fields, and become

mindful of health as a collective enterprise addressing chronic diseases including cardiac disease

(Sun, 2014). Solutions to public health do not exclusively revolve around health considerations


but are embedded in economics, culture, politics and ethics stimulating a multi-faceted approach

(Savitz, Poole, & Miller, 1999). Traditional sickness-based health systems constructed to take

action against acute and communicable diseases are ill-equipped to provide the difficult,

integrated, multifaceted and sustained activities required to tackle chronic disease (Willis, Riley,

Herbert, & Best, 2013)

EMS data has the ability to substantiate an initial point prior to intervention, assess

development and contribute to the health risk reduction program. EMS data can identify the

target populations that are at most risk. The information obtained can be shared and engage

stakeholders within the community and build collaborative partnerships (Johnson, 2011).

Extensive knowledge has been acquired through large databases and registries for myocardial

infarctions and successfully integrated cardiac rehabilitation programs into patient care ensuing

from the collected data (Herlitz et al., 2008).

The systematic retrieval of community health information is limited and local health

departments are further restrained concerning behavioral measurement of their target populations

by survey or observational methods (Roussos & Fawcett, 2000). EMS data is one source of

community health information that assisted with early detection of reportable infectious diseases

but has not been extensively utilized or studied. According to the Center of Disease Control

(CDC) EMS data has been a useful tool to ascertain signs and symptoms using real time

recognition of outbreaks. The Center for Disease Control automatic surveillance of EMS records

enhances detection and supplements public health surveillance (CDC, 2010). Dietz et al

investigated the advantage of EMS electric records in conjunction with heroin overdoses. EMS

data isolated on scene information, location, demographics and relevant clinical data from the

patient care reports. The EMS data provided a cost effective method to employ real-time facts to


aid in detection of patterns and indication of heroin use (Dietze, Cvetkovski, Rumbold, & Miller,

2000).

Health risk factors generally speaking are situations that individuals favor regarding

particular behaviors and predispose them to health consequences (Sun, 2014). Cardiac risk

factors have been divided into two categories fixed and modifiable. Fixed factors are those that

are unable to change such as biology and genetics. Modifiable risk factors are those that can be

altered or eradicated (Taniguchi et al., 2012). Modifiable factors pertain to the physical

environment, social environment, individual behavior, and health services (Hudmon, Addleton,

Vitale, Christiansen, & Mejicano, 2011). Risk can be expressed in qualitative and quantitative

factors. Statistical information addresses the quantitative factor of risk and aids in expressing

trends and patterns within certain populations (Sun, 2014).

According to the American Heart Association (AHA) from 1999 -2009 the death rates

caused by hypertension, a modifiable cardiac disease risk factor increased approximately

seventeen percent and the approximate deaths escalated forty four percent (Go et al., 2013, p.

e79). Based on the 2007- 2010 data thirty three percent of adults greater than 20 years of age

have hypertension of which eighty two percent are unaware and seventy five percent are

controlled with medication. Seventy-five percent of patients with hypertension have modified

their cardiac risk through medication and reduce the probability of extensive health issues (Go et

al., 2013, p. e79). Stroke, elevated cholesterol and diabetes are other modifiable risk factors for

cardiac health according to the AHA. The AHA identifies seven metrics to characterize

cardiovascular health divided into four health behaviors and three health factors. The four health

behaviors are cessation of smoking, physical activity, healthy diet, and energy balance (weight

control). The three health factors are ideal total cholesterol levels, blood pressure and fasting


glucose within normal range. The health metrics with the greatest bearing for poor cardiac

health are the three health factors, poor diet, lack of physical activity and body weight (Go et al.,

2013). Zeng et al focused on cardiac risk behaviors, age, gender, race and qualifying events to

determine if a reduction of cardiac risk and behaviors would reduce hospitalizations and

Medicare costs. Modest savings were noted compared to those participants without lifestyle

modifications (Zeng et al., 2013).

Alexander et al developed a worksite cardiac health risk reduction program that

addressed biological, physical and social risk factors within the worksite community. The goals

were to influence lifestyle and health behaviors, augment productivity and shrink future health

care expenditures (Alexander et al., 2012). Health risk assessments of the employees targeted

modifiable interventions and were implemented by a systematic mapping of those at risk and

were directed to the appropriate intervention program to the risk areas identified (Alexander et

al., 2012).

Zeng et al. discussed the benefits of lifestyle modification programs and noted the

achievement of favorable outcomes in cardiac risk factors and cardiac function (2013). The

program was composed of the following:

• Diet and nutrition counseling • Aerobic exercise • Stress management • Small group support (Zeng et al., 2013)

The CDC investigated effective measures to lessen cardiac disease morbidity. They stated

aspirin therapy, blood pressure management, cholesterol control and smoking cessation

contributed to cardiac disease risk reduction (CDC, n.d.). Evidence based programs aid to

improve modifiable cardiac risk but also assist with socioeconomic and cultural issues that

appear in particular populaces. This further supports the critical role of local knowledge,


community outreach, and public health as interventions that are fostered and put into action

(Trickett et al., 2011).

The Department of Health and Human Services created the Healthy People 2020 program

that strives to bring awareness of nationwide health improvements priorities, comprehend causal

factor of health, raise public awareness, furnish measurable objectives and goals, engage

multiple sectors and strengthen evidence based research and knowledge and stipulate critical

research evaluation and data collection (Healthy People, n.d.). This 30 year program continues

to enrich the health of Americans through collaborative partnerships within the community,

empowering individuals and measurement of prevention interventions. One of the foundational

measures is determinants of health. The CDC defines determinates of health as, “the range of

personal, social, economic, and environmental factors that influence health status (Healthy

People, n.d.)” Individual factors, social factors, health services, biology and genetics, and

individual behaviors create interrelationships that bring about individual and population health.

The AHA refers to a Healthy People 2020 goal; achieve a twenty percent improvement of

cardiac health for all Americans (Go et al., 2013, p. e14). The overreaching goals of Healthy

People 2020 are as follows:

• Attain high quality, longer lives free of preventable disease, disability, injury or premature death

• Achieve health equity, eliminate disparities and improve health of all groups • Create social and physical environment that promotes good health for all • Promote quality of life, healthy development and healthy behaviors across all life

stages(Hudmon et al., 2011, p. 62)

Mobilize, Assess, Plan, Implement Track (MAP-IT) is a component of Healthy People

2020 to support recruitment of collaborative partnerships, evaluate the needs of your community,

generate and execute a program, and track community progress. Through the MAP-IT a vast

amount of information is available for strategic management especially the Community Tool


Box offering in depth resources to analyze, take action and implement community initiatives

(Community Tool Box, n.d.). Action planning for the community and system implementation is

advantageous because it provides focus and clarity to produce change, develop accountability

and ownership to facilitate community and system change of programs, policies, and practices

(Roussos & Fawcett, 2000).

Throughout the literature review collaborative partnerships or networks were identified as

essential to the success, sustainability, expansion of resources for community outreach programs

(Roussos & Fawcett, 2000) (Trickett et al., 2011) (Willis et al., 2013)(Healthy People, n.d.).

Coalitions of individuals and organizations from a mixture of community sectors can bring

mental and physical resources concurrently to accomplish goals which characterize collaborative

partnerships. The integration of public health professionals, allied health professionals,

politicians, local business leaders, local hospital systems, experts and other community

stakeholders constitute collaborative partnerships simplifying efficient use of resources,

numerous opportunities for learning and better capacity to tackle multifaceted challenges (Willis

et al., 2013). Successful strategies to enrich collaborative partnership are embedded in effective

communication, for example, communicating a clear and concise vision and mission,

communication of ongoing action planning, and engagement of leadership within different

sectors (Roussos & Fawcett, 2000).

The City of Twinsburg recently initiated a general fitness initiative designated as Fitness

in Twinsburg (FIT). The program was developed through a compilation of City employees and

the Cleveland Clinic Foundation (CCF). The goal was to develop a fitness program to create a

healthier community, healthier workplace, build sustainable relationship with community

partners, utilize available resources within the community, impact obesity and chronic disease in


a positive manner, and development of tracking outcomes. The program consists of health

screenings, education, and a U change U program. The focus of the interactive learning

environment of the U change U program is to tackle integrative health, behavior change, stress

management, physical activity, and nutrition to integrate all the information into a healthy

lifestyle (C. Bronson, personal communication, January 17, 2014).

Community interventions are social processes within the community that are

complicated yet critical. Demographics, culture, economics and geography influence public

health in addition to individuals’ behavior and biological traits (Trickett et al., 2011).

Individuals that share common demographic characteristics have the capability to become a

target audience for cardiac risk reduction program. The demographic characteristics can be

obtained from EMS patient reports to identify needs and determine allocation of resources

(Roussos & Fawcett, 2000).

Procedures

The first step of the applied research project was to select a significant issue within the

Community that has a negative impact for the people of Twinsburg, Ohio. Twinsburg Fire

Department is a fire-based emergency medical service that does not have an emergency medical

prevention presence in the Twinsburg Community. The purpose is to reduce the number of

emergency cardiac responses through collaborative partnerships and development of a cardiac

community risk reduction program. Research questions were developed in order to approach the

problem in a systematic manner. Twinsburg Fire Department EMS data, Interviews, literature

reviews, CDC, AHA, and Census data were utilized to answer the questions.

Twinsburg Fire Department EMS data was obtained from EMS charts.com; an electronic

data base linked to the TFD Medical Director and the Medical Command Hospital System,


Universities Health Hospitals Systems (UHHS). Twinsburg Fire Department paramedics are

required to document all emergency and non-emergency medical calls into this data base.

EMScharts.com is a software company that designs software specific to EMS organizations. The

second source of data was derived from the U.S. Census providing population data. The

American Fact Finder tool was retrieved and formulated reports for each census tract in

Twinsburg, Ohio. The reports retrieved were the 2007-2011 American Community Survey

(ACS), age and sex and the 2007-2011, American Community Survey (ACS) selected social

characteristics in the United States. According to National Fire Prevention Association (NFPA),

census tract information supplies population and demographic facts that are put to use for

development of public fire prevention planning and is a favored source of information (Johnson,

2011). The Center of Disease Control, National Prevention Council, and the American Heart

Association (AHA) websites were accessed presenting additional statistical data and strategies

for cardiac risk reduction.

A total of 1,716 EMS calls in 2013 were analyzed of which 161 were identified as

cardiac by the medical compliant. Information was organized using a custom report from

EMScharts.com and downloaded into an Excel spreadsheet. The variables consisted of date

dispatched, record identification number, resident status, gender, age, address of incident, city of

incident, outcome, medical compliant, past medical history, medications, and receiving hospital.

The disadvantage of using EMScharts.com is that the accuracy of the data depends on the acuity

of the paramedic data entry. The software is developed for a variety of EMS organizations: the

specificity that is desired for this research is not available at this time in EMScharts.com. Entry

fields have been eliminated and added within EMScharts.com which have benefited the author

but limited the consistency of research to one year.


Foundation for the paper was acquired through interviews establishing the need,

resources and vision to address the health of the entire community. Conversational-type

interviews were executed with varied questions depending on the job function of those

interviewed. The President of UHHS Ahuja Hospital, Susan Juris was interviewed in addition

to a panel of doctors and nurses. Those in attendance played a significant role in prior research

from the author (S. Juris, personal communication, July 10, 2013) (DeVito-Staub, 2012). The

concept of the research was examined, feasibility to execute, and similar programs in other

communities were also discussed. Mayor Kathy Procop provided her vision for the health of

Twinsburg and health of the employees. During the interview she expressed her concerns and

the direction of the author’s research. Resources were discussed. Prior to our meeting a

representative from the Cleveland Clinic Foundation, (CCF) was in contact with the Mayor

regarding similar concerns as the author. Information was provided to the author and recruited

by the Mayor of Twinsburg to assist in the development of the Fitness in Twinsburg (FIT)

initiative. The information obtained from the FIT meetings was pertinent and substantial to the

direction of the applied research project to construct a community cardiac risk profile. Chad

Bronson a Community Outreach representative from CCF was contacted and offered a great deal

of information and ideas. Lastly, information was gained from Laura Siefert, coordinator for the

Twinsburg Senior Center. She expressed the needs, current programs, and resources that are in

progress pertaining to cardiac wellness for the seniors in the Twinsburg Community.

A series of emails were exchanged between the UHHS EMS coordinator, Dan

Ellenberger and the EMScharts.com coordinator regarding access to medical information for

Twinsburg Fire Department and selected general information for the forty-one fire departments

under the UHHS medical command.


A literature review was executed focusing on prevention of cardiac emergencies by the

fire service, prevention and prevalence of cardiac health in the community and public health.

The author discovered a large amount of fire prevention information, injury prevention

approaches within the fire service and prevention strategies from the public health community

but limited information regarding fire service initiatives to reduce the risks of medical illness in

the community. Inferences were made that addressed cardiac health in public health and applied

them towards the fire service specifically fire-based EMS.

Who is requesting emergency medical response for cardiac events in Twinsburg?

The author analyzed EMS data, CDC trend tables and a literature review.

Understanding the impact of gender, age, and race were investigated and compared to the general

population. Understanding the vulnerability of the variables and how they correlate with cardiac

wellness was achieved through the literature review. The range of medical categories obtained

from the EMScharts.com 2013 data were narrowed to include cardiac related events which

included cardiac arrest (non-traumatic), cardiac problems (not chest pain), chest pain, and chest

pain STEMI, hypertension, and hypotension. The medical category is based on the paramedic’s

evaluation of the patient not the diagnosis of the emergency department doctor which limited the

research. Complaints of weakness, for example, may indicate a cardiac etiology but were not

included since it did not specifically identify cardiac involvement. Other medical categories were

excluded for this same reason such as flu-like symptoms, headache, dizziness, and changes in

mental status, general medical, general weakness, and unconscious fainting all may be a

symptom of an asymptotic cardiac event.


What are the pre-existing conditions of the Twinsburg emergency cardiac patient?

EMSchart.com medical data was analyzed. Modifiable predominant risk factors

accessible in EMScharts.com data and identified by the AHA and CDC were scrutinized. The

modifiable risk factors are as follows: hypertension, diabetes, elevated cholesterol and stroke.

The risk factors were employed to establish a level of pre-existing risk for the study population

and the impact of risk on gender and age. The number of total entries and those pertaining to

cardiac issues listed in the medical history were tallied and correlated to age.

This portion of the literature review concentrated on cardiac health prevention,

prevalence of heart disease, and factors that pre-dispose populations to cardiac events

specifically genetic, modifiable risk factors, and social aspects.

Where are the TFD emergency cardiac patients located?

EMScharts.com electronic data, ACS and Census data were used to answer this research

question. The addresses of incidents were obtained from EMScharts.com. The data was mapped

to the corresponding census tract. The author referred to ACS data and applied selected social

characteristics to the findings and investigated trends and alignment with current data. The

location of the incidents were identified as residential, commercial including industrial, senior

living and extended care. Patients were further categorized as resident or non-resident of the

City of Twinsburg. The focus of this division was to target location rather than age, gender, or

race for future cardiac wellness outreach. The literature review investigated sites of cardiac

wellness initiatives such as commercial or business, prevention program delivery based on

occupancy, and national program strategies.


What are the cardiac events, location or population groups that should be the focus of a

community cardiac risk reduction program?

The TFD medical data was compared to AHA and CDC statistics, trends and forecasts to

project the types of cardiac events. Pre-existing conditions obtained from medical history data

was evaluated to determine concentrations of recurring conditions. Modifiable risk factors and

cost of cardiac events for the people, community and local businesses were reviewed as possible

indicators for cardiac community outreach through a literature review. Interviews with Mayor

Kathy Procop and the Senior Center Coordinator of Twinsburg, Laura Siefert provided guidance

and focus to address this research question.

What are the common components of a cardiac wellness program?

This research questions was delivered by means of interviews and literature review. The

focus of the literature review was to examine a healthy heart lifestyle though preventative

screenings, nutrition, exercise, mental well-being, and stress management. Understanding these

attributes, cost, and correlation with social and demographic aspects of Twinsburg were

examined. Literature review identified customization strategies for sustainability of a community

cardiac wellness program. Lastly action research emphasized the understanding of strategies that

are necessary to implement effective and efficient uses of resources and create a positive heart

healthy impact on the Twinsburg Community. Current literature has established a system to

identify populations at risk and target specific audiences through a community risk reduction

model to assist in getting ready, assessing community risk, intervention strategies, action and

evaluations to identify at risk populations (United States Fire Administration [USFA], 2012).


Limitations

The EMScharts.com data is limited to the accuracy of the paramedic data entry. Errors

can occur with data entry, transcription of patient notes into the data base, and patient error due

to age or mental status resulting from disease. The data base is developed for an assortment of

EMS organizations with emphasis on billing. Fire based EMS is in the early stage for prevention

of medical conditions. The variables are limited. The medical categories used in this research

are determined by the paramedic’s assessment of the patient and determining the most accurate

medical category that fits with the chief compliant. With cardiac ailments especially in women

asymptomatic presentation is a factor which may lead the paramedic to a medical category such

as general weakness, abdominal pain or mental status changes when in fact the doctor at the

emergency department may diagnose a heart condition. Leading to another limitation of this

research, diagnosis by the emergency department doctor is not associated with the

EMSchart.com information. The information is solely based on the paramedic perception of the

patient presentation. As previously noted the pre-hospital care community is in the early stages

of undertaking a pronounced role in public health. Limited peer-review articles discussing fire-

based EMS and non-injury prevention programs were found. Originally the author included data

from 2010-2013 however due to changes in chief complaint categories in EMScharts.com

discrepancies were noted and data was limited to 2013.

Results

Who is requesting emergency medical response for cardiac events in Twinsburg?

Electronic emergency medical records were retrieved from EMS charts and divided into

medial categories, age, gender, and transport outcomes and compared to the census bureau data.


According to data retrieved the percentage of cardiac related EMS responses has declined

from 12 % of total call volume in 2012 to 9.7% in 2013. This percentage is higher than the

cumulative data obtained from TFD’s UHHS medical command. The UHHS medical command

included forty-two EMS organizations including fire-based EMS and private ambulance. It

concluded that 8.9% of the total EMS responses were cardiac related as depicted in Appendix A.

The median age of the population of Twinsburg is 40. 4 years old; the median age of cardiac

TFD emergency responses for 2013 was 66 years old with a mode of 85 years old.

Figure 1. Cardiac responses based on age and gender

The male mean age is higher than the total mean age and had fewer requests than females

for EMS responses. Sixty-seven percent of TFD cardiac responses resulted in a patient being

transported to the hospital. Males and females both chose not to be transported 6% of the time.

The most transports were noted in in the age group of 65 years and older. The EMS responses

were further partitioned by age groups. The majority of the EMS responses to cardiac events

occurred in the over 65 year old age group with 53% of the requests followed by 45- 65 year old


age group with 30%, and 19-44 year old group with 17%. The mean distribution of age was

evaluated in conjunction with cardiac sub categories and gender as noted in Figure 2.

Figure 2. Comparison of Mean Age, Gender and Medical Sub Categories for 2013 TFD Cardiac

Responses based on 2013 Twinsburg Fire EMS data.

According to the data presented males require TFD cardiac responses at an earlier age.

However females requested EMS 56% more often than males. American Community Survey

stated that the population distribution of Twinsburg is 52% female and 48% male which may

attribute to the larger demand by females compared to males. ("U.S. Census Bureau," n.d). The

greatest disparity between age, gender and cardiac sub categories falls within the cardiac (not

chest pain) and hypertension elements. Studies have suggested that females have a greater risk of

asymptomatic chest pain compared to males. Cardiac medical sub categories and gender have

been illustrated in Appendix B.


Numerous studies have documented the disparity of race and cardiac wellness (Go et al.,

2013). Twinsburg Fire Department cardiac response data is representative of the community and

supported by Table 2.

Female Male Total TFD 2013

Cardiac Data Census Data Asian / Pacific Islander 2.2% 0.0% 1.2% 4.90% Black, Non-Hispanic 19.6% 12.7% 16.6% 15.0% Other 2.2% 1.4% 1.8% 0.5% White, Non-Hispanic 75.0% 85.9% 79.8% 78.7% Multiracial 1.1% 0.0% 0.6% 0.9%

Table 2. Ethnicity of TFD Cardiac Responses compared to U.S. Census ACS Data

Additional ethnicity figures are illustrated in Appendix C that supports the association of

demographic information of gender and ACS data sets compared to TFD EMS data.

What are the pre-existing conditions of the Twinsburg cardiac patients?

Of the four identified risk factors established for this research hypertension was the most

pronounced for males and females. Females were inclined to have a slightly higher number of

hypertension risk factor entries. Diabetes was the second most noticeable risk factor with equal

distribution among genders. Females had a slight decrease compared to males regarding

elevated cholesterol entries unlike stroke which was considerably higher in males than females

as noted in Appendix D Gender differences were limited with the category of one risk factor

and no risk factors. Risk factors with two entries were slightly elevated in females.


Figure 3. Comparison of gender related to number of pre-existing heart conditions.

None of the TFD EMS patients had a combination of four risk factors. Pre-existing conditions

were identified in the patient past medical history in their electronic chart and summarized in

Appendix D. Twenty-eight percent of TFD cardiac responses did not have a pre-existing

condition documented in their past medical history. Thirty-six percent had one pre-existing heart

condition and twenty-three percent exhibited a combination of two.

Where are the TFD emergency cardiac patients located?

The information obtained from the TFD cardiac response locations were mapped and

categorized into census tracts, occupancy type and cardiac sub categories. The Census tract

information is listed in Appendix E. The locations for Twinsburg were generalized into four

categories residential, commercial (including industrial), senior living and extended care and

linked to the corresponding census track. Sixty-four percent of the TFD cardiac responses were

commercial and residential occupancies. Surprisingly the extended care facilities only composed

twenty-three percent of the total responses. Figure 4. The author predicts that by 2015 this

number will increase with the construction of two large extended care facilities in the City of

Twinsburg. The addition of two free standing emergency departments in 2009 have attracted

medical professionals and extended care facilities including a dialysis center; all of which will

contribute to increased demand of the EMS services within the City.


Figure 4. Location of TFD cardiac EMS calls by Occupancy

Cardiac sub categories were applied to the occupancies to identify trends. The greatest

number of responses was located in residential and commercial occupancies with the chief

complaint of chest pain. Location and occupancy details are listed in Appendix F. The cardiac

sub categories were applied to the census tracts and noted that census tract 5301.04 was unlike

the other tracts. Census tract 5301.04 is the most populated tract, 65.6% of the cardiac responses

were cardiac problems (not chest pain) however the female to male ration is equal and aspects

investigated appear to within the normal range or equitable to the census tracts. This deserves

further attention. Census tract 5301.01 has a unique identifier that it has a considerable populace

of cardiac responses for cardiac problems (not chest pain). Table 1 illustrates the correlation of

census tracts and cardiac sub categories.

Table 1.Correlation of Census Tracts and Cardiac Sub Categories

5301.01 5301.03 5301.04 5301.05 5301.08 5327.01 Cardiac Arrest (Non-Traumatic) 0.0% 6.3% 12.5% 11.1% 3.8% 0.0% Cardiac Problems (not chest pain) 37.5% 6.3% 65.6% 11.1% 19.2% 6.7% Chest Pain 50.0% 81.3% 21.9% 71.4% 76.9% 86.7% Hypertension 12.5% 0.0% 0.0% 3.2% 0.0% 6.7% Hypotension 0.0% 6.3% 0.0% 3.2% 0.0% 0.0%


Appendix F depicts age and occupancy type. The two largest response locations were

residential with a median age of 68 years old and commercial occupancies with a median age of

48 years old.

What are the cardiac events, location or population groups that should be the focus of the

community cardiac risk reduction?

The occupancy type most at risk is residential areas with thirty-four percent of the cardiac

responses closely followed by commercial with thirty percent of the EMS cardiac responses.

The occupancy types were superimposed on corresponding census tracts and the findings are

illustrated in Figure 5.

Figure 5. Location types superimposed on corresponding census tracts from 2010

The locations most at risk are census tract 5301.05 and 5301.04. Census tract 5301.05

had the greatest number of cardiac responses and the least amount of recorded population within

the Twinsburg Census Tracts. There are a significant number of commercial and industrial

facilities located within census tract 5301.05 contributing to the high number of cardiac

responses to commercial 0ccupancy types. The average age of commercial type cardiac response


is 48 years old with approximately seventy-one percent of the requests categorized as chest pain.

Census tract 5301.4 represents the highest population and the greatest number of residential EMS

cardiac responses.

The Twinsburg community cardiac risk reduction program should focus on commercial

type facilities within census tract 5301.05 and residential locations within census tract 5301.04.

The cardiac event cited most frequently is chest pain for census tract 5301.05 and cardiac

problems (not chest pain) in census tract 5301.04.

The literature review and the interview with the Mayor of Twinsburg discussed the cost

of healthcare for businesses and the City of Twinsburg. The increasing cost of healthcare is

increasing with no significant relief in sight however healthcare prevention has proven to

decrease health care expenditures.

What are the common components of a cardiac wellness program?

The components of a cardiac wellness program must be tailored to the demographics and

socioeconomic status of the community. It is critical to have involvement of the community

prior to establishing a program to create empowerment of the people, cultural knowledge, and

build collaborative partnerships. The City of Twinsburg has initiated the first step through a Fit

in Twinsburg (FIT) initiative in collaboration with the Cleveland Clinic Foundation. Initial

screenings for the City employees were completed to highlight modifiable risk and provide

education to understand the results of the screening. The employees were a test group; the plans

are to offer screenings and education to the entire Community of Twinsburg. The U change U

program offered to the Community includes education on diet, exercise, life style modification

and stress management to promote healthy living. The equivalent topics should be included in a

cardiac risk reduction program.


Discussion

Pre-hospital care has the unique ability to assess the patient and their immediate

environment. The environment provides clues to lifestyle, living conditions, and social

dynamics that may not be accessible to the emergency department physician. The public health

realm provides additional resources to reduce cardiac risk, EMS demand, and healthcare costs

for the community (Bigham et al., 2013). This distinctive perspective allows Twinsburg Fire

Department Paramedics to have access to patients that are inaccessible to most health care

professionals. Paramedics are able to recognize on scene circumstances that impact health,

safety, and welfare of the patient and others who may be present (Chubb, 2001).

Electronic EMS reporting systems provide immediate data accessibility to view trends

identify high frequency patients, high frequency locations and utilize epidemiology studies

(Dietze, Cvetkovski, Rumbold, & Miller, 2000)(CDC, 2010). Public health is a natural extension

of pre-hospital care. Public health and pre-hospital care pose similar challenges to solve with

disparate and incomplete information to guide treatments but not envisage the same result each

time. The product is an undertaking to amalgamate scientific action into community action

(Alexander et al., 2012). The ability of TFD paramedics to influence target audiences on scene

allows an entry point to gain insight and educate risk reduction strategies and lessen demand for

TFD EMS (Chubb, 2001).

Twinsburg Fire Department has collaborated on a community projects that have proven

to be successful in the past. The Twinsburg Cares program was developed in 2012 with the

Twinsburg Senior Center and Twinsburg Police Department. This program helped reduce the

number of public assist responses and increase the safety for homebound citizens. Citizens were

identified by TFD paramedics and provided resource information, and advised the Senior Center


Coordinator. The Senior Center Coordinator followed-up on patients to ensure the citizen could

access resources to increase their quality of life (L. Siefert, personal communication, September,

2013).

Reduction of cardiac risk factors and promotion of healthy living can be achieved

through collaborate efforts of community leaders and city services (Hudmon et al., 2011). The

City of Twinsburg has invested a great deal in the Parks and Recreational Department which

manages a fitness center, golf course, community center, senior center, aquatic center, multiple

ball park complexes, and 100 acres of natural park land. A variety of programs are offered at

each of the facilities however a coordinated cardiac risk reduction program is not available nor is

a target audience been identified. In addition to City resources there are two free standing

emergency departments located in the City of Twinsburg, the Cleveland Clinic Foundation

(CCF) Medical Campus and the Universities Health Hospitals System (UHHS) Medical Campus.

These entities are two of the largest health hospital systems in Northeast Ohio; both of which

have access to a great number of resources and community health expertise (DeVito-Staub,

2012).

A Twinsburg Cardiac Wellness Program should focus on identification and management

of modifiable risk and education for lifestyle modification based on the author’s findings.

Recruitment of collaborative partnerships is crucial for sustainability, funding, community

leadership and cultural knowledge to customize a program that is effective for the City of

Twinsburg. Coordination of current City resources and collaborative partnerships will aid in

reaching the target audiences located in census tract 5301.04 and census tract 5301.05 as

described in the Cardiac Risk Profile for the City of Twinsburg in Appendix H. Twinsburg Fire

Department and collaborative partnerships intends to create a cardiac risk prevention program to


concentration on commercial and industrial occupancies similar to previous TFD

Cardiopulmonary Resuscitation (CPR) programs offered to local businesses free of charge. .

Although cardiac risk reduction programs may present similar information the route of

implementation should vary depending on the target audience. The residential cardiac risk

profile must entail implementation strategies to reach the entire population some of which may

never leave their home (Loyo et al., 2013). The Twinsburg Fire Department provides valuable

insight, access, and disperses information to those hard to reach residents inaccessible to general

community wellness initiatives.

Improving the health of the community can translate into a stronger health and welfare of

the citizens and business members. With strength comes a greater ability to improve local

capacity; for instance, EMS response to emerging health issues and sustainability for community

development (Trickett et al., 2011). Alignment of the stakeholders within the community has the

capacity to stimulate cardiac risk reduction strategies but also become an incentive for

community networking and collaborative partnerships (Loyo et al., 2013).

Recommendations

The discoveries from the literature review, original research and data analysis encourage

the development of a cardiac risk profile and deliver guidance to reach those most affected by

cardiac conditions and direct resources more efficiently. The following recommendations will be

proposed to TFD and the Twinsburg FIT initiative committee:

• Establish collaborative partnerships for residential and commercial occupancies

for a cardiac risk reduction program

• Tailor cardiac risk reduction program implementation based on risk profile

• Expand EMScharts.com data compilation to 3-5 years


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Appendix A

Twinsburg Fire Department Medical Categories 2012

TFD 2012 Number of EMS responses Percentage of Total Call Volume

Cardiac 206 12.0% Injury 435 25.3% Airway/ Respiratory 151 8.8% General Medical 638 37.2% Endocrine 42 2.4% Behavioral 54 3.1% Environmental 12 0.7% Poison 12 0.7% Public Assist 109 6.4% Unknown 57 3.3%


Appendix A (continued)

Twinsburg Fire Department Medical Categories 2013

TFD - 2013 Number of EMS responses Percentage of Total Call Volume

Cardiac 166 9.7%

Injury 483 28.1%

Airway 126 7.3%

General Medical 745 43.4%

Endocrine 42 2.4%

Behavioral 53 3.1%

Environmental 7 0.4%

Poison 6 0.3%

Public Assist 74 4.3%

Unknown 14 0.8% Note. This table depicts the dispersion of EMS medical categories that Twinsburg Fire Department responded to in

2012 and 2013


Appendix A (continued)

University Health Hospitals Systems Medical Categories 2013

2013 - UUHS Medical Command Number of EMS Responses Percentage of Total Call Volume

Cardiac 2855 8.9%

Injury 7578 23.7%

Airway 2872 9.0%

General Medical 14871 46.5%

Endocrine 809 2.5%

Behavioral 1318 4.1%

Environmental 78 0.2%

Poison 317 1.0%

Public Assist 465 1.5%

Unknown 797 2.5%

Note. This table depicts the dispersion of EMS medical categories of forty-two local fire EMS based organizations and private EMS organizations


Appendix B

Appendix B illustrates gender differences and similarities with TFD cardiac responses.

0%20%40%60%80%

100%

Cardiac Medical Sub Categoriesby Gender

Female

Male


Appendix B (Continued)


Appendix C

Appendix C illustrates ethnicity data obtained by TFD Cardiac EMS responses for total

population & gender.


Appendix D

Risk factor analysis by gender and pre-existing conditions


Appendix D (continued)


Appendix E

Twinsburg Census Tracts

5301.01 5301.03 5301.04 5301.05 5301.08 5327.01 Population Total 5073 4682 7033.00 2136 4684 6522 Population Males 2596 2270 3527.00 1019 2102 3365 Population Females 2477 2412 3506.00 1117 2582 3157 Population under the age of 18 33.40% 28.90% 0.26 35.6 23.60% 23.40% Population 20- 44 years old 31.10% 28.50% 0.32 15.4 35.00% 35.60% Population 45-64 years old 25.90% 30.80% 0.27 31.2 24.70% 27.70% Population 65 years old and older 9.80% 11.80% 0.15 17.9 16.50% 13.30% Median Age 37.60 41.60 38.60 43.6 39.1 39.7 Median Male Age 36.40 36.7 35.00 38.3 37.9 39.0 Median Female Age 39.40 44.2 42.00 48.5 40.4 40.4 Education Attainment High School 22.20% 31.70% 28% 25.30% 22.00% 26.8 Education Attainment Bachelor 24.80% 27% 27% 25.30% 31.00% 29.7

Education Attainment Graduate 21.60% 14.10% 13% 18.30% 17.50% 16.7 Employed 76.90% 73.20% 58% 47.10% 54% 68.9 Unemployed 1.50% 1.50% 6% 12% 4% 3.0 Not in the labor force 21.70% 25.20% 35% 40.90% 22% 28.1 Median total household income 90,147 76,491 67512.00 26,208 64,451 69,862 Mean total household income 122,946 93,732 72440.00 51,176 51,176 88,731 Median Family Income 96,111 89,601 82273.00 51,927 89,000 69,862 Mean Family Income 134,009 109,152 84771.00 64,408 101,422 88,731 Per capita income 42,000 35,964 30071.00 22,204 39,869 36,410 Median earnings for workers 49,224 39,467 35503.00 29,625 35,503 40,160 Median earnings for male workers 67,328 70,477 59189.00 56,897 64,089 64,147 Median earnings for female workers 56,022 40,556 42176.00 40,530 42,179 45,477 Below poverty level last 12 months (all) 0.80% 1.2% 0.06 5.50% 1.30% 1.20%

("U.S. Census Bureau," n.d)


Appendix F

Information presented on location, census tract information and occupancy for TFD

Cardiac EMS responses.

Cardiac Sub Categories Commercial Extended

Care Residential Senior Living Totals Cardiac Arrest (Non-Traumatic) 2 5 2 0 9 Cardiac Problems (not chest pain) 6 4 10 1 21 Chest Pain 35 28 40 14 117 Hypertension 4 0 2 5 11 Hypotension 1 1 1 0 3 Total 48 38 55 20 161


Appendix G


Appendix H

Twinsburg Community Cardiac Risk Profile

Based on 2013 Twinsburg Fire Department Cardiac Emergency Responses

High Risk Locations:

Census Tract 5301.04

Census Tract 5301.05

Locations of Interest

Census Tract 5301.04 – Residential Locations

Census Tract 5301.05 – Commercial/ Industrial Locations

Cardiac Risk Focus

Census Tract 5301.04 – Hypertension

Census Tract 5301.05 – Hypertension

Age Range Focus

Census Tract 5301.04 – 65 and older

Census Tract 5301.05 – 45 – 65 years old

Gender Focus

Census Tract 5301.04 – Equal focus female and male

Census Tract 5301.05 – Equal focus female and male


Appendix I

Communication List

Name Organization Method Date Kathy Procop Twinsburg City Mayor Interview 5-Jun-13 Dan Ellenberger UHHS EMS Coordinator Interview 9-Jul-13 Susan Juris University Health Hospital Systems Interview 10-Jul-13 Matt Sabo UHHS & EMS Charts Coordinator Phone conversation 20-Jul-13 Matt Sabo UHHS & EMS Charts Coordinator Phone conversation 9-Aug-13 Matt Sabo UHHS & EMS Charts Coordinator Meeting 9-Sep-13 Laura Siefter Twinsburg Senior Center Phone conversation 14-Sep-13 Dan Ellenberger UHHS EMS Coordinator Phone conversation 20-Sep-13 Dan Ellenberger UHHS EMS Coordinator Phone conversation 30-Oct-13 Chad Bronson Cleveland Clinic Foundation Interview 17-Jan-14 Chad Bronson Cleveland Clinic Foundation FIT Meeting 9-Feb-14 Kathy Procop Twinsburg City Mayor FIT Meeting 9-Feb-14 Lynn Racine Twinsburg Fire Prevention Interview 4-Mar-14 Chad Bronson Cleveland Clinic Foundation FIT Meeting 10-Mar-14 Kathy Procop Twinsburg City Mayor FIT Meeting 10-Mar-14 Don Simon Twinsburg Fire Operations Email 14-Apr-14


Documents

Constructing a community cardiac health risk profile ...nfa.usfa.fema.gov/pdf/efop/efo48512.pdfHeart Association (AHA) a projected 40.8 % of the Unites States population will have