Automated external defibrillator accessibility is crucial for bystander defibrillation and survival: A registry-based study

The impact of locked cabinets for automated external defibrillators (AEDs) on cardiac arrest and AED outcomes: A scoping review

Background

Rapid public defibrillation with automated external defibrillators (AEDs) is critical to improving out-of-hospital cardiac arrest survival. Concerns about AED theft and vandalism have led to implementing security measures, including locked cabinets. This scoping review, conducted as part of the evidence review for the International Liaison Committee on Resuscitation, explores the impact of securing AEDs in locked cabinets.

Methods

Searches of Medline, Embase, Cochrane, CINAHL (from database inception to 25/5/2024) and Google Scholar (first 200 articles). Studies of any type or design, published with an English abstract, examining the impact of locked AED cabinets were included. The included studies were grouped by outcomes, and an iterative narrative synthesis was performed.

Results

We screened 2,096 titles and found 10 relevant studies: 8 observational studies (4 published as conference abstracts) and 2 simulation studies. No study reported patient outcomes. Studies reported data on between 36 and 31,938 AEDs. Most studies reported low rates (<2%) of theft/missing/vandalism, including AEDs that were accessible 24/7. The only study comparing unlocked and locked cabinets showed minimal difference in theft and vandalism rates (0.3% vs. 0.1%). Two simulation studies showed significantly slower AED retrieval when additional security measures, included locked cabinets, were used. A survey of first responders reported half (25/50) were injured while accessing an AED that required breaking glass to access.

Conclusion

The limited literature suggests that vandalism and the loss of AEDs are rare and occur in locked and unlocked cabinets. Research on this topic is needed that focuses on real-life retrieval and patient outcomes.

An innovative Hearing AED alarm system shortens delivery time of automated external defibrillator - A randomized controlled simulation study

Background

Early defibrillation with an automated external defibrillator (AED) is a key element in the out-of-hospital cardiac arrest (OHCA) chain. However, a public automatic defibrillator (PAD) is often not easily accessible during emergency situations. Here, we have developed an AED-based alarm system together with a smartphone Hearing AED application (APP) that would activate registered public access AED within 300 m radius from the location of an OHCA event. It also alerts nearby related personnel to bring in the AED to the OHCA location for emergency assistance. The aim of this study is to determine if this novel Hearing AED alarm system shortens the AED delivery time.

Methods

This was a randomized controlled simulation study. Participants were randomly assigned to one of the 3 groups: (a) bystander group, (b) APP responder group, and (c) AED alarm responder in equal ratios. The bystanders were stationed at the OHCA scene, and must access a nearby AED by the instruction of the dispatcher of emergency medical services. APP responders were stationed within 300 m of the cardiac arrest scene, and were activated by the Hearing AED APP. The AED alarm responders were brought to AED location, and were activated by the AED-based alarm device mounted on an AED case. We measured the time taken to find and bring the nearby AED to the OHCA scene. The primary outcome was the total delivery time in each group. The secondary outcomes were times needed: (a) from the starting point to AED place, (b) from AED place to the OHCA scene, and (c) the operation time.

Results

We enrolled 90 participants in this study. The total AED delivery times were significantly different across the 3 groups. The shortest time was in the AED alarm responder group, compared with the other two groups. The median time from the starting point to AED was statistically shorter in the bystander group than in the APP responder group (116.0 sec, IQR 80.0-135.0 vs 159.0 sec, IQR 98.5-200.5, p = 0.029). In the analysis with the general linear model, we found statistically shorter total AED delivery time in the AED alarm responder group (β = -122.4, p = 0.004). In contrast, the APP responder group was associated with a markedly longer total AED delivery time (β = 104.6, P=0.016).

Conclusion

In this simulation study, the Hearing AED system contributed to shortening the AED delivery time. Further studies are needed to determine its validation in the real world situation in the future.

Incidence and Outcomes After Out-of-Hospital Cardiac Arrest at Train Stations in Denmark

BACKGROUND

Following international guidelines, communities have deployed automated external defibrillators at train stations without substantive evidence.

METHODS AND RESULTS

We geocoded public out-of-hospital cardiac arrests (OHCAs) (2016-2020), automated external defibrillators, and train stations. The stations were divided into the following groups according to passenger flow: 1 (0-499), 2 (500-4999), 3 (5000-9999), and 4 (>10 000) passengers per day. Risk ratios (RRs) were calculated using Poisson regression of rates, and odds ratios (ORs) were analyzed through logistic regression. OHCAs at train stations accounted for 102 (2.3%) of 4467 public OHCAs. The incidence rate (IR) and RR for OHCAs were for group 1: IR, 0.02 OHCA per station per year, RR, 1.0 (reference); group 2: IR, 0.07, RR, 4.1 (95% CI, 2.3-7.3); group 3: IR, 0.25, RR, 12.7 (95% CI, 6.2-25.9); and group 4: IR, 0.34, RR, 16.3 (95% CI, 8.6-30.9). Compared with other public OHCAs, OHCAs at train stations were just as likely to receive bystander cardiopulmonary resuscitation (OR, 1.13 [95% CI, 0.60-2.12]). However, they had higher odds of bystander defibrillation (OR, 1.66 [95% CI, 1.06-2.58]), were more likely to achieve return of spontaneous circulation (OR, 1.88 [95% CI, 1.24-2.85]), and survive 30 days (OR, 2.37 [95% CI, 1.57-3.59]).

CONCLUSIONS

The incidence of OHCAs at train stations was associated with passenger flow, with the busiest stations having a 16-fold higher risk of OHCAs than the lowest. OHCAs at train stations had better outcomes compared with other public OHCAs.

A Call to Action to Improve Cardiac Arrest Outcomes: A Report From the National Summit for Cardiac Arrest

Sudden cardiac arrest (SCA) represents a major cause of premature mortality globally, with enormous impact and financial cost to victims, families, and communities. SCA prevention should be considered a health priority in Australia. National Cardiac Arrest Summits were held in June 2022 and March 2023, with inclusion from multi-faceted endeavours related to SCA prevention. It was agreed to establish a multidisciplinary Australian Sudden Cardiac Arrest Alliance (AuSCAA) working group charged with developing a national unified strategy, with clear and measurable quality indicators and standardised outcome measures, to amplify the goal of SCA prevention throughout Australia. A multi-faceted prevention strategy will include i) endeavours to progress community awareness, ii) improved fundamental mechanistic understanding, iii) implementation of best-practice resuscitation strategies for all demographics and locations, iv) secondary risk assessment directed to family members, and v) development of (near) real-time registry of cardiac arrest cases to inform areas of need and effectiveness of interventions. Together, we can and should reduce the impact of SCA in Australia.

Installation of Public Access Defibrillators for Out-of-Hospital Cardiac Arrests: Identifying Suitable Locations by Using a Geographic Information System

BACKGROUND

Survival following an out-of-hospital cardiac arrest depends on prompt defibrillation. Despite the efforts made to install automated external defibrillators (AEDs) in crowded areas, their usage rate remains suboptimal. This study evaluated the efficiency of installing AEDs at key landmarks in Taoyuan City to enhance accessibility and usage.

METHODS AND RESULTS

This retrospective cohort study analyzed nontraumatic public out-of-hospital cardiac arrest cases in Taoyuan City from 2017 to 2021, using data from the Taoyuan Fire Department and a regional registry. AED data were collected for 1163 devices. A geographic information system mapped target locations within the city, and real-world walking routes were examined to assess coverage. The primary outcome was actual coverage and the coverage efficiency ratio, calculated as the actual coverage divided by the number of facilities at a location. The coverage efficiency ratio compared the coverage efficiency of target locations with existing public access defibrillators (PADs). Top locations for superior coverage in both downtown and outside downtown areas were bus stops and convenience stores (7-Eleven and FamilyMart), which outperformed existing PADs. Convenience stores had a higher coverage efficiency ratio than the public service sector. Bus stops showed high AED usage rates before ambulance arrival.

CONCLUSIONS

The current PAD locations in Taoyuan City offer limited coverage, which highlights the need for strategically installed AEDs, particularly in convenience stores. Policymakers should consider using the cultural relevance and accessibility of convenience stores, particularly 7-Eleven branches, to enhance AED usage rates.

Association between bystander automated external defibrillator use and survival in witnessed out-of-hospital cardiac arrest: A nationwide observational study in South Korea

AIM

Sudden cardiac arrest is a global health issue, with out-of-hospital cardiac arrest (OHCA) posing a major challenge. Bystander cardiopulmonary resuscitation (CPR) and automated external defibrillators (AEDs) improve survival and neurological outcomes. However, their actual usage involves numerous constraints. Therefore, to determine the association between bystander AED use and survival of patients with OHCA, we analyzed South Korea's national OHCA database.

METHODS

This retrospective study included cases from the Korea Disease Control and Prevention Agency's Out-of-Hospital Cardiac Arrest Surveillance database from January 2016 to December 2021. Adult OHCA cases treated with bystander intervention were categorized into two groups, CPR with AEDs and without AEDs. Propensity score matching was employed to control for confounders and analyze bystander AED use's impact on survival to discharge and neurological outcomes.

RESULTS

Of 182,508 OHCA cases, 35,840 met the inclusion criteria, with 234 (0.7%) receiving bystander CPR with AEDs. The survival rate to discharge in the AED and non-AED group was 46.6% and 23.0%, respectively. However, after adjusting for potential confounders, bystander AED use did not significantly affect survival to discharge (adjusted odds ratio [aOR] 1.01, 95% confidence interval [CI] 0.70-1.44) or favorable neurological outcomes (aOR 1.08, 95% CI 0.99-1.18).

CONCLUSION

Survival to discharge or favorable neurological outcomes of patients with OHCA managed using bystander-applied AEDs and those without showed no significant difference. Factors such as AED accessibility and bystander preparedness influence the impact of bystander AED use. Further research should optimize AED deployment and usage strategies to enhance patient survival rate.

Strategic placement of volunteer responder system defibrillators

Volunteer responder systems (VRS) alert and guide nearby lay rescuers towards the location of an emergency. An application of such a system is to out-of-hospital cardiac arrests, where early cardiopulmonary resuscitation (CPR) and defibrillation with an automated external defibrillator (AED) are crucial for improving survival rates. However, many AEDs remain underutilized due to poor location choices, while other areas lack adequate AED coverage. In this paper, we present a comprehensive data-driven algorithmic approach to optimize deployment of (additional) public-access AEDs to be used in a VRS. Alongside a binary integer programming (BIP) formulation, we consider two heuristic methods, namely Greedy and Greedy Randomized Adaptive Search Procedure (GRASP), to solve the gradual Maximal Covering Location (MCLP) problem with partial coverage for AED deployment. We develop realistic gradually decreasing coverage functions for volunteers going on foot, by bike, or by car. A spatial probability distribution of cardiac arrest is estimated using kernel density estimation to be used as input for the models and to evaluate the solutions. We apply our approach to 29 real-world instances (municipalities) in the Netherlands. We show that GRASP can obtain near-optimal solutions for large problem instances in significantly less time than the exact method. The results indicate that relocating existing AEDs improves the weighted average coverage from 36% to 49% across all municipalities, with relative improvements ranging from 1% to 175%. For most municipalities, strategically placing 5 to 10 additional AEDs can already provide substantial improvements.

Development of a centralised national AED (automated external defibrillator) network across all ambulance services in the United Kingdom

Background

Early cardiopulmonary resuscitation and defibrillation is key to increasing survival following an out-of-hospital-cardiac-arrest (OHCA). However, automated external defibrillators (AEDs) are used in a very small percentage of cases. Despite large numbers of AEDs in the community, the absence of a unified system for registering their locations across the UK's ambulance services may have resulted in missed opportunities to save lives. Therefore, representatives from the resuscitation community worked alongside ambulance services to develop a single repository for data on the location of AEDs in the UK.

Methods

A national defibrillator network, "The Circuit", was developed by the British Heart Foundation in collaboration with the Association of Ambulance Chief Executives, the UK ambulance services, the Resuscitation Council UK and St John Ambulance. The database allows individuals or organisations to record information about AED location, accessibility, and availability. The database synchronises with ambulance computer aided dispatch systems to provide UK ambulance services with real-time information on the nearest, available AED.

Results

The Circuit was successfully rolled out to all 14 UK ambulance services. Since 2019, 82,108 AEDs have been registered. Of the AED data collected by The Circuit, 54% were not previously registered to any ambulance service, and are therefore new registrations.

Conclusion

The Circuit provides ambulance services with a single point of access to AED locations in the UK. Since the launch of the system the number of defibrillators registered has doubled. Linking the Circuit data with patient outcome data will help understand whether improving the accessibility to AEDs is associated with increased survival.

Resuscitation of out-of-hospital cardiac arrest victims in Austria's largest helicopter emergency medical service: A retrospective cohort study

Background

Helicopter emergency medical services (HEMS) play a fundamental role in prehospital care. However, the impact of HEMS on survival of patients with out-of-hospital cardiac arrest (OHCA) is widely unknown. Therefore, the purpose of this study was to assess demographics, treatment, and outcome of patients with OHCA attended by physician-staffed helicopters.

Methods

Retrospective cohort study enrolling OHCA patients treated by HEMS during a ten-year period (2010-2019) in Austria. Patients were identified using electronic mission records of 13 HEMS bases run by the Austrian Automobile, Motorcycle and Touring Club (OEAMTC), and subsequently matched with the national register of deaths to determine 30-day and one-year survival rates. Results are reported according to the 2015 Utstein Style. Multivariable logistic regression analysis was used to identify factors associated with patient outcome.

Results

In total, 9344 presumed OHCA missions were identified. Cardiopulmonary resuscitation was attempted or continued by HEMS in 3889 cases. Approximately 32.2% of patients achieved return of spontaneous circulation (ROSC) and 22.5% sustained ROSC until arrival at the emergency department. Thirty-day and one-year survival rates were 14.0% and 12.4% respectively. HEMS response time, on-scene time, age, pathogenesis, arrest location, witness-status, first monitored rhythm, bystander automated external defibrillator (AED) use, airway type and administration of adrenaline were independent predictors of 30-day survival.

Conclusions

This study provides an extensive insight into the management of OHCA in an almost nationwide HEMS sample. Thirty-day and one-year survival rates are high, indicating high-quality care and systematic selection of patients with favorable prognosis.

Impact of cardiopulmonary resuscitation duration on functional outcome, level of independence, and survival among patients with in-hospital cardiac arrests: A pilot study

BACKGROUND

Cardiovascular diseases (CVDs) are the leading cause of cardiac arrest (CA), which are presented as sudden cardiac arrest (SCA) and sudden cardiac death (SCD). To assess the impact of CPR duration on the functional outcome, level of independence, and survival among patients with in-hospital cardiac arrest (IHCA).

MATERIAL AND METHODS

This prospective longitudinal pilot study was conducted at a tertiary care hospital in South India. Data were collected using consecutive sampling techniques from nine patients with IHCA, and outcomes were measured using the cerebral performance category (CPC) and Katz level of independence (LOI) during the immediate post-CPR, 30th day, and 90th day. Based on the principles of pilot study design, descriptive statistics was used to analyze the results. Inferential statistics analysis was not applicable based on the sample size of the pilot study.

RESULTS

Nine patients were included in this pilot study. The mean and median age of the patients were 48.11 ± 8.66 (46, IQR, 32-67 years) and 77.8% were male patients. The primary medical diagnosis was cardiology and neurology conditions among 44.4% and 22.2% of patients. The mean and median CPR duration was 12.11 ± 4.59 minutes (IQR, 8-15.50) and 44.4% achieved a return of spontaneous circulation (ROSC) with a mean ROSC time of 5.56 ± 7.418. The mean CPC score in the immediate post-CPR period and 30th day was 4 ± 1.732 and 4.56 ± 1.33, with mortality of 66.7% and 33.3% survivors in the immediate post-CPR period. While the mean LOI score among the survivors during the immediate post-CPR and 30th day was zero and four. which highlights the complete dependency of patients during the immediate post-CPR with significant improvement by the 30th day and unchanged until the 90th day.

CONCLUSIONS

The overall mortality and survival were 88.8% and 11.1%, respectively, by the 90th day. The pilot study is feasible at the end of the study. However, due to the difficulty in obtaining CA, an additional tertiary hospital was included in the larger study.

Combinations of First Responder and Drone Delivery to Achieve 5-Minute AED Deployment in OHCA

Background

Defibrillation in the critical first minutes of out-of-hospital cardiac arrest (OHCA) can significantly improve survival. However, timely access to automated external defibrillators (AEDs) remains a barrier.

Objectives

The authors estimated the impact of a statewide program for drone-delivered AEDs in North Carolina integrated into emergency medical service and first responder (FR) response for OHCA.

Methods

Using Cardiac Arrest Registry to Enhance Survival registry data, we included 28,292 OHCA patients ≥18 years of age between 1 January 2013 and 31 December 2019 in 48 North Carolina counties. We estimated the improvement in response times (time from 9-1-1 call to AED arrival) achieved by 2 sequential interventions: 1) AEDs for all FRs; and 2) optimized placement of drones to maximize 5-minute AED arrival within each county. Interventions were evaluated with logistic regression models to estimate changes in initial shockable rhythm and survival.

Results

Historical county-level median response times were 8.0 minutes (IQR: 7.0-9.0 minutes) with 16.5% of OHCAs having AED arrival times of <5 minutes (IQR: 11.2%-24.3%). Providing all FRs with AEDs improved median response to 7.0 minutes (IQR: 6.2-7.8 minutes) and increased OHCAs with <5-minute AED arrival to 22.3% (IQR: 16.4%-30.9%). Further incorporating optimized drone networks (326 drones across all 48 counties) improved median response to 4.8 minutes (IQR: 4.3-5.2 minutes) and OHCAs with <5-minute AED arrival to 56.3% (IQR: 46.9%-64.2%). Survival rates were estimated to increase by 34% for witnessed OHCAs with estimated drone arrival <5 minutes and ahead of FR and emergency medical service.

Conclusions

Deployment of AEDs by FRs and optimized drone delivery can improve AED arrival times which may lead to improved clinical outcomes. Implementation studies are needed.

Incidence and Survival of Out-of-Hospital Cardiac Arrest in Public Housing Areas in 3 European Capitals

BACKGROUND

Strategies to reach out-of-hospital cardiac arrests (called cardiac arrest) in residential areas and reduce disparities in care and outcomes are warranted. This study investigated incidences of cardiac arrests in public housing areas.

METHODS

This register-based cohort study included cardiac arrest patients from Amsterdam (the Netherlands) from 2016 to 2021, Copenhagen (Denmark) from 2016 to 2021, and Vienna (Austria) from 2018 to 2021. Using Poisson regression adjusted for spatial correlation and city, we compared cardiac arrest incidence rates (number per square kilometer per year and number per 100 000 inhabitants per year) in public housing and other residential areas and examined the proportion of cardiac arrests within public housing and adjacent areas (100-m radius).

RESULTS

Overall, 9152 patients were included of which 3038 (33.2%) cardiac arrests occurred in public housing areas and 2685 (29.3%) in adjacent areas. In Amsterdam, 635/1801 (35.3%) cardiac arrests occurred in public housing areas; in Copenhagen, 1036/3077 (33.7%); and in Vienna, 1367/4274 (32.0%). Public housing areas covered 42.4 (12.6%) of 336.7 km2 and 1 024 470 (24.6%) of 4 164 700 inhabitants. Across the capitals, we observed a lower probability of 30-day survival in public housing versus other residential areas (244/2803 [8.7%] versus 783/5532 [14.2%]). The incidence rates and rate ratio of cardiac arrest in public housing versus other residential areas were incidence rate, 16.5 versus 4.1 n/km2 per year; rate ratio, 3.46 (95% CI, 3.31-3.62) and incidence rate, 56.1 versus 36.8 n/100 000 inhabitants per year; rate ratio, 1.48 (95% CI, 1.42-1.55). The incidence rates and rate ratios in public housing versus other residential areas were consistent across the 3 capitals.

CONCLUSIONS

Across 3 European capitals, one-third of cardiac arrests occurred in public housing areas, with an additional third in adjacent areas. Public housing areas exhibited consistently higher cardiac arrest incidences per square kilometer and 100 000 inhabitants and lower survival than other residential areas. Public housing areas could be a key target to improve cardiac arrest survival in countries with a public housing sector.

Challenges & barriers for real-time integration of drones in emergency cardiac care: Lessons from the United States, Sweden, & Canada

Importance

Out-of-hospital cardiac arrest (OHCA) is a leading cause of morbidity and mortality in the US and Europe (∼600,000 incident events annually) and around the world (∼3.8 million). With every minute that passes without cardiopulmonary resuscitation or defibrillation, the probability of survival decreases by 10%. Preliminary studies suggest that uncrewed aircraft systems, also known as drones, can deliver automated external defibrillators (AEDs) to OHCA victims faster than ground transport and potentially save lives.

Objective

To date, the United States (US), Sweden, and Canada have made significant contributions to the knowledge base regarding AED-equipped drones. The purpose of this Special Communication is to explore the challenges and facilitators impacting the progress of AED-equipped drone integration into emergency medicine research and applications in the US, Sweden, and Canada. We also explore opportunities to propel this innovative and important research forward.

Evidence review

In this narrative review, we summarize the AED-drone research to date from the US, Sweden, and Canada, including the first drone-assisted delivery of an AED to an OHCA. Further, we compare the research environment, emergency medical systems, and aviation regulatory environment in each country as they apply to OHCA, AEDs, and drones. Finally, we provide recommendations for advancing research and implementation of AED-drone technology into emergency care.

Findings

The rates that drone technologies have been integrated into both research and real-life emergency care in each country varies considerably. Based on current research, there is significant potential in incorporating AED-equipped drones into the chain of survival for OHCA emergency response. Comparing the different environments and systems in each country revealed ways that each can serve as a facilitator or barrier to future AED-drone research.

Conclusions and relevance

The US, Sweden, and Canada each offers different challenges and opportunities in this field of research. Together, the international community can learn from one another to optimize integration of AED-equipped drones into emergency systems of care.

Survival and neurological outcome after bystander versus lay responder defibrillation in out-of-hospital cardiac arrest: A sub-study of the BOX trial

BACKGROUND AND AIM

Bystander defibrillation is associated with increased survival with good neurological outcome after out-of-hospital cardiac arrest (OHCA). Dispatch of lay responders could increase defibrillation rates, however, survival with good neurological outcome in these remain unknown. The aim was to compare long-term survival with good neurological outcome in bystander versus lay responder defibrillated OHCAs.

METHODS

This is a sub-study of the BOX trial, which included OHCA patients from two Danish tertiary cardiac intensive care units from March 2017 to December 2021. The main outcome was defined as 3-month survival with good neurological performance (Cerebral Performance Category of 1or 2, on a scale from 1 (good cerebral performance) to 5 (death or brain death)). For this study EMS witnessed OHCAs were excluded.

RESULTS

Of the 715 patients, a lay responder arrived before EMS in 125 cases (16%). In total, 81 patients were defibrillated by a lay responder (11%), 69 patients by a bystander (10%) and 565 patients by the EMS staff (79%). The 3-month survival with good neurological outcome was 65% and 81% in the lay responder and bystander defibrillated groups, respectively (P = 0.03).

CONCLUSION

In patients with OHCA, 3-month survival with good neurological outcome was higher in bystander defibrillated patients compared with lay responder defibrillated patients.

Public Out-of-Hospital Cardiac Arrest in Residential Neighborhoods

BACKGROUND

Although one-half of all public out-of-hospital cardiac arrests (OHCAs) occur outside private homes in residential neighborhoods, their characteristics and outcomes remain unexplored.

OBJECTIVES

The authors assessed interventions before ambulance arrival and survival for public OHCA patients in residential neighborhoods.

METHODS

Public OHCAs from Vienna (2018-2021) and Copenhagen (2016-2020) were designated residential neighborhoods or nonresidential areas. Interventions (cardiopulmonary resuscitation [CPR], automated external defibrillator [AED] attached, and defibrillation) and 30-day survival were compared using a generalized estimation equation model adjusted for age and time of day and presented as ORs.

RESULTS

We included 1,052 and 654 public OHCAs from Vienna and Copenhagen, respectively, and 68% and 55% occurred in residential neighborhoods, respectively. The likelihood of CPR, defibrillation, and survival in residential neighborhoods vs nonresidential areas (reference) were as follows: CPR Vienna, 73% vs 78%, OR: 0.78 (95% CI: 0.57-1.06), CPR Copenhagen, 83% vs 90%, OR: 0.54 (95% CI: 0.34-0.88), and CPR combined, 76% vs 84%, OR: 0.70 (95% CI: 0.53-0.90); AED attached Vienna, 36% vs 44%, OR: 0.69 (95% CI: 0.53-0.90), AED attached Copenhagen, 21% vs 43%, OR: 0.33 (95% CI: 0.24-0.48), and AED attached combined, 31% vs 44%, OR: 0.53 (95% CI: 0.42-0.65); defibrillation Vienna, 14% vs 20%, OR: 0.61 (95% CI: 0.43-0.87), defibrillation Copenhagen, 16% vs 36%, OR: 0.35 (95% CI: 0.24-0.51), and defibrillation combined, 15% vs 27%, OR: 0.46 (95% CI: 0.36-0.61); and 30-day survival rate Vienna, 21% vs 26%, OR: 0.84 (95% CI: 0.58-1.20), 30-day survival rate Copenhagen, 33% vs 44%, OR: 0.65 (95% CI: 0.47-0.90), and 30-day survival rate combined, 25% vs 36%, OR: 0.73 (95% CI: 0.58-0.93).

CONCLUSIONS

Two-thirds of public OHCAs occurred in residential neighborhoods with fewer resuscitative efforts before ambulance arrival and lower survival than in nonresidential areas. Targeted efforts to improve early CPR and defibrillation for public OHCA patients in residential neighborhoods are needed.

Community intervention to improve defibrillation before ambulance arrival in residential neighbourhoods with a high risk of out-of-hospital cardiac arrest: study protocol of a cluster-randomised trial (the CARAMBA trial)

INTRODUCTION

In Denmark, multiple national initiatives have been associated with improved bystander defibrillation and survival following out-of-hospital cardiac arrest (OHCA) in public places. However, OHCAs in residential neighbourhoods continue to have poor outcomes. The Cardiac Arrest in Residential Areas with MoBile volunteer responder Activation trial aims to improve bystander defibrillation and survival following OHCA in residential neighbourhoods with a high risk of OHCA. The intervention consists of: (1) strategically deployed automated external defibrillators accessible at all hours, (2) cardiopulmonary resuscitation (CPR) training of residents and (3) recruitment of residents for a volunteer responder programme.

METHODS AND ANALYSIS

This is a prospective, pair-matched, cluster-randomised, superiority trial with clusters of 26 residential neighbourhoods, testing the effectiveness of the intervention in a real-world setting. The areas are randomised for intervention or control. Intervention and control areas will receive the standard OHCA emergency response, including volunteer responder activation. However, targeted automated external defibrillator deployment, CPR training and volunteer responder recruitment will only be provided in the intervention areas. The primary outcome is bystander defibrillation, and the secondary outcome is 30-day survival. Data on patients who had an OHCA will be collected through the Danish Cardiac Arrest Registry.

ETHICS AND DISSEMINATION

Approval to store OHCA data has been granted from the Legal Office, Capital Region of Denmark (j.nr: 2012-58-0004, VD-2018-28, I-Suite no: 6222, and P-2021-670). In Denmark, formal approval from the ethics committee is only obtainable when the study regards testing medicine or medical equipment on humans or using genome or diagnostic imagine as data source. The Ethics Committee of the Capital Region of Denmark has evaluated the trial and waived formal approval unnecessary (H-19037170). Results will be published in peer-reviewed papers and shared with funders, stakeholders, and housing organisations through summaries and presentations.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT04446585).

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.

The Lancet Commission to reduce the global burden of sudden cardiac death: a call for multidisciplinary action

Despite major advancements in cardiovascular medicine, sudden cardiac death (SCD) continues to be an enormous medical and societal challenge, claiming millions of lives every year. Efforts to prevent SCD are hampered by imperfect risk prediction and inadequate solutions to specifically address arrhythmogenesis. Although resuscitation strategies have witnessed substantial evolution, there is a need to strengthen the organisation of community interventions and emergency medical systems across varied locations and health-care structures. With all the technological and medical advances of the 21st century, the fact that survival from sudden cardiac arrest (SCA) remains lower than 10% in most parts of the world is unacceptable. Recognising this urgent need, the Lancet Commission on SCD was constituted, bringing together 30 international experts in varied disciplines. Consistent progress in tackling SCD will require a completely revamped approach to SCD prevention, with wide-sweeping policy changes that will empower the development of both governmental and community-based programmes to maximise survival from SCA, and to comprehensively attend to survivors and decedents' families after the event. International collaborative efforts that maximally leverage and connect the expertise of various research organisations will need to be prioritised to properly address identified gaps. The Commission places substantial emphasis on the need to develop a multidisciplinary strategy that encompasses all aspects of SCD prevention and treatment. The Commission provides a critical assessment of the current scientific efforts in the field, and puts forth key recommendations to challenge, activate, and intensify efforts by both the scientific and global community with new directions, research, and innovation to reduce the burden of SCD worldwide.

Characteristics and Treatment Outcomes of Out-of-Hospital Cardiac Arrests Occurring in Public Places: A National Population-Based Observational Study

Sudden cardiac arrest, particularly out-of-hospital cardiac arrest (OHCA), is a global public health concern. However, limited research exists on the epidemiology of OHCAs occurring in public places, trends and impact of bystander intervention, and influence of extraordinary circumstances. This study investigated the epidemiological factors, bystander characteristics, and outcomes of OHCAs that occurred in public places in South Korea from 2016 to 2021 and analyzed the impact of the coronavirus disease 2019 (COVID-19) pandemic. A retrospective analysis was conducted using an Out-of-Hospital Cardiac Arrest Surveillance database, including 33,206 cases of OHCA that occurred in public places. Cases with do-not-resuscitate orders or insufficient data were excluded. A steady increase in bystander-performed cardiopulmonary resuscitation over the years and a constant decrease in bystander automated external defibrillator (AED) use were observed. Survival-to-discharge rates for OHCAs remained relatively steady until a marginal decrease was observed during the pandemic (pandemic, 13.1%; pre-pandemic, 14.4%). Factors affecting survival included the presence of a shockable rhythm, witnessed arrest, cardiac arrest due to disease, use of bystander AED, and period relative to the COVID-19 pandemic. These findings emphasize the critical role of bystanders in outcomes of OHCAs and inform public health strategies on better management of OHCAs in public places.

Geographical Association Between Basic Life Support Courses and Bystander Cardiopulmonary Resuscitation and Survival from OHCA in Denmark

Introduction

Annually, approximately 4% of the entire adult population of Denmark participate in certified basic life support (BLS) courses. It is still unknown whether increases in BLS course participation in a geographical area increase bystander cardiopulmonary resuscitation (CPR) or survival from out-of-hospital cardiac arrest (OHCA). The aim of the study was to examine the geographical association between BLS course participation, bystander CPR, and 30-day survival from OHCA.

Methods

This nationwide register-based cohort study includes all OHCAs from the Danish Cardiac Arrest Register. Data concerning BLS course participation were supplied by the major Danish BLS course providers. A total of 704,234 individuals with BLS course certificates and 15,097 OHCA were included from the period 2016-2019. Associations were examined using logistic regression and Bayesian conditional autoregressive analyses conducted at municipality level.

Results

A 5% increase in BLS course certificates at municipality level was significantly associated with an increased likelihood of bystander CPR prior to ambulance arrival with an adjusted odds ratio (OR) of 1.34 (credible intervals: 1.02;1.76). The same trends were observed for OHCAs in out-of-office hours (4pm-08am) with a significant OR of 1.43 (credible intervals: 1.09;1.89). Local clusters with low rate of BLS course participation and bystander CPR were identified.

Conclusion

This study found a positive effect of mass education in BLS on bystander CPR rates. Even a 5% increase in BLS course participation at municipal level significantly increased the likelihood of bystander CPR. The effect was even more profound in out-of-office hours with an increase in bystander CPR rate at OHCA.

Public access defibrillation: challenges and new solutions

PURPOSE OF REVIEW

The purpose of this article is to review the current status of public access defibrillation and the various utility modalities of early defibrillation.

RECENT FINDINGS

Defibrillation with on-site automated external defibrillators (AEDs) has been the conventional approach for public access defibrillation. This strategy is highly effective in cardiac arrests occurring in close proximity to on-site AEDs; however, only a few cardiac arrests will be covered by this strategy. During the last decades, additional strategies for public access defibrillation have developed, including volunteer responder programmes and drone assisted AED-delivery. These programs have increased chances of early defibrillation within a greater radius, which remains an important factor for survival after out-of-hospital cardiac arrest.

SUMMARY

Recent advances in the use of public access defibrillation show great potential for optimizing early defibrillation. With new technological solutions, AEDs can be transported to the cardiac arrest location reaching OHCAs in both public and private locations. Furthermore, new technological innovations could potentially identify and automatically alert the emergency medical services in nonwitnessed OHCA previously left untreated.

Bystander cardiopulmonary resuscitation, automated external defibrillator use, and survival after out-of-hospital cardiac arrest

INTRODUCTION

We aimed to investigate the association between bystander cardiopulmonary resuscitation (CPR) with and without automated external defibrillator (AED) use and neurological outcomes after out-of-hospital cardiac arrest (OHCA) in Korea.

METHODS

This cross-sectional study used a nationwide Korean OHCA registry between 2015 and 2019. Patients were categorised into no bystander CPR and bystander CPR with and without AED use groups. The primary outcome was good neurological recovery at discharge. We also analysed the interaction effects of place of arrest, response time, and whether the OHCA was witnessed.

RESULTS

In total, 93,623 patients were included. Among them, 35,486 (37.9%) were in the no bystander CPR group, 56,187 (60.0%) were in the bystander CPR without AED use group, and 1950 (2.1%) were in the bystander CPR with AED use group. Good neurological recovery was demonstrated in 1286 (3.6%), 3877 (6.9%), and 208 (10.7%) patients in the no CPR, bystander CPR without AED use, and bystander CPR with AED use groups, respectively. Compared to the no bystander CPR group, the adjusted odds ratio (95% confidence intervals) for good neurological recovery was 1.54 (1.45-1.65) and 1.37 (1.15-1.63) in the bystander CPR without and with AED use groups, respectively. The effect of bystander CPR with AED use was more apparent in OHCAs with witnessed arrest and prolonged response time (≥8 min).

CONCLUSION

Bystander CPR was associated with better neurological recovery compared to no bystander CPR; however, the benefits of AED use were not significant. Efforts to disseminate bystander AED availability and ensure proper utilisation are warranted.

Volunteer responder provision of support to relatives of out-of-hospital cardiac arrest patients: a qualitative study

OBJECTIVES

Smartphone dispatch of volunteer responders for out-of-hospital cardiac arrest (OHCA) is implemented worldwide. While basic life support courses prepare participants to provide CPR, the courses rarely address the possibility of meeting a family member or relative in crisis. This study aimed to examine volunteer responders' provision of support to relatives of cardiac arrest patients and how relatives experienced the interaction with volunteer responders.

DESIGN

In this qualitative study, we conducted 16 semistructured interviews with volunteer responders and relatives of cardiac arrest patients.

SETTING

Interviews were conducted face to face and by video and recorded and transcribed verbatim.

PARTICIPANTS

Volunteer responders dispatched to cardiac arrests and relatives of cardiac arrest patients were included in the study. Participants were included from all five regions of Denmark.

RESULTS

A thematic analysis was performed with inspiration from Braun and Clarke. We identified three themes: (1) relatives' experiences of immediate relief at arrival of assistance, (2) volunteer responders' assessment of relatives' needs and (3) the advantage of being healthcare educated.

CONCLUSIONS

Relatives to out-of-hospital cardiac arrest patients benefited from volunteer responders' presence and support and experienced the mere presence of volunteer responders as supportive. Healthcare-educated volunteer responders felt confident and skilled to provide care for relatives, while some non-healthcare-educated volunteer responders felt they lacked the proper training and knowledge to provide emotional support for relatives. Future basic life support courses should include a lesson on how to provide emotional support to relatives of cardiac arrest patients.

Spatiotemporal Optimization for the Placement of Automated External Defibrillators Using Mobile Phone Data

With over 350,000 cases occurring each year, out-of-hospital cardiac arrest (OHCA) remains a severe public health concern in the United States. The correct and timely use of automated external defibrillators (AEDs) has been widely acknowledged as an effective measure to improve the survival rate of OHCA. While general guidelines have been provided by the American Heart Association (AHA) for AED deployment, the lack of detailed instructions hindered the adoption of such guidelines under dynamic scenarios with various time and space distributions. Formulating the AED deployment as a location optimization problem under budget and resource constraints, we proposed an overlayed spatio-temporal optimization (OSTO) method, which accounted for the spatiotemporal heterogeneity of potential OHCAs. To highlight the effectiveness of the proposed model, we applied the proposed method to Washington DC using user-generated anonymized mobile device location data. The results demonstrated that optimization-based planning provided an improved AED coverage level. We further evaluated the effectiveness of adding additional AEDs by analyzing the cost-coverage increment curve. In general, our framework provides a systematic approach for municipalities to integrate inclusive planning and budget-limited efficiency into their final decision-making. Given the high practicality and adaptability of the framework, the OSTO is highly amenable to different healthcare facilities' deployment tasks with flexible demand and resource restraints.

Association Between Number of Volunteer Responders and Interventions Before Ambulance Arrival for Cardiac Arrest

BACKGROUND

Volunteer responder (VR) programs for activation of laypersons in out-of-hospital cardiac arrest (OHCA) have been deployed worldwide, but the optimal number of VRs to dispatch is unknown.

OBJECTIVES

The purpose of this study was to investigate the association between the number of VRs arriving before Emergency Medical Services (EMS) and the proportion of bystander cardiopulmonary resuscitation (CPR) and defibrillation.

METHODS

We included OHCAs not witnessed by EMS with VR activation from the Capital Region (September 2, 2017, to May 14, 2019) and the Central Region of Denmark (November 5, 2018, to December 31, 2019). We created 4 groups according to the number of VRs arriving before EMS: 0, 1, 2, and 3 or more. Using a logistic regression model adjusted for EMS response time, we examined associations between the number of VRs arriving before EMS and bystander CPR and defibrillation.

RESULTS

We included 906 OHCAs. The adjusted ORs for bystander CPR were 2.40 (95% CI: 1.42-4.05), 3.18 (95% CI: 1.39-7.26), and 2.70 (95% CI: 1.32-5.52) when 1, 2, or 3 or more VRs arrived before EMS (reference), respectively. The adjusted OR for bystander defibrillation increased when 1 (1.97 [95% CI: 1.12-3.52]), 2 (2.88 [95% CI: 1.48-5.58]), or 3 or more (3.85 [95% CI: 2.11-7.01]) VRs arrived before EMS (reference). The adjusted OR of bystander defibrillation increased to 1.95 (95% CI: 1.18-3.22) when ≥3 VRs arrived first compared with 1 VR arriving first (reference).

CONCLUSIONS

We found an association of increased bystander CPR and defibrillation when 1 or more VRs arrived before the EMS with a trend toward increased bystander defibrillation with increasing number of VRs arriving first.

AED applied, not recommending defibrillation - A validation study of the new variable AED in the Danish Cardiac Arrest Registry

AIM

This study aimed to design and implement a new variable, the automated external defibrillator (AED) variable, within the Danish Cardiac Arrest Registry. The introduction of the new variable aims to investigate and solve the challenges of reporting out-of-hospital cardiac arrests.

METHODS

This validation study examined all patients with out-of-hospital cardiac arrest from 2016 to 2019. Their medical records were reviewed to establish a variable for AED. All patients with an AED applied were included, and comparative analyses were carried out. The primary outcome was 30-day survival, and the secondary outcome was the return of spontaneous circulation (ROSC) at any time.

RESULTS

A total of 1576 cases were included; of those, 747 cases had an AED applied and received a shock, and in 829 cases, an AED was applied without delivering a shock. Most defibrillated patients were witnessed by bystanders n = 541, (72%). They presented a higher number of ROSC (57%) and higher 30-day survival, (35,2%) compared to patients who were not defibrillated. Of this group, only 47% patients were witnessed; 18% survived more than 30 days, p < 0.001. When comparing AED present with no AED present, the AED group were significantly more likely to be witnessed by bystanders and to have cardiopulmonary resuscitation by bystanders. No significant differences were found regarding the initial rhythm between the two groups. 30-day survival rate was 20% in the AED group compared to 14% in the non-AED group, yielding an OR of 1.14 (95% CI 1.20-1.66).

CONCLUSION

This study highlights the differences between OHCA patients receiving defibrillation and those not receiving defibrillation after AED placement. These differences emphasise the need for uniform reporting of out-of-hospital cardiac arrest. This study showed improvement in the completeness of the registration of OHCA by implementing the AED variable. However, a future effort to improve registration completeness is needed.

Factors affecting public access defibrillator placement decisions in the United Kingdom: A survey study

Aim

This study aimed to understand current community PAD placement strategies and identify factors which influence PAD placement decision-making in the United Kingdom (UK).

Methods

Individuals, groups and organisations involved in PAD placement in the UK were invited to participate in an online survey collecting demographic information, facilitators and barriers to community PAD placement and information used to decide where a PAD is installed in their experiences. Survey responses were analysed through descriptive statistical analysis and thematic analysis.

Results

There were 106 included responses. Distance from another PAD (66%) and availability of a power source (63%) were most frequently used when respondents are deciding where best to install a PAD and historical occurrence of cardiac arrest (29%) was used the least. Three main themes were identified influencing PAD placement: (i) the relationship between the community and PADs emphasising community engagement to create buy-in; (ii) practical barriers and facilitators to PAD placement including securing consent, powering the cabinet, accessibility, security, funding, and guardianship; and (iii) 'risk assessment' methods to estimate the need for PADs including areas of high footfall, population density and type, areas experiencing health inequalities, areas with delayed ambulance response and current PAD provision.

Conclusion

Decision-makers want to install PADs in locations that maximise impact and benefit to the community, but this can be constrained by numerous social and infrastructural factors. The best location to install a PAD depends on local context; work is required to determine how to overcome barriers to optimal community PAD placement.

Smartphone-activated volunteer responders and bystander defibrillation for out-of-hospital cardiac arrest in private homes and public locations

AIMS

To investigate the association between the arrival of smartphone-activated volunteer responders before the Emergency Medical Services (EMS) and bystander defibrillation in out-of-hospital cardiac arrest (OHCA) at home and public locations.

METHODS AND RESULTS

This is a retrospective study (1 September 2017-14 May 2019) from the Stockholm Region of Sweden and the Capital Region of Denmark. We included 1271 OHCAs, of which 1029 (81.0%) occurred in private homes and 242 (19.0%) in public locations. The main outcome was bystander defibrillation. At least one volunteer responder arrived before EMS in 381 (37.0%) of OHCAs at home and 84 (34.7%) in public. More patients received bystander defibrillation when a volunteer responder arrived before EMS at home (15.5 vs. 2.2%, P < 0.001) and in public locations (32.1 vs. 19.6%, P = 0.030). Similar results were found among the 361 patients with an initial shockable heart rhythm (52.7 vs. 11.5%, P < 0.001 at home and 60.0 vs. 37.8%, P = 0.025 in public). The standardized probability of receiving bystander defibrillation increased with longer EMS response times in private homes. The 30-day survival was not significantly higher when volunteer responders arrived before EMS (9.2 vs. 7.7% in private homes, P = 0.41; and 40.5 vs. 35.4% in public locations, P = 0.44).

CONCLUSION

Bystander defibrillation was significantly more common in private homes and public locations when a volunteer responder arrived before the EMS. The standardized probability of bystander defibrillation increased with longer EMS response times in private homes. Our findings support the activation of volunteer responders and suggest that volunteer responders could increase bystander defibrillation, particularly in private homes.

Association between location of out-of-hospital cardiac arrest, on-scene socioeconomic status, and accessibility to public automated defibrillators in two large metropolitan areas in Canada and France

AIM

To compare walking access times to automated external defibrillators (AEDs) between area-level quintiles of socioeconomic status (SES) in out-of-hospital cardiac arrest (OHCA) cases occurring in 2 major urban regions of Canada and France.

METHODS

This was an international, multicenter, retrospective cohort study of adult, non-traumatic OHCA cases in the metropolitan Vancouver (Canada) and Rhône County (France) regions that occurred between 2014 and 2018. We calculated area-level SES for each case, using quintiles of country-specific scores (Q5 = most deprived). We identified AED locations from local registries. The primary outcome was the simulated walking time from the OHCA location to the closest AED (continuous and dichotomized by a 3-minute 1-way threshold). We fit multivariate models to analyze the association between OHCA-to-AED walking time and outcomes (Q5 vs others).

RESULTS

A total of 6,187 and 3,239 cases were included from the Metro Vancouver and Rhône County areas, respectively. In Metro Vancouver Q5 areas (vs Q1-Q4), areas, AEDs were farther from (79 % over 400 m from case vs 67 %, p < 0.001) and required longer walking times to (97 % above 3 min vs 91 %, p < 0.001) cases. In Rhône Q5 areas, AEDs were closer than in other areas (43 % over 400 m from case vs 50 %, p = 0.01), yet similarly poorly accessible (85 % above 3 min vs 86 %, p = 0.79). In multivariate models, AED access time ≥ 3 min was associated with decreased odds of survival at hospital discharge in Metro Vancouver (odds ratio 0.41, 95 % CI [0.23-0.74], p = 0.003).

CONCLUSIONS

Accessibility of public AEDs was globally poor in Metro Vancouver and Rhône, and even poorer in Metro Vancouver's socioeconomically deprived areas.

Increased bystander intervention when volunteer responders attend out-of-hospital cardiac arrest

Aim

The primary aim was to investigate the association between alarm acceptance compared to no-acceptance by volunteer responders, bystander intervention, and survival in out-of-hospital cardiac arrest.

Materials and methods

This retrospective observational study included all suspected out-of-hospital cardiac arrests (OHCAs) with activation of volunteer responders in the Capital Region of Denmark (1 November 2018 to 14 May 2019), the Central Denmark Region (1 November 2018 to 31 December 2020), and the Northern Denmark Region (14 February 2020 to 31 December 2020). All OHCAs unwitnessed by Emergency Medical Services (EMS) were analyzed on the basis on alarm acceptance and arrival before EMS. The primary outcomes were bystander cardio-pulmonary resuscitation (CPR), bystander defibrillation and secondary outcome was 30-day survival. A questionnaire sent to all volunteer responders was used with respect to their arrival status.

Results

We identified 1,877 OHCAs with volunteer responder activation eligible for inclusion and 1,725 (91.9%) of these had at least one volunteer responder accepting the alarm (accepted). Of these, 1,355 (79%) reported arrival status whereof 883 (65%) arrived before EMS. When volunteer responders accepted the alarm and arrived before EMS, we found increased proportions and adjusted odds ratio for bystander CPR {94 vs. 83%, 4.31 [95% CI (2.43–7.67)] and bystander defibrillation [13 vs. 9%, 3.16 (1.60–6.25)]} compared to cases where no volunteer responders accepted the alarm.

Conclusion

We observed a fourfold increased odds ratio for bystander CPR and a threefold increased odds ratio for bystander defibrillation when volunteer responders accepted the alarm and arrived before EMS.

Are first responders first? The rally to the suspected out-of-hospital cardiac arrest

BACKGROUND

Time is the crucial factor in the "chain of survival" treatment concept for out-of-hospital cardiac arrest (OHCA). We aimed to measure different response time intervals by comparing emergency medical system (EMS), fire fighters and smartphone aided volunteer responders.

METHODS

In two large Swedish regions, volunteer responders were timed from the alert until they arrived at the scene of the suspected OHCA. The first arriving volunteer responders who tried to fetch an automated external defibrillator (AED-responder) and who ran to perform bystander cardiopulmonary resuscitation (CPR-responder) were compared to both the first arriving EMS and fire fighters. Three-time intervals were measured, from call to dispatch, the unit response time (from dispatch to arrival) and the total response time.

RESULTS

During 22 months, 2631 suspected OHCAs were included. The median time from call to dispatch was in minutes 1.8 (95% CI = 1.7-1.8) for EMS, 2.9 (95% CI = 2.8-3.0) for fire-fighters and 3.0 (95% CI = 2.9-3.1) for volunteer responders. The median unit response time was 8.3 (95% CI = 8.1-8.5) for EMS, 6.8 (95% CI = 6.7-6.9) for fire fighters and 6.0 (95% CI = 5.7-6.2) for AED-responders and 4.6 (95% CI = 4.5-4.8) for CPR-responders. The total response time was 10.4 (95% CI = 10.1-10.6) for EMS, 10.2 (95% CI = 9.9-10.4) for fire fighters, 9.6 (95% CI = 9.1-9.8) for AED-responders and 8.2 (95% CI = 8.0-8.3) for CPR-responders.

CONCLUSION

First arriving volunteer responders had the shortest unit response time when compared to both fire fighters and EMS, however this advantage was reduced by delays introduced at the dispatch center. Earlier automatic dispatch should be considered in further studies.

Location of out-of-hospital cardiac arrests and automated external defibrillators in relation to schools in an English ambulance service region

•

Out-of-hospital cardiac arrest (OHCA) remains low both in England and worldwide.

•

About a third of all OHCAs occur within 300 m of a school.

•

Considering the usage rates of public access defibrillators there is significant potential for increasing their use.

•

Improving access to automated external defibrillators (AED) in schools and their registration with Emergency Medical Services could lead to greater use.

•

A strategy for placing AEDs in schools is likely to be cost-effective.

Introduction

This study sought to identify the availability of automated external defibrillators (AEDs) in schools in the region served by West Midlands Ambulance Service University NHS Trust (WMAS), United Kingdom, and the number of out-of-hospital cardiac arrests (OHCA) that occurred at or near to schools. A secondary aim was to explore the cost effectiveness of school-based defibrillators.

Methods

This observational study used data from the national registry for OHCA (University of Warwick) to identify cases occurring at or near schools between January 2014 and December 2016 in WMAS region (n = 11,399). A school survey (n = 2,453) was carried out in September 2017 to determine the presence of AEDs and their registration status with WMAS. Geographical Information System mapping software identified OHCAs occurring within a 300-metre radius of a school. An economic analysis calculated the cost effectiveness of school-based AEDs.

Results

A total of 39 (0.34%) of all OHCAs occurred in schools, although 4,250 (37.3%) of OHCAs in the region were estimated to have occurred within 300 metres of a school. Of 323 school survey responses, 184 (57%) had an AED present, of which 24 (13.0%) were available 24 h/day. Economic modelling of a school-based AED programme showed additional quality-adjusted life years (QALY) of 0.26 over the lifetime of cardiac arrest survivors compared with no AED programme. The incremental cost-effectiveness ratio (ICER) was £8,916 per QALY gained.

Conclusion

Cardiac arrests in schools are rare. Registering AEDs with local Emergency Medical Services and improving their accessibility within their local community would increase their utility.

The National Danish Cardiac Arrest Registry for Out-of-Hospital Cardiac Arrest - A Registry in Transformation

Aim of the Database

The aim of the Danish Cardiac Arrest Registry is to monitor the quality of prehospital cardiac arrest treatment, evaluate initiatives regarding prehospital treatment of cardiac arrest, and facilitate research.

Study Population

All patients with prehospital cardiac arrest in Denmark treated by the emergency medical services in whom resuscitation or defibrillation has been attempted.

Main Variables

The Danish Cardiac Arrest Register records descriptive and qualitative variables as outlined in the “Utstein” template for reporting out-of-hospital-cardiac arrest. Main variables include whether the case was witnessed, whether the cardiac arrest was electrocardiographically monitored, the timing of cardiopulmonary resuscitation, and the timing of the first analysis of the cardiac rhythm. The outcome measures are the status of the patient at handover to the hospital, return of spontaneous circulation, and 30-day survival after event.

Database Status

The Danish Cardiac Arrest Registry was established in June 2001, and all Danish emergency medical services are reporting to the database.

Conclusion

The Danish Cardiac Arrest Registry is among the oldest Danish national clinical registries, with a high quality of clinical data and coverage. This registry provides the prerequisite for all research on out-of-hospital cardiac arrest research in Denmark and is essential for monitoring and improving the quality of care for patients suffering from out-of-hospital cardiac arrest.

Trends in maintenance status and usability of public automated external defibrillators during a 5-year on-site inspection

This study aimed to assess the trend of the maintenance status and usability of public automated external defibrillators (AEDs). Public AEDs installed in Seoul from 2013 to 2017 were included. An inspector checked the maintenance status and usability of the AEDs annually using a checklist. During the study period, 23,619 AEDs were inspected. Access to the AEDs was improved, including the absence of obstacles near the AEDs (from 90.2% in 2013 to 99.1% in 2017, p < 0.0001) and increased AED signs (from 34.3% in 2013 to 91.3% in 2017, p < 0.0001). The rate of AEDs in normal operation (from 94.0% in 2013 to 97.6% in 2017, p < 0.0001), good battery status (from 95.6% in 2013 to 96.8% in 2017, p = 0.0016), and electrode availability increased (from 97.1% in 2013 to 99.0% in 2017, p < 0.0001); the rate of electrode validity decreased (from 90.0% in 2013 to 87.2% in 2017, p < 0.0001). The overall rate of the non-ready-to-use AEDs and AEDs with less than 24-h usability accounted for 15.4% and 44.1% of the total number of AEDs, respectively. Although most AEDs had a relatively good maintenance status, a significant proportion of public AEDs were not available for 24-h use. Invalid electrodes and less than 24-h accessibility were the main reasons that limited the 24-h usability of public AEDs.

Public Access Defibrillators and Socioeconomic Factors on the Small—Scale Spatial Level in Berlin

BACKGROUND

The use of a public access defibrillator (PAD) increases the probability of surviving an out-of-hospital cardiac arrest (OHCA). No strategies exist, however, for the optimal distribution of PADs in an urban area in order to meet existing needs and ensure equal access for all potential users. It thus seems likely that the accessibility of PADs on the spatial level varies widely as a function of living circumstances.

METHODS

This cross-sectional study is based on registry data concerning PAD (2022, n = 776) and OHCA (2018-2020, n = 4051), along with data on socioeconomic factors on the spatial level in Berlin (12 districts and 137 subdistricts). Associations of socioeconomic factors with the number of PADs per 10 000 inhabitants and the PAD coverage rate of sites of previous OHCAs were investigated.

RESULTS

The median number of PADs per 10 000 inhabitants ranged from 0.46 to 2.67 at the district level, and only five districts had a median PAD coverage rate of sites of previous OHCAs above 0%, after aggregation of the analyses at the subdistrict level. Subdistricts with a more favorable economic status and a greater income disparity had a higher PAD density. Socially disadvantaged subdistricts had no association with PAD density.

CONCLUSION

There are large deficits in the distribution of PADs at the small-scale spatial level in Berlin with respect to the goals of meeting existing needs and ensuring equal access for all potential users. The findings presented here will be of importance for the planning of future PAD programs so that the distributional efficiency and fairness of PAD in urban areas can be improved.

Strategic placement of automated external defibrillators (AEDs) for cardiac arrests in public locations and private residences

Aim

The aim of our study was to determine whether businesses can be identified that rank highly for their potential to improve coverage of out-of-hospital cardiac arrests (OHCAs) by automated external defibrillators (AEDs), both in public locations and private residences.

Methods

The cohort comprised 10,422 non-traumatic OHCAs from 2014 to 2020 in Perth, Western Australia. We ranked 115 business brands (across 5,006 facilities) for their potential to supplement coverage by the 3,068 registered public-access AEDs in Perth, while accounting for AED access hours.

Results

Registered public-access AEDs provided 100 m coverage of 23% of public-location arrests, and 4% of arrests in private residences. Of the 10 business brands ranked highest for increasing the coverage of public OHCAs, six brands were ranked in the top 10 for increased coverage of OHCAs in private residences. A public phone brand stood out clearly as the highest-ranked of all brands, with more than double the coverage-increase of the second-ranked brand. If all 115 business brands hosted AEDs with 24-7 access, 57% of OHCAs would remain without 100 m coverage for public arrests, and 92% without 100 m coverage for arrests in private residences.

Conclusion

Many businesses that ranked highly for increased coverage of arrests in public locations also rank well for increasing coverage of arrests in private residences. However, even if the business landscape was highly saturated with AEDs, large gaps in coverage of OHCAs would remain, highlighting the importance of considering other modes of AED delivery in metropolitan landscapes.

Health inequities in out-of-hospital cardiac arrest

PURPOSE OF REVIEW

Out-of-hospital cardiac arrest (OHCA) is a time-critical emergency in which a rapid response following the chain of survival is crucial to save life. Disparities in care can occur at each link in this pathway and hence produce health inequities. This review summarises the health inequities that exist for OHCA patients and suggests how they may be addressed.

RECENT FINDINGS

There is international evidence that the incidence of OHCA is increased with increasing deprivation and in ethnic minorities. These groups have lower rates of bystander CPR and bystander-initiated defibrillation, which may be due to barriers in accessing cardiopulmonary resuscitation training, provision of public access defibrillators, and language barriers with emergency call handlers. There are also disparities in the ambulance response and in-hospital care following resuscitation. These disadvantaged communities have poorer survival following OHCA.

SUMMARY

OHCA disproportionately affects deprived communities and ethnic minorities. These groups experience disparities in care throughout the chain of survival and this appears to translate into poorer outcomes. Addressing these inequities will require coordinated action that engages with disadvantaged communities.

Activation of Citizen Responders to Out‐of‐Hospital Cardiac Arrest During the COVID‐19 Outbreak in Denmark 2020

Background

Little is known about how COVID‐19 influenced engagement of citizen responders dispatched to out‐of‐hospital cardiac arrest (OHCA) by a smartphone application. The objective was to describe and analyze the Danish Citizen Responder Program and bystander interventions (both citizen responders and nondispatched bystanders) during the first COVID‐19 lockdown in 2020.

Methods and Results

All OHCAs from January 1, 2020, to June 30, 2020, with citizen responder activation in 2 regions of Denmark were included. We compared citizen responder engagement for OHCA in the nonlockdown period (January 1, 2020, to March 10, 2020, and April 21, 2020, to June 30, 2020) with the lockdown period (March 11, 2020, to April 20, 2020). Data are displayed in the order lockdown versus nonlockdown period. Bystander cardiopulmonary resuscitation rates did not differ in the 2 periods (99% versus 92%; P=0.07). Bystander defibrillation (9% versus 14%; P=0.4) or return‐of‐spontaneous circulation (23% versus 23%; P=1.0) also did not differ. A similar amount of citizen responders accepted alarms during the lockdown (6 per alarm; interquartile range, 6) compared with the nonlockdown period (5 per alarm; interquartile range, 5) (P=0.05). More citizen responders reported performing chest‐compression‐only cardiopulmonary resuscitation during lockdown compared with nonlockdown (79% versus 59%; P=0.0029), whereas fewer performed standardized cardiopulmonary resuscitation, including ventilations (19% versus 38%; P=0.0061). Finally, during lockdown, more citizen responders reported being not psychologically affected by attending an OHCA compared with nonlockdown period (68% versus 56%; P<0.0001). Likewise, fewer reported being mildly affected during lockdown (26%) compared with nonlockdown (35%) (P=0.003).

Conclusions

The COVID‐19 lockdown in Denmark was not associated with decreased bystander‐initiated resuscitation in OHCAs attended by citizen responders.

Optimizing Outcomes After Out-of-Hospital Cardiac Arrest With Innovative Approaches to Public-Access Defibrillation: A Scientific Statement From the International Liaison Committee on Resuscitation

Out-of-hospital cardiac arrest is a global public health issue experienced by ≈3.8 million people annually. Only 8% to 12% survive to hospital discharge. Early defibrillation of shockable rhythms is associated with improved survival, but ensuring timely access to defibrillators has been a significant challenge. To date, the development of public-access defibrillation programs, involving the deployment of automated external defibrillators into the public space, has been the main strategy to address this challenge. Public-access defibrillator programs have been associated with improved outcomes for out-of-hospital cardiac arrest; however, the devices are used in <3% of episodes of out-of-hospital cardiac arrest. This scientific statement was commissioned by the International Liaison Committee on Resuscitation with 3 objectives: (1) identify known barriers to public-access defibrillator use and early defibrillation, (2) discuss established and novel strategies to address those barriers, and (3) identify high-priority knowledge gaps for future research to address. The writing group undertook systematic searches of the literature to inform this statement. Innovative strategies were identified that relate to enhanced public outreach, behavior change approaches, optimization of static public-access defibrillator deployment and housing, evolved automated external defibrillator technology and functionality, improved integration of public-access defibrillation with existing emergency dispatch protocols, and exploration of novel automated external defibrillator delivery vectors. We provide evidence- and consensus-based policy suggestions to enhance public-access defibrillation and guidance for future research in this area.

Optimizing outcomes after out-of-hospital cardiac arrest with innovative approaches to public-access defibrillation: A scientific statement from the International Liaison Committee on Resuscitation

Out-of-hospital cardiac arrest is a global public health issue experienced by ≈3.8 million people annually. Only 8% to 12% survive to hospital discharge. Early defibrillation of shockable rhythms is associated with improved survival, but ensuring timely access to defibrillators has been a significant challenge. To date, the development of public-access defibrillation programs, involving the deployment of automated external defibrillators into the public space, has been the main strategy to address this challenge. Public-access defibrillator programs have been associated with improved outcomes for out-of-hospital cardiac arrest; however, the devices are used in <3% of episodes of out-of-hospital cardiac arrest. This scientific statement was commissioned by the International Liaison Committee on Resuscitation with 3 objectives: (1) identify known barriers to public-access defibrillator use and early defibrillation, (2) discuss established and novel strategies to address those barriers, and (3) identify high-priority knowledge gaps for future research to address. The writing group undertook systematic searches of the literature to inform this statement. Innovative strategies were identified that relate to enhanced public outreach, behavior change approaches, optimization of static public-access defibrillator deployment and housing, evolved automated external defibrillator technology and functionality, improved integration of public-access defibrillation with existing emergency dispatch protocols, and exploration of novel automated external defibrillator delivery vectors. We provide evidence- and consensus-based policy suggestions to enhance public-access defibrillation and guidance for future research in this area.

Citizen Responder Activation in Out-of-Hospital Cardiac Arrest by Time of Day and Day of Week

Background

We aim to examine diurnal and weekday variations in citizen responder availability and intervention at out‐of‐hospital cardiac arrest (OHCA) resuscitation.

Methods and Results

We included confirmed OHCAs where citizen responders were activated by a smartphone application in the Capital Region of Denmark between September 1, 2017 and August 31, 2018. OHCAs were analyzed by time of day (daytime: 07:00 am–03:59 pm, evening: 4:00–11:59 pm, and nighttime: 12:00–06:59 am) and day of week (Monday–Friday or Saturday–Sunday/public holidays). We included 438 OHCAs where 6836 citizen responders were activated. More citizen responders accepted alarms in the evening (mean 4.8 [95% CI, 4.4–5.3]) compared with daytime (3.7 [95% CI, 3.4–4.4]) and nighttime (1.8 [95% CI, 1.5–2.2]) (P<0.001), and more accepted alarms during weekends (4.3 [95% CI, 3.8–4.9]) compared with weekdays (3.4 [95% CI, 3.2–3.7]) (P<0.001). Proportion of OHCAs where at least 1 citizen responder arrived before Emergency Medical Services were significantly different between day (42.9%), evening (50.3%), and night (26.1%) (P<0.001), and between weekdays (37.2%) and weekends (53.5%) (P=0.002). When responders arrived before Emergency Medical Services, there was no difference of bystander cardiopulmonary resuscitation or defibrillation between daytime, evening, and nighttime (P=0.75 and P=0.22, respectively) or between weekend and weekdays (P=0.29 and P=0.12, respectively).

Conclusions

Citizen responders were more likely to accept OHCA alarms during evening and weekends, with the highest proportion of responders arriving before Emergency Medical Services in the evening. However, there was no significant difference in delivering cardiopulmonary resuscitation or early defibrillation among cases where citizen responders arrived before Emergency Medical Services.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03835403.

The effect of the GoodSAM volunteer first-responder app on survival to hospital discharge following out-of-hospital cardiac arrest

AIMS

Bystander cardiopulmonary resuscitation and defibrillation can double survival to hospital discharge in out-of-hospital cardiac arrest. Mobile phone applications, such as GoodSAM, alerting nearby volunteer first-responders about out-of-hospital cardiac arrest could potentially improve bystander cardiopulmonary resuscitation and defibrillation, leading to better patient outcomes. The aim of this study was to determine GoodSAM's effect on survival to hospital discharge following out-of-hospital cardiac arrest.

METHODS AND RESULTS

We collected data from the Out-of-Hospital Cardiac Arrest Outcomes Registry (University of Warwick, UK) submitted by the London Ambulance Service (1 April 2016 to 31 March 2017) and East Midlands Ambulance Service (1 January 2018 to 17 June 2018) and matched out-of-hospital cardiac arrests to GoodSAM alerts. We constructed logistic regression models to determine if there was an association between a GoodSAM first-responder accepting an alert and survival to hospital discharge, adjusting for location type, presenting rhythm, age, gender, ambulance service response time, cardiac arrest witnessed status, and bystander actions. Survival to hospital discharge was 9.6% (393/4196) in London and 7.2% (72/1001) in East Midlands. A GoodSAM first-responder accepted an alert for out-of-hospital cardiac arrest in 1.3% (53/4196) cases in London and 5.4% (51/1001) cases in East Midlands. When a responder accepted an alert, the adjusted odds ratio for survival to hospital discharge was 3.15 (95% CI: 1.19-8.36, P = 0.021) in London and 3.19 (95% CI: 1.17-8.73, P = 0.024) in East Midlands.

CONCLUSION

Alert acceptance was associated with improved survival in both ambulance services. Alert acceptance rates were low, and challenges remain to maximize the potential benefit of GoodSAM.