First-response treatment after out-of-hospital cardiac arrest: a survey of current practices across 29 countries in Europe

Prediction model for future OHCAs based on geospatial and demographic data: An observational study

This study used demographic data in a novel prediction model to identify areas with high risk of out-of-hospital cardiac arrest (OHCA) in order to target prehospital preparedness. We combined data from the nationwide Danish Cardiac Arrest Registry with geographical- and demographic data on a hectare level. Hectares were classified in a hierarchy according to characteristics and pooled to square kilometers (km2). Historical OHCA incidence of each hectare group was supplemented with a predicted annual risk of at least 1 OHCA to ensure future applicability. We recorded 19,090 valid OHCAs during 2016 to 2019. The mean annual OHCA rate was highest in residential areas with no point of public interest and 100 to 1000 residents per hectare (9.7/year/km2) followed by pedestrian streets with multiple shops (5.8/year/km2), areas with no point of public interest and 50 to 100 residents (5.5/year/km2), and malls with a mean annual incidence per km2 of 4.6. Other high incidence areas were public transport stations, schools and areas without a point of public interest and 10 to 50 residents. These areas combined constitute 1496 km2 annually corresponding to 3.4% of the total area of Denmark and account for 65% of the OHCA incidence. Our prediction model confirms these areas to be of high risk and outperforms simple previous incidence in identifying future risk-sites. Two thirds of out-of-hospital cardiac arrests were identified in only 3.4% of the area of Denmark. This area was easily identified as having multiple residents or having airports, malls, pedestrian shopping streets or schools. This result has important implications for targeted intervention such as automatic defibrillators available to the public. Further, demographic information should be considered when implementing such interventions.

Improving survival after cardiac arrest in Europe: The synergetic effect of rescue chain strategies

Sudden cardiac arrest is a global problem and is considered the third leading cause of death in industrialized countries. Patient survival rates after out-of-hospital cardiac arrest (OHCA) vary significantly between countries and continents. In particular, the 2021 European Resuscitation Council (ERC) Resuscitation Guidelines place a special focus on the chain of survival of patients after OHCA. As a complex, interconnected approach, the focus is on: Raising awareness for cardiac arrest and lay resuscitation, school children's education in resuscitation "KIDS SAVE LIVES", first responder systems - technologies to engage the community, telephone-assisted resuscitation (telephone-CPR; T-CPR) by dispatchers, and cardiac arrest centers (CAC) for further treatment in specialized hospitals. The Systems Saving Lives approach is a comprehensive strategy that emphasizes the interconnectedness of all links in the chain of survival following an OHCA, with a particular focus on the relationship between the community and emergency medical services (EMS). This system-level approach emphasizes the importance of the connection between all those involved in the chain of survival. It has a high potential to improve overall survival after OHCA. Therefore, it is recommended that these strategies be promoted and expanded in all countries.

Volunteer Responder Interventions in Out-of-Hospital Cardiac Arrest in Urban, Suburban, and Rural Areas

BACKGROUND

Patients with out-of-hospital cardiac arrest (OHCA) in rural areas experience longer emergency response times and have lower survival rates compared with patients in urban areas. Volunteer responders might improve care and outcomes for patients with OHCA specifically in rural areas. Therefore, we investigated volunteer responder interventions based on the degree of urbanization.

METHODS AND RESULTS

We included 1310 OHCAs from 3 different regions in Denmark where volunteer responders had arrived at the OHCA location. The location was classified as urban, suburban, or rural according to the Eurostat Degree of Urbanization Tool. A logistic regression model was used to examine associations between the degree of urbanization and volunteer responder arrival before emergency medical services, cardiopulmonary resuscitation, or defibrillation. We found the odds for volunteer responder arrival before emergency medical services more than doubled in rural areas (odds ratio [OR], 2.60 [95% CI, 1.91-3.53]) and suburban areas (OR, 2.05 [95% CI, 1.56-2.69]) compared with urban areas. In OHCA cases where volunteer responders arrived first, odds for bystander cardiopulmonary resuscitation was tripled in rural areas (OR, 3.83 [95% CI, 1.64-8.93]) and doubled in suburban areas (OR, 2.27 [95% CI, 1.17-4.41]) compared with urban areas. Bystander defibrillation was more common in suburban areas (OR, 1.53 [95% CI, 1.02-2.31]), where almost 1 out of 4 patients received bystander defibrillation, compared with urban areas.

CONCLUSIONS

Volunteer responders are significantly more likely to arrive before emergency medical services in rural and suburban areas than in urban areas. Patients with OHCA received more cardiopulmonary resuscitation in rural and suburban areas and more defibrillation in suburban areas than in urban areas.

Reporting standard for describing first responder systems, smartphone alerting systems, and AED networks

Standardized reporting of data is crucial for out-of-hospital cardiac arrest (OHCA) research. While the implementation of first responder systems dispatching volunteers to OHCA is encouraged, there is currently no uniform reporting standard for describing these systems. A steering committee established a literature search to identify experts in smartphone alerting systems. These international experts were invited to a conference held in Hinterzarten, Germany, with 40 researchers from 13 countries in attendance. Prior to the conference, participants submitted proposals for parameters to be included in the reporting standard. The conference comprised five workshops covering different aspects of smartphone alerting systems. Proposed parameters were discussed, clarified, and consensus was achieved using the Nominal Group Technique. Participants voted in a modified Delphi approach on including each category as a core or supplementary element in the reporting standard. Results were presented, and a writing group developed definitions for all categories and items, which were sent to participants for revision and final voting using LimeSurvey web-based software. The resulting reporting standard consists of 68 core items and 21 supplementary items grouped into five topics (first responder system, first responder network, technology/algorithm/strategies, reporting data, and automated external defibrillators (AED)). This proposed reporting standard generated by an expert opinion group fills the gap in describing first responder systems. Its adoption in future research will facilitate comparison of systems and research outcomes, enhancing the transfer of scientific findings to clinical practice.

Implementation and use of a supraglottic airway device in the management of out-of-hospital cardiac arrest by firefighter first responders - A prospective feasibility study

Aim

We wanted to assess the implementation and use of a supraglottic airway (SGA) for on-call firefighter first responders in out-of-hospital cardiac arrest.

Methods

We trained 502 firefighter first responders, located at 35 fire stations in the South-East of Norway, in the use of SGA during cardiopulmonary resuscitation in adult out-of-hospital cardiac arrest. Training consisted of 45 minutes of theoretical and practical training in small groups.Primary outcome was successful ventilation with SGA assessed by both firefighter first responders and first paramedic arriving on-scene. Secondary outcomes included time expenditure and complications related to the procedure, evaluation of the training, and descriptive characteristics of the out-of-hospital cardiac arrest cases.

Results

An SGA was used by firefighter first responders in 23 out-of-hospital cardiac arrests, and successful ventilation was achieved in 20 (87%) cases. Air-leak was described in the three unsuccessful cases. The median procedural time was 30 seconds (IQR = 15-40), with no observed procedural complications. Firefighter first responders arrived in median time 9 minutes (IQR = 6-10 min) before the ambulance. They performed chest compressions on all patients and 6 (26%) of the patients received shock with semi-automatic external defibrillator. After training, all participants were able to successfully ventilate a manikin with the SGA. The cost of the SGA equipment for all fire stations was 3955 GBP.

Conclusion

Implementation of an SGA for firefighter first responders in out-of-hospital cardiac arrest management seems feasible, safe and can be introduced with limited amount of training and limited use of resources.

Professional prehospital clinicians' experiences of ethical challenges associated with the collaboration with organised voluntary first responders: a qualitative study

BACKGROUND

Volunteer First Responders are used worldwide. In the Region of Southern Denmark, two types of programs have been established. One of these programs consists of voluntary responders without any requirements of education or training who are summoned to prehospital cardiac arrests. The other type of program is established primarily in the rural areas of the region and consists of volunteers with some mandatory education in first aid. These volunteers are summoned to all urgent cases along with the ambulances. Cooperation between professional healthcare workers and nonprofessionals summoned through official channels may be challenging. This study aimed to explore prehospital clinicians' experiences of ethical challenges in cooperation with volunteer first responders.

METHODS

We conducted 16 semi-structured interviews at four different ambulance stations in the Region of Southern Denmark. Five emergency physicians and 11 emergency medical technicians/paramedics were interviewed. The interviews were transcribed, and the data were analysed using systematic text condensation.

RESULTS

The study's 16 interviews resulted in the identification of some specific categories that challenged the cooperation between the two parties. We identified three main categories: 1. Beneficence, the act of doing good, 2. The risk of harming patients' autonomy 3. Non-maleficence, which is the obligation not to inflict harm on others.

CONCLUSION

This study provides an in-depth insight into the ethical challenges between prehospital clinicians and voluntary first responders from the perspective of the prehospital clinicians. Both programs are considered to have value but only when treating patients with cardiac arrest. Our study highlights potential areas of improvement in the two Danish voluntary programs in their current form.

Predictors, Prevalence, and Clinical Outcomes of Out-of-Hospital Cardiac Arrests in Croatia: A Nationwide Study

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) remains a pivotal health challenge globally. In Croatia, there has been a knowledge gap regarding the prevalence, predictors, and outcomes of OHCA patients. This study aims to determine the prevalence, prediction, and outcomes of OHCA patients in Croatia.

METHODS

An extensive one-year analysis was performed on all OHCA treated by the Emergency Medical Service in Croatia, based on the Utstein recommendations. Data were extracted from Croatian Institute of Emergency Medicine databases, focusing on adult individuals who experienced sudden cardiac arrest in out-of-hospital settings in Croatia.

RESULTS

From 7773 OHCA cases, 9.5% achieved spontaneous circulation pre-hospital. Optimal outcomes corresponded to EMS intervention within ≤13 min post-arrest onset AUC = 0.577 (95% CI: 0.56-0.59; p < 0.001) and female gender OR = 1.81 (95% CI: 1.49-2.19; p < 0.001). Northern Croatia witnessed lower success rates relative to the capital city Zagreb OR = 0.68 (95% CI: 0.50-0.93; p = 0.015).

CONCLUSIONS

Early intervention by EMS, specifically within a 13-min period following the onset of a cardiac arrest, significantly enhances the probability of achieving successful OHCA outcomes. Gender differences and specific initial heart rhythms further influenced the likelihood of successful outcomes. Regional disparities, with reduced success rates in northern Croatia compared to the City of Zagreb, were evident.

Prehospital Predictors of Survival in Patients with Out-of-Hospital Cardiac Arrest

Background and Objectives: Despite advances in the treatment of heart diseases, the outcome of patients experiencing sudden cardiac arrest remains poor. The aim of our study was to determine the prehospital variables as predictors of survival outcomes in out-of-hospital cardiac arrest (OHCA) victims. Materials and Methods: This was a retrospective observational cohort study of OHCA cases. EMS protocols created in accordance with the Utstein style reporting for OHCA, first responder intervention reports, medical dispatch center dispatch protocols and hospital medical reports were all reviewed. Multivariate logistic regression was performed with the following variables: age, gender, witnessed status, location, bystander CPR, first rhythm, and etiology. Results: A total of 381 interventions with resuscitation attempts were analyzed. In more than half (55%) of them, bystander CPR was performed. Thirty percent of all patients achieved return of spontaneous circulation (ROSC), 22% of those achieved 30-day survival (7% of all OHCA victims), and 73% of those survived with Cerebral Performance Score 1 or 2. The logistic regression model of adjustment confirms that shockable initial rhythm was a predictor of ROSC [OR: 4.5 (95% CI: 2.5-8.1)] and 30-day survival [OR: 9.3 (95% CI: 2.9-29.2)]. Age was also associated (≤67 years) [OR: 3.9 (95% CI: 1.3-11.9)] with better survival. Conclusions: Elderly patients have a lower survival rate. The occurrence of bystander CPR in cardiac arrest remains alarmingly low. Shockable initial rhythm is associated with a better survival rate and neurological outcome compared with non-shockable rhythm.

OECD indicator 'AMI 30-day mortality' is neither comparable between countries nor suitable as indicator for quality of acute care

BACKGROUND

Hospital mortality after acute myocardial infarction (AMI, ICD-10: I21-I22) is used as OECD indicator of the quality of acute care. The reported AMI hospital mortality in Germany is more than twice as high as in the Netherlands or Scandinavia. Yet, in Europe, Germany ranks high in health spending and availability of cardiac procedures. We provide insights into this contradictory situation.

METHODS

Information was collected on possible factors causing the reported differences in AMI mortality such as prevalence of risk factors or comorbidities, guideline conform treatment, patient registration, and health system structures of European countries. International experts were interviewed. Data on OECD indicators 'AMI 30-day mortality using unlinked data' and 'average length of stay after AMI' were used to describe the association between these variables graphically and by linear regression.

RESULTS

Differences in prevalence of risk factors or comorbidities or in guideline conform acute care account only to a smaller extent for the reported differences in AMI hospital mortality. It is influenced mainly by patient registration rules and organization of health care. Non-reporting of day cases as patients and centralization of AMI care-with more frequent inter-hospital patient transfers-artificially lead to lower calculated hospital mortality. Frequency of patient transfers and national reimbursement policies affect the average length of stay in hospital which is strongly associated with AMI hospital mortality (adj R2 = 0.56). AMI mortality reported from registries is distorted by different underlying populations.

CONCLUSION

Most of the variation in AMI hospital mortality is explained by differences in patient registration and organization of care instead of differences in quality of care, which hinders cross-country comparisons of AMI mortality. Europe-wide sentinel regions with comparable registries are necessary to compare (acute) care after myocardial infarction.

The association between the experience of lay responders and response interval to medical emergencies in a rural area: an observational study

AIM

The aim of this retrospective observational study was to determine how response intervals correlated to the experience of the community first responders (CFRs) using data collected from the Danish Island of Langeland via a global positioning system (GPS)-based system.

METHODS

All medical emergency calls involving CFRs in the time period from 21st of April 2012 to 31st of December 2017 were included. Each emergency call activated 3 CFRs. Response intervals were calculated using the time from when the system alerted the CFRs to CFR time of arrival at the emergency site measured by GPS. CFRs response intervals were grouped depending on their level of experience according to ≤ 10, 11-24, 25-49, 50-99, ≥ 100 calls accepted and arrived on-site.

RESULTS

A total of 7273 CFR activations were included. Median response interval for the CFR arriving first on-site (n = 3004) was 4:05 min (IQR 2:42-6:01) and median response interval for the arrival of the CFR with an automated external defibrillator (n = 2594) was 5:46 min (IQR 3:59-8:05). Median response intervals were 5:53 min (3:43-8:29) for ≤ 10 calls (n = 1657), 5:39 min (3:49-8:01) for 11-24 calls (n = 1396), 5:45 min (3:49-8:00) for 25-49 calls (n = 1586), 5:07 min (3:38-7:26) for 50-99 calls (n = 1548) and 4:46 min (3:14-7:32) for ≥ 100 calls (n = 1086) (p < 0.001). There was a significant negative correlation between experience and response intervals (p < 0.001, Spearman's rho = -0.0914).

CONCLUSION

This study found an inverse correlation between CFR experience and response intervals, which could lead to increased survival after a time-critical incident.

Volunteer responder provision of support to relatives of out-of-hospital cardiac arrest patients: a qualitative study

OBJECTIVES

Smartphone dispatch of volunteer responders for out-of-hospital cardiac arrest (OHCA) is implemented worldwide. While basic life support courses prepare participants to provide CPR, the courses rarely address the possibility of meeting a family member or relative in crisis. This study aimed to examine volunteer responders' provision of support to relatives of cardiac arrest patients and how relatives experienced the interaction with volunteer responders.

DESIGN

In this qualitative study, we conducted 16 semistructured interviews with volunteer responders and relatives of cardiac arrest patients.

SETTING

Interviews were conducted face to face and by video and recorded and transcribed verbatim.

PARTICIPANTS

Volunteer responders dispatched to cardiac arrests and relatives of cardiac arrest patients were included in the study. Participants were included from all five regions of Denmark.

RESULTS

A thematic analysis was performed with inspiration from Braun and Clarke. We identified three themes: (1) relatives' experiences of immediate relief at arrival of assistance, (2) volunteer responders' assessment of relatives' needs and (3) the advantage of being healthcare educated.

CONCLUSIONS

Relatives to out-of-hospital cardiac arrest patients benefited from volunteer responders' presence and support and experienced the mere presence of volunteer responders as supportive. Healthcare-educated volunteer responders felt confident and skilled to provide care for relatives, while some non-healthcare-educated volunteer responders felt they lacked the proper training and knowledge to provide emotional support for relatives. Future basic life support courses should include a lesson on how to provide emotional support to relatives of cardiac arrest patients.

Factors associated with the arrival of smartphone-activated first responders before the emergency medical services in Out-of-Hospital cardiac arrest dispatch

BACKGROUND

First responder programs were developed to speed up access to cardiopulmonary resuscitation and defibrillation for out-of-hospital cardiac arrest (OHCA) victims. Little is known about the factors influencing the efficiency of the first responders arriving before the EMS and, therefore, effectively contributing to the chain of survival.

OBJECTIVES

The primary objective of this retrospective observational study was to identify the factors associated with first responders' arrival before EMS in the context of a regional first responder program arranged to deliver automated external defibrillators on suspected OHCA scenes.

METHODS

Eight hundred ninety-six dispatches where FRs intervened were collected from 2018 to 2022. A robust Poisson regression was performed to estimate the role of the time of day, the immediate availability of a defibrillator, the type of first responder, distances between the responder, the event and the dispatched vehicle, and the nearest available defibrillator on the probability of responder arriving before EMS. Moreover, a geospatial logistic regression model was built.

RESULTS

Responders arrived before EMS in 13.4% of dispatches and delivered a shock in 0.9%. The immediate availability of a defibrillator for the responder (OR = 3.24) and special categories such as taxi drivers and police (OR = 1.74) were factors significantly associated with the responder arriving before EMS. Moreover, a geospatial effect suggested that first responder programs may have a greater impact in rural areas.

CONCLUSIONS

When dispatched to OHCA scenes, responders already carrying defibrillators could more probably reach the scene before EMS. Special first responder categories are more competitive and should be further investigated.

Effect of Smartphone Dispatch of Volunteer Responders on Automated External Defibrillators and Out-of-Hospital Cardiac Arrests: The SAMBA Randomized Clinical Trial

Importance

Smartphone dispatch of volunteer responders to nearby out-of-hospital cardiac arrests (OHCAs) has emerged in several emergency medical services, but no randomized clinical trials have evaluated the effect on bystander use of automated external defibrillators (AEDs).

Objective

To evaluate if bystander AED use could be increased by smartphone-aided dispatch of lay volunteer responders with instructions to collect nearby AEDs compared with instructions to go directly to patients with OHCAs to start cardiopulmonary resuscitation (CPR).

Design, Setting, and Participants

This randomized clinical trial assessed a system for smartphone dispatch of volunteer responders to individuals experiencing OHCAs that was triggered at emergency dispatch centers in response to suspected OHCAs and randomized 1:1. The study was conducted in 2 main Swedish regions: Stockholm and Västra Götaland between December 2018 and January 2020. At study start, there were 3123 AEDs in Stockholm and 3195 in Västra Götaland and 24 493 volunteer responders in Stockholm and 19 117 in Västra Götaland. All OHCAs in which the volunteer responder system was activated by dispatchers were included. Excluded were patients with no OHCAs, those with OHCAs not treated by the emergency medical services, and those with OHCAs witnessed by the emergency medical services.

Interventions

Volunteer responders were alerted through the volunteer responder system smartphone application and received map-aided instructions to retrieve nearest available public AEDs on their way to the OHCAs. The control arm included volunteer responders who were instructed to go directly to the OHCAs to perform CPR.

Main Outcomes and Measures

Overall bystander AED attachment, including those attached by volunteer responders and lay volunteers who did not use the smartphone application.

Results

Volunteer responders were activated for 947 patients with OHCAs. Of those, 461 were randomized to the intervention group (median [IQR] age of patients, 73 [61-81] years; 295 male patients [65.3%]) and 486 were randomized to the control group (median [IQR] age of patients, 73 [63-82] years; 312 male patients [65.3%]). Primary outcome of AED attachment occurred in 61 patients (13.2%) in the intervention arm vs 46 patients (9.5%) in the control arm (difference, 3.8% [95% CI, -0.3% to 7.9%]; P = .08). The majority of AEDs were attached by lay volunteers who were not using the smartphone application (37 in intervention arm, 28 in control). There were no significant differences in secondary outcomes. Among the volunteer responders using the application, crossover was 11% and compliance to instructions was 31%. Volunteer responders attached 38% (41 of 107) of all AEDs and provided 45% (16 of 36) of all defibrillations and 43% (293 of 666) of all CPR.

Conclusions and Relevance

In this study, smartphone dispatch of volunteer responders to OHCAs to retrieve nearby AEDs vs instructions to directly perform CPR did not significantly increase volunteer AED use. High baseline AED attachement rate and crossover may explain why the difference was not significant.

Trial Registration

ClinicalTrials.gov Identifier: NCT02992873.

Development and Validation of a Novel Ultra-Compact and Cost-Effective Device for Basic Hands-On CPR Training: A Randomized, Sham-Controlled, Blinded Trial

To examine the performance of a novel low-cost, ultra-compact, and attractive auditory feedback device for training laypeople in external chest compressions (ECCs), we conducted a quasi-experimental cross-sectional study from September to November 2021 at the Faculty of Nursing of Albacete, University of Castille-La Mancha, Spain. The ECC sequence was performed in the laboratory with the new device for basic hands-on CPR training. Results: One hundred college students were included in this study. The compression rate/min with the new device was 97.6, and the adequate %ECC was 52.4. According to the status of body mass index (BMI) and muscle strength of the upper limbs in the bivariate analysis, it was observed that the new device discriminated between those who performed correct ECCs according to their BMI and muscle strength and those who did not, which led to significantly influenced results in terms of the percentage of ECCs with correct depth. Conclusions: The new ultra-compact auditory feedback device "Salvando a Llanetes^®" demonstrated utility for teaching and learning ECCs in basic CPR. We can affirm that the analyzed device is an adequate, safe and economical method for teaching "CPR Hands-Only™" to the general population.

Are there socioeconomic disparities in geographic accessibility to community first responders to out-of-hospital cardiac arrest in Ireland?

Out-of-hospital cardiac arrest (OHCA) is a leading cause of death worldwide. Without appropriate early resuscitation interventions, the prospect of survival is limited. This means that an effective community response is a critical enabler of increasing the number of people who survive. However, while OHCA incidence is higher in more deprived areas, propensity to volunteer is, in general, associated with higher socioeconomic status. In this context, we consider whether there are socioeconomic disparities in geographic accessibility to volunteer community first responders (CFRs) in Ireland, where CFR groups have developed organically and communities self-select to participate. We use geographic information systems and propensity score matching to generate a set of control areas with which to compare established CFR catchment areas. Differences between CFRs and controls in terms of the distribution of catchment deprivation and social fragmentation scores are assessed using two-sided Kolmogorov-Smirnov tests. Overall we find that while CFR schemes are centred in more deprived and socially fragmented areas, beyond a catchment of 4 min there is no evidence of differences in area-level deprivation or social fragmentation. Our findings show that self-selection as a model of CFR recruitment does not lead to more deprived areas being disadvantaged in terms of access to CFR schemes. This means that community-led health interventions can develop to the benefit of community members across the socioeconomic spectrum and may be relevant for other countries and jurisdictions looking to support similar models within communities.

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Out-of-hospital cardiac arrest (OHCA) is a major cause of unexpected death.

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OHCA is more prevalent in deprived areas and community response is key for survival.

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Irish community first responders (CFRs) self-select to participate in CFR schemes.

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We consider if there are socioeconomic disparities in geographic access to CFRs.

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Self-selection does not result in deprived areas having worse access to CFR schemes.

Firefighters as first-responders in out-of-hospital cardiac arrest- a retrospective study of a time-gain selective dispatch system in the Skåne Region, Sweden

AIM

To analyze the impact of a time-gain selective, first-responder dispatch system on the presence of a shockable initial rhythm (SIR), return of spontaneous circulation (ROSC) and 30-day survival after out-of-hospital cardiac arrest (OHCA).

METHOD

A retrospective observational study comprising OHCA registry data and dispatch data in the Skåne Region, Sweden (2010-2018). Data were categorized according to dispatch procedures, two ambulances (AMB-only) versus two ambulances and firefighter first-responders (DUAL-dispatch), based on the dispatcher's estimation of a time-gain. Dual dispatch was sub-categorized by arrival of first vehicle (first-responder or ambulance). Logistic regressions were used, additionally with groups matched (1:1) for age, witnessed event, bystander cardiopulmonary resuscitation and ambulance response time. Adjusted and conditional odds-ratios (aOR, cOR) with 95% confidence intervals (CI) are presented.

RESULTS

Of 3,245 eligible cases, 43% were DUAL-dispatches with first-responders first on scene (FR-first) in 72%. Despite a five-minute median reduction in response time in the FR-first group, no association with SIR was found (aOR 0.83, 95%CI 0.64-1.07) nor improved 30-day survival (aOR 1.03, 95%CI 0.72-1.47). A positive association between ROSC and the FR-first group (aOR 1.25, 95%CI 1.02-1.54) disappeared in the matched analysis (cOR 1.12, 95%CI 0.87-1.43). Time to first monitored rhythm was 7:06 minutes in the FR-first group versus 3:01 in the combined AMB-only/AMB-first groups.

CONCLUSION

In this time-gain selective first-responder dispatch system, a shorter response time was not associated with increased SIR, improved ROSC rate or survival. Process measures differed between the study groups which could account for the observed findings and requires further investigation.

How technology can save lives in cardiac arrest

PURPOSE OF REVIEW

Technology is being increasingly implemented in the fields of cardiac arrest and cardiopulmonary resuscitation. In this review, we describe how recent technological advances have been implemented in the chain of survival and their impact on outcomes after cardiac arrest. Breakthrough technologies that are likely to make an impact in the future are also presented.

RECENT FINDINGS

Technology is present in every link of the chain of survival, from prediction, prevention, and rapid recognition of cardiac arrest to early cardiopulmonary resuscitation and defibrillation. Mobile phone systems to notify citizen first responders of nearby out-of-hospital cardiac arrest have been implemented in numerous countries with improvement in bystanders' interventions and outcomes. Drones delivering automated external defibrillators and artificial intelligence to support the dispatcher in recognising cardiac arrest are already being used in real-life out-of-hospital cardiac arrest. Wearables, smart speakers, surveillance cameras, and artificial intelligence technologies are being developed and studied to prevent and recognize out-of-hospital and in-hospital cardiac arrest.

SUMMARY

This review highlights the importance of technology applied to every single step of the chain of survival to improve outcomes in cardiac arrest. Further research is needed to understand the best role of different technologies in the chain of survival and how these may ultimately improve outcomes.

First responder systems can stay operational under pandemic conditions: results of a European survey during the COVID-19 pandemic

Background

Dispatching first responders (FR) to out-of-hospital cardiac arrest in addition to the emergency medical service has shown to increase survival. The promising development of FR systems over the past years has been challenged by the outbreak of COVID-19. Whilst increased numbers and worse outcomes of cardiac arrests during the pandemic suggest a need for expansion of FR schemes, appropriate risk management is required to protect first responders and patients from contracting COVID-19. This study investigated how European FR schemes were affected by the pandemic and what measures were taken to protect patients and responders from COVID-19.

Methods

To identify FR schemes in Europe we conducted a literature search and a web search. The schemes were contacted and invited to answer an online questionnaire during the second wave of the pandemic (December 2020/ January 2021) in Europe.

Results

We have identified 135 FR schemes in 28 countries and included responses from 47 FR schemes in 16 countries. 25 schemes reported deactivation due to COVID-19 at some point, whilst 22 schemes continued to operate throughout the pandemic. 39 schemes communicated a pandemic-specific algorithm to their first responders. Before the COVID-19 outbreak 20 FR systems did not provide any personal protective equipment (PPE). After the outbreak 19 schemes still did not provide any PPE. The majority of schemes experienced falling numbers of accepted call outs and decreasing registrations of new volunteers. Six schemes reported of FR having contracted COVID-19 on a mission.

Conclusions

European FR schemes were considerably affected by the pandemic and exhibited a range of responses to protect patients and responders. Overall, FR schemes saw a decrease in activity, which was in stark contrast to the high demand caused by the increased incidence and mortality of OHCA during the pandemic. Given the important role FR play in the chain of survival, a balanced approach upholding the safety of patients and responders should be sought to keep FR schemes operational.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-022-00998-3.

Identifying priorities for the collection and use of data related to community first response and out-of-hospital cardiac arrest: protocol for a nominal group technique study

Introduction: Out-of-hospital cardiac arrest (OHCA) is a devastating health event that affects over 2000 people each year in Ireland. Survival rate is low, but immediate intervention and initiation of cardiopulmonary resuscitation (CPR) and administration of an automated external defibrillator (AED) can increase chances of survival. It is not always possible for the emergency medical services (EMS) to reach OHCA cases quickly. As such, volunteers, including lay and professional responders (e.g. off-duty paramedics and fire-fighters), trained in CPR and AED use, are mobilised by the EMS to respond locally to prehospital medical emergencies (e.g. OHCA and stroke). This is known as community first response (CFR). Data on the impact of CFR interventions are limited. This research aims to identify the most important CFR data to collect and analyse, the most important uses of CFR data, as well as barriers and facilitators to data collection and use. This can inform policies to optimise the practice of CFR in Ireland. Methods: The nominal group technique (NGT) is a structured consensus process where key stakeholders (e.g. CFR volunteers, clinicians, EMS personnel, and patients/relatives) develop a set of prioritised recommendations. This study will employ the NGT, incorporating an online survey and online consensus meeting, to develop a priority list for the collection and use of CFR data in Ireland. Stakeholder responses will also identify barriers and facilitators to data collection and use, as well as indicators that improvements to these processes have been achieved. The maximum sample size for the NGT will be 20 participants to ensure sufficient representation from stakeholder groups. Discussion: This study, employing the NGT, will consult key stakeholders to establish CFR data collection, analysis, and use priorities. Results from this study will inform CFR research, practice, and policy, to improve the national CFR service model and inform international response programs.

Association of GPS-Based Logging and Manual Confirmation of the First Responders' Arrival Time in a Smartphone Alerting System: An Observational Study

The latest guidelines for cardiopulmonary resuscitation recommend that in case of suspected cardiac arrest first responders, who are close to the emergency location, should be notified by a smartphone app or text message. Smartphone Alerting Systems (SAS) aim to reduce the resuscitation-free interval. Thus, there is a need for uniform reporting of process times. Objective: To compare the response times in a SAS either by using global positioning system (GPS) data or by manual confirmation of first responders arriving at the scene. Methods: In the region of Freiburg (Southern Germany, 1,531 km², 493,000 inhabitants), a SAS is activated when the emergency dispatch center receives a call regarding suspected cardiac arrest. First responders who accept a mission are tracked using GPS. GPS-based times are logged for each responder when their position is within a radius of 100, 50, or 10 meters around the geographical position of the reported emergency. When arriving at the patient location, the first responders manually confirm "arrived" via their app. GPS-based and manually confirmed response arrival times were compared for all cases between 1 October and 31 March. Results: 192 missions with correct manual logging of the arrival time were included. GPS-based times were available in 175 (91%), 100 (52%), and 30 (16%) cases within radii of 100, 50, and 10 meters, respectively. GPS arrival times were approximately 1.5 minutes shorter when using a 100-meter radius and significantly longer when using a 10-meter radius. No difference was found for a 50-meter radius, but this would result in a lack of data in nearly half of the cases. Conclusion: GPS-based logging of arrival times leads to missing data. A 100-meter circle is associated with a low number of missing values, but 1.5 minutes must be added for the last 100 meters the first responder has to move. A wide range of the difference in response times (GPS vs. manual confirmation) must be regarded as a disadvantage. Manual confirmation reveals precise response times, but first responders may forget to confirm when they arrive. Trial registration: DRKS00016625 (14 April 2019).

Möglichkeiten der Überbrückung des therapiefreien Intervalls bei Notfällen

Bei Notfällen besteht bis zur professionellen Hilfe durch den Rettungsdienst ein therapiefreies Intervall, das durch verschiedene Organisationsformen überbrückt werden soll, um dem Notfallpatienten eine adäquate Erste Hilfe zuteilwerden zu lassen. Die Hilfsfrist des Rettungsdienstes ist eine länderdifferente planerische Größe und bietet keine ausreichende Gewähr eines frühzeitigen Erreichens des Patienten, sondern definiert vielmehr die Infrastruktur des Rettungsdienstes. Eine spontane Hilfeleistung durch Notfallzeugen ist trotz des Bemühens einer bundesweiten Schulung der Bevölkerung in Erster Hilfe nicht durchgehend zu erwarten. Die Telefonreanimation durch die Leitstelle mit Anleitung des Anrufers zur Reanimation stellt eine Möglichkeit zum frühzeitigen Beginn einer Wiederbelebung dar. Engagierte ausgebildete, zufällig erreichbare Ersthelfer können über verschiedene Kommunikationsmittel an den Notfallort entsandt werden, um Erste Hilfe zu leisten. Eine organisierte Überbrückung des therapiefreien Intervalls stellen die verschiedenen First-Responder-Systeme dar. Eine Sonderform ist der dem Rettungsdienst zugehörige Gemeindenotfallsanitäter. Die Vor- und Nachteile der einzelnen Organisationssysteme werden gegenübergestellt.

A review on initiatives for the management of daily medical emergencies prior to the arrival of emergency medical services

Emergency services worldwide face increasing cost pressure that potentially limits their existing resources. In many countries, emergency services also face the issues of staff shortage-creating extra challenges and constraints, especially during crisis times such as the COVID-19 pandemic-as well as long distances to sparsely populated areas resulting in longer response times. To overcome these issues and potentially reduce consequences of daily (medical) emergencies, several countries, such as Sweden, Germany, and the Netherlands, have started initiatives using new types of human resources as well as equipment, which have not been part of the existing emergency systems before. These resources are employed in response to medical emergency cases if they can arrive earlier than emergency medical services (EMS). A good number of studies have investigated the use of these new types of resources in EMS systems, from medical, technical, and logistical perspectives as their study domains. Several review papers in the literature exist that focus on one or several of these new types of resources. However, to the best of our knowledge, no review paper that comprehensively considers all new types of resources in emergency medical response systems exists. We try to fill this gap by presenting a broad literature review of the studies focused on the different new types of resources, which are used prior to the arrival of EMS. Our objective is to present an application-based and methodological overview of these papers, to provide insights to this important field and to bring it to the attention of researchers as well as emergency managers and administrators.

Immediate psychological impact on citizen responders dispatched through a mobile application to out-of-hospital cardiac arrests

Background

Activating citizen responders may increase survival after out-of-hospital cardiac arrest (OHCA) but could induce significant psychological impact on the citizen responders. We examined psychological impact among citizen responders within the first days following resuscitation attempt.

Methods and Results

A mobile phone application to activate citizen responders to perform cardiopulmonary resuscitation (CPR) was implemented in the Capital Region of Denmark. All dispatched citizen responders (September 2017 to May 2019) received a survey 90 minutes after an alarm, including self-rating of perceived psychological impact on a scale of 1–4.

Of 5,395 included citizen responders, most (88.6%) completed the survey within 24 hours.

The majority reported no psychological impact (68.6%), whereas 24.7%, 5.5% and 1.2% reported low, moderate, or severe impact, respectively. Severe impact was more commonly reported in the following groups: No CPR training (3.8% vs 1.2%, p = 0.02), age < 30 years (2.0% vs 0.9%, p < 0.001), female sex (1.8% vs 0.7%, p < 0.001), provided CPR (2.7% vs 1.0%, p < 0.001), and arrived prior to the emergency medical services (EMS) (2.8% vs 0.7%, p < 0.001) compared to no to moderate impact.

Chi square test, Mann-Whitney U test, Fischer’s exact test and a logistic regression model were used to assess differences in psychological impact across groups.

Conclusion

Very few citizen responders reported severe psychological impact. Lack of prior CPR training, younger age, female sex, performing CPR and arrival prior to the EMS were associated with greater psychological impact. Though very few citizen responders reported severe impact, the possibility of professional debriefing should be considered in citizen responder programs.

Collaboration between emergency physicians and citizen responders in out-of-hospital cardiac arrest resuscitation

BACKGROUND

Citizen responder programmes dispatch volunteer citizens to initiate resuscitation in nearby out-of-hospital cardiac arrests (OHCA) before the Emergency Medical Services (EMS) arrival. Little is known about the interaction between citizen responders and EMS personnel during the resuscitation attempt. In the Capital Region of Denmark, emergency physicians are dispatched to all suspected OHCAs. The aim of this study was to evaluate how emergency physicians perceived the collaboration with citizen responders during resuscitation attempts.

METHOD

This cross-sectional study was conducted through an online questionnaire. It included all 65 emergency physicians at Copenhagen EMS between June 9 and December 13, 2019 (catchment area 1.8 million). The questionnaire examined how emergency physicians perceived the interaction with citizen responders at the scene of OHCA (use of citizen responders before and after EMS arrival, citizen responders' skills in cardiopulmonary resuscitation (CPR), and challenges in this setting).

RESULTS

The response rate was 87.7% (57/65). Nearly all emergency physicians (93.0%) had interacted with a citizen responder at least once. Of those 92.5%(n = 49) considered it relevant to activate citizen responders to OHCA resuscitation, and 67.9%(n = 36) reported the collaboration as helpful. When citizen responders arrived before EMS, 75.5%(n = 40) of the physicians continued to use citizen responders to assist with CPR or to carry equipment. Most (84.9%, n = 45) stated that citizen responders had the necessary skills to perform CPR. Challenges in the collaboration were described by 20.7%(n = 11) of the emergency physicians and included citizen responders being mistaken for relatives, time-consuming communication, or crowding problems during resuscitation.

CONCLUSION

Emergency physicians perceived the collaboration with citizen responders as valuable, not only for delivery of CPR, but were also considered an extra helpful resource providing non-CPR related tasks such as directing the EMS to the arrest location, carrying equipment and taking care of relatives.

Identifying priorities for the collection and use of data related to community first response and out-of-hospital cardiac arrest: protocol for a nominal group technique study

Introduction: Out-of-hospital cardiac arrest (OHCA) is a devastating health event that affects over 2000 people each year in Ireland. Survival rate is low, but immediate intervention and initiation of cardiopulmonary resuscitation (CPR) and administration of an automated external defibrillator (AED) can increase chances of survival. It is not always possible for the emergency medical services (EMS) to reach OHCA cases quickly. As such, volunteers, including lay and professional responders (e.g. off-duty paramedics and fire-fighters), trained in CPR and AED use, are mobilised by the EMS to respond locally to prehospital medical emergencies (e.g. OHCA and stroke). This is known as community first response (CFR). Data on the impact of CFR interventions are limited. This research aims to identify the most important CFR data to collect and analyse, the most important uses of CFR data, as well as barriers and facilitators to data collection and use. This can inform policies to optimise the practice of CFR in Ireland. Methods: The nominal group technique (NGT) is a structured consensus process where key stakeholders (e.g. CFR volunteers, clinicians, EMS personnel, and patients/relatives) develop a set of prioritised recommendations. This study will employ the NGT, incorporating an online survey and online consensus meeting, to develop a priority list for the collection and use of CFR data in Ireland. Stakeholder responses will also identify barriers and facilitators to data collection and use, as well as indicators that improvements to these processes have been achieved. The maximum sample size for the NGT will be 20 participants to ensure sufficient representation from stakeholder groups. Discussion: This study, employing the NGT, will consult key stakeholders to establish CFR data collection, analysis, and use priorities. Results from this study will inform CFR research, practice, and policy, to improve the national CFR service model and inform international response programs.

Risk of Physical Injury for Dispatched Citizen Responders to Out-of-Hospital Cardiac Arrest

Background

Citizen responder programs are implemented worldwide to dispatch volunteer citizens to participate in out‐of‐hospital cardiac arrest resuscitation. However, the risk of injuries in relation to activation is largely unknown. We aimed to assess the risk of physical injury for dispatched citizen responders.

Methods and Results

Since September 2017, citizen responders have been activated through a smartphone application when located close to a suspected cardiac arrest in the Capital Region of Denmark. A survey was sent to all activated citizen responders, including a specific question about risk of acquiring an injury during activation. We included all surveys from September 1, 2017, to May 15, 2020. From May 15, 2019, to May 15, 2020, we followed up on all survey nonresponders by phone call, e‐mail, or text messages to examine if nonresponders were at higher risk of severe or fatal injuries. In 1665 suspected out‐of‐hospital cardiac arrests, 9574 citizen responders were dispatched and 76.6% (7334) answered the question regarding physical injury. No injury was reported by 99.3% (7281) of the responders. Being at risk of physical injury was reported by 0.3% (24), whereas 0.4% (26) reported an injury (25 minor injuries and 1 severe injury [ankle fracture]). When following up on nonresponders (2472), we reached 99.1% (2449). No one reported acquired injuries, and only 1 reported being at risk of injury.

Conclusions

We found low risk of physical injury reported by volunteer citizen responders dispatched to out‐of‐hospital cardiac arrest. Risk of injury should be considered and monitored as a safety measure in citizen responder programs.

Association of Psychological Distress, Contextual Factors, and Individual Differences Among Citizen Responders

Background

Little is known about the psychological risks of dispatched citizen responders who have participated in resuscitation attempts.

Methods and Results

A cross‐sectional survey study was performed with 102 citizen responders who participated in a resuscitation attempt from July 23, 2018, to August 22, 2018, in the Capital Region of Denmark. Psychological distress, defined as symptoms of posttraumatic stress disorder, was assessed 3 weeks after the resuscitation attempt and measured with the Impact of Event Scale‐Revised. Perceived stress was measured with the Perceived Stress Scale. Individual differences were assessed as the personality traits of agreeableness, conscientiousness, extraversion, neuroticism, and openness to experience with the Big Five Inventory, general self‐efficacy, and coping mechanisms (Brief Coping Orientation to Problems Experienced Inventory). Associations between continuous variables were examined with the Pearson correlation. The associations between psychological distress levels and contextual factors and individual differences were analyzed in multivariable linear regression models to determine factors independently associated with psychological distress levels. The mean overall posttraumatic stress disorder score was 0.65 of 12; the mean perceived stress score was 7.61 of 40. The most common coping mechanisms were acceptance and emotional support. Low perceived stress was significantly associated with high general self‐efficacy, and high perceived stress was significantly associated with high scores on neuroticism and openness to experience. Non–healthcare professionals were less likely to report symptoms of posttraumatic stress disorder.

Conclusions

Citizen responders who participated in resuscitation reported low levels of psychological distress. Individual differences were significantly associated with levels of psychological distress and should be considered when engaging citizen responders in resuscitation.

Activation of citizen responders to out-of-hospital cardiac arrest

PURPOSE OF REVIEW

To discuss different approaches to citizen responder activation and possible future solutions for improved citizen engagement in out-of-hospital cardiac arrest (OHCA) resuscitation.

RECENT FINDINGS

Activating volunteer citizens to OHCA has the potential to improve OHCA survival by increasing bystander cardiopulmonary resuscitation (CPR) and early defibrillation. Accordingly, citizen responder systems have become widespread in numerous countries despite very limited evidence of their effect on survival or cost-effectiveness. To date, only one randomized trial has investigated the effect of citizen responder activation for which the outcome was bystander CPR. Recent publications are of observational nature with high risk of bias. A scoping review published in 2020 provided an overview of available citizen responder systems and their differences in who, when, and how to activate volunteer citizens. These differences are further discussed in this review.

SUMMARY

Implementation of citizen responder programs holds the potential to improve bystander intervention in OHCA, with advancing technology offering new improvement possibilities. Information on how to best activate citizen responders as well as the effect on survival following OHCA is warranted to evaluate the cost-effectiveness of citizen responder programs.

Transportation during and after cardiac arrest: who, when, how and where?

PURPOSE OF REVIEW

Out-of-hospital cardiac arrest (OHCA) is the most devastating and time-critical medical emergency. Survival after OHCA requires an integrated system of care, of which transport by emergency medical services is an integral component. The transport system serves to commence and ensure uninterrupted high-quality resuscitation in suitable patients who would benefit, terminate resuscitation in those that do not, provide critical interventions, as well as convey patients to the next appropriate venue of care. We review recent evidence surrounding contemporary issues in the transport of OHCA, relating to who, where, when and how to transport these patients.

RECENT FINDINGS

We examine the clinical and systems-related evidence behind issues including: contemporary approaches to field termination of resuscitation in patients in whom continued resuscitation and transport to hospital would be medically futile, OHCA patients and organ donation, on-scene versus intra-transport resuscitation, significance of response time, intra-transport interventions (mechanical chest compression, targeted temperature management, ECMO-facilitated cardiopulmonary resuscitation), OHCA in high-rise locations and cardiac arrest centers. We highlight gaps in current knowledge and areas of active research.

SUMMARY

There remains limited evidence to guide some decisions in transporting the OHCA patient. Evidence is urgently needed to elucidate the roles of cardiac arrest centers and ECPR in OHCA.

General practice and cardiac arrest community first response in Ireland

Background

In Ireland, the MERIT 3 scheme enables doctors to volunteer as cardiac arrest community first responders and receive text message alerts from emergency medical services (EMS) to facilitate early care.

Aim

To establish the sustainability, systems and clinical outcomes of a novel, general practice based, cardiac arrest first response initiative over a four-year period.

Methods

Data on alerts, responses, incidents and outcomes were gathered prospectively using EMS control data, incident data reported by responders and corroborative data from the national Out-of-Hospital Cardiac Arrest Registry.

Results

Over the period 2016–2019, 196 doctors joined MERIT 3 and 163 (83.2%) were alerted on one or more occasions; 61.3% of those alerted responded to at least one alert. Volunteer doctors attended 300 patients of which 184 (61.3%) had suffered OHCA and had a resuscitation attempt. Responders arrived to OHCA before EMS on 75 occasions (40.8%), initiated chest compressions on seven occasions (3.8%), and brought the first defibrillator on 42 occasions (22.8%). Information on the first monitored rhythm was available for 149/184 (81.0%) patients and was shockable in 30/149 (20.1%); in 9/30 cases, shocks were administered by responders. The overall survival rate was 11.0% (national survival rate 7.3%). Doctors also provided advanced life support and were closely involved in decision making on ceasing resuscitation.

Conclusion

The MERIT 3 initiative in Ireland has been sustained over a four-year period and has demonstrated the ability of volunteer doctors to provide early care for OHCA patients as well as more complex interventions including end-of-life care. Further development of this strategy is warranted.

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.

European Resuscitation Council Guidelines 2021: Epidemiology of cardiac arrest in Europe

In this section of the European Resuscitation Council Guidelines 2021, key information on the epidemiology and outcome of in and out of hospital cardiac arrest are presented. Key contributions from the European Registry of Cardiac Arrest (EuReCa) collaboration are highlighted. Recommendations are presented to enable health systems to develop registries as a platform for quality improvement and to inform health system planning and responses to cardiac arrest.

Management of first responder programmes for out-of-hospital cardiac arrest during the COVID-19 pandemic in Europe

AIM

First responder (FR) programmes dispatch professional FRs (police and/or firefighters) or citizen responders to perform cardiopulmonary resuscitation (CPR) and use automated external defibrillators (AED) in out-of-hospital cardiac arrest (OHCA). We aimed to describe management of FR-programmes across Europe in response to the Coronavirus Disease 2019 (COVID-19) pandemic.

METHODS

In June 2020, we conducted a cross-sectional survey sent to OHCA registry representatives in 18 European countries with active FR-programmes. The survey was administered by e-mail and included questions regarding management of both citizen responder and FR-programmes. A follow-up question was conducted in October 2020 assessing management during a potential "second wave" of COVID-19.

RESULTS

All representatives responded (response rate = 100%). Fourteen regions dispatched citizen responders and 17 regions dispatched professional FRs (9 regions dispatched both). Responses were post-hoc divided into three categories: FR activation continued unchanged, FR activation continued with restrictions, or FR activation temporarily paused. For citizen responders, regions either temporarily paused activation (n = 7, 50.0%) or continued activation with restrictions (n = 7, 50.0%). The most common restriction was to omit rescue breaths and perform compression-only CPR. For professional FRs, nine regions continued activation with restrictions (52.9%) and five regions (29.4%) continued activation unchanged, but with personal protective equipment available for the professional FRs. In three regions (17.6%), activation of professional FRs temporarily paused.

CONCLUSION

Most regions changed management of FR-programmes in response to the COVID-19 pandemic. Studies are needed to investigate the consequences of pausing or restricting FR-programmes for bystander CPR and AED use, and how this may impact patient outcome.

Smartphone-based dispatch of community first responders to out-of-hospital cardiac arrest - statements from an international consensus conference

Background

Over the past decade Smartphone-based activation (SBA) of Community First Responders (CFR) to out-of-hospital cardiac arrests (OHCA) has gained much attention and popularity throughout Europe. Various programmes have been established, and interestingly there are considerable differences in technology, responder spectrum and the degree of integration into the prehospital emergency services. It is unclear whether these dissimilarities affect outcome. This paper reviews the current state in five European countries, reveals similarities and controversies, and presents consensus statements generated in an international conference with the intention to support public decision making on future strategies for SBA of CFR.

Methods

In a consensus conference a three-step approach was used: (i) presentation of current research from five European countries; (ii) workshops discussing evidence amongst the audience to generate consensus statements; (iii) anonymous real-time voting applying the modified RAND-UCLA Appropriateness method to adopt or reject the statements. The consensus panel aimed to represent all stakeholders involved in this topic.

Results

While 21 of 25 generated statements gained approval, consensus was only found for 5 of them. One statement was rejected but without consensus. Members of the consensus conference confirmed that CFR save lives. They further acknowledged the crucial role of emergency medical control centres and called for nationwide strategies.

Conclusions

Members of the consensus conference acknowledged that smartphone-based activation of CFR to OHCA saves lives. The statements generated by the consensus conference may assist the public, healthcare services and governments to utilise these systems to their full potential, and direct the research community towards fields that still need to be addressed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00841-1.

European first responder systems and differences in return of spontaneous circulation and survival after out-of-hospital cardiac arrest: A study of registry cohorts

BACKGROUND

In Europe, survival-rates after out-of-hospital cardiac arrest (OHCA) vary widely between regions. Whether a system dispatching First Responders (FRs; main FR-types: firefighters, police officers, citizen-responders) is present or not may be associated with survival-rates. This study aimed to assess the association between having a dispatched FR-system and rates of return of spontaneous circulation (ROSC) and survival across Europe.

METHODS

Results of an inventory of dispatched FR-systems for OHCA in Europe were combined with aggregate ROSC and survival data from the EuReCa-TWO study and additionally collected data. Regression analysis (weighted on number of patients included per region) was performed to study the association between having a dispatched FR-system and ROSC and survival-rates to hospital discharge in the total population and in patients with shockable initial rhythm, witnessed OHCA and bystander cardiopulmonary resuscitation (CPR; Utstein comparator group). For regions without a dispatched FR-system, the theoretical survival-rate if a dispatched FR-system would have existed was estimated.

FINDINGS

We included 27 European regions. There were 15,859 OHCAs in the total group and 2,326 OHCAs in the Utstein comparator group. Aggregate ROSC and survival-rates were significantly higher in regions with an FR-system compared to regions without (ROSC: 36% [95%CI 35%-37%] vs. 24% [95%CI 23%-25%]; P<0.001; survival in total population [N=15.859]: 13% [95%CI 12%-15%] vs. 5% [95%CI 4%-6%]; P<0.001; survival in Utstein comparator group [N=2326]: 33% [95%CI 30%-36%] vs. 18% [95%CI 16%-20%]; P<0.001), and in regions with more than one FR-type compared to regions with only one FR-type. All main FR-types were associated with higher survival-rates (all P<0.050).

INTERPRETATION

European regions with dispatched FRs showed higher ROSC and survival-rates than regions without.

FUNDING

This project/work has received funding from the European Union's Horizon 2020 research and innovation programme under acronym ESCAPE-NET, registered under grant agreement No 733381 (IO, HLT and MTB) and the European Union's COST programme under acronym PARQ, registered under grant agreement No CA19137 (IO, DC, HLT, MTB). HLT and MTB were supported by a grant from the Netherlands CardioVascular Research Initiative, Dutch Heart Foundation, Dutch Federation of University Medical Centres, Netherlands Organization for Health Research and Development, Royal Netherlands Academy of Sciences - CVON2017-15 RESCUED (HLT), and CVON2018-30 Predict2 (HLT and MTB).

Knowledge and attitudes to cardiopulmonary resuscitation (CPR)- a cross-sectional population survey in Sweden

Aim of the study

Rates of bystander CPR are increasing, yet mortality after out-of-hospital cardiac arrest (OHCA) remains high. The aim of this survey was to explore public knowledge and attitudes to CPR. Our hypotheses were that recent CPR training (< 5 years) would be associated with a high-quality response in a case vignette of OHCA with agonal breathing, and associated with an interest to become a smartphone app responder in suspected OHCA.

Methods

Data were collected through a web survey. Respondents (≥18 years) in Skåne County, Sweden were members of a panel created by a market research company. Data were weighted with respect to gender, age, municipalities and level of education to increase generalisability to the general population.

Results

A total of 1060 eligible answers were analysed. Seventy-six percent of non-healthcare professionals (n = 912) had participated in a CPR course at some time in life, 58 percent during the previous five years. The recommended CPR algorithm was known by 57 percent, whereas knowledge of the location of the nearest automated external defibrillator (AED) in a home environment was poor. Recent CPR training (< 5 years) did not favour high-quality response in a case vignette of OHCA with agonal breathing, but was one predictor of wanting to become a smartphone app responder.

Conclusion

This study highlights possible areas of improvement in CPR training, which might improve OHCA identification and facilitate knowledge retention. The potential to recruit smartphone app responders seems promising in certain groups.

Description of Emergency Medical Services, treatment of cardiac arrest patients and cardiac arrest registries in Europe

Background

Variation in the incidence, survival rate and factors associated with survival after cardiac arrest in Europe is reported. Some studies have tried to fill the knowledge gap regarding the epidemiology of out-of-hospital cardiac arrest in Europe but were unable to identify reasons for the reported differences. Therefore, the purpose of this study was to describe European Emergency Medical Systems, particularly from the perspective of country and ambulance service characteristics, cardiac arrest identification, dispatch, treatment, and monitoring.

Methods

An online questionnaire with 51 questions about ambulance and dispatch characteristics, on-scene management of cardiac arrest and the availability and dataset in cardiac arrest registries, was sent to all national coordinators who participated in the European Registry of Cardiac Arrest studies. In addition, individual invitations were sent to the remaining European countries.

Results

Participants from 28 European countries responded to the questionnaire. Results were combined with official information on population density. Overall, the number of Emergency Medical Service missions, level of training of personnel, availability of Helicopter Emergency Medical Services and the involvement of first responders varied across and within countries. There were similarities in team training, availability of key resuscitation equipment and permission for ongoing performance of cardiopulmonary resuscitation during transported. The quality of reporting to cardiac arrest registries varied, as well as the data availability in the registries.

Conclusions

Throughout Europe there are important differences in Emergency Medical Service systems and the response to out-of-hospital cardiac arrest. Explaining these differences is complicated due to significant variation in how variables are reported to and used in registries.