Factors Influencing Physician Decision Making to Attempt Advanced Resuscitation in Asystolic Out-of-Hospital Cardiac Arrest

Relatives' influence on the treatment of acutely critically ill patients in prehospital emergency medicine: a qualitative study of healthcare professionals' experiences and attitudes

BACKGROUND

Family presence during resuscitation is a growing topic in the field of prehospital emergency medicine. Emergency medicine service (EMS) providers interact with the relatives of acutely critically ill patients daily. Previous studies have found varying preferences towards family presence during resuscitation. Some EMS providers experience family presence affects patient treatment. The study aimed to gain insight into how EMS providers experience relatives of critically ill patients influence patient treatment.

METHODS

We used semi-structured individual interviews of specially trained paramedics and anaesthetists specialised in prehospital emergency medicine. A total of 11 interviews were conducted at a University Hospital in Copenhagen. Inductive qualitative contents analysis was used to analyse the data.

RESULTS

Relatives were defined as family, spouses, children, partners, close friends or colleagues, and, for some participants, more peripheral relationships such as schoolmates or acquaintances. We identified four themes, describing how EMS providers experience relatives' influence on patient treatment: 'supporting optimal patient treatment', 'futile resuscitation', 'negative impact on patient treatment', and 'the paediatric patient'.

CONCLUSIONS

Our study illustrates how EMS providers experience that treatment is influenced by relatives of acutely critically ill patients in the prehospital emergency medicine setting. Relatives can help or challenge treatment, and also influence EMS providers' clinical decision-making. Our findings can guide those working in prehospital emergency medicine towards utilising relatives of critically ill patients and increasing our understanding of how relatives can influence EMS providers' treatment and their clinical decision-making. Future studies should seek to quantify relatives' effect on treatment and investigate the clinical and ethical aspects of futile resuscitation.

Factors influencing prehospital physicians' decisions to initiate advanced resuscitation for asystolic out-of-hospital cardiac arrest patients

BACKGROUND

The decision to initiate or continue advanced life support (ALS) in out-of-hospital cardiac arrest (OHCA) could be difficult due to the lack of information and contextual elements, especially in non-shockable rhythms. This study aims to explore factors associated with clinicians' decision to initiate or continue ALS and the conditions associated with higher variability in asystolic patients.

METHODS

This retrospective observational study enrolled 2653 asystolic patients on whom either ALS was attempted or not by the emergency medical services (EMS) physician. A multivariable logistic regression analysis was performed to find the factors associated with the decision to access ALS. A subgroup analysis was performed on patients with a predicted probability of ALS between 35% and 65%. The single physicians' behaviour was compared to that predicted by the model taking into account the entire agency.

RESULTS

Age, location of event, bystander CPR and EMS-witnessed event were independent factors influencing physicians' choices about ALS. Non-medical OHCA, younger patients, less experienced physicians, presence of breath activity at the emergency call and a longer time for ALS arrival were more frequent among cases with an expected higher variability in behaviours with ALS. Significant variability was detected between physicians.

CONCLUSIONS

Significant inter-physician variability in access to ALS could be present within the same EMS, especially among less experienced physicians, non-medical OHCA and in presence of signs of life during emergency call. This arbitrariness has been observed and should be properly addressed by EMS team members as it raises ethical issues regarding the disparity in treatment.

External validation and insights about the calibration of the return of spontaneous circulation after cardiac arrest (RACA) score

Background

The return of spontaneous circulation (ROSC) after cardiac arrest (RACA) score was developed as a tool to predict ROSC probability (pROSC) based on easily available information and it could be useful to compare the performances of different EMS agencies or the effects of eventual interventions.

We performed an external validation of the RACA score in a cohort of out of hospital cardiac arrest (OHCA) patients managed by the EMS of the metropolitan city of Bologna, Italy.

Methods

We analyzed data from 2,310 OHCA events prospectively collected between January 2009 and June 2021. Discrimination was assessed with the area under the ROC curve (AUROC), while the calibration belts were used for the comparison of observed versus expected ROSC rates. The AUROCs from our cohort and other validation cohorts were compared using a studentized range test.

Results

The AUROC for the study population was 0.691, comparable to that described by previous validation studies. Despite an acceptable overall calibration, we found a poor calibration for asystole and low pROSC ranges in PEA and shockable rhythms. The model showed a good calibration for patients aged over 80, while no differences in performance were found when evaluating events before and after the implementation of 2015 ERC guidelines.

Conclusions

Despite AUROC values being similar in different validation studies for RACA score, we suggest separating the different rhythms when assessing ROSC probability with the RACA score, especially for asystole.