Witnessed collapse and bystander cardiopulmonary resuscitation: what is really going on?

CPR training and CPR performance: do CPR-trained bystanders perform CPR?

OBJECTIVES

To determine factors associated with cardiopulmonary resuscitation (CPR) provision by CPR-trained bystanders and to determine factors associated with CPR performance by trained bystanders.

METHODS

The authors performed a prospective, observational study (January 1997 to May 2003) of individuals who called 911 (bystanders) at the time of an out-of-hospital cardiac arrest. A structured telephone interview of adult cardiac-arrest bystanders was performed beginning two weeks after the incident. Elements gathered during interviews included bystander and patient demographics, identifying whether the bystander was CPR trained, when and by whom the CPR was performed, and describing the circumstances of the event. If CPR was not performed, we asked the bystanders why CPR was not performed. Logistic regression was used to calculate odds ratios and 95% confidence intervals (95% CI) for factors associated with CPR performance.

RESULTS

Of 868 cardiac arrests, 684 (78.1%) bystander interviews were completed. Of all bystanders interviewed, 69.6% were family members of the victims, 36.8% of the bystanders had more than a high-school education, and 54.1% had been taught CPR at some time. In 21.2% of patients, the bystander immediately started CPR, and in 33.6% of cases, someone started CPR before the arrival of emergency medical services (EMS). Important overall predictors of CPR performance were the following: witnessed arrest (OR = 2.3; 95% CI = 1.4 to 3.8); bystander was CPR trained (OR = 6.6; 95% CI = 3.5 to 12.5); bystander had more than a high-school education (OR = 2.0; 95% CI = 1.2 to 3.1), or arrest occurred in a public location (OR = 3.1; 95% CI = 1.7 to 5.8). These variables were significant predictors of CPR performance among CPR-trained bystanders, as was CPR training within five years (OR = 4.5; 95% CI = 2.8 to 7.3). Common reasons that the CPR-trained bystanders cited for not performing CPR were the following: 37.5% stated that they panicked, 9.1% perceived that they would not be able to do CPR correctly, and 1.1% thought that they would hurt the patient. Surprisingly, only 1.1% objected to performing mouth-to-mouth resuscitation.

CONCLUSIONS

A minority of CPR-trained bystanders performed CPR. CPR provision was more common in CPR-trained bystanders with more than a high-school education and when CPR training had been within five years. Previously espoused reasons for not doing CPR (mouth-to-mouth, infectious-disease risk) were not the reasons that bystanders cited for not doing CPR. Further work is needed to maximize CPR provision after CPR training.

Cost-effectiveness of training unselected laypersons in cardiopulmonary resuscitation and defibrillation

PURPOSE

The cost-effectiveness of cardiopulmonary resuscitation (CPR) and defibrillation training for laypersons unselected for risk of encountering cases of cardiac arrest is not known. We compared the costs and health benefits of alternative resuscitation training strategies for adults without professional first-responder duties who are at average risk of encountering cases of out-of-hospital cardiac arrest.

METHODS

We constructed a cost-effectiveness analytic model. Data on cardiac arrest epidemiology and the effectiveness of CPR/defibrillation training were obtained from the medical literature. Instructional costs were determined from a survey of training programs. Downstream cardiac arrest survivor quality-adjusted life expectancy and long-term health care costs were derived from prior studies. We compared three strategies for training unselected laypersons: CPR/defibrillation training alone, training combined with home defibrillator purchase, and no training. The main outcome measures were total instructional costs for trainees combined with health care costs for additional cardiac arrest survivors, and quality-adjusted survival for additional patients resuscitated by trainees.

RESULTS

CPR/defibrillation training yielded 2.7 quality-adjusted hours of life at a cost of 62 US dollars per trainee (202,400 US dollars per quality-adjusted life-year [QALY] gained). Training laypersons in CPR/defibrillation with subsequent defibrillator purchase cost 2,489,700 US dollars per QALY. In contrast, CPR/defibrillation training cost less than 75,000 US dollars per QALY if trainees lived with persons older than 75 years or with persons who had cardiac disease, or if total training costs were less than 10 US dollars.

CONCLUSION

Training unselected laypersons in CPR/defibrillation is costly compared with other public health initiatives. Conversely, training laypersons selected by occupation, low training costs, or having high-risk household companions is substantially more efficient.