Bystander Cardiopulmonary Resuscitation Quality: Potential for Improvements in Cardiac Arrest Resuscitation

Incorporation of Drone Technology Into the Chain of Survival for OHCA: Estimation of Time Needed for Bystander Treatment of OHCA and CPR Performance

BACKGROUND

Drone-delivered automated external defibrillators (AEDs) hold promises in the treatment of out-of-hospital cardiac arrest. Our objective was to estimate the time needed to perform resuscitation with a drone-delivered AED and to measure cardiopulmonary resuscitation (CPR) quality.

METHODS

Mock out-of-hospital cardiac arrest simulations that included a 9-1-1 call, CPR, and drone-delivered AED were conducted. Each simulation was timed and video-recorded. CPR performance metrics were recorded by a Laerdal Resusci Anne Quality Feedback System. Multivariable regression modeling examined factors associated with time from 9-1-1 call to AED shock and CPR quality metrics (compression rate, depth, recoil, and chest compression fraction). Comparisons were made among those with recent CPR training (≤2 years) versus no recent (>2 years) or prior CPR training.

RESULTS

We recruited 51 research participants between September 2019 and March 2020. The median age was 34 (Q1-Q3, 23-54) years, 56.9% were female, and 41.2% had recent CPR training. The median time from 9-1-1 call to initiation of CPR was 1:19 (Q1-Q3, 1:06-1:26) minutes. A median time of 1:59 (Q1-Q3, 01:50-02:20) minutes was needed to retrieve a drone-delivered AED and deliver a shock. The median CPR compression rate was 115 (Q1-Q3, 109-124) beats per minute, the correct compression depth percentage was 92% (Q1-Q3, 25-98), and the chest compression fraction was 46.7% (Q1-Q3, 39.9%-50.6%). Recent CPR training was not associated with CPR quality or time from 9-1-1 call to AED shock. Younger age (per 10-year increase; β, 9.97 [95% CI, 4.63-15.31] s; P<0.001) and prior experience with AED (β, -30.0 [95% CI, -50.1 to -10.0] s; P=0.004) were associated with more rapid time from 9-1-1 call to AED shock. Prior AED use (β, 6.71 [95% CI, 1.62-11.79]; P=0.011) was associated with improved chest compression fraction percentage.

CONCLUSION

Research participants were able to rapidly retrieve an AED from a drone while largely maintaining CPR quality according to American Heart Association guidelines. Chest compression fraction was lower than expected.

Wider Dissemination of Simplified Chest Compression-Only Cardiopulmonary Resuscitation Training Combined With Conventional Cardiopulmonary Resuscitation Training and 10-Year Trends in Cardiopulmonary Resuscitation Performed by Bystanders in a City

BACKGROUND

Little is known about how to effectively increase bystander cardiopulmonary resuscitation (CPR), so we evaluated the 10-year trend of the proportion of bystander CPR in an area with wide dissemination of chest compression-only CPR (CCCPR) training combined with conventional CPR training.Methods and Results: We conducted a descriptive study after a community intervention, using a prospective cohort from September 2010 to December 2019. The intervention consisted of disseminating CCCPR training combined with conventional CPR training in Toyonaka City since 2010. We analyzed all non-traumatic out-of-hospital cardiac arrest (OHCA) patients resuscitated by emergency medical service personnel. The primary outcome was the trend of the proportion of bystander CPR. We conducted multivariate logistic regression models and assessed the adjusted odds ratio (AOR) using a 95% confidence interval (CI) to determine bystander CPR trends. Since 2010, we have trained 168,053 inhabitants (41.9% of the total population of Toyonaka City). A total of 1,508 OHCA patients were included in the analysis. The proportion of bystander CPR did not change from 2010 (43.3%) to 2019 (40.0%; 1-year incremental AOR 1.02 [95% CI: 0.98-1.05]).

CONCLUSIONS

The proportion of bystander CPR did not increase even after wider dissemination of CPR training. In addition to continuing wider dissemination of CPR training, other strategies such as the use of technology are necessary to increase bystander CPR.

Comparison of outcomes of out-of-hospital cardiac arrest patients: Emergency calls placed from mobile phones vs. landline phones

Background

Until recently, calls to the emergency medical service (EMS) from landline phones, which display the caller's exact location at the dispatch center, had been common. Since the use of mobile phones has become widespread, many emergency calls are now made from mobile phones. Differences in outcomes of out-of-hospital cardiac arrest (OHCA) patients for whom EMS was called from mobile versus landline phones has not yet been fully elucidated.

Methods

We performed a retrospective, population-based analysis in Kobe, Japan to examine whether EMS calls from mobiles improved the prognosis of OHCA patients over EMS calls placed from landlines. The primary outcome was favorable neurological outcome, defined as Cerebral Performance Category (CPC) scores of 1 or 2 at discharge. Secondary outcomes were survival at one-month, survival at discharge, and time durations between call and EMS activities.

Results

Of 4,231 OHCA cases, 2,194 cases (706 landline cases vs. 1,488 mobile cases) were included in this study. The percentages of favorable neurological outcomes were 0.7% (5/706) in the landline group and 3.8% (56/1,488) in the mobile group. Adjusted multivariable logistic regression revealed that favorable neurological outcomes (odds ratio [OR] 3.03, 95% confidence interval [CI] 1.12-8.17, p = 0.03) were better in the mobile group, while one-month survival (OR 1.30, 95% CI 0.80-2.14, p = 0.29) was not significantly different. Bystander CPR was more frequently administered in the mobile group (landlines 61.3% vs. mobiles 68.4%, p < 0.01). Time durations between call to EMS dispatch (184.5 [IQR 157-220 s] vs. 205 [IQR 174-248 s], p < 0.01) and EMS arrival (476.5 [IQR 377-599 s] vs. 491 [IQR 407.5-611.5 s], p < 0.01) were shorter in the landline group.

Conclusions

Although the landline caller location display system seems effective for shorter times between EMS call and EMS arrival, mobile phone use was associated with better neurological outcomes.

Association Between Bystander Physical Limitations, Delays in Chest Compression During Telecommunicator-Assisted Cardiopulmonary Resuscitation, and Outcome After Out-of-Hospital Cardiac Arrest

BACKGROUND

Promptly initiated bystander cardiopulmonary resuscitation (CPR) improves survival from out-of-hospital cardiac arrest (OHCA). Many OHCA patients require repositioning to a firm surface. We examined the association between repositioning, chest compression (CC) delay, and patient outcomes.

METHODS

We used a quality improvement registry from review of 9-1-1 dispatch audio recordings of OHCA among adults eligible for telecommunicator-assisted CPR (T-CPR) between 2013 and 2021. OHCA was categorized into 3 groups: CC not delayed, CC delayed due to bystander physical limitations to reposition the patient, or CC delayed for other (non-physical) reasons. The primary outcome was the repositioning interval, defined as the interval between the start of positioning instructions and CC onset. We used logistic regression to assess the odds ratio of survival according to CPR group, adjusting for potential confounders.

RESULTS

Of the 3,482 OHCA patients eligible for T-CPR, CPR was not delayed in 1,223 (35%), delayed due to repositioning in 1,413 (41%), and delayed for other reasons in 846 (24%). The repositioning interval was longest for the physical limitation delay group (137 secs, IQR-148) compared to the other delay group (81 secs, IQR-70) and the no delay group (51 secs, IQR-32) (p<0.001). Unadjusted survival was lowest in the physical limitation delay group (11%) versus the no delay (17%) and other delay (19%) groups and persisted after adjustment (p =0.009).

CONCLUSION

Bystander physical limitations are a common barrier to repositioning patients to begin CPR and are associated with lower likelihood of receiving CPR, longer times to begin CC, and lower survival.

Clinical outcomes following out-of-hospital cardiac arrest: The minute-by-minute impact of bystander cardiopulmonary resuscitation

AIMS

The time-dependent prognostic role of bystander cardiopulmonary resuscitation (CPR) for out-of-hospital cardiac arrest (OHCA) patients has not been described with great precision, especially for neurologic outcomes. Our objective was to assess the association between bystander CPR, emergency medical service (EMS) response time, and OHCA patients' outcomes.

METHODS

This cohort study used the Resuscitation Outcomes Consortium Cardiac Epidemiologic Registries. Bystander-witnessed adult OHCA treated by EMS were included. The primary outcome was survival to hospital discharge and secondary outcome was survival with a good neurologic outcome (modified Rankin scale 0-2). Multivariable logistic regression models were used to assess the associations and interactions between bystander CPR, EMS response time and clinical outcomes.

RESULTS

Out of 229,637 patients, 41,012 were included (18,867 [46.0%] without bystander CPR and 22,145 [54.0%] with bystander CPR). Bystander CPR was independently associated with higher survival (adjusted odds ratio [AOR] = 1.70 [95%CI 1.61-1.80]) and survival with a good neurologic outcome (AOR = 1.87 [95%CI 1.70-2.06]), while longer EMS response times were independently associated with lower survival to hospital discharge (each additional minute of EMS response time: AOR = 0.92 [95%CI 0.91-0.93], p < 0.001) and lower survival with a good neurologic outcome (AOR = 0.88 [95%CI 0.86-0.89], p < 0.001). There was no interaction between bystander CPR and EMS response time's association with survival (p = 0.12) and neurologic outcomes (p = 0.65).

CONCLUSIONS

Although bystander CPR is associated with an immediate increase in odds of survival and of good neurologic outcome for OHCA patients, it does not influence the negative association between longer EMS response time and survival and good neurologic outcome.

Sex difference in the association between type of bystander CPR and clinical outcomes in patients with out of hospital cardiac arrest

Background

A recent study suggested that women with out-of-hospital cardiac arrest have a smaller survival benefit with bystander cardiopulmonary resuscitation than men. We evaluated whether this weaker association between bystander cardiopulmonary resuscitation and survival in women is related to dispatcher-assisted vs unassisted bystander cardiopulmonary resuscitation.

Methods

In a national registry in the Republic of Korea, we identified adult patients with out-of-hospital cardiac arrest during 2013-2018. The main exposure was type of bystander cardiopulmonary resuscitation (categorized as none, dispatcher-assisted, and unassisted). The primary outcome was favourable neurological survival. Multivariable logistic regression evaluated for an interaction between sex and type of bystander cardiopulmonary resuscitation.

Results

Of 93,245 patients with out-of-hospital cardiac arrest, there were 31,578 (33.9%) women and 61,667 (66.1%) men. Overall, both types of bystander cardiopulmonary resuscitation were associated with favourable neurological survival (unassisted: adjusted OR, 1.81 [95% CI: 1.66-1.98]; dispatcher-assisted: adjusted OR, 1.44 [95% CI: 1.33-1.56]). When unassisted cardiopulmonary resuscitation was administered, the association between bystander cardiopulmonary resuscitation and favourable neurological survival was similar between women and men: adjusted ORs of 1.59 (95% CI: 1.30-1.95) in women and 1.88 (95% CI: 1.71-2.08) in men; interaction p = 0.65). In contrast, when dispatcher-assisted cardiopulmonary resuscitation was administered, the association differed by sex: adjusted ORs of 1.08 (95% CI: 0.90-1.92) in women and 1.55 (95% CI: 1.42-1.69) in men; interaction p < 0.0002).

Conclusions

Dispatcher-assisted cardiopulmonary resuscitation was associated with favourable neurological survival in men but not in women whereas unassisted bystander cardiopulmonary resuscitation was associated with favourable neurological survival in women and men.

Effectiveness of school-based CPR training among adolescents to enhance knowledge and skills in CPR: A systematic review

BACKGROUND

 Cardiac arrest is responsible for 5% - 10% of all deaths among children age 5-19 years; therefore, strategies to prevent poor outcomes post cardiac arrest among children are critical within schools.

OBJECTIVES

 The purpose of this study was to systematically review the effectiveness of cardiopulmonary resuscitation (CPR) training on CPR knowledge and skills among adolescent school children.

METHOD

 This systematic review was conducted and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. The complete bibliographic databases of PubMed, Cochrane Library, CINAHL and Web of Science were searched from January 2012 to August 2021. Included studies met all the eligibility criteria. The Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies (EPHPP) and Mixed Method Appraisal tool were used to appraise the quality of the included studies.

RESULTS

 Fourteen studies were included in the review, and 5418 participants were found in the databases. The studies were mainly conducted during the last decade, which suggests that the public's attention has been directed toward training schoolchildren in CPR. The most common interventions were taught in video simulation training courses. They also used subjective assessments to evaluate the participants' knowledge and skills.

CONCLUSION

 Findings from this systematic review reveal that CPR training within school settings effectively promoted a change in CPR knowledge and skills among adolescents. Hence, continuous training of CPR among schoolchildren should be encouraged by policymakers, school authorities, parents and teachers to optimise the prompt usage of the skills in any cardiac event. However, a high-quality randomised controlled trial would enhance the strength of evidence in this area.

Bystander-witnessed cardiopulmonary resuscitation by nonfamily is associated with neurologically favorable survival after out-of-hospital cardiac arrest in Miyazaki City District

BACKGROUND

Bystander intervention in cases of out-of-hospital cardiac arrest (OHCA) is a key factor in bridging the gap between the event and the arrival of emergency health services at the site. This study investigated the implementation rate of bystander cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) and 1-month survival after OHCA in Miyazaki prefecture and Miyazaki city district as well as compared them with those of eight prefectures in the Kyushu-Okinawa region in Japan. In addition, we analyzed prehospital factors associated with survival outcomes in Miyazaki city district.

METHODS

We used data from an annual report released by the Fire and Disaster Management Agency of Japan (n = 627,982) and the Utstein reporting database in Miyazaki city district (n = 1,686) from 2015 to 2019.

RESULT

Despite having the highest rate of bystander CPR (20.8%), the 1-month survival rate (15.7%) of witnessed OHCA cases of cardiac causes in Miyazaki city district was comparable with that in the eight prefectures between 2015 and 2019. However, rates of survival (10.7%) in Miyazaki prefecture were lower than those in other prefectures. In 1,686 patients with OHCA (74 ± 18 years old, 59% male) from the Utstein reporting database identical to the 5-year study period in Miyazaki city district, binary logistic regression analysis demonstrated that age of the recipient [odds ratio (OR) 0.979, 95% confidential interval (CI) 0.964-0.993, p = 0.004)], witness of the arrest event (OR 7.501, 95% CI 3.229-17.428, p < 0.001), AED implementation (OR 14.852, 95% CI 4.226-52.201, p < 0.001), and return of spontaneous circulation (ROSC) before transport (OR 31.070, 95% CI 16.585-58.208, p < 0.001) predicted the 1-month survival with favorable neurological outcomes. In addition, chest compression at a public place (p < 0.001) and by nonfamily members (p < 0.001) were associated with favorable outcomes (p = 0.015).

CONCLUSIONS

We found differences in 1-month survival rates after OHCA in the Kyushu-Okinawa region of Japan. Our results suggest that on-field ROSC with defibrillation performed by nonfamily bystanders who witnessed the event determines 1-month neurological outcomes after OHCA in Miyazaki city district. Continued education of citizens on CPR techniques and better access to AED devices may improve outcomes.

Evaluation of telephone-assisted cardiopulmonary resuscitation recommendations for out-of-hospital cardiac arrest

AIM OF THE STUDY

While out-of-hospital cardiac arrest (OHCA) is associated with poor survival, early bystander CPR (B-CPR) and telephone CPR (T-CPR) improves survival from OHCA. American Heart Association (AHA) Scientific Statements outline recommendations for T-CPR. We assessed these recommendations and hypothesized that meeting performance standards is associated with increased likelihood of survival. Additional variables were analyzed to identify future performance measurements.

METHODS

We conducted a retrospective cohort study of non-traumatic, adult, OHCA using the Singapore Pan-Asian Resuscitation Outcomes Study. The primary outcome was likelihood of survival; secondary outcomes were pre-hospital Return of Spontaneous Circulation (ROSC) and B-CPR.

RESULTS

From 2012 to 2016, 2,574 arrests met inclusion criteria. Mean age was 68 ± 15; of 2,574, 1,125 (44%) received T-CPR with 5% (135/2574) survival. T-CPR cases that met the Lerner et al. performance metrics analyzed, demonstrated no statistically significant association with survival. Cases which met the Kurz et al. criteria, "Time for Dispatch to Recognize Need for CPR" and "Time to First Compression," had adjusted odds ratios of survival of 1.01 (95% CI:1.00, 1.02; p = <0.01) and 0.99 (95% CI:0.99, 0.99; p = <0.01), respectively. Identified barriers to CPR decreased the odds of T-CPR and B-CPR being performed. Patients with prehospital ROSC had higher odds of B-CPR being performed. EMS response time < 8 minutes was associated with increased survival among patients receiving T-CPR.

CONCLUSION

AHA scientific statements on T-CPR programs serve as ideal starting points for increasing the quality of T-CPR systems and patient outcomes. More work is needed to identify other system performance measures.

Improve Cardiac Emergency Preparedness by Building a Team-Based Cardiopulmonary Resuscitation Educational Plan

Objective

To design an innovative team-based cardiopulmonary resuscitation (CPR) educational plan for multiple bystanders and evaluate whether it was associated with better teamwork and higher quality of resuscitation.

Methods

The team-based CPR plan defined the process for a three-person team, emphasize task allocation, leadership, and closed-loop communication. Participants qualified for single-rescuer CPR skills were randomized into teams of 3. The teamwork performance and CPR operation skills were evaluated in one simulated cardiac arrest scenario before and after training on the team-based CPR plan. The primary outcomes were measured by the Team Emergency Assessment Measure (TEAM) scale and chest compression fraction (CCF).

Results

Forty-three teams were included in the analysis. The team-based CPR plan significantly improved the team performance (global rating 6.7 ± 1.3 vs. 9.0 ± 0.7, corrected p < 0.001 after Bonferroni's correction). After implementing the team-based CPR plan, CCF increased [median 59 (IQR 48–69) vs. 64 (IQR 57–71%)%, corrected p = 0.002], while hands-off time decreased [median 233.2 (IQR 181.0–264.0) vs. 207 (IQR 174–222.9) s, corrected p = 0.02]. We found the average compression depth was significantly improved through the team-based CPR training [median 5.1 (IQR 4.7–5.6) vs. 5.3 (IQR 4.9–5.5) cm, p = 0.03] but no more significantly after applying the Bonferroni's correction (corrected p = 0.35). The compression depths were significantly improved by collaborating and exchanging the role of compression among the participants after the 6th min.

Conclusion

The team-based CPR plan is feasible for improving bystanders teamwork performance and effective for improving resuscitation quality in prearrival care. We suggest a wide application of the team-based CPR plan in the educational program for better resuscitation performance in real rescue events.

Out of hospital cardiac arrest: Past, present, and future

Advances in resuscitation following out-of-hospital cardiac arrest (OHCA) provide an opportunity to improve public health. This review reflects on past developments, present status, and future possibilities using the science-education-implementation framework of the Utstein Formula and the clinical framework of the links in the chain of survival. With the discovery of CPR and defibrillation in the mid 20th century, resuscitation developed a scientific construct for progress. Systems of emergency community response provided operational efficiency to treat OHCA. Contemporary resuscitation involves integrated interventions in the chain of survival: early recognition, early CPR, early defibrillation, expert and timely advanced life support and hospital care, and multidimensional rehabilitation. Implementation of scientific advances is especially challenging given the unexpected nature of OHCA, the need for time-sensitive interventions, and the substantial collective of stakeholders involved in the chain of survival. Systematic measurement provides the foundation to evaluate performance and guide implementation initiatives. For many systems, telecommunicator CPR and high-performance CPR by emergency professionals are accessible, near-term programs to improve OHCA outcome. Smart technologies that activate, coordinate, and/or coach community "volunteers" to accelerate early CPR and defibrillation have conceptual promise, though robust implementation has been achieved by only a handful of systems. Longer-term strategies may leverage technology to develop a high-fidelity "life-detector" or engineer and disseminate a specialized consumer defibrillator designed to bridge care until arrival of professional response.

Bystander Cardiopulmonary Resuscitation Quality: Potential for Improvements in Cardiac Arrest Resuscitation

Background

Bystander cardiopulmonary resuscitation (CPR) is a critical intervention to improve survival following out‐of‐hospital cardiac arrest. We evaluated the quality of bystander CPR and whether performance varied according to the number of bystanders or provision of telecommunicator CPR (TCPR).

Methods and Results

We investigated non‐traumatic out‐of‐hospital cardiac arrest occurring in a large metropolitan emergency medical system during a 6‐month period. Information about bystander care was ascertained through review of the 9‐1‐1 recordings in addition to emergency medical system and hospital records to determine bystander CPR status (none versus TCPR versus unassisted), the number of bystanders on‐scene, and CPR performance metrics of compression fraction and compression rate. Of the 428 eligible out‐of‐hospital cardiac arrest, 76.4% received bystander CPR including 43.7% unassisted CPR and 56.3% TCPR; 35.2% had one bystander, 33.3% had 2 bystanders, and 31.5% had ≥3 bystanders. Overall compression fraction was 59% with a compression rate of 88 per minute. CPR differed according to TCPR status (fraction=52%, rate=87 per minute for TCPR versus fraction=69%, rate=102 for unassisted CPR, P<0.05 for each comparison) and the number of bystanders (fraction=55%, rate=87 per minute for 1 bystander, fraction=59%, rate=89 for 2 bystanders, fraction=65%, rate=97 for ≥3 bystanders, test for trend P<0.05 for each metric). Additional bystander actions were uncommon to include rotation of compressors (3.1%) or application of an automated external defibrillator (8.0%).

Conclusions

Bystander CPR quality as gauged by compression fraction and rate approached guideline goals though performance depended upon the type of CPR and number of bystanders.