International variation in survival after out-of-hospital cardiac arrest: A validation study of the Utstein template

Outcomes and interventions in patients transported to hospital with ongoing CPR after out-of-hospital cardiac arrest - An observational study

Introduction

The main objective was to present characteristics and outcome of patients without sustained field return of spontaneous circulation (ROSC) transported to hospital with ongoing cardiopulmonary resuscitation (CPR). Our secondary objectives were to investigate hospital-based interventions and the performance of the universal Termination of Resuscitation-rule (uTOR).

Methods

In this retrospective observational cohort study, out-of-hospital cardiac arrest (OHCA) patients arriving to the emergency department of a university hospital in Sweden during a six-year period (2010–2015) were identified using a prospectively recorded hospital-based registry. Additional data were retrieved from medical records and from the Swedish cardiopulmonary resuscitation registry.

Results

Among 409 patients transported with ongoing CPR, 7 survived to hospital discharge (1.7%). Hospital-based interventions against a suspected cause of arrest were attempted during ongoing resuscitation in 34 patients (8.3%), of whom 3 survived to hospital discharge. The remaining 4 survivors had spontaneous in-hospital ROSC. Survivors presented with either a shockable rhythm (n = 4) or pulseless electrical activity (n = 3). The uTOR identified non-survivors with a positive predictive value (PPV) of 98.4% and a specificity of 71.4% for termination.

Conclusion

Survival after OHCA where sustained prehospital ROSC is not achieved is rare and available in-hospital interventions are rarely utilised. No patient with asystole as the first recorded rhythm survived. The uTOR identified non-survivors with a PPV of 98.4% but showed poor specificity.

Intensive care-treated cardiac arrest: a retrospective study on the impact of extended age on mortality, neurological outcome, received treatments and healthcare-associated costs

Background

Cardiac arrest (CA) is a leading cause of death worldwide. As population ages, the need for research focusing on CA in elderly increases. This study investigated treatment intensity, 12-month neurological outcome, mortality and healthcare-associated costs for patients aged over 75 years treated for CA in an intensive care unit (ICU) of a tertiary hospital.

Methods

This single-centre retrospective study included adult CA patients treated in a Finnish tertiary hospital’s ICU between 2005 and 2013. We stratified the study population into two age groups: <75 and \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\ge$$\end{document}≥75 years. We compared interventions defined by the median daily therapeutic scoring system (TISS-76) between the age groups to find differences in treatment intensity. We calculated cost-effectiveness by dividing the total one-year healthcare-associated costs of all patients by the number of survivors with a favourable neurological outcome. Favourable outcome was defined as a cerebral performance category (CPC) of 1–2 at 12 months after cardiac arrest. Logistic regression analysis was used to identify independent associations between age group, mortality and neurological outcome.

Results

This study included a total of 1,285 patients, of which 212 (16 %) were \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\ge$$\end{document}≥75 years of age. Treatment intensity was lower for the elderly compared to the younger group, with median TISS scores of 116 and 147, respectively (p < 0.001). The effective cost in euros for patients with a good one-year neurological outcome was €168,000 for the elderly and €120,000 for the younger group. At 12 months after CA 24 % of the patients in the elderly group and 47 % of the patients in the younger group had a CPC of 1–2 (p < 0.001). Age was an independent predictor of mortality (multivariate OR = 2.90, 95 % CI: 1.94–4.31, p < 0.001) and neurological outcome (multivariate OR = 3.15, 95 % CI: 2.04–4.86, p < 0.001).

Conclusions

The elderly ICU-treated CA patients in this study had worse neurological outcomes, higher mortality and lower cost-effectiveness than younger patients. Elderly received less intense treatment. Further efforts are needed to recognize the tools for assessing which elderly patients benefit from a more aggressive treatment approach in order to improve the cost-effectiveness of post-CA management.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00923-0.

To ventilate or not to ventilate during bystander CPR - A EuReCa TWO analysis

BACKGROUND

Survival after out-of-hospital cardiac arrest (OHCA) is still low. For every minute without resuscitation the likelihood of survival decreases. One critical step is initiation of immediate, high quality cardiopulmonary resuscitation (CPR). The aim of this subgroup analysis of data collected for the European Registry of Cardiac Arrest Study number 2 (EuReCa TWO) was to investigate the association between OHCA survival and two types of bystander CPR namely: chest compression only CPR (CConly) and CPR with chest compressions and ventilations (FullCPR).

METHOD

In this subgroup analysis of EuReCa TWO, all patients who received bystander CPR were included. Outcomes were return of spontaneous circulation and survival to 30-days or hospital discharge. A multilevel binary logistic regression analysis with survival as the dependent variable was performed.

RESULTS

A total of 5884 patients were included in the analysis, varying between countries from 21 to 1444. Survival was 320 (8%) in the CConly group and 174 (13%) in the FullCPR group. After adjustment for age, sex, location, rhythm, cause, time to scene, witnessed collapse and country, patients who received FullCPR had a significantly higher survival rate when compared to those who received CConly (adjusted odds ration 1.46, 95% confidence interval 1.17-1.83).

CONCLUSION

In this analysis, FullCPR was associated with higher survival compared to CConly. Guidelines should continue to emphasise the importance of compressions and ventilations during resuscitation for patients who suffer OHCA and CPR courses should continue to teach both.

Planning for Chaos: Developing the Concept of Emergency Preparedness through the Experience of the Paramedic

OBJECTIVE

Emergency preparedness is a developing specialty with a limited evidence base. Published literature primarily offers a retrospective view of experience, with few studies examining and understanding the individual lived experience of practitioners prospectively. This study explores paramedics' lived experience of emergency preparedness and applies that learning.

METHODS

Thirteen paramedics were recruited through purposive sampling. Face-to-face semi-structured interviews explored their individual experiences of emergency preparedness, in line with the idiographic focus of Interpretative Phenomenological Analysis.

RESULTS

Through data analysis, the following superordinate themes were identified for further discussion: self-determination, control, and experience-based practice. Participants appeared to value their role and the unpredictable environment in which they worked. Personal resilience, an area that they suggested is not covered effectively within individual preparation, was viewed as important. The participants articulated that risk, threat, uncertainty, safety, trust, and control were important concepts within individual preparedness. These paramedics valued practice-based knowledge and education as credible and transferrable to their clinical work.

CONCLUSION

Evidence from this study suggests that standard emergency preparedness, with the focus at organizational level, is not sufficient for the individual workers or for an overall effective response. Dimensions of individual preparedness are presented, with the paramedic central to the experience within a conceptual model (the DiEP model), creating a new form of emergency preparedness that reflects the individual paramedic's experience.

European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care

The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation and organ donation.

European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2021: Post-resuscitation care

The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation, and organ donation.

Temporal Trends of Out-of-Hospital Cardiac Arrests Without Resuscitation Attempt by Emergency Medical Services

BACKGROUND

Significant improvements in survival from out-of-hospital cardiac arrest (OHCA) have been reported; however, these are based only on data from OHCA in whom resuscitation is initiated by emergency medical services (EMS). We aimed to assess the characteristics and temporal trends of OHCA without resuscitation attempt by EMS.

METHODS

Prospective population-based study between 2011 and 2016 in the Greater Paris area (6.7 million inhabitants). All cases of OHCA were included in collaboration with EMS units, 48 different hospitals, and forensic units.

RESULTS

Among 15 207 OHCA (mean age 70.7±16.9 years, 61.6% male), 5486 (36.1%) had no resuscitation attempt by EMS. Factors that were independently associated with increase in likelihood of no resuscitation attempt included: age of patients (odds ratio, 1.06 per year [95% CI, 1.05-1.06], P<0.001), female sex (odds ratio, 1.21 [95% CI, 1.10-1.32], P=0.002), OHCA at home location (odds ratio, 3.38 [95%CI, 2.86-4.01], P<0.001), and absence of bystander (odds ratio, 1.94 [95% CI, 1.74-2.16], P<0.001). Overall, the annual number of OHCA increased by 9.1% (from 2923 to 3189, P=0.028). This increase was related to an increase of the annual number of OHCA without resuscitation attempt by EMS by 26.3% (from 993 to 1253, P=0.012), while the annual number of OHCA with resuscitation attempt by EMS did not significantly change (from 1930 to 1936, P=0.416). Considering only cases with resuscitation attempt, survival rate at hospital discharge increased (from 7.3% to 9.5%, P=0.02). However, when considering all OHCA, survival improvement did not reach statistical significance (from 4.8% to 5.7%, P=0.17).

CONCLUSIONS

We demonstrated an increase of the total number of OHCA related to an increase of the number of OHCA without resuscitation attempt by EMS. This increasing proportion of OHCA without resuscitation attempt attenuates improvement in survival rates achieved in EMS-treated patients.

Characteristics and outcome after out-of-hospital cardiac arrest with the emphasis on workplaces: an observational study from the Swedish Registry of Cardiopulmonary Resuscitation

Background

Characteristics and outcome in out-of-hospital cardiac arrest (OHCA) occurring at workplaces is sparsely studied.

Aim

To describe (1) the characteristics and 30-day survival of OHCAs occurring at workplaces in comparison to OHCAs at other places and (2) factors associated with survival after OHCAs at workplaces.

Methods

Data on OHCAs were obtained from the Swedish Registry of Cardiopulmonary Resuscitation from 1 January 2008 to 31 December 2018. Characteristics and factors associated with survival were analysed with emphasis on the location of OHCAs.

Results

Among 47,685 OHCAs, 529 cases (1%) occurred at workplaces. Overall, in the fully adjusted model, all locations of OHCA, with the exception of crowded public places, displayed significantly lower probability of survival than workplaces. Exhibiting a shockable rhythm was the strongest predictor of survival among patients with OHCAs at workplaces; odds ratio (95% CI) 5.80 (2.92-12.31). Odds ratio for survival for women was 2.08 (95% CI 1.07-4.03), compared with men. At workplaces other than private offices, odds ratio for survival was 0.41 (95% CI 0.16-0.95) for cases who did not receive bystander CPR, as compared to those who did receive CPR. Among patients who were found in a shockable rhythm were 23% defibrillated before arrival of ambulance, which was more frequent than in any other location.

Conclusion

Out-of-hospital cardiac arrest occurring at workplaces and crowded public places display the highest probability of survival, as compared with other places outside hospital. An initial shockable cardiac rhythm was the strongest predictor of survival for OHCA at workplaces.

Willingness to perform bystander cardiopulmonary resuscitation: A scoping review

Background

Despite the proven effectiveness of rapid initiation of cardiopulmonary resuscitation (CPR) for patients with out-of-hospital cardiac arrest (OHCA) by bystanders, fewer than half of the victims actually receive bystander CPR. We aimed to review the evidence of the barriers and facilitators for bystanders to perform CPR.

Methods

This scoping review was conducted as part of the continuous evidence evaluation process of the International Liaison Committee on Resuscitation (ILCOR), and followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. This review included studies assessing barriers or facilitators for the lay rescuers to perform CPR in actual emergency settings and excluded studies that overlapped with other ILCOR systematic reviews/scoping reviews (e.g. dispatcher instructed CPR etc). The key findings were classified into three kinds of factors: personal factors; CPR knowledge; and procedural issues.

Results

We identified 18 eligible studies. Of these studies addressing the reduced willingness to respond to cardiac arrest, 14 related to "personal factors", 3 to "CPR knowledge", and 2 to "procedural issues". On the other hand, we identified 5 articles assessing factors increasing bystanders' willingness to perform CPR. However, we observed significant heterogeneity among study populations, methodologies, factors definitions, outcome measures utilized and outcomes reported.

Conclusions

We found that a number of factors were present in actual settings which either inhibit or facilitate lay rescuers' performance of CPR. Interventional strategies to improve CPR performance of lay rescuers in the actual settings should be established, taking these factors into consideration.

Cost-effectiveness of a novel smartphone application to mobilize first responders after witnessed OHCA in Belgium

Background

EVapp (Emergency Volunteer Application) is a Belgian smartphone application that mobilizes volunteers to perform cardiopulmonary resuscitation (CPR) and defibrillation with publicly available automatic external defibrillators (AED) after an emergency call for suspected out of hospital cardiac arrest (OHCA). The aim is to bridge the time before the arrival of the emergency services.

Methods

An accessible model was developed, using literature data, to simulate survival and cost-effectiveness of nation-wide EVapp implementation. Initial validation was performed using field data from a first pilot study of EVapp implementation in a city in Flanders, covering 2.5 years of implementation.

Results

Simulation of nation-wide EVapp implementation resulted in an additional yearly 910 QALY gained over the current baseline case scenario (worst case 632; best case 3204). The cost per QALY associated with EVapp implementation was comparable to the baseline scenario, i.e., 17 vs 18 k€ QALY⁻¹.

Conclusions

EVapp implementation was associated with a positive balance on amount of QALY gained and cost of QALY. This was a consequence of both the lower healthcare costs for patients with good neurological outcome and the more efficient use of yet available resources, which did not outweigh the costs of operation.

Incidence and Outcomes of Out-of-Hospital Cardiac Arrest in Singapore and Victoria: A Collaborative Study

Background Incidence and outcomes of out-of-hospital cardiac arrest (OHCA) vary between communities. We aimed to examine differences in patient characteristics, prehospital care, and outcomes in Singapore and Victoria. Methods and Results Using the prospective Singapore Pan-Asian Resuscitation Outcomes Study and Victorian Ambulance Cardiac Arrest Registry, we identified 11 061 and 32 003 emergency medical services-attended adult OHCAs between 2011 and 2016 respectively. Incidence and survival rates were directly age adjusted using the World Health Organization population. Survival was analyzed with logistic regression, with model selection via backward elimination. Of the 11 061 and 14 834 emergency medical services-treated OHCAs (overall mean age±SD 65.5±17.2; 67.4% males) in Singapore and Victoria respectively, 11 054 (99.9%) and 5595 (37.7%) were transported, and 440 (4.0%) and 2009 (13.6%) survived. Compared with Victoria, people with OHCA in Singapore were older (66.7±16.5 versus 64.6±17.7), had less shockable rhythms (17.7% versus 30.3%), and received less bystander cardiopulmonary resuscitation (45.7% versus 58.5%) and defibrillation (1.3% versus 2.5%) (all P<0.001). Age-adjusted OHCA incidence and survival rates increased in Singapore between 2011 and 2016 (P<0.01 for trend), but remained stable, though higher, in Victoria. Likelihood of survival increased significantly (P<0.001) with arrest in public locations (adjusted odds ratio [aOR] 1.81), witnessed arrest (aOR 2.14), bystander cardiopulmonary resuscitation (aOR 1.72), initial shockable rhythm (aOR 9.82), and bystander defibrillation (aOR 2.04) but decreased with increasing age (aOR 0.98) and emergency medical services response time (aOR 0.91). Conclusions Singapore reported increasing OHCA incidence and survival rates between 2011 and 2016, compared with stable, albeit higher, rates in Victoria. Survival differences might be related to different emergency medical services practices including patient selection for resuscitation and transport.

Description of Emergency Medical Services, treatment of cardiac arrest patients and cardiac arrest registries in Europe

Background

Variation in the incidence, survival rate and factors associated with survival after cardiac arrest in Europe is reported. Some studies have tried to fill the knowledge gap regarding the epidemiology of out-of-hospital cardiac arrest in Europe but were unable to identify reasons for the reported differences. Therefore, the purpose of this study was to describe European Emergency Medical Systems, particularly from the perspective of country and ambulance service characteristics, cardiac arrest identification, dispatch, treatment, and monitoring.

Methods

An online questionnaire with 51 questions about ambulance and dispatch characteristics, on-scene management of cardiac arrest and the availability and dataset in cardiac arrest registries, was sent to all national coordinators who participated in the European Registry of Cardiac Arrest studies. In addition, individual invitations were sent to the remaining European countries.

Results

Participants from 28 European countries responded to the questionnaire. Results were combined with official information on population density. Overall, the number of Emergency Medical Service missions, level of training of personnel, availability of Helicopter Emergency Medical Services and the involvement of first responders varied across and within countries. There were similarities in team training, availability of key resuscitation equipment and permission for ongoing performance of cardiopulmonary resuscitation during transported. The quality of reporting to cardiac arrest registries varied, as well as the data availability in the registries.

Conclusions

Throughout Europe there are important differences in Emergency Medical Service systems and the response to out-of-hospital cardiac arrest. Explaining these differences is complicated due to significant variation in how variables are reported to and used in registries.

Community lessons to understand resuscitation excellence (culture): Association between emergency medical services (EMS) culture and outcome after out-of-hospital cardiac arrest

BACKGROUND

The large geographic variation in outcome after out-of-hospital cardiac arrest (OHCA) is not well explained by traditional patient and emergency medical services (EMS) characteristics. A 'culture of excellence' in resuscitation within an EMS is believed to be an important factor that influences quality of care and outcome in patients with OHCA. However, whether a culture of excellence is associated with improved survival after OHCA is not known.

METHODOLOGY

We linked survey responses from EMS agency medical directors related to resuscitation culture to a retrospective analysis of prospectively collected data from the Resuscitation Outcomes Consortium (ROC) Epistry - Cardiac Arrest. We used a multivariable random effects model to assess whether EMS culture strategies were associated with OHCA survival to hospital discharge.

RESULTS

Of the 46 EMS medical directors surveyed, 35 (76%) provided a complete response. Included were n = 66,597 cases of OHCA who received attempted resuscitation by one of n = 123 EMS agencies from July 1, 2010, through June 30, 2015. Overall survival to discharge was 11%. Organizational values and goals were independently associated with survival to hospital discharge in all OHCAs (adjusted odds ratio [AOR] 1.27, 95% confidence interval [CI] 1.09-1.48) and the subgroup restricted to bystander witnessed OHCAs with initial shockable rhythm (AOR 1.55, 95% CI 1.21-1.99).

CONCLUSIONS

An organizational goal to improve OHCA survival was independently associated with improved survival to discharge. EMS agencies looking to improve OHCA survival should consider implementing an organizational goal to improve OHCA survival and empower quality improvement personnel to drive that goal.

Brain injury after cardiac arrest: from prognostication of comatose patients to rehabilitation

More patients are surviving cardiac arrest than ever before; however, the burden now lies with estimating neurological prognoses in a large number of patients who were initially comatose, in whom the ultimate outcome is unclear. Neurologists, neurointensivists, and clinical neurophysiologists must accurately balance the concern that overly conservative prognostication could leave patients in a severely disabled state, with the possibility that inaccurately pessimistic prognostication could lead to the withdrawal of life-sustaining treatment in patients who might otherwise have a good functional outcome. Prognostic tools have improved greatly, including electrophysiological tests, neuroimaging, and chemical biomarkers. Conclusions about the prognosis should be delayed at least 72 h after arrest to allow for the clearance of sedative drugs. Cognitive impairments, emotional problems, and fatigue are common among patients who have survived cardiac arrest, and often go unrecognised despite being related to caregiver burden and a decreased participation in society. Through simple screening, these problems can be identified, and patients can be provided with adequate information and rehabilitation.

Telephone CPR: Current Status, Challenges, and Future Perspectives

With each successive update of the cardiopulmonary resuscitation (CPR) guidelines, the role of dispatchers in sudden cardiac arrest (CA) has grown. Dispatchers instruct callers in how to perform CPR until the arrival of emergency medical service (EMS) professionals. This is widely known as telephone CPR (TCPR) or dispatch-assisted CPR (DACPR). Studies have shown the efficacy of TCPR in increasing the survival rate of sudden CA. The TCPR process, however, is challenging and needs to be constantly evaluated and refined in order to improve the survival rate of sudden CA victims throughout the world. In this review article, the current status, challenges, and future perspectives of TCPR are discussed with a view to providing a research foundation from which to launch further studies into the effective role of dispatchers in sudden CA.

Effects of Prehospital Factors on Survival of Out-Of-Hospital Cardiac Arrest Patients: Age-Dependent Patterns

Many prehospital factors that are known to influence survival rates after out-of-hospital cardiac arrest (OHCA) have been rarely studied as to how their influence varies depending on the age. In this study, we tried to find out what prehospital factors affect the survival rate after OHCA by age groups and how large the effect size of those factors is in each age group. We used the South Korean OHCA registry, which includes information on various prehospital factors relating OHCA and final survival status. The association between prehospital factors and survival was explored through logistic regression analyses for each age group. The effects of prehospital factors vary depending on the patient’s age. Being witnessed was relatively more influential in younger patients and the presence of first responders became more important as patients became older. While bystander cardiopulmonary resuscitation (CPR) did not appear to significantly affect survival in younger people, use of an automated external defibrillator (AED) showed the largest effect size on the survival in all age groups. Since the pathophysiology and etiologies of OHCA vary according to age, more detailed information on life support by age is needed for the development and application of more specialized protocols for each age.

Low hemoglobin and venous saturation levels are associated with poor neurological outcomes after cardiac arrest

INTRODUCTION

Hemoglobin (Hb) is a main determinant of tissue oxygen delivery and anemia could be particularly harmful in post-anoxic brain injury. The aim of this study was to evaluate the association of Hb and venous Hb oxygen saturation (SvO₂/ScvO₂) with long-term neurological outcome in patients admitted after cardiac arrest (CA).

METHODS

Analysis of adult CA patients admitted to the Department of Intensive Care of the Erasme University Hospital (Brussels, Belgium) over 9 years. We retrieved all data concerning CA characteristics as well as Hb during the first 48 h since injury as well as the need for red blood cells transfusions (RBCT). Minimum Hb and Hb oxygen saturation values were recorded. Neurological outcome was evaluated 3 months after CA. Unfavorable neurological outcome (UO) was defined as a Cerebral Performance Categories (CPC) score of 3-5.

RESULTS

We treated 414 patients patients with CA, including 231 (56%) out-of-hospital cardiac arrest (OHCA) and 158 (38%) with an initial shockable rhythm. Median Hb concentration on admission was 12.0 [9.9-13.7] g/dL and the lowest Hb concentration was 10.0 [8.1-11.0] g/dL; 127 patients (31%) received at least one RBCT. Hb oxygen saturation on admission was 67 [59-74]%, while the lowest value was 60 [53-68]%. Low Hb and Hb oxygen saturation values were independently associated with UO; the optimal cut-off to predict UO was <9.9 g/dL and <60%, respectively.

CONCLUSIONS

Low hemoglobin values and low values of oxygen venous saturation are significantly associated with unfavorable neurological outcome in adult patients resuscitated from cardiac arrest.

Out-of-hospital cardiac arrest across the World: First report from the International Liaison Committee on Resuscitation (ILCOR)

BACKGROUND

Since development of the Utstein style recommendations for the uniform reporting of cardiac arrest, increasing numbers of national and regional out-of-hospital cardiac arrest (OHCA) registries have been established worldwide. The International Liaison Committee on Resuscitation (ILCOR) created the Research and Registries Working Group and aimed to systematically report data collected from these registries.

METHODS

We conducted two surveys of voluntarily participating national and regional registries. The first survey aimed to identify which core elements of the current Utstein style for OHCA were collected by each registry. The second survey collected descriptive summary data from each registry. We chose the data collected for the second survey based on the availability of core elements identified by the first survey.

RESULTS

Seven national and four regional registries were included in the first survey and nine national and seven regional registries in the second survey. The estimated annual incidence of emergency medical services (EMS)-treated OHCA was 30.0-97.1 individuals per 100,000 population. The combined data showed the median age varied from 64 to 79 years and more than half were male in all 16 registries. The provision of bystander cardiopulmonary resuscitation (CPR) and bystander automated external defibrillator (AED) use was 19.1-79.0% in all registries and 2.0-37.4% among 11 registries, respectively. Survival to hospital discharge or 30-day survival after EMS-treated OHCA was 3.1-20.4% across all registries. Favorable neurological outcome at hospital discharge or 30 days after EMS-treated OHCA was 2.8-18.2%. Survival to hospital discharge or 30-day survival after bystander-witnessed shockable OHCA ranged from 11.7% to 47.4% and favorable neurological outcome from 9.9% to 33.3%.

CONCLUSION

This report from ILCOR describes data on systems of care and outcomes following OHCA from nine national and seven regional registries across the world. We found variation in reported survival outcomes and other core elements of the current Utstein style recommendations for OHCA across nations and regions.

GPs who volunteer to be first responders for out-of-hospital cardiac arrest: A qualitative study

Background: Out-of-hospital cardiac arrest (OHCA) is a major cause of premature mortality. Survival is possible when timely cardiopulmonary resuscitation and defibrillation are available in the community. GPs are well placed to provide early OHCA care and significantly increased rates of survival are achieved when GPs participate in resuscitation. A novel project alerts volunteer GP first responders to nearby OHCAs in Ireland.

Objectives: To explore the reasons why GPs volunteer to be OHCA first responders and their experience of participation.

Methods: A qualitative study involving in-depth, semi-structured interviews followed by thematic analysis was undertaken in 2017/18. Fourteen GPs from differing geographical areas in Ireland, who volunteered as OHCA first-responders were recruited to participate by purposive methods.

Results: GP participation in OHCA voluntary first response was understood as a function of GPs relationship to the community, their ability to manage competing demands in their personal and professional lives and also specific participatory gains. GPs expressed both altruistic motivations and a sense of obligation. GPs described a complex, multifaceted role in providing OHCA first response; they derived an inherent sense of satisfaction in delivering potentially life-saving interventions but also in the provision of holistic, compassionate end-of-life care for patients and their families. Participation was not without psychosocial risk for GPs.

Conclusion: GPs volunteer to provide early OHCA emergency care because of their relationship to the community. Care provided is complex and includes both resuscitation and end-of-life care.

Community first responders for out-of-hospital cardiac arrest in adults and children

BACKGROUND

Mobilization of community first responders (CFRs) to the scene of an out-of-hospital cardiac arrest (OHCA) event has been proposed as a means of shortening the interval from occurrence of cardiac arrest to performance of cardiopulmonary resuscitation (CPR) and defibrillation, thereby increasing patient survival.

OBJECTIVES

To assess the effect of mobilizing community first responders (CFRs) to out-of-hospital cardiac arrest events in adults and children older than four weeks of age, in terms of survival and neurological function.

SEARCH METHODS

We searched the following databases for relevant trials in January 2019: CENTRAL, MEDLINE (Ovid SP), Embase (Ovid SP), and Web of Science. We also searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov, and we scanned the abstracts of conference proceedings of the American Heart Association and the European Resuscitation Council.

SELECTION CRITERIA

We included randomized and quasi-randomized trials (RCTs and q-RCTs) that compared routine emergency medical services (EMS) care versus EMS care plus mobilization of CFRs in instances of OHCA.Trials with randomization by cluster were eligible for inclusion, including cluster-design studies with intervention cross-over.In some communities, the statutory ambulance service/EMS is routinely provided by the local fire service. For the purposes of this review, this group represents the statutory ambulance service/EMS, as distinct from CFRs, and was not included as an eligible intervention.We did not include studies primarily focused on opportunistic bystanders. Individuals who were present at the scene of an OHCA event and who performed CPR according to telephone instruction provided by EMS call takers were not considered to be CFRs.Studies primarily assessing the impact of specific additional interventions such as administration of naloxone in narcotic overdose or adrenaline in anaphylaxis were also excluded.We included adults and children older than four weeks of age who had experienced an OHCA.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed all titles and abstracts received to assess potential eligibility, using set inclusion criteria. We obtained and examined in detail full-text copies of all papers considered potentially eligible, and we approached authors of trials for additional information when necessary. We summarized the process of study selection in a PRISMA flowchart.Three review authors independently extracted relevant data using a standard data extraction form and assessed the validity of each included trial using the Cochrane 'Risk of bias' tool. We resolved disagreements by discussion and consensus.We synthesized findings in narrative fashion due to the heterogeneity of the included studies. We used the principles of the GRADE system to assess the certainty of the body of evidence associated with specific outcomes and to construct a 'Summary of findings' table.

MAIN RESULTS

We found two completed studies involving a total of 1136 participants that ultimately met our inclusion criteria. We also found one ongoing study and one planned study. We noted significant heterogeneity in the characteristics of interventions and outcomes measured or reported across these studies, thus we could not pool study results.One completed study considered the dispatch of police and fire service CFRs equipped with automatic external defibrillators (AEDs) in an EMS system in Amsterdam and surrounding areas. This study was an RCT with allocation made by cluster according to non-overlapping geographical regions. It was conducted between 5 January 2000 and 5 January 2002. All participants were 18 years of age or older and had experienced witnessed OHCA. The study found no difference in survival at hospital discharge (odds ratio (OR) 1.3, 95% confidence interval (CI) 0.8 to 2.2; 1 RCT; 469 participants; low-certainty evidence), despite the observation that all 72 incidences of defibrillation performed before EMS arrival occurred in the intervention group (OR and 95% CI - not applicable; 1 RCT; 469 participants; moderate-certainty evidence). This study reported increased survival to hospital admission in the intervention group (OR 1.5, 95% CI 1.1 to 2.0; 1 RCT; 469 participants; moderate-certainty evidence).The second completed study considered the dispatch of nearby lay volunteers in Stockholm, Sweden, who were trained to perform cardiopulmonary resuscitation (CPR). This represented a supplementary CFR intervention in an EMS system where police and fire services were already routinely dispatched to OHCA in addition to EMS ambulances. This study, an RCT, included both witnessed and unwitnessed OHCA and was conducted between 1 April 2012 and 1 December 2013. Participants included adults and children eight years of age and older. Researchers found no difference in 30-day survival (OR 1.34, 95% CI 0.79 to 2.29; 1 RCT; 612 participants; low-certainty evidence), despite a significant increase in CPR performed before EMS arrival (OR 1.49, 95% CI 1.09 to 2.03; 1 RCT; 665 participants; moderate-certainty evidence).Neither of the included completed studies considered neurological function at hospital discharge or at 30 days, measured by cerebral performance category or by any other means. Neither of the included completed studies considered health-related quality of life. The overall certainty of evidence for the outcomes of included studies was low to moderate.

AUTHORS' CONCLUSIONS

Moderate-certainty evidence shows that context-specific CFR interventions result in increased rates of CPR or defibrillation performed before EMS arrival. It remains uncertain whether this can translate to significantly increased rates of overall patient survival. When possible, further high-quality RCTs that are adequately powered to measure changes in survival should be conducted.The included studies did not consider survival with good neurological function. This outcome is likely to be important to patients and should be included routinely wherever survival is measured.We identified one ongoing study and one planned trial whose results once available may change the results of this review. As this review was limited to randomized and quasi-randomized trials, we may have missed some important data from other study types.