The survival benefit of dual dispatch of EMS and fire-fighters in out-of-hospital cardiac arrest may differ depending on population density--a prospective cohort study

Prehospital Predictors of Survival in Patients with Out-of-Hospital Cardiac Arrest

Background and Objectives: Despite advances in the treatment of heart diseases, the outcome of patients experiencing sudden cardiac arrest remains poor. The aim of our study was to determine the prehospital variables as predictors of survival outcomes in out-of-hospital cardiac arrest (OHCA) victims. Materials and Methods: This was a retrospective observational cohort study of OHCA cases. EMS protocols created in accordance with the Utstein style reporting for OHCA, first responder intervention reports, medical dispatch center dispatch protocols and hospital medical reports were all reviewed. Multivariate logistic regression was performed with the following variables: age, gender, witnessed status, location, bystander CPR, first rhythm, and etiology. Results: A total of 381 interventions with resuscitation attempts were analyzed. In more than half (55%) of them, bystander CPR was performed. Thirty percent of all patients achieved return of spontaneous circulation (ROSC), 22% of those achieved 30-day survival (7% of all OHCA victims), and 73% of those survived with Cerebral Performance Score 1 or 2. The logistic regression model of adjustment confirms that shockable initial rhythm was a predictor of ROSC [OR: 4.5 (95% CI: 2.5-8.1)] and 30-day survival [OR: 9.3 (95% CI: 2.9-29.2)]. Age was also associated (≤67 years) [OR: 3.9 (95% CI: 1.3-11.9)] with better survival. Conclusions: Elderly patients have a lower survival rate. The occurrence of bystander CPR in cardiac arrest remains alarmingly low. Shockable initial rhythm is associated with a better survival rate and neurological outcome compared with non-shockable rhythm.

Association of Degree of Urbanization and Survival in Out-of-Hospital Cardiac Arrest

Background Survival from out-of-hospital cardiac arrest (OHCA) varies across regions. The aim of this study was to evaluate the association between urbanization (rural, suburban, and urban areas), bystander interventions (cardiopulmonary resuscitation and defibrillation), and 30-day survival from OHCAs in Denmark. Methods and Results We included OHCAs not witnessed by ambulance staff in Denmark from January 1, 2016, to December 31, 2020. Patients were divided according to the Eurostat Degree of Urbanization Tool in rural, suburban, and urban areas based on the 98 Danish municipalities. Poisson regression was used to estimate incidence rate ratios. Logistic regression (adjusted for ambulance response time) tested differences between the groups with respect to bystander interventions and survival, according to degree of urbanization. A total of 21 385 OHCAs were included, of which 8496 (40%) occurred in rural areas, 7025 (33%) occurred in suburban areas, and 5864 (27%) occurred in urban areas. Baseline characteristics, as age, sex, location of OHCA, and comorbidities, were comparable between groups. The annual incidence rate ratio of OHCA was higher in rural areas (1.54 [95% CI, 1.48-1.58]) compared with urban areas. Odds for bystander cardiopulmonary resuscitation were lower in suburban (0.86 [95% CI, 0.82-0.96]) and urban areas (0.87 [95% CI, 0.80-0.95]) compared with rural areas, whereas bystander defibrillation was higher in urban areas compared with rural areas (1.15 [95% CI, 1.01-1.31]). Finally, 30-day survival was higher in suburban (1.13 [95% CI, 1.02-1.25]) and urban areas (1.17 [95% CI, 1.05-1.30]) compared with rural areas. Conclusions Degree of urbanization was associated with lower rates of bystander defibrillation and 30-day survival in rural areas compared with urban areas.

Prehospital Time Interval for Urban and Rural Emergency Medical Services: A Systematic Literature Review

The aim of this study was to discuss the differences in pre-hospital time intervals between rural and urban communities regarding emergency medical services (EMS). A systematic search was conducted through various relevant databases, together with a manual search to find relevant articles that compared rural and urban communities in terms of response time, on-scene time, and transport time. A total of 37 articles were ultimately included in this review. The sample sizes of the included studies was also remarkably variable, ranging between 137 and 239,464,121. Twenty-nine (78.4%) reported a difference in response time between rural and urban areas. Among these studies, the reported response times for patients were remarkably variable. However, most of them (number (n) = 27, 93.1%) indicate that response times are significantly longer in rural areas than in urban areas. Regarding transport time, 14 studies (37.8%) compared this outcome between rural and urban populations. All of these studies indicate the superiority of EMS in urban over rural communities. In another context, 10 studies (27%) reported on-scene time. Most of these studies (n = 8, 80%) reported that the mean on-scene time for their populations is significantly longer in rural areas than in urban areas. On the other hand, two studies (5.4%) reported that on-scene time is similar in urban and rural communities. Finally, only eight studies (21.6%) reported pre-hospital times for rural and urban populations. All studies reported a significantly shorter pre-hospital time in urban communities compared to rural communities. Conclusions: Even with the recently added data, short pre-hospital time intervals are still superior in urban over rural communities.

Emergency medical services in rural and urban Saudi Arabia: A qualitative study of Red Crescent emergency personnel' perceptions of workforce and patient factors impacting effective delivery

Individuals who experience a traumatic injury or an acute illness are often reliant on initial healthcare assessment and support from a pre-hospital emergency medical service (EMS). These community-based support models perform a vital role in the provision of life-saving support, but research indicates that the availability, accessibility and resources of EMS are not equivalent in rural and urban areas, and there has been little recognition of the issues facing rural EMS provision outside of the USA, Europe and Australia. The purpose of the current study was to examine the lived experiences of Saudi Arabian EMS personnel, defined as emergency medical technicians, paramedics and local station managers. A semi-structured interview approach was used to collect data from 20 interviewees (10 each with rural and urban personnel) in the Riyadh region of the Kingdom of Saudi Arabia. This methodology was used to identify the key issues that these staff face in their day-to-day work practice and ascertain factors that may lead to service delivery issues in rural and urban areas. Data analyses identified three thematic categories impacting EMS delivery; two of these, Personnel Factors and Patient Factors, are the focus of this paper. The participants noted a number of key issues, including a lack of appropriate local training and limited resources in rural areas, as well as general areas of concern regarding the wider EMS staff demographic makeup and poor public awareness about the exact role of the EMS. Three key recommendations arising from this study include specialised training and ongoing accessible education for rural EMS staff to allow for better support for patients; consideration of supplementing the current EMS with additional external specialist staff; and the development and implementation of national public education programmes focusing on the role of the EMS within the community.

Firefighters as first-responders in out-of-hospital cardiac arrest- a retrospective study of a time-gain selective dispatch system in the Skåne Region, Sweden

AIM

To analyze the impact of a time-gain selective, first-responder dispatch system on the presence of a shockable initial rhythm (SIR), return of spontaneous circulation (ROSC) and 30-day survival after out-of-hospital cardiac arrest (OHCA).

METHOD

A retrospective observational study comprising OHCA registry data and dispatch data in the Skåne Region, Sweden (2010-2018). Data were categorized according to dispatch procedures, two ambulances (AMB-only) versus two ambulances and firefighter first-responders (DUAL-dispatch), based on the dispatcher's estimation of a time-gain. Dual dispatch was sub-categorized by arrival of first vehicle (first-responder or ambulance). Logistic regressions were used, additionally with groups matched (1:1) for age, witnessed event, bystander cardiopulmonary resuscitation and ambulance response time. Adjusted and conditional odds-ratios (aOR, cOR) with 95% confidence intervals (CI) are presented.

RESULTS

Of 3,245 eligible cases, 43% were DUAL-dispatches with first-responders first on scene (FR-first) in 72%. Despite a five-minute median reduction in response time in the FR-first group, no association with SIR was found (aOR 0.83, 95%CI 0.64-1.07) nor improved 30-day survival (aOR 1.03, 95%CI 0.72-1.47). A positive association between ROSC and the FR-first group (aOR 1.25, 95%CI 1.02-1.54) disappeared in the matched analysis (cOR 1.12, 95%CI 0.87-1.43). Time to first monitored rhythm was 7:06 minutes in the FR-first group versus 3:01 in the combined AMB-only/AMB-first groups.

CONCLUSION

In this time-gain selective first-responder dispatch system, a shorter response time was not associated with increased SIR, improved ROSC rate or survival. Process measures differed between the study groups which could account for the observed findings and requires further investigation.

The Association of Fire or Police First Responder Initiated Interventions with Out of Hospital Cardiac Arrest Survival

OBJECTIVE

Fire and police first responders are often the first to arrive in medical emergencies and provide basic life support services until specialized personnel arrive. This study aims to evaluate rates of fire or police first responder-initiated cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use, as well as their associated impact on out-of-hospital cardiac arrest (OHCA) outcomes.

METHODS

We completed a secondary data analysis of the MI-CARES registry from 2014 to 2019. We reported rates of CPR initiation and AED use by fire or police first responders. Multilevel modeling was utilized to evaluate the relationship between fire/police first responder-initiated interventions and outcomes of interest: ROSC upon emergency department arrival, survival to hospital discharge, and good neurologic outcome.

RESULTS

Our cohort included 25,067 OHCA incidents. We found fire or police first responders initiated CPR in 31.8% of OHCA events and AED use in 6.1% of OHCA events. Likelihood of sustained ROSC on ED arrival after CPR initiated by a fire/police first responder was not statistically different as compared to EMS initiated CPR (aOR 1.01, CI 0.93-1.11). However, fire/police first responder interventions were associated with significantly higher odds of survival to hospital discharge and survival with good neurologic outcome (aOR 1.25, 95% CI 1.08-1.45 and aOR 1.40, 95% CI 1.18-1.65, respectively). Similar associations were see when examining fire or police initiated AED use.

CONCLUSIONS

Fire or police first responders may be an underutilized, potentially powerful mechanism for improving OHCA survival. Future studies should investigate barriers and opportunities for increasing first responder interventions by these groups in OHCA.

Urban-Rural differences in Cardiac Arrest outcomes: a retrospective population-based cohort study

Background

Approximately 10% of people who suffer an out-of-hospital cardiac arrest (OHCA) treated by paramedics survive to hospital discharge. Survival differs by up to 19.2% between urban centres and rural areas. Our goal was to investigate the differences in OHCA survival between urban centres and rural areas.

Methods

This was a retrospective cohort study of OHCA patients treated by Nova Scotia Emergency Medical Services (EMS) in 2017. Cases of traumatic, expected, and noncardiac OHCA were excluded. Data were collected from the Emergency Health Service electronic patient care record system and the discharge abstract database. Geographic information system analysis classified cases as being in urban centres (population > 1000 people) or rural areas, using 2016 Canadian Census boundaries. The primary outcome was survival to hospital discharge. Multivariable logistic regression covariates were age, sex, bystander resuscitation, whether the arrest was witnessed, public location, and preceding symptoms.

Results

A total of 510 OHCAs treated by Nova Scotia Emergency Medical Services were included for analysis. A total of 12% (n = 62) survived to discharge. Patients with OHCAs in urban centres were 107% more likely to survive than those with OHCAs in rural areas (adjusted odds ratio = 2.1; 95% confidence interval = 1.1 to 3.8; P = 0.028). OHCAs in urban centres had a significantly shorter mean time to defibrillation of shockable rhythm (11.2 minutes ± 6.2) vs those in rural areas (17.5 minutes ± 17.3).

Conclusions

Nova Scotia has an urban vs rural disparity in OHCA care that is also seen in densely populated OHCA centres. Survival is improved in urban centres. Further improvements in overall survival, especially in rural areas, may arise from community engagement in OHCA recognition and optimized healthcare delivery.

A review on initiatives for the management of daily medical emergencies prior to the arrival of emergency medical services

Emergency services worldwide face increasing cost pressure that potentially limits their existing resources. In many countries, emergency services also face the issues of staff shortage-creating extra challenges and constraints, especially during crisis times such as the COVID-19 pandemic-as well as long distances to sparsely populated areas resulting in longer response times. To overcome these issues and potentially reduce consequences of daily (medical) emergencies, several countries, such as Sweden, Germany, and the Netherlands, have started initiatives using new types of human resources as well as equipment, which have not been part of the existing emergency systems before. These resources are employed in response to medical emergency cases if they can arrive earlier than emergency medical services (EMS). A good number of studies have investigated the use of these new types of resources in EMS systems, from medical, technical, and logistical perspectives as their study domains. Several review papers in the literature exist that focus on one or several of these new types of resources. However, to the best of our knowledge, no review paper that comprehensively considers all new types of resources in emergency medical response systems exists. We try to fill this gap by presenting a broad literature review of the studies focused on the different new types of resources, which are used prior to the arrival of EMS. Our objective is to present an application-based and methodological overview of these papers, to provide insights to this important field and to bring it to the attention of researchers as well as emergency managers and administrators.

Emergency Medical Services (EMS) Transportation of Trauma Patients by Geographic Locations and In-Hospital Outcomes: Experience from Qatar

Background: Prehospital care provided by emergency medical services (EMS) plays an important role in improving patient outcomes. Globally, prehospital care varies across countries and even within the same country by the geographic location and access to medical services. We aimed to explore the prehospital trauma care and in-hospital outcomes within the urban and rural areas in the state of Qatar. Methods: A retrospective analysis was conducted utilizing data from the Qatar National Trauma Registry for trauma patients who were transported by EMS to a level 1 trauma center between 2017 and 2018. Data were analyzed and compared between urban and rural areas and among the different municipalities in which the incidents occurred. Results: Across the study duration, 1761 patients were transported by EMS. Of that, 59% were transported from an urban area and 41% from rural areas. There were significant differences in the on-scene time and total prehospital time as a function of urban and rural areas and municipalities; however, the response time across the study groups was comparable. There were no significant differences in blood transfusion, intubation, hospital length of stay, and mortality. Conclusion: Within different areas in Qatar, the EMS response time and in-hospital outcomes were comparable. This indicates that the provision of prehospital care across the country is similar. The prehospital and acute in-hospital care are accessible for everyone in the country at no cost. Understanding the differences in EMS utilization and prehospital times contributes to the policy development in terms of equitable distribution of healthcare resources.

Smartphone-based dispatch of community first responders to out-of-hospital cardiac arrest - statements from an international consensus conference

Background

Over the past decade Smartphone-based activation (SBA) of Community First Responders (CFR) to out-of-hospital cardiac arrests (OHCA) has gained much attention and popularity throughout Europe. Various programmes have been established, and interestingly there are considerable differences in technology, responder spectrum and the degree of integration into the prehospital emergency services. It is unclear whether these dissimilarities affect outcome. This paper reviews the current state in five European countries, reveals similarities and controversies, and presents consensus statements generated in an international conference with the intention to support public decision making on future strategies for SBA of CFR.

Methods

In a consensus conference a three-step approach was used: (i) presentation of current research from five European countries; (ii) workshops discussing evidence amongst the audience to generate consensus statements; (iii) anonymous real-time voting applying the modified RAND-UCLA Appropriateness method to adopt or reject the statements. The consensus panel aimed to represent all stakeholders involved in this topic.

Results

While 21 of 25 generated statements gained approval, consensus was only found for 5 of them. One statement was rejected but without consensus. Members of the consensus conference confirmed that CFR save lives. They further acknowledged the crucial role of emergency medical control centres and called for nationwide strategies.

Conclusions

Members of the consensus conference acknowledged that smartphone-based activation of CFR to OHCA saves lives. The statements generated by the consensus conference may assist the public, healthcare services and governments to utilise these systems to their full potential, and direct the research community towards fields that still need to be addressed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00841-1.

Socioeconomic disparities in Rapid ambulance response for out-of-hospital cardiac arrest in a public emergency medical service system: A nationwide observational study

OBJECTIVES

This study aimed to examine whether county socioeconomic status (SES) is associated with emergency medical service (EMS) response time and dual dispatch response of out-of-hospital cardiac arrest (OHCA) patients using county property tax per capita in Korea.

METHODS

All EMS-treated adults who suffered OHCAs were enrolled between 2015 and 2017, excluding cases witnessed by EMS providers. The main exposure was property tax per capita in the county where the OHCA occurred. The primary outcome was response time interval, with a secondary outcome of dual dispatch response. Negative binomial regression analysis to calculate incidence rate ratio (IRR) with a 95% confidence interval (CI) was conducted for EMS response time. A multivariable logistic regression analysis for response time interval (<8 min) and dual dispatch response was also conducted.

RESULTS

A total of 71,326 patients in 228 counties were enrolled. Compared to the lowest SES quartile, OHCA patients in the highest SES quartile had shorter median (interquartile range [IQR]) response time intervals (9.5 [5.9] minutes vs. 7.6 [4.2] minutes, IRR [95% CI] 0.95 [0.94-0.96], respectively). The AOR (95% CI) for response time within 8 min was 1.07 (1.01-1.13) for the highest SES quartile compared to the lowest SES quartile. Those in the highest SES quartile also had higher rates of dual dispatch response compared to those in the lowest quantile (50.9% vs 26.6%; AOR [95% CI]: 2.16 [2.03-2.30]).

CONCLUSION

In OHCA patients, those in a lower SES are associated with longer response times and lower dual dispatch response.

Pre-hospital factors and survival after out-of-hospital cardiac arrest according to population density, a nationwide study

AIM

This study aimed to examine the impact of population density on bystander cardiopulmonary resuscitation (CPR) and survival after out-of-hospital cardiac arrest (OHCA).

METHODS

Through the Danish Cardiac Arrest Registry (2001-2013), OHCAs ≥18 years of presumed cardiac cause were identified, and divided according to the OHCA location in four population density groups (inhabitants/km2) based on urban/rural area-definitions: low (<300/km2), medium (300-1499/km2), high (1500-2999/km2), very high (>3000/km2). The association between population density, bystander cardiopulmonary resuscitation (CPR) and survival was examined using logistic regression, adjusted for age, sex, comorbitidies and calendar-year.

RESULTS

18,248 OHCAs were identified. Patients in areas of high compared to low population density were older, more often female, had more comorbidities, more witnessed arrests (very high: 59.6% versus low: 55.0%), shorter response time (very high: 10 min versus low: 14 min), but less bystander CPR (very high: 34.3% versus low: 45.1%). Thirty-day survival was higher in areas of higher population density (very high: 10.2% vs. low 5.3%), also in best-cases of witnessed arrests with bystander CPR and response time <10 min (very high: 33.6% versus low: 13.8%). The same trends were found in adjusted analyses with lower odds for bystander CPR (odds ratio [OR] 0.55 95% confidence interval [CI] 0.46-0.66) and higher odds for 30-day survival (OR 2.78, 95%CI 1.95-3.96) in the highest population density areas compared to low.

CONCLUSIONS

Having an OHCA in higher populated areas were found associated with less bystander CPR, but higher survival. Identification of area-related factors can help target future pre-hospital care.

Using firefighters as medical first responders to shorten response time in rural areas in Sweden

OBJECTIVE

To map out and describe an earlier response by using firefighters as medical first responders on while waiting for the ambulance and first incident person assignments focusing on frequency, event time and survival >30 days after performed cardiopulmonary resuscitation.

DESIGN

Retrospective descriptive design.

SETTING

Ambulance service in a county of southern Sweden with a population of 200 000 inhabitants (23/km² ).

PARTICIPANTS

Data were collected from four data systems within different organizations; emergency medical communication centre, fire deparment, ambulance services and conty hospital analysis unit.

MAIN OUTCOME MEASURE(S)

Data from 600 while waiting for the ambulance assignments, whereof 120 with first incident person present, collected between 1 January 2012 and 31 December 2016. Between 1 June 2014 and 1 October 2015, the two fire departments were dually dispatched on out-of-hospital cardiac arrests.

RESULTS

Three main findings were made: there was a prolonged process time for dispatching fire fighters on while waiting for the ambulance assignments. Dual dispatches did not shorten the process time for dispatching full-time firefighters, and, in a majority of while waiting for the ambulance assignments where cardiopulmonary resuscitation was performed, firefighters or first incident persons arrived first on the scene.

CONCLUSION

Minimising every minute that delays the performance of life-saving actions is crucial. By dispatching firefighters on while waiting for the ambulance assignments in rural areas, the response time in a majority of assignments was shortened. However, there was substantial delay in dispatching firefighters due to prolonged process time at the emergency medical communication centre. The emergency medical communication centre operator's ability to quickly assess the need for while waiting for the ambulance assignments plays a crucial role in the chain of survival.

Effectiveness of the Dual Dispatch to Cardiac Arrest Policy in Houston, Texas

CONTEXT

Houston policy is to dual dispatch medically trained firefighters, in addition to emergency medical services (EMS) units to out-of-hospital cardiac arrest (OHCA) cases. While believed to improve public health outcomes, no research exists supporting the policy that when firefighters respond before a better-equipped EMS unit, they increase the probability of survival.

OBJECTIVE

To inform EMS policy decisions regarding the effectiveness of dual dispatch by determining the impact of medically trained firefighter dispatch on return of spontaneous circulation (ROSC), a measure of survivability, in OHCA 911 calls while controlling for the subsequent arrival of an EMS unit.

DESIGN

This retrospective study uses logistic regression to determine the association between ROSC and response time for fire apparatus first responders controlling for arrival of the EMS unit.

SETTING

Out-of-hospital cardiac arrest cases in Houston between May 2008 and April 2013 when dual dispatch was used.

PARTICIPANTS

A total of 6961 OHCA cases with the complete data needed for the analysis.

MAIN OUTCOME MEASURES

Logistic regression of the dependence of OHCA survival using the indicator ROSC, as related to the fire first responder response times controlling for subsequent arrival of the EMS.

RESULTS

Fire apparatus arrived first in 46.7% of cases, a median value of 1.5 minutes before an EMS unit. Controlling for subsequent arrival time of EMS has no effect on ROSC achieved by the fire first responder. If the firefighters had not responded, the resulting 1.5-minute increase in response time equates to a decrease in probability of attaining ROSC of 20.1% for cases regardless of presenting heart rhythm and a 47.7% decrease for ventricular fibrillation cases in which bystander cardiopulmonary resuscitation was initiated.

CONCLUSIONS

The firefighter first responder not only improved response time but also greatly increased survivability independent of the arrival time of the better-equipped EMS unit, validating the public health benefit of the dual dispatch policy in Houston.

Care and outcomes of urban and non-urban out-of-hospital cardiac arrest patients during the HeartRescue Project in Washington state and North Carolina

AIM

We examined overall and temporal differences in out-of-hospital cardiac arrest (OHCA) care and outcomes by urban versus non-urban setting separately for North Carolina (NC) and Washington State (WA) during HeartRescue initiatives and associations of urban/non-urban settings with outcome by state.

METHODS

OHCAs of presumed cardiac etiology from counties with complete registry enrollment in NC during 2010-2014 (catchment population = 3,143,809) and WA during 2011-2014 (catchment population = 3,653,506) were identified. Geospatial arrest location data and US Census classification were used to categorize urban areas with ≥50,000 versus non-urban <50,000 people.

RESULTS

Included were 7731 NC cases (78.9% urban) and 4472 WA cases (85.8% urban). Bystander cardiopulmonary resuscitation (CPR) increased from 36.9% (2010) to 50.3% (2014) in NC non-urban areas versus 58.2% (2011) to 69.2% (2014) in WA; and from 39.3% to 51.1% in NC urban areas versus 52.4% to 61.8% in WA. Crude discharge survival odds ratio (OR) was 2.49 (95%CI 1.96-3.16) for urban versus non-urban NC cases not declared dead in field (N = 4241). Adjusted for age, sex, public location, bystander-witness status, time between emergency call and emergency medical service (EMS) arrival, calendar-year, bystander and first-responder CPR and defibrillation and direct PCI-center transport, OR was 1.30 (95%CI 0.98-1.73). In WA, corresponding crude and adjusted ORs were 1.38 (95%CI 0.99-1.93) and 1.46 (95%CI 1.00-2.13). In both states, bystander and first-responder CPR and defibrillation and direct PCI-hospital transport were associated with increased survival.

CONCLUSIONS

During HeartRescue initiatives, bystander CPR increased in urban and non-urban locations. Bystander and first-responder interventions and direct PCI-hospital transport were associated with improved outcomes, including in non-urban areas.

Does second EMS unit response time affect outcomes of OHCA in multi-tiered system? A nationwide observational study

OBJECTIVES

The time dependence of a multi-tier response for out-of-hospital cardiac arrest (OHCA) is unclear. The aim of this study was to evaluate the time-dependent effect of EMS response type in a multi-tiered system on the clinical outcomes of OHCA.

METHODS

Adult EMS-treated OHCA of presumed cardiac etiology who were not witnessed by EMS between January 2015 and December 2017 were included. The main exposure was EMS response type: single-tier response, early multi-tier response (0-18 min from call to second EMS arrival), and late multi-tier response (19 min from call to second EMS arrival). The primary outcome was good neurologic recovery at the time of discharge from the hospital. Multivariate logistic regression analysis was performed, adjusting for patient-community and prehospital variables.

RESULTS

Among 54,436 patients, 29,995 patients (55.1%), 21,552 patients (39.6%), and 2889 patients (5.3%) were treated by single-tiered EMS, early multi-tiered EMS, and late multi-tiered EMS, respectively. Good neurological recovery and survival to discharge were more frequent in the early multi-tiered response group (6.4% and 9.7%) than in the single-tiered response group (4.8% and 7.5%) or late multi-tiered response group (3.1% and 5.8%). Compared to the single-tiered response group, the early multi-tiered response group was more likely to have good neurological recovery (adjusted OR, 95% CI: 1.15 [1.06-1.26]), but the late multi-tiered response group was less likely to have good neurological recovery (adjusted OR, 95% CI: 0.76 [0.61-0.96]).

CONCLUSION

In our basic to intermediate-tiered EMS system, early multi-tier response was associated with improved survival and good neurological recovery.

Dispatcher Identification of Out-of-Hospital Cardiac Arrest and Neurologically Intact Survival: A Retrospective Cohort Study

Introduction:

To date, there are no published data on the association of patient-centered outcomes and accurate public-safety answering point (PSAP) dispatch in an American population. The goal of this study is to determine if PSAP dispatcher recognition of out-of-hospital cardiac arrest (OHCA) is associated with neurologically intact survival to hospital discharge.

Methods:

This retrospective cohort study is an analysis of prospectively collected Quality Assurance/Quality Improvement (QA/QI) data from the San Antonio Fire Department (SAFD; San Antonio, Texas USA) OHCA registry from January 2013 through December 2015. Exclusion criteria were: Emergency Medical Services (EMS)-witnessed arrest, traumatic arrest, age <18 years old, no dispatch type recorded, and missing outcome data. The primary exposure was dispatcher recognition of cardiac arrest. The primary outcome was neurologically intact survival (defined as Cerebral Performance Category [CPC] 1 or 2) to hospital discharge. The secondary outcomes were: bystander cardiopulmonary resuscitation (CPR), automated external defibrillator (AED) use, and prehospital return of spontaneous return of circulation (ROSC).

Results:

Of 3,469 consecutive OHCA cases, 2,569 cases were included in this analysis. The PSAP dispatched 1,964/2,569 (76.4%) of confirmed OHCA cases correctly. The PSAP dispatched 605/2,569 (23.6%) of confirmed OHCA cases as another chief complaint. Neurologically intact survival to hospital discharge occurred in 99/1,964 (5.0%) of the recognized cardiac arrest group and 28/605 (4.6%) of the unrecognized cardiac arrest group (OR = 1.09; 95% CI, 0.71–1.70). Bystander CPR occurred in 975/1,964 (49.6%) of the recognized cardiac arrest group versus 138/605 (22.8%) of the unrecognized cardiac arrest group (OR = 3.34; 95% CI, 2.70–4.11).

Conclusion:

This study found no association between PSAP dispatcher identification of OHCA and neurologically intact survival to hospital discharge. Dispatcher identification of OHCA remains an important, but not singularly decisive link in the OHCA chain of survival.

Experiences among firefighters and police officers of responding to out-of-hospital cardiac arrest in a dual dispatch programme in Sweden: an interview study

OBJECTIVES

The objective of this study was to explore firefighters' and police officers' experiences of responding to out-of-hospital cardiac arrest (OHCA) in a dual dispatch programme.

DESIGN

A qualitative interview study with semi-structured, open-ended questions where critical incident technique (CIT) was used to collect recalled cardiac arrest situations from the participants' narratives. The interviews where transcribed verbatim and analysed with inductive content analysis.

SETTING

The County of Stockholm, Sweden.

PARTICIPANTS

Police officers (n=10) and firefighters (n=12) participating in a dual dispatch programme with emergency medical services in case of suspected OHCA of cardiac or non-cardiac origin.

RESULTS

Analysis of 60 critical incidents was performed resulting in three consecutive time sequences (preparedness, managing the scene and the aftermath) with related categories, where first responders described the complexity of the cardiac arrest situation. Detailed information about the case and the location was crucial for the preparedness, and information deficits created stress, frustration and incorrect perceptions about the victim. The technical challenges of performing cardiopulmonary resuscitation and managing the airway was prominent and the need of regular team training and education in first aid was highlighted.

CONCLUSIONS

Participating in dual dispatch in case of suspected OHCA was described as a complex technical and emotional process by first responders. Providing case discussions and opportunities to give, and receive feedback about the case is a main task for the leadership in the organisations to diminish stress among personnel and to improve future OHCA missions.

Application of a Dual-Dispatch System for Out-of-Hospital Cardiac Arrest Patients: Will More Hands Save More Lives?

BACKGROUND

Recovery after out-of-hospital cardiac arrest (OHCA) is difficult, and emergency medical services (EMS) systems apply various strategies to improve outcomes. Multi-dispatch is one means of providing high-quality cardiopulmonary resuscitation (CPR), but no definitive best-operation guidelines are available. We assessed the effects of a basic life support (BLS)-based dual-dispatch system for OHCA.

METHODS

This prospective observational study of 898 enrolled OHCA patients, conducted in Daegu, Korea from March 1, 2015 to June 30, 2016, involved patients > 18 years old with suspected cardiac etiology OHCA. In Daegu, EMS started a BLS-based dual-dispatch system in March 2015, for cases of cardiac arrest recognition by a dispatch center. We assessed the association between dual-dispatch and OHCA outcomes using multivariate logistic regressions. We also analyzed the effect of dual-dispatch according to the stratified on-scene time.

RESULTS

Of 898 OHCA patients (median, 69.0 years; 65.5% men), dual-dispatch was applied in 480 (53.5%) patients. There was no difference between the single-dispatch group (SDG) and the dual-dispatch group (DDG) in survival at discharge and neurological outcomes (survival discharge, P = 0.176; neurological outcomes, P = 0.345). In the case of less than 10 minutes of on-scene time, the adjusted odds ratio was 1.749 (95% confidence interval [CI], 0.490-6.246) for survival discharge and 6.058 (95% CI, 1.346-27.277) for favorable neurological outcomes in the DDG compared with the SDG.

CONCLUSION

Dual-dispatch was not associated with better OHCA outcomes for the entire study population, but showed favorable neurological outcomes when the on-scene time was less than 10 minutes.

Lay People Training in CPR and in the Use of an Automated External Defibrillator, and Its Social Impact: A Community Health Study

Out-of-hospital cardiac arrest (OHCA) mortality remains high. The best survival rates are achieved when trained people provide OHCA victims with cardiopulmonary resuscitation (CPR); however, it is estimated that only 25% of victims receive CPR. This community health study aims to evaluate the effectiveness of a training programme in basic CPR and in the use of an automatic external defibrillator (AED) on knowledge and skills for lay people, and its social impact. The training courses were based on Catalan Council of Resuscitation guidelines. Data were collected on sociodemographic characteristics, evaluation of knowledge and practical skills at baseline and at the end of the training courses, and also on the social impact of the programme. A total of 36 training courses with 482 participants were carried out, and most participants achieved a qualification of suitable. The mean score in knowledge was 3.1 ± 1.1 at baseline and 3.8 ± 1.2 (p = 0.001) at the end of the programme. Participants rated the training courses as very satisfactory, considered the training useful, and felt more qualified to respond to an emergency. This study shows that a high percentage of participants acquired skills in basic CPR and use of an AED, which confirms the usefulness and effectiveness of training courses and its important social impact.

Factors Impacting Patient Outcomes Associated with Use of Emergency Medical Services Operating in Urban Versus Rural Areas: A Systematic Review

The goal of this systematic review was to examine the existing literature base regarding the factors impacting patient outcomes associated with use of emergency medical services (EMS) operating in urban versus rural areas. A specific subfocus on low and lower-middle-income countries was planned but acknowledged in advance as being potentially limited by a lack of available data. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed during the preparation of this systematic review. A comprehensive literature search of PubMed, EBSCO (Elton B. Stephens Company) host, Web of Science, ProQuest, Embase, and Scopus was conducted through May 2018. To appraise the quality of the included papers, the Critical Appraisal Skills Programme Checklists (CASP) were used. Thirty-one relevant and appropriate studies were identified; however, only one study from a low or lower-middle-income country was located. The research indicated that EMS in urban areas are more likely to have shorter prehospital times, response times, on-scene times, and transport times when compared to EMS operating in rural areas. Additionally, urban patients with out-of-hospital cardiac arrest or trauma were found to have higher survival rates than rural patients. EMS in urban areas were generally associated with improved performance measures in key areas and associated higher survival rates than those in rural areas. These findings indicate that reducing key differences between rural and urban settings is a key factor in improving trauma patient survival rates. More research in rural areas is required to better understand the factors which can predict these differences and underpin improvements. The lack of research in this area is particularly evident in low- and lower-middle-income countries.

Response time in the emergency services. Systematic review

The growth of the urban population raises concern about municipal public managers in the sense of providing emergency medical services (EMS) that are aligned with the needs of prehospital emergency medical care demanded by the population. The literature review aims at presenting the response time of emergency medical services in several parts of the world and discussing some factors that interfere in the result of this indicator such as GDP (Gross Domestic Product) percentage spent on health and life expectancy of countries. The study will also show that in some of the consulted articles, authors suggest to EMS recommendations for decreasing the response time using simulations, heuristics and metaheuristics. Response time is a basic indicator of emergency medical services, in such a way that researchers use the descriptive statistics to evaluate this parameter. Europe and the USA outstand in the publication of studies that present this information. Some articles use stochastic and mathematical methods to suggest models that simulate scenarios of response time reduction and suggest such proposals to the local EMS. Countries in which the response time was identified have a high index of human development and life expectancy between 74.7 and 83.7 years.

Field termination-of-resuscitation rule for refractory out-of-hospital cardiac arrests in Japan

BACKGROUND

Guidelines for cardiopulmonary resuscitation (CPR) recommend using the universal termination-of-resuscitation (TOR) rule to identify out-of-hospital cardiac arrest (OHCA) patients eligible for field termination of resuscitation, thus avoiding medically futile transportation to the hospital. However, in Japan, emergency medical services (EMS) personnel are forbidden from terminating CPR in the field and transport almost all patients with OHCA to hospitals. We aimed to develop and validate a novel TOR rule to identify patients eligible for field termination of CPR.

METHODS

We analyzed 540,478 patients with OHCA from 2011 to 2015 using a Japanese registry. Main outcome measures were specificity and positive predictive value (PPV) of the newly developed TOR rule in predicting 1-month mortality after OHCA.

RESULTS

Recursive partitioning analysis in the development group (n=434,208) showed that EMS personnel could consider TOR if patients with OHCA met all of the following five criteria: (1) initial asystole, (2) arrest unwitnessed by a bystander, (3) age ≥81 years, (4) no bystander-administered CPR or automated external defibrillator use before EMS arrival, and (5) no return of spontaneous circulation after EMS-initiated CPR for 14min. For patients meeting these criteria, specificity and PPV for predicting 1-month mortality were 99.2% [95% confidence interval (CI), 99.0-99.3%] and 99.7% (95% CI, 99.6-99.7%), respectively, for the development group and were 99.5% (95% CI, 99.3-99.7%) and 99.8% (95% CI, 99.7-99.9%), respectively, for the validation group. Implementation of this novel rule would reduce patient transports to hospitals by 10.6% in the development group and 10.4% in the validation group.

CONCLUSIONS

Having both high specificity and PPV of >99% for predicting 1-month mortality, our developed TOR rule may be applied in the field for Japanese patients with OHCA who meet all five criteria. Prospective validation studies and establishment of prehospital EMS protocol are required before implementing this rule.

Inter-disciplinary cooperation in a physician-staffed emergency medical system

BACKGROUND

On-scene management of pre-hospital emergencies is often inter-disciplinary, involving ground-emergency medical services (EMS), police- and fire services, and in Norway general practitioners on-call. This can also be supplemented by physician-staffed EMS (P-EMS), utilizing helicopters or rapid response vehicles. We hypothesized that P-EMS cooperates extensively with other emergency services, and therefore the primary aim of this study was to investigate the fraction of inter-disciplinary cooperation between P-EMS and other emergency services.

METHODS

Retrospective, observational study of primary pre-hospital missions with patient contact performed at a Norwegian P-EMS base from 01.01.06 to 31.12.15. Descriptive statistics, comparisons using Student`s t-test, and chi-squared test for trend were applied.

RESULTS

Inter-disciplinary cooperation occurred in 94.3% of the 8580 missions, of which physician-staffed EMS cooperated with ground EMS in 92.4%, general practitioner 32.9%, police service 11.6% and fire service 11.8%. Trauma constituted 34.4 and cardiac arrest 14.1% of missions. The mean National Advisory Committee for Aeronautics score was 4.21 (95% Confidence Interval 4.18-4.24). There was an overall decrease in cooperation with general practitioners and the police service (P < 0.001). During helicopter missions, we reported a decrease in general practitioner cooperation compared to an increase during rapid response car missions (P < 0.001). In cardiac arrest cases, cooperation with both general practitioners and the fire service increased (P < 0.001).

CONCLUSION

Physician-staffed EMS cooperates extensively with other professional emergency services, especially ground-EMS. On-scene cooperation with general practitioners decreased, whereas there was an increased cooperation with the fire service in a "first-responder" role during cardiac arrest missions.

Cardiopulmonary resuscitation quality during CPR practice versus during a simulated life-saving event

INTRODUCTION

As a part of the emergency medical services, the Swedish fire brigade can increase the survival rate in out-of-hospital cardiac arrests.

AIM

To compare the quality of cardiopulmonary resuscitation (CPR) performed by firefighters at a routine CPR practice versus when involved in a simulated life-saving event.

METHODS

In this study, 80 firefighters divided into two groups performed CPR according to guidelines: one group indoors during a routine training session; the other group outdoors during a smoke diving exercise wearing personal protective clothing and self-contained breathing apparatus. Descriptive and inferential statistics were used to analyze the data.

RESULTS

The results showed a tendency for the outdoor group to perform CPR with better ventilation and compression quality, as compared to the indoor group. The ventilation of the manikin was not hampered by the firefighters wearing personal protective clothes and self-contained breathing apparatus, as the Swedish firefighters remove their facial mask and ventilate the patient with their mouth using a pocket mask.

CONCLUSIONS

Overall, the results in both groups showed a high quality of CPR which can be related to the fire brigade training and education traditions. CPR training is regularly performed, which in turn helps to maintain CPR skills.

Emerging and Future Technologies in Out-of-Hospital Cardiac Arrest Care

The care for victims of out-of-hospital cardiac arrest is evolving and will be influenced by future and emerging technologies that will play a role in the systems of care for these patients. Recent advances in extracorporeal life support and point-of-care ultrasound imaging, both in-hospital and out-of-hospital, may offer a therapeutic solution in some systems for patients with refractory or recurrent cardiac arrest. Drones capable of delivering automated external defibrillators to the scene of an out-of-hospital cardiac arrest, advances in digital and mobile technologies to notify and leverage bystander response, and wearable life detection technologies may improve survival.

Apples to apples: can differences in out-of-hospital cardiac arrest incidence and outcomes between Sweden and Ireland be explained by core Utstein variables?

BACKGROUND

Variation in reported incidence and outcome based on aggregated data is a persistent feature of out-of-hospital cardiac arrest (OHCA) epidemiology.

OBJECTIVE

To investigate the extent to which patient-level analysis using core 'Utstein' variables explains inter-country variation between Sweden and the Republic of Ireland.

METHODS

A retrospective cross-sectional comparative study was performed, including all Swedish and Irish OHCA cases attended by Emergency Medical Services (EMS-attended OHCA) where resuscitation was attempted from 1st January 2012 to 31st December 2014. Incidence rates per 100,000 population were adjusted for age and gender. Two subgroups were extracted: (1) Utstein - adult patients, bystander-witnessed collapse, presumed medical aetiology, initial shockable rhythm and (2) Emergency Medical Service (EMS)-witnessed events. Multivariable logistic regression analysis was used to identify predictors of survival following multiple imputations of data.

RESULTS

Five thousand eight hundred eighty six Irish and 15,303 Swedish patients were included. Swedish patients were older than Irish patients (median age 71 vs. 66 years respectively). Adjusted incidence was significantly higher in Sweden compared to the Republic of Ireland (52.9 vs. 43.1 per 100,000 population per year). Proportionate survival in Sweden was greater for both subgroups and all age categories. Regression analysis of the Utstein subgroup predicted approximately 17% of variation in outcome, but there was a large unexplained 'country effect' for survival in favour of Sweden (OR 4.40 (95% CI 2.55-7.56)).

CONCLUSIONS

Using patient level data, a proportion of inter-country variation was explained, but substantial variation was not explained by the core Utstein variables. Researchers and policy makers should be aware of the potential for unmeasured differences when comparing OHCA incidence and outcomes between countries.

Dispatch of Firefighters and Police Officers in Out-of-Hospital Cardiac Arrest: A Nationwide Prospective Cohort Trial Using Propensity Score Analysis

BACKGROUND

Dispatch of basic life support-trained first responders equipped with automated external defibrillators in addition to advanced life support-trained emergency medical services personnel in out-of-hospital cardiac arrest (OHCA) has, in some minor cohort studies, been associated with improved survival. The aim of this study was to evaluate the association between basic life support plus advanced life support response and survival in OHCA at a national level.

METHODS AND RESULTS

This prospective cohort study was conducted from January 1, 2012, to December 31, 2014. People who experienced OHCA in 9 Swedish counties covered by basic life support plus advanced life support response were compared with a propensity-matched contemporary control group of people who experienced OHCA in 12 counties where only emergency medical services was dispatched, providing advanced life support. Primary outcome was survival to 30 days. The analytic sample consisted of 2786 pairs (n=5572) derived from the total cohort of 7308 complete cases. The median time from emergency call to arrival of emergency medical services or first responder was 9 minutes in the intervention group versus 10 minutes in the controls (P<0.001). The proportion of patients admitted alive to the hospital after resuscitation was 31.4% (875/2786) in the intervention group versus 24.9% (694/2786) in the controls (conditional odds ratio, 1.40; 95% confidence interval, 1.24-1.57). Thirty-day survival was 9.5% (266/2786) in the intervention group versus 7.7% (214/2786) in the controls (conditional odds ratio, 1.27; 95% confidence interval, 1.05-1.54).

CONCLUSIONS

In this nationwide interventional trial, using propensity score matching, dispatch of first responders in addition to emergency medical services in OHCA was associated with a moderate, but significant, increase in 30-day survival.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT02184468.

Use of a geographic information system to identify differences in automated external defibrillator installation in urban areas with similar incidence of public out-of-hospital cardiac arrest: a retrospective registry-based study

OBJECTIVES

Early defibrillation in out-of-hospital cardiac arrest (OHCA) is of importance to improve survival. In many countries the number of automated external defibrillators (AEDs) is increasing, but the use is low. Guidelines suggest that AEDs should be installed in densely populated areas and in locations with many visitors. Attempts have been made to identify optimal AED locations based on the incidence of OHCA using geographical information systems (GIS), but often on small datasets and the studies are seldom reproduced. The aim of this paper is to investigate if the distribution of public AEDs follows the incident locations of public OHCAs in urban areas of Stockholm County, Sweden.

METHOD

OHCA data were obtained from the Swedish Register for Cardiopulmonary Resuscitation and AED data were obtained from the Swedish AED Register. Urban areas in Stockholm County were objectively classified according to the pan-European digital mapping tool, Urban Atlas (UA). Furthermore, we reclassified and divided the UA land cover data into three classes (residential, non-residential and other areas). GIS software was used to spatially join and relate public AED and OHCA data and perform computations on relations and distance.

RESULTS

Between 1 January 2012 and 31 December 2014 a total of 804 OHCAs occurred in public locations in Stockholm County and by December 2013 there were 1828 AEDs available. The incidence of public OHCAs was similar in residential (47.3%) and non-residential areas (43.4%). Fewer AEDs were present in residential areas than in non-residential areas (29.4% vs 68.8%). In residential areas the median distance between OHCAs and AEDs was significantly greater than in non-residential areas (288 m vs 188 m, p<0.001).

CONCLUSION

The majority of public OHCAs occurred in areas classified in UA as 'residential areas' with limited AED accessibility. These areas need to be targeted for AED installation and international guidelines need to take geographical location into account when suggesting locations for AED installation.

Unmanned aerial vehicles (drones) in out-of-hospital-cardiac-arrest

Background

The use of an automated external defibrillator (AED) prior to EMS arrival can increase 30-day survival in out-of-hospital cardiac arrest (OHCA) significantly. Drones or unmanned aerial vehicles (UAV) can fly with high velocity and potentially transport devices such as AEDs to the site of OHCAs. The aim of this explorative study was to investigate the feasibility of a drone system in decreasing response time and delivering an AED.

Methods

Data of Global Positioning System (GPS) coordinates from historical OHCA in Stockholm County was used in a model using a Geographic Information System (GIS) to find suitable placements and visualize response times for the use of an AED equipped drone. Two different geographical models, urban and rural, were calculated using a multi-criteria evaluation (MCE) model. Test-flights with an AED were performed on these locations in rural areas.

Results

In total, based on 3,165 retrospective OHCAs in Stockholm County between 2006–2013, twenty locations were identified for the potential placement of a drone.

In a GIS-simulated model of urban OHCA, the drone arrived before EMS in 32 % of cases, and the mean amount of time saved was 1.5 min. In rural OHCA the drone arrived before EMS in 93 % of cases with a mean amount of time saved of 19 min. In these rural locations during (n = 13) test flights, latch-release of the AED from low altitude (3–4 m) or landing the drone on flat ground were the safest ways to deliver an AED to the bystander and were superior to parachute release.

Discussion

The difference in response time for EMS between urban and rural areas is substantial, as is the possible amount of time saved using this UAV-system. However, yet another technical device needs to fit into the chain of survival. We know nothing of how productive or even counterproductive this system might be in clinical reality.

Conclusions

To use drones in rural areas to deliver an AED in OHCA may be safe and feasible. Suitable placement of drone systems can be designed by using GIS models. The use of an AED equipped drone may have the potential to reduce time to defibrillation in OHCA.

Spatial Variation and Resuscitation Process Affecting Survival after Out-of-Hospital Cardiac Arrests (OHCA)

BACKGROUND

Ambulance response times and resuscitation efforts are critical predictors of the survival rate after out-of-hospital cardiac arrests (OHCA). On the other hand, rural-urban differences in the OHCA survival rates are an important public health issue.

METHODS

We retrospectively reviewed the January 2011-December 2013 OHCA registry data of Kaohsiung City, Taiwan. With particular focus on geospatial variables, we aimed to unveil risk factors predicting the overall OHCA survival until hospital admission. Spatial analysis, network analysis, and the Kriging method by using geographic information systems were applied to analyze spatial variations and calculate the transport distance. Logistic regression was used to identify the risk factors for OHCA survival.

RESULTS

Among the 4,957 patients, the overall OHCA survival to hospital admission was 16.5%. In the multivariate analysis, female sex (adjusted odds ratio:, AOR, 1.24 [1.06-1.45]), events in public areas (AOR: 1.30 [1.05-1.61]), exposure to automated external defibrillator (AED) shock (AOR: 1.70 [1.30-2.23]), use of laryngeal mask airway (LMA) (AOR: 1.35 [1.16-1.58]), non-trauma patients (AOR: 1.41 [1.04-1.90]), ambulance bypassed the closest hospital (AOR: 1.28 [1.07-1.53]), and OHCA within the high population density areas (AOR: 1.89 [1.55-2.32]) were positively associated with improved OHCA survival. By contrast, a prolonged total emergency medical services (EMS) time interval was negatively associated with OHCA survival (AOR: 0.98 [0.96-0.99]).

CONCLUSIONS

Resuscitative efforts, such as AED or LMA use, and a short total EMS time interval improved OHCA outcomes in emergency departments. The spatial heterogeneity of emergency medical resources between rural and urban areas might affect survival rate.