Out-of-hospital cardiac arrests in nursing homes and primary care facilities in Pirkanmaa, Finland

Resuscitation of older adults in Norway; a comparison of survival and outcome after out-of-hospital cardiac arrest in healthcare institutions and at home

BACKGROUND

Perceptions about expected outcome after out-of-hospital cardiac arrest (OHCA) influence treatment decisions, and there is a need for updated evidence about outcomes for the elderly.

METHOD

We conducted a cross-sectional study of cases reported to the Norwegian Cardiac Arrest Registry from 2015 through 2021 of patients 60 years and older, suffering cardiac arrest in healthcare institutions or at home. We examined reasons for emergency medical service (EMS) withholding or withdrawing resuscitation. We compared survival and neurological outcome for EMS-treated patients and explored factors associated with survival using multivariate logistic regression.

RESULT

We included 12,191 cases and the EMS started resuscitation in 10,340 (85%). The incidence per capita of OHCA the EMS were alerted to was 267/100,000 in healthcare institutions and 134/100,000 at home. Resuscitation was most frequently withdrawn due to medical history (n = 1251). In healthcare institutions, 72 of 1503 (4.8%) patients survived to 30 days compared to 752 of 8837 (8.5%) at home (P <.001). We found survivors in all age cohorts both in healthcare institutions and at home, and most of the 824 survivors had a good neurological outcome with a Cerebral Performance Category ≤2 (88%).

CONCLUSION

Medical history was the most frequent reason for EMS not to start or continue resuscitation, indicating a need for a discussion about, and documentation of, advance directives in this age group. When EMS attempted resuscitation, most survivors had a good neurological outcome, both in healthcare institutions and at home.

Advising and limiting medical treatment during phone consultation: a prospective multicentre study in HEMS settings

Background

We investigated paramedic-initiated consultation calls and advice given via telephone by Helicopter Emergency Medical Service (HEMS) physicians focusing on limitations of medical treatment (LOMT).

Methods

A prospective multicentre study was conducted on four physician-staffed HEMS bases in Finland during a 6-month period.

Results

Of all 6115 (mean 8.4/base/day) paramedic-initiated consultation calls, 478 (7.8%) consultation calls involving LOMTs were included: 268 (4.4%) cases with a pre-existing LOMT, 165 (2.7%) cases where the HEMS physician issued a new LOMT and 45 (0.7%) cases where the patient already had an LOMT and the physician further issued another LOMT. The most common new limitation was a do-not-attempt cardiopulmonary resuscitation (DNACPR) order (n = 122/210, 58%) and/or ‘not eligible for intensive care’ (n = 96/210, 46%). In 49 (23%) calls involving a new LOMT, termination of an initiated resuscitation attempt was the only newly issued LOMT. The most frequent reasons for issuing an LOMT during consultations were futility of the overall situation (71%), poor baseline functional status (56%), multiple/severe comorbidities (56%) and old age (49%). In the majority of cases (65%) in which the HEMS physician issued a new LOMT for a patient without any pre-existing LOMT, the physician felt that the patient should have already had an LOMT. The patient was in a health care facility or a nursing home in half (49%) of the calls that involved issuing a new LOMT. Access to medical records was reported in 29% of the calls in which a new LOMT was issued by an HEMS physician.

Conclusion

Consultation calls with HEMS physicians involving patients with LOMT decisions were common. HEMS physicians considered end-of-life questions on the phone and issued a new LOMT in 3.4% of consultations calls. These decisions mainly concerned termination of resuscitation, DNACPR, intubation and initiation of intensive care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-022-01002-8.

Nursing Home Versus Community Resuscitation After Cardiac Arrest: Comparative Outcomes and Risk Factors

OBJECTIVE

To investigate the characteristics and outcomes of patients who experienced cardiac arrest in nursing homes compared with those in private residences and determine prognostic factors for survival.

DESIGN

This was a retrospective study that analyzed data from an Utstein-style registry of the Tokyo Fire Department.

SETTING AND PARTICIPANTS

We identified patients aged ≥65 years who experienced cardiac arrest in a nursing home or private residence from the population-based registry of out-of-hospital cardiac arrests in Tokyo, Japan, from 2014 to 2018.

METHODS

Patients were grouped into the nursing home or the private residence groups according to their cardiac arrest location. We compared the characteristics and outcomes between the 2 groups and determined prognostic factors for survival in the nursing home group. The primary outcome was 1-month survival after cardiac arrest.

RESULTS

In total, 37,550 patient records (nursing home group = 6271; private residence group = 31,279) were analyzed. Patients in the nursing home group were significantly older and more often had witnessed arrest, bystander cardiopulmonary resuscitation (CPR), and shock delivery using an automated external defibrillator. The 1-month survival rate was significantly higher in the nursing home group (2.6% vs 1.8%, P < .001). In the best scenario (daytime emergency call, witnessed cardiac arrest, bystander CPR provided), the 1-month survival rate after cardiac arrest in the nursing home group was 8.0% (95% confidence interval 6.4-9.9%), while none survived if they had neither witness nor bystander CPR.

CONCLUSIONS AND IMPLICATIONS

Survival outcome was significantly better in the nursing home group than in the private residence group and was well stratified by 3 prognostic factors: emergency call timing, witnessed status, and bystander CPR provision. Our results suggest that a decision to withhold vigorous treatment solely based on nursing home residential status is not justified, while termination of resuscitation may be determined by considering significant prognostic factors.

Type of bystander and rate of cardiopulmonary resuscitation in nursing home patients suffering out-of-hospital cardiac arrest

AIM

We investigated bystander cardiopulmonary resuscitation (CPR) provision rate and survival outcomes of out-of-hospital cardiac arrest (OHCA) patients in nursing homes by bystander type.

METHODS

A population-based observational study was conducted for nursing home OHCAs during 2013-2018. The exposure was the bystander type: medical staff, non-medical staff, or family. The primary outcome was bystander CPR provision rate; the secondary outcomes were prehospital return of spontaneous circulation (ROSC) and survival to discharge. Multivariable logistic regression analysis which corrected for various demographic and clinical characteristics evaluated bystander type impact on study outcomes. Bystander CPR rate trend was investigated by bystander type.

RESULTS

Of 8281 eligible OHCA patients, 26.0%, 70.8%, and 3.2% cases were detected by medical staff, non-medical staff, and family, respectively. Provision rate of bystander CPR was 69.9% and rate of bystander defibrillation was 0.4% in total. Bystander CPR was provided by medical staff, non-medical staff, and families in 74.8%, 68.9%, and 52.1% respectively. Total survival rate was 2.2%, out of which, 3.3% was for medical staff, 3.2% for non-medical staff, and 0.6% for family. Compared to the results of detection by medical staff, the adjusted odds ratios (95% CIs) for provision of bystander CPR were 0.56 (0.49-0.63) for detection by non-medical staff and 0.33 (0.25-0.44) for detection by family. The bystander CPR rates of all three groups increased over time, and among them, the medical staff group increased the most. For prehospital ROSC and survival to discharge, no significant differences were observed according to bystander type.

CONCLUSION

Although OHCA was detected more often by non-medical staff, they provided bystander CPR less frequently than the medical staff did. To improve survival outcome of nursing home OHCA, bundle interventions including increasing the usage of automated external defibrillators and expanding CPR training for non-medical staff in nursing home are needed.

Limiting treatment in pre-hospital care: A prospective, observational multicentre study

BACKGROUND

Data are scarce on the withdrawal of life-sustaining therapies and limitation of care orders (LCOs) during physician-staffed Helicopter Emergency Medical Service (HEMS) missions. We investigated LCOs and the quality of information available when physicians made treatment decisions in pre-hospital care.

METHODS

A prospective, nationwide, multicentre study including all Finnish physician-staffed HEMS bases during a 6-month study period. All HEMS missions where a patient had pre-existing LCOs and/or a new LCO were included.

RESULTS

There were 335 missions with LCOs, which represented 5.7% of all HEMS missions (n = 5895). There were 181 missions with pre-existing LCOs, and a total of 170 new LCOs were issued. Usually, the pre-existing LCO was a do not attempt cardiopulmonary resuscitation order only (n = 133, 74%). The most frequent new LCO was 'termination of cardiopulmonary resuscitation' only (n = 61, 36%), while 'no intensive care' combined with some other LCO was almost as common (n = 54, 32%). When issuing a new LCO for patients who did not have any preceding LCOs (n = 153), in every other (49%) case the physicians thought that the patient should have already had an LCO. When the physician made treatment decisions, patients' background information from on-scene paramedics was available in 260 (78%) of the LCO missions, while patients' medical records were available in 67 (20%) of the missions.

CONCLUSION

Making LCOs or treating patients with pre-existing LCOs is an integral part of HEMS physicians' work, with every twentieth mission involving LCO patients. The new LCOs mostly concerned withholding or withdrawal of cardiopulmonary resuscitation and intensive care.

Limitation of treatment in prehospital care - the experiences of helicopter emergency medical service physicians in a nationwide multicentre survey

Background

Making ethically sound treatment limitations in prehospital care is a complex topic. Helicopter Emergency Medical Service (HEMS) physicians were surveyed on their experiences with limitations of care orders in the prehospital setting, including situations where they are dispatched to healthcare facilities or nursing homes.

Methods

A nationwide multicentre study was conducted among all HEMS physicians in Finland in 2017 using a questionnaire with closed five-point Likert-scale questions and open questions. The Ethics Committee of the Tampere University Hospital approved the study protocol (R15048).

Results

Fifty-nine (88%) physicians responded. Their median age was 43 (IQR 38–47) and median medical working experience was 15 (IQR 10–20) years. All respondents made limitation of care orders and 39% made them often. Three fourths (75%) of the physicians were often dispatched to healthcare facilities and nursing homes and the majority (93%) regularly met patients who should have already had a valid limitation of care order. Every other physician (49%) had sometimes decided not to implement a medically justifiable limitation of care order because they wanted to avoid conflicts with the patient and/or the next of kin and/or other healthcare staff. Limitation of care order practices varied between the respondents, but neither age nor working experience explained these differences in answers. Most physicians (85%) stated that limitations of care orders are part of their work and 81% did not find them especially burdensome. The most challenging patient groups for treatment limitations were the under-aged patients, the severely disabled patients and the patients in healthcare facilities or residing in nursing homes.

Conclusion

Making limitation of care orders is an important but often invisible part of a HEMS physician’s work. HEMS physicians expressed that patients in long-term care were often without limitations of care orders in situations where an order would have been ethically in accordance with the patient’s best interests.

Electronic supplementary material

The online version of this article (10.1186/s13049-019-0663-x) contains supplementary material, which is available to authorized users.