Utstein-style audit of Protocol C: A non-standard resuscitation protocol for healthcare professionals

European first responder systems and differences in return of spontaneous circulation and survival after out-of-hospital cardiac arrest: A study of registry cohorts

BACKGROUND

In Europe, survival-rates after out-of-hospital cardiac arrest (OHCA) vary widely between regions. Whether a system dispatching First Responders (FRs; main FR-types: firefighters, police officers, citizen-responders) is present or not may be associated with survival-rates. This study aimed to assess the association between having a dispatched FR-system and rates of return of spontaneous circulation (ROSC) and survival across Europe.

METHODS

Results of an inventory of dispatched FR-systems for OHCA in Europe were combined with aggregate ROSC and survival data from the EuReCa-TWO study and additionally collected data. Regression analysis (weighted on number of patients included per region) was performed to study the association between having a dispatched FR-system and ROSC and survival-rates to hospital discharge in the total population and in patients with shockable initial rhythm, witnessed OHCA and bystander cardiopulmonary resuscitation (CPR; Utstein comparator group). For regions without a dispatched FR-system, the theoretical survival-rate if a dispatched FR-system would have existed was estimated.

FINDINGS

We included 27 European regions. There were 15,859 OHCAs in the total group and 2,326 OHCAs in the Utstein comparator group. Aggregate ROSC and survival-rates were significantly higher in regions with an FR-system compared to regions without (ROSC: 36% [95%CI 35%-37%] vs. 24% [95%CI 23%-25%]; P<0.001; survival in total population [N=15.859]: 13% [95%CI 12%-15%] vs. 5% [95%CI 4%-6%]; P<0.001; survival in Utstein comparator group [N=2326]: 33% [95%CI 30%-36%] vs. 18% [95%CI 16%-20%]; P<0.001), and in regions with more than one FR-type compared to regions with only one FR-type. All main FR-types were associated with higher survival-rates (all P<0.050).

INTERPRETATION

European regions with dispatched FRs showed higher ROSC and survival-rates than regions without.

FUNDING

This project/work has received funding from the European Union's Horizon 2020 research and innovation programme under acronym ESCAPE-NET, registered under grant agreement No 733381 (IO, HLT and MTB) and the European Union's COST programme under acronym PARQ, registered under grant agreement No CA19137 (IO, DC, HLT, MTB). HLT and MTB were supported by a grant from the Netherlands CardioVascular Research Initiative, Dutch Heart Foundation, Dutch Federation of University Medical Centres, Netherlands Organization for Health Research and Development, Royal Netherlands Academy of Sciences - CVON2017-15 RESCUED (HLT), and CVON2018-30 Predict2 (HLT and MTB).

Advancing resuscitation science

PURPOSE OF REVIEW

To describe an alternative approach for improving survival of patients with out-of-hospital cardiac arrest (OHCA). The survival of patients with OHCA has been poor and relatively unchanged for decades in spite of recurrent national and international guidelines. Although there are exceptions, many thought and continue to think that any change in the guidelines for cardiopulmonary resuscitation should be based on randomized controlled trials in humans. However, many factors, including the need for informed consent, the marked variability of patients, and the variability of the type and quality of bystander and advanced resuscitation efforts, all make such studies problematic. Thus, potentially life-saving procedures are often withheld for decades, resulting in unnecessary loss of life.

RECENT FINDINGS

Many improvements in public health conditions have been made using models of continuous quality improvement. When applied to resuscitation science, once baseline data are obtained, changes based on reliable experimental findings are instituted and outcomes measured. This approach has now been shown to result in significant improvement in neurologically intact survival of patients with OHCA.

SUMMARY

Following this model, we found significant improvement in survival of patients with a witnessed OHCA primary cardiac arrest.

Usefulness of cardiac arrest centers - extending lifesaving post-resuscitation therapies: the Arizona experience -

The post-cardiac arrest syndrome is a complex, multisystems response to the global ischemia and reperfusion injury that occurs with the onset of cardiac arrest, its treatment (cardiopulmonary resuscitation) and the re-establishment of spontaneous circulation. Regionalization of post-cardiac arrest care, utilizing specified cardiac arrest centers (CACs), has been proposed as the best solution to providing optimal care for those successfully resuscitated after out-of-hospital cardiac arrest. A multidisciplinary team of intensive care specialists, including critical care/pulmonologists, cardiologists (general, interventional, and electrophysiology), neurologists, and physical medicine/rehabilitation experts, is crucial for such centers. Particular attention to the timely initiation of targeted temperature management and early coronary angiography/percutaneous coronary intervention is best provided by such CACs. A State-wide program of CACs was started in Arizona in 2007. This is a voluntary program, whereby medical centers agree to provide all resuscitated cardiac arrest patients brought to their facility with state-of-the-art post-resuscitation care, including targeted temperature management for comatose patients and strong consideration for emergent coronary angiography for all patients with a likely cardiac etiology for their cardiac arrest. Survival improved by more than 50% at facilities that became CACs with a commitment to provide aggressive post-resuscitation care to all such patients. Providing aggressive, post-resuscitation care is the next real opportunity to increase long-term survival for cardiac arrest patients.

Current Approaches to Cardiopulmonary Resuscitation

Real progress has been made in improving long-term outcome after out-of-hospital cardiac arrest in the past 10 years. Many communities have doubled their survival-to-hospital-discharge rate during this period. Common features of such successful programs include the following: (1) 911 dispatcher-assisted cardiopulmonary resuscitation (CPR) instruction, (2) bystander chest compression-only CPR program, (3) public access defibrillation, including targeted automated external defibrillator programs, (4) renewed emphasis on minimally interrupted chest compressions by emergency medical services responders, and (5) aggressive postresuscitation care, including targeted temperature management and early coronary angiography and intervention. An important lesson from these successful community efforts is that multiple, simultaneous changes to the local cardiac arrest response system are necessary to improve survival. The next exciting step in this quest appears to be the treatment of refractory cardiac arrest with the combination of mechanical CPR, intra-arrest hypothermia, extracorporeal CPR with mechanical circulatory support devices, and early coronary intervention.

Use of cardiocerebral resuscitation or AHA/ERC 2005 Guidelines is associated with improved survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis

OBJECTIVE

To determine whether the use of cardiocerebral resuscitation (CCR) or AHA/ERC 2005 Resuscitation Guidelines improved patient outcomes from out-of-hospital cardiac arrest (OHCA) compared to older guidelines.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE, EMBASE, Web of Science and the Cochrane Library databases. We also hand-searched study references and consulted experts.

STUDY SELECTION

Design: randomised controlled trials and observational studies.

POPULATION

OHCA patients, age >17 years.

COMPARATORS

'Control' protocol versus 'Study' protocol. 'Control' protocol defined as AHA/ERC 2000 Guidelines for cardiopulmonary resuscitation (CPR). 'Study' protocol defined as AHA/ERC 2005 Guidelines for CPR, or a CCR protocol.

OUTCOME

Survival to hospital discharge.

QUALITY

High-quality or medium-quality studies, as measured by the Newcastle Ottawa Scale using predefined categories.

RESULTS

Twelve observational studies met inclusion criteria. All the three studies using CCR demonstrated significantly improved survival compared to use of AHA 2000 Guidelines, as did five of the nine studies using AHA/ERC 2005 Guidelines. Pooled data demonstrate that use of a CCR protocol has an unadjusted OR of 2.26 (95% CI 1.64 to 3.12) for survival to hospital discharge among all cardiac arrest patients. Among witnessed ventricular fibrillation/ventricular tachycardia (VF/VT) patients, CCR increased survival by an OR of 2.98 (95% CI 1.92 to 4.62). Studies using AHA/ERC 2005 Guidelines showed an overall trend towards increased survival, but significant heterogeneity existed among these studies.

CONCLUSIONS

We demonstrate an association with improved survival from OHCA when CCR protocols or AHA/ERC 2005 Guidelines are compared to use of older guidelines. In the subgroup of patients with witnessed VF/VT, there was a threefold increase in OHCA survival when CCR was used. CCR appears to be a promising resuscitation protocol for Emergency Medical Services providers in increasing survival from OHCA. Future research will need to be conducted to directly compare AHA/ERC 2010 Guidelines with the CCR approach.

Out-of-hospital cardiac arrest in Cork, Ireland

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) in Ireland accounts for approximately 5000 deaths annually. Little published evidence exists on survival from OHCA in this country to date. We aimed to characterise and describe 'presumed cardiac' OHCA in Cork City and County attended by the Ambulance Service.

METHODS

Dispatch records, ambulance patient records and hospital records for a 1-year period were examined for patient demographics, OHCA characteristics, interventions and patient outcomes.

RESULTS

There were 231 'presumed cardiac' OHCAs attended over the study period; 130 (56%) were in urban locations and 101 (44%) in rural. OHCAs were lay-witnessed in 20% (n=46), and 22% (n=50) received bystander CPR. Shockable rhythm was present in 36 cases (16%) on initial assessment, and there was no difference in presence of shockable rhythm between urban and rural OHCAs (18% vs 13%, p=0.31). Resuscitation was attempted in 176 cases (77.5%), of whom 27 (15%) achieved return of spontaneous circulation and 13 (7.4%) survived to leave hospital. Survival when the initial rhythm was shockable was 16.7% (6 of 36 patients). Despite longer response times for rural compared with urban OHCAs (median (IQR) 16.5 (11.0-23.5) vs 9 (7-12) min, p<0.001), survival to leave hospital alive where resuscitation was attempted was similar (7.4% vs 7.4%, p=0.99, respectively).

CONCLUSION

A survival rate of 16.7% in shockable rhythms indicates scope for improvement which would influence the overall survival rate which was found to be 7.4%. Real-time feedback of performance and quality of the continuum of patient care through a clinical-quality cardiac arrest registry would monitor and incentivise such initiatives.

Protocol C: a nonguidelines-compliant approach to improve survival of patients with out-of-hospital cardiac arrest

PURPOSE OF REVIEW

To describe a resuscitation protocol for out-of-hospital cardiac arrest designed for healthcare professionals that demands more from rescuers than does conventional cardiopulmonary resuscitation. It was introduced with the aim of improving survival that has remained disappointingly poor worldwide.

RECENT FINDINGS

Survival to hospital discharge, that could be measured accurately in one city, improved appreciably with the use of the novel protocol. The implications are discussed in relation to the scientific background and relevant literature.

SUMMARY

Uniform resuscitation protocols for lay and for professional use may not be appropriate. Only randomized trials can indicate the potential value of this challenge to conventional wisdom.