Large urban center improves out-of-hospital cardiac arrest survival

Impact of community-based interventions on out-of-hospital cardiac arrest outcomes: a systematic review and meta-analysis

Survival following out-of-hospital cardiac arrest (OHCA) remains low, typically less than 10%. Bystander cardiopulmonary resuscitation (CPR) and bystander-AED use have been shown to improve survival by up to fourfold in individual studies. Numerous community-based interventions have been implemented worldwide in an effort to enhance rates of bystander-CPR, bystander-AED use, and improve OHCA survival. This systematic review and meta-analysis aims to evaluate the effect of such interventions on OHCA outcomes. Medline and Embase were systematically searched from inception through July 2021 for studies describing the implementation and effect of one or more community-based interventions targeting OHCA outcomes. Two reviewers screened articles, extracted data, and evaluated study quality using the Newcastle-Ottawa Scale. For each outcome, data were pooled using random-effects meta-analysis. Of the 2481 studies identified, 16 met inclusion criteria. All included studies were observational. They reported a total of 1,081,040 OHCAs across 11 countries. The most common interventions included community-based CPR training (n = 12), community-based AED training (n = 9), and dispatcher-assisted CPR (n = 8). Health system interventions (hospital or paramedical services) were also described in 11 of the included studies. Evidence certainty among all outcomes was low or very low according to GRADE criteria. On meta-analysis, community-based interventions with and without health system interventions were consistently associated with improved OCHA outcomes: rates of bystander-CPR, bystander-AED use, survival, and survival with a favorable neurological outcome. Bystander CPR-14 studies showed a significant increase in post-intervention bystander-CPR rates (n = 285 752; OR 2.26 [1.74, 2.94]; I2 = 99%, and bystander AED use (n = 37 882; OR 2.08 [1.44, 3.01]; I2 = 54%) and durvival-10 studies, pooling survival to hospital discharge and survival to 30 days (n = 79 206; OR 1.59 [1.20, 2.10]; I2 = 95%. The results provide foundational support for the efficacy of community-based interventions in enhancing OHCA outcomes. These findings inform our recommendation that communities, regions, and countries should implement community-based interventions in their pre-hospital strategy for OHCA. Further research is needed to identify which specific intervention types are most effective.

Three-year trends in out-of-hospital cardiac arrest across the world: second report from the International Liaison Committee on Resuscitation (ILCOR)

BACKGROUND

The International Liaison Committee on Resuscitation (ILCOR) Research and Registries Working Group previously reported data on systems of care and outcomes of out-of-hospital cardiac arrest (OHCA) in 2015 from 16 national and regional registries. To describe the temporal trends with updated data on OHCA, we report the characteristics of OHCA from 2015 through 2017.

METHODS

We invited national and regional population-based OHCA registries for voluntary participation and included emergency medical services (EMS)-treated OHCA. We collected descriptive summary data of core elements of the latest Utstein style recommendation during 2016 and 2017 at each registry. For registries that participated in the previous 2015 report, we also extracted the 2015 data.

RESULTS

Eleven national registries in North America, Europe, Asia, and Oceania, and 4 regional registries in Europe were included in this report. Across registries, the estimated annual incidence of EMS-treated OHCA was 30.0-97.1 individuals per 100,000 population in 2015, 36.4-97.3 in 2016, and 40.8-100.2 in 2017. The provision of bystander cardiopulmonary resuscitation (CPR) varied from 37.2% to 79.0% in 2015, from 2.9% to 78.4% in 2016, and from 4.1% to 80.3% in 2017. Survival to hospital discharge or 30-day survival for EMS-treated OHCA ranged from 5.2% to 15.7% in 2015, from 6.2% to 15.8% in 2016, and from 4.6% to 16.4% in 2017.

CONCLUSION

We observed an upward temporal trend in provision of bystander CPR in most registries. Although some registries showed favourable temporal trends in survival, less than half of registries in our study demonstrated such a trend.

Effect of a Targeted Ambulance Treatment Quality Improvement Programme on Outcomes from Out-of-Hospital Cardiac Arrest: A Metropolitan Citywide Intervention Study

The performance of ambulance crew affects the quality of pre-hospital treatment, which is vital to the survival for out-of-hospital cardiac arrest (OHCA) patients, yet remains suboptimal in China. In this retrospective analysis study, we aimed to examine the effect of a citywide quality improvement programme on provision of prehospital advanced life support (ALS) by emergency medical service (EMS) system. EMS-treated adult OHCA patients after the implementation of the programme (1 January 2021 to 30 June 2022) were compared with historical controls (1 June 2019 to 31 August 2020) in Suzhou. Multivariable logistic regression analysis and propensity score matching procedures were applied to compare the outcomes between two periods for total OHCA cases and subgroup of cases treated by fixed or non-fixed ambulance crews. A total of 1465 patients (pre-period/post-period: 610/855) were included. In the 1:1 matched analysis of 591 cases for each period, significant improvement (p < 0.05) was observed for the proportion of intravenous (IV) access (23.4% vs. 68.2%), advanced airway management (49.2% vs. 57.0%), and return of spontaneous circulation (ROSC) at handover (5.4% vs. 9.0%). The fixed ambulance crews performed better than non-fixed group in IV access and advanced airway management for both periods. There were significant increases in IV access (AOR 12.66, 95%CI 9.02−18.10, p < 0.001), advanced airway management (AOR 1.67, 95% CI 1.30−2.16, p < 0.001) and ROSC at handover (AOR 2.37, 95%CI 1.38−4.23, p = 0.002) after intervention in unfixed group, while no significant improvement was observed in fixed group except for IV access (AOR 7.65, 95%CI 9.02−18.10, p < 0.001). In conclusion, the quality improvement program was positively associated with the provision of prehospital ALS interventions and prehospital ROSC following OHCA. The fixed ambulance crews performed better in critical care provision and prehospital outcome, yet increased protocol adherence and targeted training could fill the underperformance of non-fixed crews efficaciously.

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.

European Resuscitation Council Guidelines 2021: Systems saving lives

The European Resuscitation Council (ERC) has produced these Systems Saving Lives guidelines, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include chain of survival, measuring performance of resuscitation, social media and smartphones apps for engaging community, European Restart a Heart Day, World Restart a Heart, KIDS SAVE LIVES campaign, lower-resource setting, European Resuscitation Academy and Global Resuscitation Alliance, early warning scores, rapid response systems, and medical emergency team, cardiac arrest centres and role of dispatcher.

The effect of system performance improvement on patients with cardiac arrest: A systematic review

AIM

The aim of our review was to understand the effect of interventions to improve system-level performance on the clinical outcomes of patients with cardiac arrest.

METHODS

We searched PubMed, Ovid EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) databases to identify randomised controlled trials and non-randomised studies published before July 21, 2020 reporting systems interventions to improve outcomes. Characteristics, study design, evaluation methods and outcomes of included studies were extracted. (PROSPERO registration CRD42020161882).

RESULTS

One cluster randomised trial and 26 non-randomised studies were included. There were 18 studies focusing on interventions for patients with out-of-hospital cardiac arrest and 9 studies for patients with in-hospital cardiac arrest. Interventions included implementation of a bundle of care strategy, evaluation of cardiopulmonary resuscitation (CPR) quality with feedback/debriefing, data surveillance, and CPR training programs. Although improved survival with favorable neurologic outcome at discharge after the implementation of specific interventions was found in 13 studies, improved survival to hospital discharge in 14 studies and improved survival to admission in 3 studies, there were still 7 studies showing no significant improvement of clinical outcomes after interventions.

CONCLUSION

Although only moderate to very low certainty of evidence exists to support the effect of system-level performance improvement on the clinical outcomes of patients, we recommend that organisations or communities evaluate their performance and target key areas with the goal to improve performance because of no known risks and the potential for a large beneficial effect.

Education, Implementation, and Teams: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

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.

Education, Implementation, and Teams: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

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.

Part 7: Systems of Care: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Survival after cardiac arrest requires an integrated system of people, training, equipment, and organizations working together to achieve a common goal. Part 7 of the 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care focuses on systems of care, with an emphasis on elements that are relevant to a broad range of resuscitation situations. Previous systems of care guidelines have identified a Chain of Survival, beginning with prevention and early identification of cardiac arrest and proceeding through resuscitation to post-cardiac arrest care. This concept is reinforced by the addition of recovery as an important stage in cardiac arrest survival. Debriefing and other quality improvement strategies were previously mentioned and are now emphasized. Specific to out-of-hospital cardiac arrest, this Part contains recommendations about community initiatives to promote cardiac arrest recognition, cardiopulmonary resuscitation, public access defibrillation, mobile phone technologies to summon first responders, and an enhanced role for emergency telecommunicators. Germane to in-hospital cardiac arrest are recommendations about the recognition and stabilization of hospital patients at risk for developing cardiac arrest. This Part also includes recommendations about clinical debriefing, transport to specialized cardiac arrest centers, organ donation, and performance measurement across the continuum of resuscitation situations.

Dispatcher-Assisted Cardiopulmonary Resuscitation: Disparity between Urban and Rural Areas

Methods

Patients with out-of-hospital cardiac arrest (OHCA) were prospectively registered in Taichung. The 29 districts of Taichung city were divided into urban and rural areas based on whether the population density is more than 1,000 people per square kilometer. Prehospital data were collected according to the Utstein-style template, and telephone auditory records were collected by a dispatch center.

Results

2,716 patients were enrolled during the study period. 88.4% OHCA occurred in urban areas and 11.6% in rural areas. 74.9% after dispatcher assistance, laypersons performed CPR in urban areas and 67.7% in rural areas (p=0.023). The proportion of laypersons continued CPR until an emergency medical technician's (EMT) arrival was higher in the urban areas (59.57% vs 52.27%, p=0.039). Laypersons continued CPR until an EMT' arrival would increase the chance of return of spontaneous circulation in urban and rural areas, with adjusted odds ratio (aOR) of 1.02, 95% confidence interval (CI) of 0.82–1.27, and aOR of 1.49, 95% CI of 0.80–2.80, respectively. Continued laypersons CPR until the EMT' arrival also improved survival with favorable neurological function, with aOR of 1.16, 95% CI of 0.61–2.20 in urban areas and aOR of 2.90 95% CI of 0.18–46.81 in rural areas.

Conclusion

Bystanders in urban areas exhibited higher ratio of acceptance of DACPR. However, after DACPR intervention, prognosis improvement was considerably higher in rural areas than in urban areas.

Mechanical, Team-Focused, Video-Reviewed Cardiopulmonary Resuscitation Improves Return of Spontaneous Circulation After Emergency Department Implementation

Background

Outcomes in cardiac arrest remain suboptimal. Mechanical cardiopulmonary resuscitation (CPR) has not demonstrated clear clinical benefit; however, video review provides the capability to monitor CPR quality and provide constructive feedback to individuals and teams to improve their performance. The aim of our study was to evaluate cardiac arrest outcomes before and after initiation of a mechanical, team‐focused, video‐reviewed CPR intervention.

Methods and Results

In 2018, our emergency department began using mechanical CPR; a new team‐focused strategy with nurse‐led Advanced Cardiovascular Life Support; and biweekly, multidisciplinary video review of cardiac arrests. A revised approach to resuscitation was generated from a performance improvement session, and in situ simulation was used to disseminate our approach. The primary outcome of this study was the return of spontaneous circulation rate before and after our mechanical, team‐focused, video‐reviewed CPR intervention. Secondary outcomes included survival to admission and discharge. Multivariable logistic regression modeling was used. The pre‐ and postintervention groups were similar at baseline. A total of 248 patients were included in our study (97 before and 151 after mechanical, team‐focused, video‐reviewed CPR). Return of spontaneous circulation was higher in the intervention group (41% versus 26%; P=0.014). There were nonsignificant increases in survival to admission (26% versus 20%; P=0.257) and survival to discharge (7% versus 3%; P=0.163). After controlling for covariates, the odds of return of spontaneous circulation remained higher after the intervention (odds ratio, 2.11; 95% CI, 1.14–3.89).

Conclusions

Implementation of our mechanical, team‐focused, video‐reviewed CPR intervention for cardiac arrest patients in our emergency department improved return of spontaneous circulation rates. Survival to hospital admission and discharge did not improve.