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Smyth MA, Gunson I, Coppola A, Johnson S, Greif R, Lauridsen KG, Taylor-Philips S, Perkins GD. Termination of Resuscitation Rules and Survival Among Patients With Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis. JAMA Netw Open 2024; 7:e2420040. [PMID: 38958975 PMCID: PMC11222995 DOI: 10.1001/jamanetworkopen.2024.20040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 05/02/2024] [Indexed: 07/04/2024] Open
Abstract
Importance Termination of resuscitation (TOR) rules may help guide prehospital decisions to stop resuscitation, with potential effects on patient outcomes and health resource use. Rules with high sensitivity risk increasing inappropriate transport of nonsurvivors, while rules without excellent specificity risk missed survivors. Further examination of the performance of TOR rules in estimating survival of out-of-hospital cardiac arrest (OHCA) is needed. Objective To determine whether TOR rules can accurately identify patients who will not survive an OHCA. Data Sources For this systematic review and meta-analysis, the MEDLINE, Embase, CINAHL, Cochrane Library, and Web of Science databases were searched from database inception up to January 11, 2024. There were no restrictions on language, publication date, or time frame of the study. Study Selection Two reviewers independently screened records, first by title and abstract and then by full text. Randomized clinical trials, case-control studies, cohort studies, cross-sectional studies, retrospective analyses, and modeling studies were included. Systematic reviews and meta-analyses were reviewed to identify primary studies. Studies predicting outcomes other than death, in-hospital studies, animal studies, and non-peer-reviewed studies were excluded. Data Extraction and Synthesis Data were extracted by one reviewer and checked by a second. Two reviewers assessed risk of bias using the Revised Quality Assessment Tool for Diagnostic Accuracy Studies. Cochrane Screening and Diagnostic Tests Methods Group recommendations were followed when conducting a bivariate random-effects meta-analysis. This review followed the Preferred Reporting Items for a Systematic Review and Meta-Analysis of Diagnostic Test Accuracy Studies (PRISMA-DTA) statement and is registered with the International Prospective Register of Systematic Reviews (CRD42019131010). Main Outcomes and Measures Sensitivity and specificity tables with 95% CIs and bivariate summary receiver operating characteristic (SROC) curves were produced. Estimates of effects at different prevalence levels were calculated. These estimates were used to evaluate the practical implications of TOR rule use at different prevalence levels. Results This review included 43 nonrandomized studies published between 1993 and 2023, addressing 29 TOR rules and involving 1 125 587 cases. Fifteen studies reported the derivation of 20 TOR rules. Thirty-three studies reported external data validations of 17 TOR rules. Seven TOR rules had data to facilitate meta-analysis. One clinical study was identified. The universal termination of resuscitation rule had the best performance, with pooled sensitivity of 0.62 (95% CI, 0.54-0.71), pooled specificity of 0.88 (95% CI, 0.82-0.94), and a diagnostic odds ratio of 20.45 (95% CI, 13.15-31.83). Conclusions and Relevance In this review, there was insufficient robust evidence to support widespread implementation of TOR rules in clinical practice. These findings suggest that adoption of TOR rules may lead to missed survivors and increased resource utilization.
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Affiliation(s)
- Michael A. Smyth
- Medical School, University of Warwick, Coventry, England
- University Hospital Coventry and Warwickshire NHS Trust, Coventry, England
| | - Imogen Gunson
- West Midlands Ambulance Service University NHS Foundation Trust, Brierly Hill, England
| | - Alison Coppola
- University Hospitals Plymouth NHS Trust, Plymouth, England
| | | | - Robert Greif
- Department of Anesthesiology and Pain Therapy, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
- School of Medicine, Sigmund Freud University, Vienna, Austria
| | - Kasper G. Lauridsen
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Medicine, Randers Regional Hospital, Randers, Denmark
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Gavin D. Perkins
- Medical School, University of Warwick, Coventry, England
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, England
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Htet NN, Jafari D, Walker JA, Pourmand A, Shaw A, Dinh K, Tran QK. Trend of Outcome Metrics in Recent Out-of-Hospital-Cardiac-Arrest Research: A Narrative Review of Clinical Trials. J Clin Med 2023; 12:7196. [PMID: 38002808 PMCID: PMC10672249 DOI: 10.3390/jcm12227196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/10/2023] [Accepted: 11/13/2023] [Indexed: 11/26/2023] Open
Abstract
Cardiopulmonary resuscitation (CPR) research traditionally focuses on survival. In 2018, the International Liaison Committee on Resuscitation (ILCOR) proposed more patient-centered outcomes. Our narrative review assessed clinical trials after 2018 to identify the trends of outcome metrics in the field OHCA research. We performed a search of the PubMed database from 1 January 2019 to 22 September 2023. Prospective clinical trials involving adult humans were eligible. Studies that did not report any patient-related outcomes or were not available in full-text or English language were excluded. The articles were assessed for demographic information and primary and secondary outcomes. We included 89 studies for analysis. For the primary outcome, 31 (35%) studies assessed neurocognitive functions, and 27 (30%) used survival. For secondary outcomes, neurocognitive function was present in 20 (22%) studies, and survival was present in 10 (11%) studies. Twenty-six (29%) studies used both survival and neurocognitive function. Since the publication of the COSCA guidelines in 2018, there has been an increased focus on neurologic outcomes. Although survival outcomes are used frequently, we observed a trend toward fewer studies with ROSC as a primary outcome. There were no quality-of-life assessments, suggesting a need for more studies with patient-centered outcomes that can inform the guidelines for cardiac-arrest management.
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Affiliation(s)
- Natalie N. Htet
- Department of Emergency Medicine, Stanford University, Stanford, CA 94305, USA;
| | - Daniel Jafari
- Donald and Barbara Zucker School of Medicine Hofstra Northwell, Hempstead, NY 11549, USA;
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY 11030, USA
| | - Jennifer A. Walker
- Department of Emergency Medicine, Baylor Scott and White All Saints Medical Center, Fort Worth, TX 76104, USA;
- Department of Emergency Medicine, Burnett School of Medicine, Texas Christian University, Fort Worth, TX 76109, USA
| | - Ali Pourmand
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC 20037, USA;
| | - Anna Shaw
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Khai Dinh
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Quincy K. Tran
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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Shibahashi K, Konishi T, Ohbe H, Yasunaga H. Cost-effectiveness analysis of termination-of-resuscitation rules for patients with out-of-hospital cardiac arrest. Resuscitation 2022; 180:45-51. [PMID: 36176229 DOI: 10.1016/j.resuscitation.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 08/10/2022] [Accepted: 09/12/2022] [Indexed: 10/31/2022]
Abstract
AIM To evaluate the cost-effectiveness of practices with and without termination-of-resuscitation (TOR) rules for out-of-hospital cardiac arrest (OHCA), using an analytic model based on a nationwide population-based registry in Japan. METHODS A combined model using a decision tree and Markov model was developed to compare costs and treatment effectiveness of three scenarios: basic life support (BLS) TOR rules (BLS-rule scenario), advanced life support (ALS) TOR rules (ALS-rule scenario), and no TOR rules (No-rule scenario). A nationwide population-based OHCA registry from January 1 to December 31, 2019 and published data were used. Analyses were performed from healthcare payers' perspectives. Life-time incremental cost-effectiveness ratio (ICER) was determined by the difference in cost between two scenarios, divided by the difference in quality adjusted life year (QALY). RESULTS The OHCA registry included 126,271 patients (57.3% men; median age, 80 years). The BLS-rule scenario yielded lower cost and less QALY than the ALS-rule scenario and No-rule scenario. With reference to the BLS-rule scenario, the ICERs for the ALS-rule scenario and No-rule scenario were 81,000 and 98,762 USD per QALY, respectively. The BLS-rule scenario was cost-effective in 100% of simulations at the willingness-to-pay threshold in Japan (5 million JPY = 45,455 USD). The willingness-to-pay threshold higher than 80,000 and 204,000 USD were required for the ALS-rule scenario and No-rule scenarios, respectively, to be cost-effective. CONCLUSION No-rule scenario was not cost-effective compared with BLS-rule scenario within acceptable willingness-to-pay thresholds. Further research on health economics of TOR rules is warranted to support constructive discussion on implementing TOR rules.
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Affiliation(s)
- Keita Shibahashi
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 1130033, Japan; Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, 4-23-15, Kotobashi, Sumida-ku, Tokyo 1308575, Japan.
| | - Takaaki Konishi
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 1130033, Japan
| | - Hiroyuki Ohbe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 1130033, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 1130033, Japan
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What are the care needs of families experiencing cardiac arrest?: A survivor and family led scoping review. Resuscitation 2021; 168:119-141. [PMID: 34592400 DOI: 10.1016/j.resuscitation.2021.09.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 08/30/2021] [Accepted: 09/16/2021] [Indexed: 11/20/2022]
Abstract
AIM The sudden and unexpected cardiac arrest of a family member can be a grief-filled and life-altering event. Every year many hundreds of thousands of families experience the cardiac arrest of a family member. However, care of the family during the cardiac arrest and afteris poorly understood and incompletely described. This review has been performed with persons with lived experience of cardiac arrest to describe, "What are the needs of families experiencing cardiac arrest?" from the moment of collapse until the outcome is known. METHODS This review was guided by specific methodological framework and reporting items (PRISMA-ScR) as well as best practices in patient and public involvement in research and reporting (GRIPP2). A search strategy was developed for eight online databases and a grey literature review. Two reviewers independently assessed all articles for inclusion and extracted relevant study information. RESULTS We included 47 articles examining the experience and care needs of families experiencing cardiac arrest of a family member. Forty one articles were analysed as six represented duplicate data. Ten family care need themes were identified across five domains. The domains and themes transcended cardiac arrest setting, aetiology, family-member age and family composition. The five domains were i) focus on the family member in cardiac arrest, ii) collaboration of the resuscitation team and family, iii) consideration of family context, iv) family post-resuscitation needs, and v) dedicated policies and procedures. We propose a conceptual model of family centred cardiac arrest. CONCLUSION Our review provides a comprehensive mapping and description of the experience of families and their care needs during the cardiac arrest of a family-member. Furthermore, our review was conducted with co-investigators and collaborators with lived experience of cardiac arrest (survivors and family members of survivors and non-survivors alike). The conceptual framework of family centred cardiac arrest care presented may aid resuscitation scientists and providers in adopting greater family centeredness to their work.
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Mentzelopoulos SD, Couper K, Van de Voorde P, Druwé P, Blom M, Perkins GD, Lulic I, Djakow J, Raffay V, Lilja G, Bossaert L. [Ethics of resuscitation and end of life decisions]. Notf Rett Med 2021; 24:720-749. [PMID: 34093076 PMCID: PMC8170633 DOI: 10.1007/s10049-021-00888-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 12/14/2022]
Abstract
These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.
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Affiliation(s)
- Spyros D. Mentzelopoulos
- Evaggelismos Allgemeines Krankenhaus, Abteilung für Intensivmedizin, Medizinische Fakultät der Nationalen und Kapodistrischen Universität Athen, 45–47 Ipsilandou Street, 10675 Athen, Griechenland
| | - Keith Couper
- Universitätskliniken Birmingham NHS Foundation Trust, UK Critical Care Unit, Birmingham, Großbritannien
- Medizinische Fakultät Warwick, Universität Warwick, Coventry, Großbritannien
| | - Patrick Van de Voorde
- Universitätsklinikum und Universität Gent, Gent, Belgien
- staatliches Gesundheitsministerium, Brüssel, Belgien
| | - Patrick Druwé
- Abteilung für Intensivmedizin, Universitätsklinikum Gent, Gent, Belgien
| | - Marieke Blom
- Medizinisches Zentrum der Universität Amsterdam, Amsterdam, Niederlande
| | - Gavin D. Perkins
- Medizinische Fakultät Warwick, Universität Warwick, Coventry, Großbritannien
| | | | - Jana Djakow
- Intensivstation für Kinder, NH Hospital, Hořovice, Tschechien
- Abteilung für Kinderanästhesiologie und Intensivmedizin, Universitätsklinikum und Medizinische Fakultät der Masaryk-Universität, Brno, Tschechien
| | - Violetta Raffay
- School of Medicine, Europäische Universität Zypern, Nikosia, Zypern
- Serbischer Wiederbelebungsrat, Novi Sad, Serbien
| | - Gisela Lilja
- Universitätsklinikum Skane, Abteilung für klinische Wissenschaften Lund, Neurologie, Universität Lund, Lund, Schweden
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Mentzelopoulos SD, Couper K, Voorde PVD, Druwé P, Blom M, Perkins GD, Lulic I, Djakow J, Raffay V, Lilja G, Bossaert L. European Resuscitation Council Guidelines 2021: Ethics of resuscitation and end of life decisions. Resuscitation 2021; 161:408-432. [PMID: 33773832 DOI: 10.1016/j.resuscitation.2021.02.017] [Citation(s) in RCA: 106] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.
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Affiliation(s)
| | - Keith Couper
- UK Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Warwick Medical School, University of Warwick, Coventry, UK
| | - Patrick Van de Voorde
- University Hospital and University Ghent, Belgium; Federal Department Health, Belgium
| | - Patrick Druwé
- Ghent University Hospital, Department of Intensive Care Medicine, Ghent, Belgium
| | - Marieke Blom
- Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Gavin D Perkins
- UK Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Czech Republic; Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital and Medical Faculty of Masaryk University, Brno, Czech Republic
| | - Violetta Raffay
- European University Cyprus, School of Medicine, Nicosia, Cyprus; Serbian Resuscitation Council, Novi Sad, Serbia
| | - Gisela Lilja
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Neurology, Lund, Sweden
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Druwé P, Monsieurs KG, Gagg J, Nakahara S, Cocchi MN, Élő G, van Schuppen H, Alpert EA, Truhlář A, Huybrechts SA, Mpotos N, Paal P, BjØrshol C, Xanthos T, Joly LM, Roessler M, Deasy C, Svavarsdóttir H, Nurmi J, Owczuk R, Salmeron PP, Cimpoesu D, Fuenzalida PA, Raffay V, Steen J, Decruyenaere J, De Paepe P, Piers R, Benoit DD. Impact of perceived inappropiate cardiopulmonary resuscitation on emergency clinicians' intention to leave the job: Results from a cross-sectional survey in 288 centres across 24 countries. Resuscitation 2020; 158:41-48. [PMID: 33227397 DOI: 10.1016/j.resuscitation.2020.10.043] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 09/22/2020] [Accepted: 10/06/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Cardiopulmonary resuscitation (CPR) in patients with a poor prognosis increases the risk of perception of inappropriate care leading to moral distress in clinicians. We evaluated whether perception of inappropriate CPR is associated with intention to leave the job among emergency clinicians. METHODS A cross-sectional multi-centre survey was conducted in 24 countries. Factors associated with intention to leave the job were analysed by conditional logistic regression models. Results are expressed as odds ratios with 95% confidence intervals. RESULTS Of 5099 surveyed emergency clinicians, 1836 (36.0%) were physicians, 1313 (25.7%) nurses, 1950 (38.2%) emergency medical technicians. Intention to leave the job was expressed by 1721 (33.8%) clinicians, 3403 (66.7%) often wondered about the appropriateness of a resuscitation attempt, 2955 (58.0%) reported moral distress caused by inappropriate CPR. After adjustment for other covariates, the risk of intention to leave the job was higher in clinicians often wondering about the appropriateness of a resuscitation attempt (1.43 [1.23-1.67]), experiencing associated moral distress (1.44 [1.24-1.66]) and who were between 30-44 years old (1.53 [1.21-1.92] compared to <30 years). The risk was lower when the clinician felt valued by the team (0.53 [0.42-0.66]), when the team leader acknowledged the efforts delivered by the team (0.61 [0.49-0.75]) and in teams that took time for debriefing (0.70 [0.60-0.80]). CONCLUSION Resuscitation attempts perceived as inappropriate by clinicians, and the accompanying moral distress, were associated with an increased likelihood of intention to leave the job. Interprofessional collaboration, teamwork, and regular interdisciplinary debriefing were associated with a lower risk of intention to leave the job. ClinicalTrials.gov; No.: NCT02356029.
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Affiliation(s)
- Patrick Druwé
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium.
| | - Koenraad G Monsieurs
- Department of Emergency Medicine, Antwerp University Hospital and University of Antwerp, Antwerp, Belgium
| | - James Gagg
- Department of Emergency Medicine, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, United Kingdom
| | | | - Michael N Cocchi
- Harvard Medical School, Department of Emergency Medicine and Department of Anesthesia Critical Care and Pain Medicine, Division of Critical Care, Beth Israel Deaconess Medical Center, USA
| | - Gábor Élő
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Hans van Schuppen
- Amsterdam UMC, University of Amsterdam, Department of Anesthesiology, Amsterdam, The Netherlands
| | | | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Kralove Region and University Hospital Hradec Kralove, Czech Republic
| | | | - Nicolas Mpotos
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Peter Paal
- Department of Anesthesiology and Critical Care Medicine, Hospitallers Brothers Hospital, Medical University Salzburg, Austria
| | - Conrad BjØrshol
- Department of Anesthesiology and Intensive Care, Stavanger University Hospital, The Regional Centre for Emergency Medical Research and Development (RAKOS), Department of Clinical Medicine, University of Bergen, Norway
| | - Theodoros Xanthos
- European University, Nicosia, Cyprus; Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece
| | - Luc-Marie Joly
- Department of Emergency Medicine, Rouen University Hospital, Rouen, France
| | - Markus Roessler
- Department of Anaesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Conor Deasy
- Department of Emergency Medicine, Cork University Hospital, Cork, Ireland
| | | | - Jouni Nurmi
- Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Radoslaw Owczuk
- Department of Anaesthesiology and Intensive Therapy, Medical University of Gdansk, Gdansk, Poland
| | | | - Diana Cimpoesu
- University of Medicine and Pharmacy Gr.T. Popa and Emergency County Hospital Sf. Spiridon, Iasi, Romania
| | | | | | - Johan Steen
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Johan Decruyenaere
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Peter De Paepe
- Department of Emergency Medicine, Ghent University Hospital, Ghent, Belgium
| | - Ruth Piers
- Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium
| | - Dominique D Benoit
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
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Cardiac arrest: An interdisciplinary scoping review of the literature from 2019. Resusc Plus 2020; 4:100037. [PMID: 34223314 PMCID: PMC8244427 DOI: 10.1016/j.resplu.2020.100037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/29/2020] [Accepted: 10/04/2020] [Indexed: 01/09/2023] Open
Abstract
Objectives The Interdisciplinary Cardiac Arrest Research Review (ICARE) group was formed in 2018 to conduct a systematic annual search of peer-reviewed literature relevant to cardiac arrest. Now in its second year, the goals of the review are to illustrate best practices in research and help reduce compartmentalization of knowledge by disseminating clinically relevant advances in the field of cardiac arrest across disciplines. Methods An electronic search of PubMed using keywords related to cardiac arrest was conducted. Title and abstracts retrieved by these searches were screened for relevance, classified by article type (original research or review), and sorted into 7 categories. Screened manuscripts underwent standardized scoring of overall methodological quality and impact on the categorized fields of study by reviewer teams lead by a subject-matter expert editor. Articles scoring higher than 99 percentiles by category-type were selected for full critique. Systematic differences between editors’ and reviewers’ scores were assessed using Wilcoxon signed-rank test. Results A total of 3348 articles were identified on initial search; of these, 1364 were scored after screening for relevance and deduplication, and forty-five underwent full critique. Epidemiology & Public Health represented 24% of fully reviewed articles with Prehospital Resuscitation, Technology & Care, and In-Hospital Resuscitation & Post-Arrest Care Categories both representing 20% of fully reviewed articles. There were no significant differences between editor and reviewer scoring. Conclusions The sheer number of articles screened is a testament to the need for an accessible source calling attention to high-quality and impactful research and serving as a high-yield reference for clinicians and scientists seeking to follow the ever-growing body of cardiac arrest-related literature. This will promote further development of the unique and interdisciplinary field of cardiac arrest medicine.
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Natalzia P, Murk W, Thompson JJ, Dorsett M, Cushman JT, Reed P, Clemency BM. Evidence-based crisis standards of care for out-of-hospital cardiac arrests in a pandemic. Resuscitation 2020; 156:149-156. [PMID: 32758516 PMCID: PMC7832761 DOI: 10.1016/j.resuscitation.2020.07.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/07/2020] [Accepted: 07/16/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND & PURPOSE Pandemics such as COVID-19 can lead to severe shortages in healthcare resources, requiring the development of evidence-based Crisis Standard of Care (CSC) protocols. A protocol that limits the resuscitation of out-of-hospital cardiac arrests (OHCA) to events that are more likely to result in a positive outcome can lower hospital burdens and reduce emergency medical services resources and infection risk, although it would come at the cost of lives lost that could otherwise be saved. Our primary objective was to evaluate candidate OHCA CSC protocols involving known predictors of survival and identify the protocol that results in the smallest resource burden, as measured by the number of hospitalizations required per favorable OHCA outcome achieved. Our secondary objective was to describe the effects of the CSC protocols in terms of health outcomes and other measures of resource burden. METHODS We conducted a retrospective cohort study of adult patients in the Cardiac Arrest Registry to Enhance Survival (CARES) database. Non-traumatic OHCA events from 2018 were included (n = 79,533). Candidate CSC protocols involving combinations of known predictors of good survival for OHCA were applied to the existing dataset to measure the resulting numbers of resuscitation attempts, transportations to hospital, hospital admissions, and favorable neurological outcomes. These outcomes were also assessed under Standard Care, defined as no CSC protocol applied to the data. RESULTS The CSC protocol with the smallest number of hospitalizations per survivor with a favorable neurological outcome was that an OHCA resuscitation should only be attempted if the arrest was witnessed by emergency medical services or the first monitored rhythm was shockable (number of hospitalizations: 2.26 [95% CI: 2.21-2.31] vs. 3.46 [95% CI: 3.39-3.53] under Standard Care). This rule resulted in significant reductions in resource utilization (46.1% of hospitalizations and 29.2% of resuscitation attempts compared to Standard Care) while still preserving 70.5% of the favorable neurological outcomes under Standard Care. For every favorable neurological outcome lost under this CSC protocol, 6.3 hospital beds were made free that could be used to treat other patients. CONCLUSION In a pandemic scenario, pre-hospital CSC protocols that might not otherwise be considered have the potential to greatly improve overall survival, and this study provides an evidence-based approach towards selecting such a protocol. As this study was performed using data generated before the COVID-19 pandemic, future studies incorporating pandemic-era data will further help develop evidence-based CSC protocols.
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Affiliation(s)
- Peter Natalzia
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 955 Main St., Buffalo, NY 14203, USA
| | - William Murk
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 955 Main St., Buffalo, NY 14203, USA
| | - Jeffrey J Thompson
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 955 Main St., Buffalo, NY 14203, USA
| | - Maia Dorsett
- University of Rochester Medical Center 601 Elmwood Ave., Rochester, NY 14642, USA
| | - Jeremy T Cushman
- University of Rochester Medical Center 601 Elmwood Ave., Rochester, NY 14642, USA
| | - Philip Reed
- Canisius College, 2001 Main St., Buffalo, NY 14208, USA
| | - Brian M Clemency
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 955 Main St., Buffalo, NY 14203, USA.
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10
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Greif R, Bhanji F, Bigham BL, Bray J, Breckwoldt J, Cheng A, Duff JP, Gilfoyle E, Hsieh MJ, Iwami T, Lauridsen KG, Lockey AS, Ma MHM, Monsieurs KG, Okamoto D, Pellegrino JL, Yeung J, Finn JC. Education, Implementation, and Teams: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2020; 142:S222-S283. [PMID: 33084395 DOI: 10.1161/cir.0000000000000896] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
For this 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, the Education, Implementation, and Teams Task Force applied the population, intervention, comparator, outcome, study design, time frame format and performed 15 systematic reviews, applying the Grading of Recommendations, Assessment, Development, and Evaluation guidance. Furthermore, 4 scoping reviews and 7 evidence updates assessed any new evidence to determine if a change in any existing treatment recommendation was required. The topics covered included training for the treatment of opioid overdose; basic life support, including automated external defibrillator training; measuring implementation and performance in communities, and cardiac arrest centers; advanced life support training, including team and leadership training and rapid response teams; measuring cardiopulmonary resuscitation performance, feedback devices, and debriefing; and the use of social media to improve cardiopulmonary resuscitation application.
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11
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Greif R, Bhanji F, Bigham BL, Bray J, Breckwoldt J, Cheng A, Duff JP, Gilfoyle E, Hsieh MJ, Iwami T, Lauridsen KG, Lockey AS, Ma MHM, Monsieurs KG, Okamoto D, Pellegrino JL, Yeung J, Finn JC, Baldi E, Beck S, Beckers SK, Blewer AL, Boulton A, Cheng-Heng L, Yang CW, Coppola A, Dainty KN, Damjanovic D, Djärv T, Donoghue A, Georgiou M, Gunson I, Krob JL, Kuzovlev A, Ko YC, Leary M, Lin Y, Mancini ME, Matsuyama T, Navarro K, Nehme Z, Orkin AM, Pellis T, Pflanzl-Knizacek L, Pisapia L, Saviani M, Sawyer T, Scapigliati A, Schnaubelt S, Scholefield B, Semeraro F, Shammet S, Smyth MA, Ward A, Zace D. Education, Implementation, and Teams: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation 2020; 156:A188-A239. [PMID: 33098918 DOI: 10.1016/j.resuscitation.2020.09.014] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
For this 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, the Education, Implementation, and Teams Task Force applied the population, intervention, comparator, outcome, study design, time frame format and performed 15 systematic reviews, applying the Grading of Recommendations, Assessment, Development, and Evaluation guidance. Furthermore, 4 scoping reviews and 7 evidence updates assessed any new evidence to determine if a change in any existing treatment recommendation was required. The topics covered included training for the treatment of opioid overdose; basic life support, including automated external defibrillator training; measuring implementation and performance in communities, and cardiac arrest centers; advanced life support training, including team and leadership training and rapid response teams; measuring cardiopulmonary resuscitation performance, feedback devices, and debriefing; and the use of social media to improve cardiopulmonary resuscitation application.
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Glober NK, Lardaro T, Christopher S, Tainter CR, Weinstein E, Kim D. Validation of the NUE Rule to Predict Futile Resuscitation of Out-of-Hospital Cardiac Arrest. PREHOSP EMERG CARE 2020; 25:706-711. [PMID: 33026273 DOI: 10.1080/10903127.2020.1831666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AIM We validated the NUE rule, using three criteria (Non-shockable initial rhythm, Unwitnessed arrest, Eighty years or older) to predict futile resuscitation of patients with out-of-hospital cardiac arrest (OHCA). METHODS We performed a retrospective cohort analysis of all recorded OHCA in Marion County, Indiana, from January 1, 2014 to December 31, 2019. We described patient, arrest, and emergency medical services (EMS) response characteristics, and assessed the performance of the NUE rule in identifying patients unlikely to survive to hospital discharge. RESULTS From 2014 to 2019, EMS responded to 4370 patients who sustained OHCA. We excluded 329 (7.5%) patients with incomplete data. Median patient age was 62 years (IQR 49 - 73), 1599 (39.6%) patients were female, and 1728 (42.8%) arrests were witnessed. The NUE rule identified 290 (7.2%) arrests, of whom none survived to hospital discharge. CONCLUSION In external validation, the NUE rule (Non-shockable initial rhythm, Unwitnessed arrest, Eighty years or older) correctly identified 7.2% of OHCA patients unlikely to survive to hospital discharge. The NUE rule could be used in EMS protocols and policies to identify OHCA patients very unlikely to benefit from aggressive resuscitation.
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Alqahtani S, Nehme Z, Williams B, Bernard S, Smith K. Temporal Trends in the Incidence, Characteristics, and Outcomes of Hanging-Related Out-of-Hospital Cardiac Arrest. PREHOSP EMERG CARE 2020; 24:369-377. [PMID: 31512958 DOI: 10.1080/10903127.2019.1666944] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Aim: The aim of this study was to describe temporal trends in the incidence, characteristics, and outcomes of hanging-related out-of-hospital cardiac arrest (OHCA). Method: A retrospective study of all hanging-related OHCA in Victoria, Australia, between 2000 and 2017 was conducted. Trends in incidence, characteristics, and outcomes were assessed using linear regression and a non-parametric test for trend, as appropriate. Predictors of survival to hospital discharge were identified using multivariable logistic regression. Results: Between 2000 and 2017, emergency medical services (EMS)-attended 3,891 cases of hanging-related OHCA, of which 876 cases (23%) received an attempted resuscitation. The overall incidence rate of EMS-attended cases was 3.8 cases per 100,000 person-years increasing from 2.3 cases per 100,000 person-years in 2000 to 4.7 cases in 2017 (p for trend <0.001). Incidence rates increased approximately two-fold in young adults (18-44 years) and three-fold in middle aged adults (45-64 years). Despite improvement in the rate of bystander cardiopulmonary resuscitation (from 49% in 2000-2005 to 75% in 2012-2017), the survival to hospital discharge rate remained unchanged (3% overall). Among adult survivors with 12-month follow-up (n = 10), five patients responded to telephone interviews. Of those, three (60%) reported severe functional disability. Five patients responded to telephone interviews, of which 3 patients reported severe functional disability. An initial shockable rhythm (OR 23.17, 95% CI: 5.75, 93.36) or pulseless electrical activity (OR 13.14, 95% CI: 4.79, 36.03) were associated with survival. Conclusion: The incidence of hanging-related OHCA doubled over the 18 year period with no change to survival rates. New preventative strategies are needed to reduce the community burden of these events.
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Starks MA, Alexander K. In Anticipation of the Inevitable: Preparing Older Americans for Cardiac Arrest. J Am Geriatr Soc 2019; 68:9-10. [PMID: 31840229 DOI: 10.1111/jgs.16269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 11/01/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Monique Anderson Starks
- Preparing Older Americans for OHCA, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Karen Alexander
- Preparing Older Americans for OHCA, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
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Druwé P, Benoit DD, Monsieurs KG, Gagg J, Nakahara S, Alpert EA, van Schuppen H, Élő G, Huybrechts SA, Mpotos N, Joly LM, Xanthos T, Roessler M, Paal P, Cocchi MN, Bjørshol C, Nurmi J, Salmeron PP, Owczuk R, Svavarsdóttir H, Cimpoesu D, Raffay V, Pachys G, De Paepe P, Piers R. Cardiopulmonary Resuscitation in Adults Over 80: Outcome and the Perception of Appropriateness by Clinicians. J Am Geriatr Soc 2019; 68:39-45. [PMID: 31840239 DOI: 10.1111/jgs.16270] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 08/29/2019] [Accepted: 09/05/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine the prevalence of clinician perception of inappropriate cardiopulmonary resuscitation (CPR) regarding the last out-of-hospital cardiac arrest (OHCA) encountered in an adult 80 years or older and its relationship to patient outcome. DESIGN Subanalysis of an international multicenter cross-sectional survey (REAPPROPRIATE). SETTING Out-of-hospital CPR attempts registered in Europe, Israel, Japan, and the United States in adults 80 years or older. PARTICIPANTS A total of 611 clinicians of whom 176 (28.8%) were doctors, 123 (20.1%) were nurses, and 312 (51.1%) were emergency medical technicians/paramedics. RESULTS AND MEASUREMENTS The last CPR attempt among patients 80 years or older was perceived as appropriate by 320 (52.4%) of the clinicians; 178 (29.1%) were uncertain about the appropriateness, and 113 (18.5%) perceived the CPR attempt as inappropriate. The survival to hospital discharge for the "appropriate" subgroup was 8 of 265 (3.0%), 1 of 164 (.6%) in the "uncertain" subgroup, and 2 of 107 (1.9%) in the "inappropriate" subgroup (P = .23); 503 of 564 (89.2%) CPR attempts involved non-shockable rhythms. CPR attempts in nursing homes accounted for 124 of 590 (21.0%) of the patients and were perceived as appropriate by 44 (35.5%) of the clinicians; 45 (36.3%) were uncertain about the appropriateness; and 35 (28.2%) perceived the CPR attempt as inappropriate. The survival to hospital discharge for the nursing home patients was 0 of 107 (0%); 104 of 111 (93.7%) CPR attempts involved non-shockable rhythms. Overall, 36 of 543 (6.6%) CPR attempts were undertaken despite a known written do not attempt resuscitation decision; 14 of 36 (38.9%) clinicians considered this appropriate, 9 of 36 (25.0%) were uncertain about its appropriateness, and 13 of 36 (36.1%) considered this inappropriate. CONCLUSION Our findings show that despite generally poor outcomes for older patients undergoing CPR, many emergency clinicians do not consider these attempts at resuscitation to be inappropriate. A professional and societal debate is urgently needed to ensure that first we do not harm older patients by futile CPR attempts. J Am Geriatr Soc 68:39-45, 2019.
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Affiliation(s)
- Patrick Druwé
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Dominique D Benoit
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
| | | | - James Gagg
- Department of Emergency Medicine, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, United Kingdom
| | | | | | - Hans van Schuppen
- Department of Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Gábor Élő
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Sofie A Huybrechts
- Department of Emergency Medicine, Antwerp University Hospital, Antwerp, Belgium
| | - Nicolas Mpotos
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Luc-Marie Joly
- Department of Emergency Medicine, Rouen University Hospital, Rouen, France
| | - Theodoros Xanthos
- European University, Nicosia, Cyprus, Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece
| | - Markus Roessler
- Department of Anaesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Peter Paal
- Department of Anesthesiology and Critical Care Medicine, Hospitallers Brothers Hospital, Medical University Salzburg, Salzburg, Austria
| | - Michael N Cocchi
- Harvard Medical School, Department of Emergency Medicine and Department of Anesthesia Critical Care and Pain Medicine, Division of Critical Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Conrad Bjørshol
- Department of Anesthesiology and Intensive Care, Stavanger University Hospital, The Regional Centre for Emergency Medical Research and Development (RAKOS), Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Jouni Nurmi
- Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | | | - Radoslaw Owczuk
- Department of Anaesthesiology and Intensive Therapy, Medical University of Gdansk, Gdansk, Poland
| | | | - Diana Cimpoesu
- University of Medicine and Pharmacy Gr.T. Popa and Emergency County Hospital Sf. Spiridon, Iasi, Romania
| | | | - Gal Pachys
- Emergency Department, Sourasky Medical Center, Tel Aviv, Israel
| | - Peter De Paepe
- Department of Emergency Medicine, Ghent University Hospital, Ghent, Belgium
| | - Ruth Piers
- Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium
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Glober NK, Tainter CR, Abramson TM, Staats K, Gilbert G, Kim D. A simple decision rule predicts futile resuscitation of out-of-hospital cardiac arrest. Resuscitation 2019; 142:8-13. [PMID: 31228547 DOI: 10.1016/j.resuscitation.2019.06.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 05/23/2019] [Accepted: 06/11/2019] [Indexed: 10/26/2022]
Abstract
AIM Resuscitation of cardiac arrest involves invasive and traumatic interventions and places a large burden on limited EMS resources. Our aim was to identify prehospital cardiac arrests for which resuscitation is extremely unlikely to result in survival to hospital discharge. METHODS We performed a retrospective cohort analysis of all cardiac arrests in San Mateo County, California, for which paramedics were dispatched, from January 1, 2015 to December 31, 2018, using the Cardiac Arrest Registry to Enhance Survival (CARES) database. We described characteristics of patients, arrests, and EMS responses, and used recursive partitioning to develop decision rules to identify arrests unlikely to survive to hospital discharge, or to survive with good neurologic function. RESULTS From 2015-2018, 1750 patients received EMS dispatch for cardiac arrest in San Mateo County. We excluded 44 patients for whom resuscitation was terminated due to DNR directives. Median age was 69 years (IQR 57-81), 563 (33.0%) patients were female, 816 (47.8%) had witnessed arrests, 651 (38.2%) received bystander CPR, 421 (24.7%) had an initial shockable rhythm, and 1178 (69.1%) arrested at home. A simple rule (non-shockable initial rhythm, unwitnessed arrest, and age 80 or greater) excludes 223 (13.1%) arrests, of whom none survived to hospital discharge. CONCLUSION A simple decision rule (non-shockable rhythm, unwitnessed arrest, age ≥ 80) identifies arrests for which resuscitation is futile. If validated, this rule could be applied by EMS policymakers to identify cardiac arrests for which the trauma and expense of resuscitation are extremely unlikely to result in survival.
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Affiliation(s)
- Nancy K Glober
- Department of Emergency Medicine, Stanford University, 900 Welch Road, Palo Alto, California, 94304, USA
| | - Christopher R Tainter
- Department of Emergency Medicine, University of California at San Diego, 200 W Arbor Dr, San Diego, California, 92103, USA
| | - Tiffany M Abramson
- Department of Emergency Medicine, University of Southern California, 1200 N State Street, Los Angeles, California, 90033, USA
| | - Katherine Staats
- Department of Emergency Medicine, Stanford University, 900 Welch Road, Palo Alto, California, 94304, USA
| | - Gregory Gilbert
- Department of Emergency Medicine, Stanford University, 900 Welch Road, Palo Alto, California, 94304, USA
| | - David Kim
- Department of Emergency Medicine, Stanford University, 900 Welch Road, Palo Alto, California, 94304, USA.
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