Deutsches Reanimationsregister

Ambulance deployment without transport: a retrospective difference analysis for the description of emergency interventions without patient transport in Bavaria

BACKGROUND

Not all patients who call the ambulance service are subsequently transported to hospital. In 2018, a quarter of deployments of an emergency ambulance in Bavaria were not followed by patient transport. This study describes factors that influence patient transport rates.

METHOD

This is a retrospective cross-sectional study based on data from all Integrated Dispatch Centres of the Free State of Bavaria in 2018. Included were ambulance deployments without emergency physician involvement, which were subdivided into ambulance deployments without transport and ambulance deployments with transport. The proportion of transported patients were determined for the primary reasons for deployment and for the different community types. On-scene time was compared for calls with and without patient transport. Differences were tested for statistical significance using Chi2 tests and the odds ratio was calculated to determine differences between groups.

RESULTS

Of 510,145 deployments, 147,621 (28.9%) could be classified as ambulance deployments without transport and 362,524 (71.1%) as ambulance deployments with transport.The lowest proportion of patients transported was found for activations where the fire brigade was involved ("fire alarm system" 0.6%, "fire with emergency medical services" 5.4%) and "personal emergency response system active alarm" (18.6%). The highest transport rates were observed for emergencies involving "childbirth/delivery" (96.9%) and "trauma" (83.2%). A lower proportion of patients is transported in large cities as compared to smaller cities or rural communities; in large cities, the odds ratio for emergencies without transport is 2.02 [95% confidence interval 1.98-2.06] referenced to rural communites. The median on-scene time for emergencies without transport was 20.8 min (n = 141,052) as compared to 16.5 min for emergencies with transport (n = 362,524). The shortest on-scene times for emergencies without transport were identified for activations related to "fire alarm system" (9.0 min) and "personal emergency response system active alarm" (10.6 min).

CONCLUSION

This study indicates that the proportion of patients transported depends on the reason for deployment and whether the emergency location is urban or rural. Particularly low transport rates are found if an ambulance was dispatched in connection with a fire department operation or a personal emergency medical alert button was activated. The on-scene-time of the rescue vehicle is increased for deployments without transport. The study could not provide a rationale for this and further research is needed. Trial registration This paper is part of the study "Rettungswageneinsatz ohne Transport" ["Ambulance deployment without transport"] (RoT), which was registered in the German Register of Clinical Studies under the number DRKS00017758.

German Cardiac Arrest Registry: rationale and design of G-CAR

BACKGROUND

In Germany, 70,000-100,000 persons per year suffer from out-of-hospital cardiac arrest (OHCA). Despite medical progress, survival rates with good neurological outcome remain low. For many important clinical issues, no or only insufficient evidence from randomised trials is available. Therefore, a systemic and standardised acquisition of the treatment course and of the outcome of OHCA patients is warranted.

STUDY DESIGN

The German Cardiac Arrest Registry (G-CAR) is an observational, prospective, multicentre registry. It will determine the characteristics, initial treatment strategies, invasive procedures, revascularisation therapies and the use of mechanical circulatory support devices with a focus on extracorporeal cardiopulmonary resuscitation. A special feature is the prospective 12-month follow-up evaluating mortality, neurological outcomes and several patient-reported outcomes in the psychosocial domain (health-related quality of life, cognitive impairment, depression/anxiety, post-traumatic stress disorder and social reintegration). In a pilot phase of 24 months, 15 centres will include approximately 400 consecutive OHCA patients ≥ 18 years. Parallel to and after the pilot phase, scaling up of G-CAR to a national level is envisaged.

CONCLUSION

G-CAR is the first national registry including a long-term follow-up for adult OHCA patients. Primary aim is a better understanding of the determinants of acute and long-term outcomes with the perspective of an optimised treatment.

TRIAL REGISTRY

NCT05142124. German Cardiac Arrest Registry (G-CAR).

[Treatment of severely injured patients by emergency physicians from different medical specialties : A retrospective multicenter investigation of data from the ADAC Air Recue Service and the German TraumaRegister DGU®]

BACKGROUND AND OBJECTIVE

The level 3 guidelines on treatment of patients with severe/multiple injuries provide a defined framework for an appropriate treatment of these patients. It is presumed that prehospital diagnostic and therapeutic decisions are affected by the clinical expertise and the medical disciplines of the emergency physicians.

METHODS

Retrospective, multicenter study based on data from the ADAC Air Recue Service and the TraumaRegister DGU®. In the study period 2011-2015, a total of 11,019 seriously injured patients were included. They were treated by emergency physicians from the following disciplines: anesthesiology (ANÄ), internal medicine (INN) and surgery (CHIR).

RESULTS

Of the patients 81.9% were treated by ANÄ, 7.6% by INN and 10.5% by CHIR. Preclinically, 40.5% of patients were intubated (ANÄ 43.0%, INN 31.2%, CHIR 28.3%; p < 0.001), 5.5% received pleural decompression (ANÄ 5.9%, INN 4.2%, CHIR 2.8%; p = 0.004),and 10.8% were treated with catecholamines (ANÄ 11.3%, INN 8.3%, CHIR 8.3%; p = 0.022). Unconscious patients were intubated in 96.0% (ANÄ 96.1%, INN 97.7%, CHIR 93.9%; p = 0.205). The mortality was not influenced by the medical specialty of the emergency physician.

CONCLUSION

In this air rescue cohort differences in indications for invasive procedures were observed between the groups. This may be caused by their clinical background. Using the example of intubation, it has been shown that guideline recommendations were closely followed irrespective of the medical specialty of the emergency physician.

Survival Following Lay Resuscitation

BACKGROUND

Resuscitation by laypersons is important in bridging the time between the occurrence of an out-of-hospital cardiac arrest (OHCA) and the arrival of emergency rescue service personnel. Depending on the reason for the cardiac arrest, however, the effectiveness of chest compressions is uncertain. The aim of this study was to explore the impact of lay resuscitation on survival following OHCA of different causes.

METHODS

The data set for analysis comprised all cases of cardiac arrest before the arrival of emergency rescue service personnel that were fully documented in the German Resuscitation Registry in the period 2007-2019. The following endpoints related to resuscitation by bystanders were evaluated-separately for each cause-descriptively and by means of multivariate logistic regression analysis: return of spontaneous circulation (ROSC), 30 days' survival/discharged alive from the hospital, and good neurological function at discharge.

RESULTS

Altogether, 40 604 cases of cardiac arrest were included. Resuscitation by laypersons was carried out in 35.1% of these cases. The rate of ROSC was statistically significantly higher after lay resuscitation for OHCA caused by cardiac events, drowning, intoxication, or central nervous system disorders (overall 48.1% versus 41.0%). For all causes-with the exception of trauma/bleeding to death and sepsis- the endpoint 30 days' survival/discharged alive was better with lay resuscitation (overall 17.0% versus 9.5%). In multivariate regression analysis, lay resuscitation was associated with improvement of the endpoint 30 days' survival/discharged alive only for OHCA caused by cardiac events (odds ratio [OR] 1.16) or intoxication (OR 1.81). For all other causes-except hypoxia-lay resuscitation tended to yield better results. Neurological function at discharge was also significantly better (overall 11.5% versus 6.1%) after lay resuscitation for OHCA of all causes except trauma/ bleeding to death, hypoxia, and sepsis.

CONCLUSION

Resuscitation by laypersons is associated with an improved result regarding the endpoint 30 days' survival/discharged alive in cases of OHCA caused by cardiac events and intoxication. These two groups account for 81% of the resuscitation patients in the study. Because there was also a tendency towards higher survival rates following OHCA of other causes (except hypoxia), laypersons should continue to be encouraged to attempt resuscitation in all cases of OHCA, whatever the cause.

More Than 500 Kids Could Be Saved Each Year! Ten Consensus Actions to Improve Quality of Pediatric Resuscitation in DACH-Countries (Austria, Germany, and Switzerland)

• Quality and outcome of pediatric resuscitation often does not achieve recommended goals. • Quality improvement initiatives with the aim of better survival rates and decreased morbidity of resuscitated children are urgently needed. • These initiatives should include an action framework for a comprehensive, fundamental, and interprofessional reorientation of clinical and organizational structures concerning resuscitation and post-resuscitation care of children. • The authors of this DACH position statement suggest the implementation of 10 evidence-based actions (for out-of-hospital and in-house cardiac arrests) that should improve survival rates and decrease morbidity of resuscitated children with better neurological outcome and quality of life.

[System and skill utilization in an Austrian emergency physician system: retrospective study]

BACKGROUND

The continuous rise in calls for emergency physicians and the low proportion of indicated missions has led to a loss of job attractiveness, which in turn renders services in some areas unable to sufficiently staff units. This retrospective analysis evaluated the frequency of emergency and general medical interventions in a ground-based emergency physician response system.

METHODS

A retrospective analysis of anonymized data from the electronic documentation system of the emergency physician response unit at the Medical University of Graz was carried out. Calls answered by emergency physicians between 2010 and 2018 were extracted, measures carried out were evaluated and categorized into three groups: specific emergency interventions (category I), general medical interventions (category II) and no medical activity (category III). The frequency of occurrence of these categories was compared and incidences of individual measures per 100,000 inhabitants were calculated.

RESULTS

A total of 15,409 primary responses and 322 secondary transports were extracted and analyzed. The annual rate of system activation rose almost continuously from 1442 calls in 2010 to 2301 calls in 2018. The 3687 (23.4%) cancellations resulted in 12,044 patient contacts. Of these, 2842 (18%) calls were coded as category I, 7372 (47%) as category II and 5518 (35%) as category III. The frequency of specific emergency measures and general medical interventions was estimated at 157/100,000 and 409/100,000 inhabitants, respectively.

CONCLUSIONS

No specific emergency physician interventions were required in the majority of call-outs. The current model of preclinical care does not appear to be patient-oriented and efficient. Furthermore, the low proportion of critically ill and injured patients already leads to a reduction in attractiveness for emergency physicians and may introduce the threat of quality issues due to insufficient routine experience and lack of training.

[Internal hospital emergency management : Concepts for optimization of patient safety in hospitals]

Critical incidents in hospitals can often be predicted hours before the event and can mostly be detected earlier and presumably avoided. Quality management programs from US hospitals to reduce deaths following a severe postoperative complication (failure to rescue, FTR), have in this form not yet become established in Germany. A sensitive score-based early warning system for looming complications is decisive for successful in-hospital emergency management. In addition to measurement rounds where the frequency is adapted to the severity, this includes effective communication of the results to the ward physician, who in the best case scenario solves the problem alone. If the deployment of a medical rapid response emergency team (MET) is necessary, there must be clear chain of alarm pathways and the personnel on the ward must be able to take initial bridging action until the MET arrives. The MET provides 24/7 emergency and intensive medical expertise for peripheral wards and must be familiar with the location, well-equipped and trained. Communication skills are particularly required not only to be able to handle the immediate emergency situation but also to organize the downstream diagnostics and escalation of treatment; however, the MET is only one of the links in the in-hospital rescue chain, which can only improve the patient outcome when alerted in a timely manner. Feedback systems, such as participation in the German Resuscitation Registry, allow reflection of one's own performance in a national comparison. The chances offered by a MET will only be fully realized when it is integrated into an in-hospital emergency concept and this determines the added value for patient safety.

On-the-Scene Hyaluronan and Syndecan-1 Serum Concentrations and Outcome after Cardiac Arrest and Resuscitation

Background

It is not predictable which patients will develop a severe inflammatory response after successful cardiopulmonary resuscitation (CPR), also known as “postcardiac arrest syndrome.” This pathology affects only a subgroup of cardiac arrest victims. Whole body ischemia/reperfusion and prolonged shock states after return of spontaneous circulation (ROSC) may both contribute to this devastating condition. The vascular endothelium with its glycocalyx is especially susceptible to initial ischemic damage and may play a detrimental role in the initiation of postischemic inflammatory reactions. It is not known to date if an immediate early damage to the endothelial glycocalyx, detected by on-the-scene blood sampling and measurement of soluble components (hyaluronan and syndecan-1), precedes and predicts multiple organ failure (MOF) and survival after ROSC.

Methods

15 patients after prehospital resuscitation were included in the study. Serum samples were collected on the scene immediately after ROSC and after 6 h, 12 h, 24 h, and 48 h. Hyaluronan and syndecan-1 were measured by ELISA. We associated the development of multiple organ failure and 30-day survival rates with these serum markers of early glycocalyx damage.

Results

Immediate serum hyaluronan concentrations show significant differences depending on 30-day survival. Further, the hyaluronan level is significantly higher in patients developing MOF during the initial and intermediate resuscitation period. Also, the syndecan-1 levels are significantly different according to MOF occurrence.

Conclusion

Serum markers of glycocalyx shedding taken immediately on the scene after ROSC can predict the occurrence of multiple organ failure and adverse clinical outcome in patients after cardiac arrest.

Outcome after pre-hospital cardiac arrest in accordance with underlying cause

AIM

In terms of treatment options, the underlying cause of out-of-hospital cardiac arrest (OHCA) has an impact on survival. This study aimed to examine the frequencies of different causes of OHCA and their outcomes using data from a national resuscitation registry.

METHODS

All pre-hospital cardiopulmonary resuscitations (CPR) documented in the German Resuscitation Registry between 2007 and 2017 were retrospectively investigated with regard to cause of cardiac arrest, return of spontaneous circulation (ROSC), and hospital discharge rate with good neurological outcome. To avoid selection bias, only rescue services with a return rate in the form 'further clinical treatment' of >30% were included, this resulted in a total return rate of 84% of the included data.

RESULTS

In total, 33,772 patients were included. The most common causes of OHCA were cardiac events (62.2%), hypoxia (11.1%) and trauma (3.2%), in 17.2% no or unknown cause were documented. Overall, 44.8% of patients achieved ROSC, 13.1% of patients were discharged alive from hospital and 68.3% of these were in good neurological condition (9.0% of all patients). ROSC rates differed between 8.9% (sudden infant death syndrome) and 64.4% (intracranial bleeding), while discharge rates with good neurological outcome ranged between 0.9% (sepsis) and 14.0% (intoxication).

CONCLUSION

The most common causes of OHCA are cardiac events and hypoxia. Depending on the underlying cause, outcome after pre-hospital CPR varies widely with a survival rate with good neurological outcome ranging from 0.9 to 14%.

[Systematic analysis of airway registries in emergency medicine]

BACKGROUND

A myriad of publications have contributed to an evidence-based approach to airway management in emergency services and admissions in recent years; however, it remains unclear which international registries on airway management in emergency medicine currently exist and how they are characterized concerning inclusion criteria, patient characteristics and definition of complications.

METHODS

A systematic literature research was carried out in PubMed with respect to publications from 2007-2017. All publications from airway registries collecting data on prehospital or emergency department (ED) airway management were included. Publications from pediatric intensive care units (PICU) were also included as long as they were the primary place of pediatric emergency care.

RESULTS

A total of eleven emergency airway registries (EAR) were identified that were primarily concerned with airway management. Furthermore, reported data on emergency airway management were extracted from different, national resuscitation registries. There was only one multinational EAR which exclusively collects data on pediatric emergency airway management (NEAR4KIDS, National Emergency Airway Registry for Kids). Additionally, all emergency department airway registries identified include data on pediatric emergency airway management to varying degrees (0.2-10.5%). Published observation periods were also highly variable with a minimum of 18 months and a maximum of 156 months. The ANZEDAR (Australia and New Zealand Emergency Airway Registry) is currently the largest EAR with data from 43 participating institutions in 2 different countries, while the NEAR III (National Emergency Airway Registry) includes data on 21,374 emergency intubations over a 10-year period and thus has the largest number of emergency interventions. Reported rapid sequence induction (RSI) rates in the registries are between 27.5% and 100%. First-pass success rates vary between 69% and 89%, while the reported use of video laryngoscopy is 0-73%.

CONCLUSION

This study identified eleven EARs that sometimes widely differed concerning inclusion periods, inclusion criteria, definition of complications and application of newer methods of emergency airway management. Thus, comparability of the reported results and first-pass success rates is only possible to a limited extent. The authors therefore advocate the initiation of an airway registry in emergency medicine in German-speaking countries.

[Future of emergency medicine in Germany 2.0]

In 2003 an article on the future of prehospital emergency medicine in Germany was published in the journal Der Anaesthesist. Emergency medicine in Germany, which at that time was almost exclusively defined as prehospital emergency rescue, has evolved and now in-hospital domains have increasingly moved into the focus. At that time, the primary goal was to connect prehospital management with a smooth transition to hospital admission and further care in the hospital and to further optimize the rescue chain from the actual emergency through to causative treatment. Now after 15 years, the authors have critically assessed the development postulated in 2003 and reevaluated it. Which aspects could be developed further and become firmly established, what is still open and which questions in preclinical and clinical emergency treatment of the population will occupy us in the coming 15 years? With a critical eye to the past, the present contribution aims to capture the essential and new topics and open questions and provide a fresh perspective for the future of emergency medicine. Regulation at the state level or even lower levels of government often stand in contrast to more sweeping and economically effective approaches at the federal level. Prehospital emergency medicine in Germany is on the whole well-positioned with respect to facilities and personnel; however, as far as the economic situation and the utilization of available systems are concerned, there is still substantial room for improvement.

[Mortui vivos docent : The dead teach the living]

There are considerable similarities and intersections between forensic medicine and emergency medicine. This applies especially to frustraneously resuscitated patients or other lethal clinical courses of traumatized patients who are subject to latter forensic autopsy. Cooperation between departments of emergency and forensic medicine not only has emergency medical training potential, but also the possibility of retrospective evaluation of medical emergency measures - both in individual cases and with regard to epidemiological aspects. In particular, the widespread registration of autopsied pre-hospital trauma deaths that occurred despite on-scene resuscitation attempts is useful. The pre-hospital situation represents a hotspot, but also a blind spot in the overall trauma mortality. In recent clinical registers, preclinical deaths go mostly unrecorded, despite the undisputed benefits of clinical registers.

[Consideration of guidelines, recommendations and quality indicators for treatment of stroke in the dataset "Emergency Department" of DIVI]

BACKGROUND

The dataset "Emergency Department" of the German Interdisciplinary Association of Critical Care and Emergency Medicine (DIVI) has been developed during several expert meetings. Its goal is an all-encompassing documentation of the early clinical treatment of patients in emergency departments. Using the example of the index disease acute ischemic stroke (stroke), the aim was to analyze how far this approach has been fulfilled.

MATERIAL AND METHODS

In this study German, European and US American guidelines were used to analyze the extent of coverage of the datasets on current emergency department guidelines and recommendations from professional societies. In addition, it was examined whether the dataset includes recommended quality indicators (QI) for quality management (QM) and in a third step it was examined to what extent national provisions for billing are included. In each case a differentiation was made whether the respective rationale was primary, i.e. directly apparent or whether it was merely secondarily depicted by expertise. In the evaluation an additional differentiation was made between the level of recommendations and further quality relevant criteria.

RESULTS

The modular design of the emergency department dataset comprising 676 data fields is briefly described. A total of 401 individual fields, divided into basic documentation, monitoring and specific neurological documentation of the treatment of stroke patients were considered. For 247 data fields a rationale was found. Partially overlapping, 78.9 % of 214 medical recommendations in 3 guidelines and 85.8 % of the 106 identified quality indicators were primarily covered. Of the 67 requirements for billing of performance of services, 55.5 % are primarily part of the emergency department dataset. Through appropriate expertise and documentation by a board certified neurologist, the results can be improved to almost 100 %.

CONCLUSION

The index disease stroke illustrates that the emergency department dataset of the DIVI covers medical guidelines, especially 100 % of the German guidelines with a grade of recommendation. All necessary information to document the specialized stroke treatment procedure in the German diagnosis-related groups (DRG) system is also covered. The dataset is also suitable as a documentation tool of quality management, for example, to participate in the registry of the German Stroke Society (ADSR). Best results are obtained if the dataset is applied by a physician specialized in the treatment of patients with stroke (e.g. board certified neurologist). Finally the results show that changes in medical guidelines and recommendations for quality management as well as billing-relevant content should be implemented in the development of datasets for documentation to avoid duplicate documentation.

Peyton's 4-Steps-Approach in comparison: Medium-term effects on learning external chest compression - a pilot study

INTRODUCTION

The external chest compression is a very important skill required to maintain a minimum of circulation during cardiac arrest until further medical procedures can be taken. Peyton's 4-Steps-Approach is one method of skill training, the four steps being: Demonstration, Deconstruction, Comprehension and Execution. Based on CPR skill training, this method is widely, allegedly predominantly used, although there are insufficient studies on Peyton's 4-Steps-Approach for skill training in CPR in comparison with other methods of skill training. In our study, we compared the medium- term effects on learning external chest compression with a CPR training device in three different groups: PEY (Peyton's 4-Steps-Approach), PMOD (Peyton's 4-Steps-Approach without Step 3) and STDM, the standard model, according to the widely spread method "see one, do one" (this is equal to Peyton's step 1 and 3).

MATERIAL AND METHODS

This prospective and randomised pilot study took place during the summer semester of 2009 at the SkillsLab and Simulation Centre of the University of Cologne (Kölner interprofessionelles Skills Lab und Simulationszentrum - KISS). The subjects were medical students (2(nd) and 3(rd) semester). They volunteered for the study and were randomised in three parallel groups, each receiving one of the teaching methods mentioned above. One week and 5/6 months after the intervention, an objective, structured single assessment was taken. Compression rate, compression depth, correct compressions, and the sum of correct checklist items were recorded. Additionally, we compared cumulative percentages between the groups based on the correct implementation of the resuscitation guidelines during that time.

RESULTS

The examined sample consisted of 134 subjects (68% female; age 22±4; PEY: n=62; PMOD: n=31; STDM: n=41). There was no difference between the groups concerning age, gender, pre-existing experience in CPR or time of last CPR course. The only significant difference between the groups was the mean compression rate (bpm): Group 1 (PEY) with 99±17 bpm, Group 2 (PMOD) with 101±16 bpm and Group 3 (STDM) with 90±16 bpm (p=0,007 for Group 3 vs. Group 1 and Group 3 vs. Group 2, Mann-Whitney- U-Test). We observed no significant differences between the groups after the second assessment.

CONCLUSION

Our study showed that there are no essential differences in external chest compression during CPR performed by medical students dependent on the teaching method (Peyton vs. "Non-Peyton") implemented with regard to the medium-term effects. The absence of benefits could possibly be due to the simplicity of external chest compression.

Mechanical chest compression: an alternative in helicopter emergency medical services?

Mechanical chest compression devices are mentioned in the current guidelines of the European Resuscitation Council (ERC) as an alternative in long-lasting cardiopulmonary resuscitations (CPR) or during transport with ongoing CPR. We compared manual chest compression with mechanical devices in a rescue-helicopter-based scenario using a resuscitation manikin. Manual chest compression was compared with the mechanical devices LUCAS™ 2, AutoPulse™ and animax mono (10 series each) using the resuscitation manikin AmbuMan MegaCode Wireless, which was intubated endotracheally and controlled ventilated during the entire scenario. The scenario comprised the installation of each device, transport and loading phases, as well as a 10-min phase inside the helicopter (type BK 117). We investigated practicability as well as measured compression quality. All mechanical devices could be used readily in a BK 117 helicopter. The LUCAS 2 group was the only one that fulfilled all recommendations of the ERC (frequency 102 ± 0.1 min(-1), compression depth 54 ± 3 mm, hands-off time 2.5 ± 1.6 %). Performing adequate manual chest compression was barely possible (fraction of correct compressions 21 ± 15 %). In all four groups, the total hands-off time was <10 %. Performing manual chest compressions during rescue-helicopter transport is barely possible, and only of poor quality. If rescuers are experienced, mechanical chest compression devices could be good alternatives in this situation. We found that the LUCAS 2 system complied with all recommendations of ERC guidelines, and all three tested devices worked consistently during the entire scenario.

[An urban EMS at the start of a cross-sectoral quality management system: prioritized implementation of the 2010 ERC recommendations and long-term survival after cardiac arrest]

INTRODUCTION

Due to limited resources, the 2010 European Resuscitation Council (ERC) guidelines could not be fully implemented in the Emergency Medical Services (EMS) of Brunswick, Germany. This is why implementation was prioritized according to local conditions. Thus, prehospital therapeutic hypothermia, mechanical chest compression and feedback systems were not established. Clinical data and long-term results were assessed by a QM system and room for improvement was identified.

METHODS

All attempted resuscitations from 2011 until 2014 were recorded and compared against the German Resuscitation Registry. Outcomes of adult patients following non-traumatic cardiac arrest were analyzed by year.

RESULTS

812 resuscitations were attempted (incidence 81.2/100,000 inhabitants/year). In the two years following full implementation since 2013 the discharge rate from hospital was 16.4 %, the discharge rate with a favorable neurologic outcome was 14.1 %, the 1-year survival rate was 14.4 % in 2013. A significant improvement of risk-adjusted ROSC rate during the investigation period was demonstrated. The discharge rates remained unchanged; the increase in the discharge rates paralleled the increase in CPR incidence. EMS response times were remarkably shorter.

CONCLUSION

The implementation of the ERC guidelines chosen appears to be generally safe. Fast EMS response contributed to superior results. All links of the chain of survival showed room for improvement, especially the proportion of lay rescuer CPR and telephone-assisted CPR. The high CPR incidence might indicate room for improvement in prevention. Access to resuscitation care can hardly be evaluated. Age-related access to pre-hospital resuscitation seems to be appropriate.