When dispatcher assistance is not saving lives: assessment of process compliance, barriers and outcomes in out-of-hospital cardiac arrest in a metropolitan city in China

Incidence, process of care, and outcomes of out-of-hospital cardiac arrest in China: a prospective study of the BASIC-OHCA registry

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is an important global public health issue, but its epidemiology and outcomes in low-income and middle-income countries remain largely unknown. We aim to comprehensively describe the incidence, process of care, and outcomes of OHCA in China.

METHODS

In the prospective, multicentre, population-based Baseline Investigation of Out-of-hospital Cardiac Arrest (BASIC-OHCA) registry study, participating sites were selected from both urban and rural areas in all seven geographical regions across China. All patients with OHCA assessed by emergency medical service (EMS) staff were consecutively enrolled from Aug 1, 2019, to Dec 31, 2020. Patients with suspected cardiac arrest assessed by bystanders whose return of spontaneous circulation was achieved without the need for defibrillation or EMS personnel cardiopulmonary resuscitation were excluded. Patients with all key variables missing were excluded, including resuscitation attempt, age, sex, witnessed status, cause, all process of care indicators, and all outcome measures. In this analysis, we included data for EMS agencies serving 25 monitoring sites (20 urban and five rural) that included the entire serving population, data for the whole of 2020, and at least 50 OHCA patients in 2020. Data were collected and reported using the Utstein template. We calculated the crude incidence of EMS-assessed OHCA in 2020. We also report data on baseline characteristics (including sex, cause, location of OHCA, and presence of shockable rhythm), process of care (including EMS response time, cardiopulmonary resuscitation, defibrillation, and advanced life support), and outcomes of non-traumatic OHCA between Aug 1, 2019, and Dec 31, 2020, including survival and survival with favourable neurological outcomes at discharge or 30 days, and at 6 and 12 months.

FINDINGS

Of 115·1 million people served by the 25 participating sites, 132 262 EMS-assessed patients with OHCA were enrolled, and resuscitation was attempted for 42 054 (31·8%) patients between Aug 1, 2019, and Dec 31, 2020. The crude incidence of EMS-assessed OHCA was 95·7 per 100 000 population (95% CI 95·6-95·8) in 2020. Among 38 227 individuals with non-traumatic OHCA, 25 958 (67·9%) were male, 30 282 (79·2%) had a cardiac arrest at home, 32 523 (85·1%) had a presumed cardiac cause, and 2297 (6·0%) presented with an initial shockable rhythm. 4049 (11·5%) of 35 090 patients with an unwitnessed or bystander-witnessed OHCA received dispatcher-assisted cardiopulmonary resuscitation and 7121 (20·3%) received bystander cardiopulmonary resuscitation; only 14 (<0·1%) patients were assessed by bystanders with an automated external defibrillator. The median EMS response time was 12 min (IQR 9-16). At hospital discharge or 30 days, 441 (1·2%) of 38 227 survived, 304 (0·8%) survived up to 6 months, and 269 (0·7%) up to 12 months. At hospital discharge or 30 days, 309 (0·8%) survived with favourable neurological outcomes, 257 (0·7%) had favourable neurological outcomes at 6 months, and 236 (0·6%) at 12 months.

INTERPRETATION

Our findings revealed a high burden of EMS-assessed OHCA with a low proportion of resuscitation attempts. The suboptimal implementation of chain of survival and unsatisfactory prognosis call for national efforts to improve the care and outcomes of patients with OHCA in China.

FUNDING

The National Science & Technology Fundamental Resources Investigation Program of China, the State Key Program of the National Natural Science Foundation of China, Taishan Pandeng Scholar Program of Shandong Province, the Key Research & Development Program of Shandong Province, the Interdisciplinary Young Researcher Groups Program of Shandong University, the Clinical Research Center of Shandong University, the ECCM Program of Clinical Research Center of Shandong University, and the Natural Science Foundation of Shandong Province.

Evaluation of Telephone Cardiopulmonary Resuscitation Performance in Current Practice in Saudi Arabia

Objectives

Out-of-hospital cardiac arrest (OHCA) is a global health problem with a low survival rate. Telephone cardiopulmonary resuscitation (T-CPR) guidance by emergency medical services (EMS) dispatchers can improve CPR performance and, consequently, survival rates. Accordingly, the American Heart Association (AHA) has released performance standards for T-CPR in current practice to improve its quality. However, no study has examined T-CPR performance in Saudi Arabia. Therefore, this study aims to evaluate T-CPR performance in the Saudi Arabian EMS system.

Methods

A retrospective observation of OHCA calls in current practice was conducted in Riyadh, Saudi Arabia. OHCA calls were reviewed to identify those that met the selection criteria. Variables collected included return of spontaneous circulation (ROSC), OHCA recognition rate, time from EMS call receipt to location acquisition, to OHCA recognition and to commencement of CPR.

Results

A total of 308 OHCA cases were reviewed, and 100 calls were included. ROSC was identified in 10% of the included calls. OHCA was correctly recognized in 62% of the calls. The time to OHCA identification and CPR performance from EMS call receipt were found to be 303 s and 367 s, respectively.

Conclusion

T-CPR performance in Saudi Arabia is below AHA standards. However, this is similar to what has been reported in the literature. Avoiding any unnecessary call transfer during OHCA calls and prompt identification of callers' locations could improve T-CPR performance.

Survival outcome among patients with out-of-hospital cardiac arrest who received cardiopulmonary resuscitation in China: a systematic review and meta-analysis

BACKGROUND

This study aimed to assess the survival outcomes among patients with out-of-hospital cardiac arrest (CA) who received cardiopulmonary resuscitation (CPR) in China.

METHODS

Relevant studies, published between January 1, 2010 and September 5, 2022, were retrieved from databases, including EMBASE, PubMed, Cochrane Library, the China Biology Medicine disk, China National Knowledge Infrastructure, and Wanfang databases. We included clinical studies in which all patients were diagnosed with CA and underwent out-of-hospital CPR, and the outcome variables were at least one of the following: return of spontaneous circulation (ROSC), survival to admission, survival to hospital discharge, 1-month survival, achieved good neurological outcomes, and 1-year survival. Two investigators independently extracted the study data and assessed its quality using a modified Newcastle-Ottawa Scale tool. The data were pooled using random-effects models.

RESULTS

Of the 3620 identified studies, 49 (63,378 patients) were included in the meta-analysis. The pooled ROSC rate was 9.0% (95% confidence interval [CI] 7.5-10.5%, I² = 97%), the pooled survival to admission rate was 5.0% (95% CI 2.7-8.0%, I² = 98%), and the pooled survival to discharge rate was 1.8% (95% CI 1.2-2.5%, I² = 95%). Additionally, the ROSC rate of patients with bystander CPR was significantly higher than that of those without bystander CPR, and the pooled odds ratio (OR) was 7.92 (95% CI 4.32-14.53, I² = 85%). The ROSC rate of participants who started CPR within 5 min was significantly higher than that of those who started CPR after 5 min, and the pooled OR was 5.92 (95% CI 1.92-18.26, I² = 85%). The ROSC rate of participants with defibrillation was significantly higher than that of those without defibrillation, and the pooled OR was 8.52 (95% CI 3.72-19.52, I² = 77%).

CONCLUSION

The survival outcomes of out-of-hospital CPR in China are far below the world average. Therefore, the policy of providing automated external defibrillators (AEDs) in public places and strengthening CPR training for healthcare providers and public personnel should be encouraged and disseminated nationwide. Trial registration This study was registered in PROSPERO (CRD42022326165) on 29 April 2022.

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.

Video-assisted bystander cardiopulmonary resuscitation improves the quality of chest compressions during simulated cardiac arrests: A systemic review and meta-analysis

BACKGROUND

It remains unclear whether video aids can improve the quality of bystander cardiopulmonary resuscitation (CPR).

AIM

To summarize simulation-based studies aiming at improving bystander CPR associated with the quality of chest compression and time-related quality parameters.

METHODS

The systematic review was conducted according to the PRISMA guidelines. All relevant studies were searched through PubMed, EMBASE, Medline and Cochrane Library databases. The risk of bias was evaluated using the Cochrane collaboration tool.

RESULTS

A total of 259 studies were eligible for inclusion, and 6 randomised controlled trial studies were ultimately included. The results of meta-analysis indicated that video-assisted CPR (V-CPR) was significantly associated with the improved mean chest compression rate [OR = 0.66 (0.49-0.82), P < 0.001], and the proportion of chest compression with correct hand positioning [OR = 1.63 (0.71-2.55), P < 0.001]. However, the difference in mean chest compression depth was not statistically significant [OR = 0.18 (-0.07-0.42), P = 0.15], and V-CPR was not associated with the time to first chest compression compared to telecommunicator CPR [OR = -0.12 (-0.88-0.63), P = 0.75].

CONCLUSION

Video real-time guidance by the dispatcher can improve the quality of bystander CPR to a certain extent. However, the quality is still not ideal, and there is a lack of guidance caused by poor video signal or inadequate interaction.

Monitoring cardiopulmonary resuscitation quality in emergency departments: a national survey in China on current knowledge, attitudes, and practices

Background

To investigate current knowledge, attitudes, and practices for CPR quality control among emergency physicians in Chinese tertiary hospitals.

Methods

Anonymous questionnaires were distributed to physicians in 75 tertiary hospitals in China between January and July 2018.

Results

A total of 1405 respondents answered the survey without obvious logical errors. Only 54.4% respondents knew all criteria of high-quality CPR. A total of 91.0% of respondents considered CPR quality monitoring should be used, 72.4% knew the objective method for monitoring, and 63.2% always/often monitored CPR quality during actual resuscitation. The main problems during CPR were related to chest compression: low quality due to fatigue (67.3%), inappropriate depth (57.3%) and rate (54.1%). The use of recommended monitoring methods was reported as follows, ETCO₂ was 42.7%, audio-visual feedback devices was 10.1%, coronary perfusion pressure was 17.9%, and invasive arterial pressure was 31.1%. A total of 96.3% of respondents considered it necessary to participate in regular CPR retraining, but 21.4% did not receive any retraining. The ideal retraining interval was considered to be 3 to 6 months, but the actual interval was 6 to 12 months. Only 49.7% of respondents reported that feedback devices were always/often used in CPR training.

Conclusion

Chinese emergency physicians were very concerned about CPR quality, but they did not fully understand the high-quality criteria and their impact on prognosis. CPR quality monitoring was not a routine procedure during actual resuscitation. The methods recommended in guidelines were rarely used in practice. Many physicians had not received retraining or received retraining at long intervals. Feedback devices were not commonly used in CPR training.

National survey of do not attempt resuscitation decisions on out-of-hospital cardiac arrest in China

BACKGROUND

To investigate and understand the determinants of decisions not to attempt resuscitation following out-of-hospital cardiac arrest, to contribute to establishing rules that are appropriate to China.

METHODS

We recruited participants through directors of emergency medical services across China. A 28-question web survey was available between February 5 and March 6, 2021 that targeted demographic information and views on emergency work and cardiopulmonary resuscitation. Each question was assigned a value between 1 and 7 based on the level of importance from low to high. T-tests, one-way analysis of variance, and Kruskal-Wallis H-tests were used to compare continuous variables. Binary logistic regression analysis was used to identify factors influencing when people considered it suitable to initiate cardiopulmonary resuscitation.

RESULTS

The study involved 4289 participants from 31 provinces, autonomous regions and municipalities in mainland China, of whom 52.8% were male. The top three reasons for not attempting cardiopulmonary resuscitation were decomposition/hypostasis/rigor mortis (6.39 ± 1.44 points), massive injury (4.57 ± 2.08 points) and family members' preference (4.35 ± 1.98 points). In total, 2761 (64.4%) thought emergency services should not attempt cardiopulmonary resuscitation when cardiac arrest had happened more than 30 min before, and there had been no bystander cardiopulmonary resuscitation. Gender (OR 1.233, p = 0.002), religion (OR 1.147, p = 0.046), level (OR 0.903, p = 0.028) or classification of city (OR 0.920, p = 0.049), years of work experience (OR 0.884, p = 0.004), and major (OR 1.032, p = 0.044) all influenced how long after cardiac arrest was considered suitable for initiating cardiopulmonary resuscitation.

CONCLUSIONS

Chinese emergency physicians have different perceptions of when not to attempt resuscitation to those practicing elsewhere. The existing guidelines for resuscitation are not suitable for China, and China-specific guidelines need to be established.

Early mechanical cardiopulmonary resuscitation can improve outcomes in patients with non-traumatic cardiac arrest in the emergency department

Objective

To compare the outcomes of patients with non-traumatic cardiac arrest (CA) who received early versus late mechanical cardiopulmonary resuscitation (CPR) with the Lund University Cardiac Assist System (LUCAS) device in the emergency department (ED).

Methods

This was a retrospective observational study in the ED of a single medical center performed from May 2018 to December 2019; 68 patients with CA were eligible. We grouped the patients according to the time to initiating LUCAS use after CA into an early group (≤4 minutes) and late group (>4 minutes).

Results

The rate of return of spontaneous circulation (ROSC) was higher in the early group vs the late group (69.2% vs 52.4%, respectively). The 4-hour survival rate was significantly higher in the early group vs the late group (83.3% vs 45.5%, respectively), and CPR duration was significantly shorter in the early group (23.3 ± 12.5 vs 31.1 ± 14.8 minutes, respectively).

Conclusion

Early mechanical CPR can improve the success of achieving ROSC and the 4-hour survival rate in patients with non-traumatic CA in the ED, considering that more benefits were observed in patients who received early vs late LUCAS device therapy.