Informing Utstein-style reporting guidelines for prehospital thrombolysis: A scoping review

BACKGROUND

Rural Australians with acute myocardial infarction (AMI) face higher mortality rates due to limited access to specialised cardiac services. Paramedic-administered prehospital thrombolysis (PHT) has emerged as an alternative to primary percutaneous intervention (pPCI) for patients facing barriers or delays to cardiac care. There is variability in PHT practices among Australian ambulance services, lacking standardised definitions and outcome measures. The aim of this scoping review was to identify quality indicators and influencing factors associated with outcomes for patients receiving PHT.

METHODS

A systematic search of literature in SCOPUS and Academic Search Complete, CINAHL and Health Source: Nursing/Academic Edition databases via EBSCO (Health) was conducted following the Joanna Briggs Institute methodology. Peer-reviewed studies from the past decade were screened using search criteria relevant to prehospital thrombolysis and quality indicators. Data extraction was performed and themed using five domains from the Utstein-style template commonly known for standardised prehospital cardiac arrest reporting.

RESULTS

After removing duplicates, the search yielded 3596 articles with 28 empirical studies meeting inclusion criteria for the review. These were primarily retrospective cohort studies performed in Australia, Canada and the United States. The scoping review identified 24 clinical quality indicators and factors related to Emergency Medical Service (EMS) systems, AMI recognition and ambulance dispatch, patient variables, PHT processes and patient outcomes. These findings correlate to the Donabedian structure-process-outcome quality of care model and have utility to inform future PHT reporting guidelines for jurisdictional ambulance services.

CONCLUSIONS

Given the variability in prehospital practice across Australian ambulance services, standardised reporting on quality indicators for PHT is needed. The Utstein-style template used to report data on pre-hospital cardiac arrest, trauma and airway management could be used for quality improvement in PHT. This review presents 24 quality indicators representing system, recognition and response, patient, process, and outcomes related to PHT. These results could be used to inform a future Delphi study and Utstein-like reporting guideline for prehospital thrombolysis.

Validation of Utstein-Based score to predict return of spontaneous circulation (UB-ROSC) in patients with out-of-hospital cardiac arrest

BACKGROUND AND AIMS

The Utstein Based-ROSC (UB-ROSC) score has been developed to predict ROSC in OHCA victims. Aim of the study was to validate the UB-ROSC score using two Utstein-based OHCA registries: the SWiss REgistry of Cardiac Arrest (SWISSRECA) and the Lombardia Cardiac Arrest Registry (Lombardia CARe), northern Italy.

METHODS

Consecutive patients with OHCA of any etiology occurring between January 1st, 2019 and December 31st 2021 were included in this retrospective validation study. UB-ROSC score was computed for each patient and categorized in one of three subgroups: low, medium or high likelihood of ROSC according to the UB-ROSC cut-offs (≤-19; -18 to 12; ≥13). To assess the performance of the UB-ROSC score in this new cohort, we assessed both discrimination and calibration. The score was plotted against the survival to hospital admission.

RESULTS

A total of 12.577 patients were included in the study. A sustained ROSC was obtained in 2.719 patients (22%). The UB-ROSC model resulted well calibrated and showed a good discrimination (AUC 0.71, 95% CI 0.70-0.72). In the low likelihood subgroup of UB-ROSC, only 10% of patients achieved ROSC, whereas the proportion raised to 36% for a score between -18 and 12 (OR 5.0, 95% CI 2.9-8.6, p < 0.001) and to 85% for a score ≥13 (OR 49.4, 95% CI 14.3-170.6, p < 0.001).

CONCLUSIONS

UB-ROSC score represents a reliable tool to predict ROSC probability in OHCA patients. Its application may help the medical decision-making process, providing a realistic stratification of the probability for ROSC.

Resuscitation of out-of-hospital cardiac arrest in China: A systematic review and Utstein-style data analysis based on the Chain of Survival

AIM

Out-of-hospital cardiac arrest (OHCA) contributes to substantial mortality, but its resuscitation status in China is unknown. We aimed to describe and analyze out-of-hospital cardiac arrest in terms of Chain of Survival.

METHODS

We systematically collected Utstein-style publications. Scenarios were prespecified, including either emergency medical service (EMS) assessing and attending cardiac arrest, resuscitation attempted by a bystander, resuscitation attempted by EMS, or in-hospital treatment. Random-effect models were used in a meta-analysis to pool rate ratios (RRs) with 95% confidence intervals (CIs) from multiple cohorts.

RESULTS

We analyzed 59 Chains involving 233,376 Chinese patients. The median rate of survival to discharge (interquartile range) was 0.35 % (0.06 %-0.61 %), 3.66 % (3.06 %-3.85 %), 1.23 % (0.57%-1.36%), and 2.73% (2.04%-3.42%) for four scenarios. The rate was significantly higher for bystander resuscitation than for EMS (P = 0.025) or in-hospital treatment (P = 0.301). However, only 4.8 % (1.6 %-8.2 %) of patients received bystander resuscitation, with no bystander defibrillation and a median response time of 9-15 minutes for EMS. Compared with controls without witnesses, arrest being witnessed and with bystander resuscitation increased rates of survival to discharge by 1.97 (I2 = 0, P for I2 = 0.583; pooled RR 2.97; 95% CI 1.47-6.02) and 6.79 (I2 = 0, P for I2 = 0.593; pooled RR 7.79; 95 % CI 3.40-17.84) times, following a markedly increasing trend.

CONCLUSIONS

A low probability of first aid at multiple points is linked to poor survival following OHCA. It is essential to strengthen front links in the Chain of Survival in China, including among witnesses, bystanders, and emergency response.

Short- and long-term survival after out-of-hospital cardiac arrest in Kaunas (Lithuania) from 2016 to 2018

BACKGROUND

No studies analysing out-of-hospital cardiac arrest (OHCA) epidemiology and outcomes in Lithuania were published in the last decade.

METHODS

We conducted a retrospective analysis of prospectively collected data. The incidence of OHCA and the demographics and outcomes of patients who were treated for OHCA between 1 and 2016 and 31 December 2018 at Kaunas Emergency Medical Service (EMS) were collected and are reported in accordance with the Utstein recommendations. Multivariable logistic regression analysis was used to identify predictors of survival to hospital discharge.

RESULTS

In total, 838 OHCA cases of EMS-treated cardiac arrest (CA) were reported (95.8 per 100.000 inhabitants). The median age was 71 (IQR 58-81) years of age, and 66.7% of patients were males. A total of 73.8% of OHCA cases occurred at home, 59.3% were witnessed by a bystander, and 54.5% received bystander cardiopulmonary resuscitation. The median EMS response time was 10 min. Cardiac aetiology was the leading cause of CA (78.8%). The initial rhythm was shockable in 27.6% of all cases. Return of spontaneous circulation at hospital transfer was evident in 24.9% of all cases. The survival to hospital discharge rate was 10.9%, and the 1-year survival rate was 6.9%. The survival to hospital discharge rate in the Utstein comparator group was 36.1%, and the 1-year survival rate was 27.2%. Five factors were associated with improved survival to hospital discharge: shockable rhythm, time from call to arrival at the patient less than 10 min, witnessed OHCA, age < 80 years, and male sex.

CONCLUSION

This is the first OHCA study from Lithuania examining OHCA epidemiology and outcomes over a three year period. Routine OHCA data collection and analysis will allow us to track the efficacy of service improvements and should become a standard practice in all Lithuanian regions.

TRIAL REGISTRATION

This research was registered in the clinicaltrials.gov database: Identifiers: NCT04784117, Unique Protocol ID: LITOHCA. Brief Title: Out-of-hospital Cardiac Arrest Epidemiology and Outcomes in Kaunas 2016-2021.

Out of hospital cardiac arrest in Western Sydney-an analysis of outcomes and estimation of future eCPR eligibility

Background

Refractory out of hospital cardiac arrest (OHCA) is associated with extremely poor outcomes. However, in selected patients extracorporeal cardiopulmonary resuscitation (eCPR) may be an effective rescue therapy, allowing time treat reversible causes. The primary goal was to estimate the potential future caseload of eCPR at historically 'low-volume' extracorporeal membrane oxygenation (ECMO) centres.

Methods

A 3-year observational study of OHCA presenting to the Emergency Department (ED of an urban referral centre without historical protocolised use of eCPR. Demographics and standard Utstein outcomes are reported. Further, an a priori analysis of each case for potential eCPR eligibility was conducted. A current eCPR selection criteria (from the 2-CHEER study) was used to determine eligibly.

Results

In the study window 248 eligible cardiac arrest cases were included in the OHCA registry. 30-day survival was 23.4% (n = 58). The mean age of survivors was 55.4 years. 17 (6.8%) cases were deemed true refractory arrests and fulfilled the 2-CHEER eligibility criteria. The majority of these cases presented within “office hours” and no case obtained a return of spontaneous circulation standard advanced life support.

Conclusions

In this contemporary OHCA registry a significant number of refractory cases were deemed potential eCPR candidates reflecting a need for future interdisciplinary work to support delivery of this therapy.

Long-Term Outcome After Out-of-Hospital Cardiac Arrest: An Utstein-Based Analysis

Background: No data are available regarding long-term survival of out-of-hospital cardiac arrest (OHCA) patients based on different Utstein subgroups, which are expected to significantly differ in terms of survival. We aimed to provide the first long-term survival analysis of OHCA patients divided according to Utstein categories.

Methods: We analyzed all the 4,924 OHCA cases prospectively enrolled in the Lombardia Cardiac Arrest Registry (Lombardia CARe) from 2015 to 2019. Pre-hospital data, survival, and cerebral performance category score (CPC) at 1, 6, and 12 months and then every year up to 5 years after the event were analyzed for each patient.

Results: A decrease in survival was observed during the follow-up in all the Utstein categories. The risk of death of the “all-EMS treated” group exceeded the general population for all the years of follow-up with standardized mortality ratios (SMRs) of 23 (95%CI, 16.8–30.2), 6.8 (95%CI, 3.8–10.7), 3.8 (95%CI, 1.7–6.7), 4.05 (95%CI, 1.9–6.9), and 2.6 (95%CI, 1.03–4.8) from the first to the fifth year of follow-up. The risk of death was higher also for the Utstein categories “shockable bystander witnessed” and “shockable bystander CPR”: SMRs of 19.4 (95%CI, 11.3–29.8) and 19.4 (95%CI, 10.8–30.6) for the first year and of 6.8 (95%CI, 6.6–13) and 8.1 (95%CI, 3.1–15.3) for the second one, respectively. Similar results were observed considering the patients discharged with a CPC of 1–2.

Conclusions: The mortality of OHCA patients discharged alive from the hospital is higher than the Italian standard population, also considering those with the most favorable OHCA characteristics and those discharged with good neurological outcome. Long-term follow-up should be included in the next Utstein-style revision.

Utstein Style for emergency care - the first 30 years

BACKGROUND

Utstein Abbey near Stavanger in Norway, hosted a meeting in 1990 on guidelines for the uniform reporting of data from out-of-hospital cardiac arrest. In this paper we describe the last 30 years of the Utstein style.

METHODS

A systematic literature search identified publications from Utstein-style meetings or groups using the Utstein format.

RESULTS

30 outputs were found, describing primarily resuscitation structure, process and outcome measures. They originated from all over the world and from multiple medical disciplines. Some were co-published in multiple journals.

CONCLUSIONS

The meeting at Utstein Abbey in 1990 has had a sustained and far-reaching impact, particularly in resuscitation science, implementation and outcomes. The Utstein format will continue to evolve following the key principles from the original meeting and with the ultimate aim of improving patient care and outcomes.

International variation in survival after out-of-hospital cardiac arrest: A validation study of the Utstein template

INTRODUCTION

Out-of-hospital cardiac arrest (OHCA) survival varies greatly between communities. The Utstein template was developed and promulgated to improve the comparability of OHCA outcome reports, but it has undergone limited empiric validation. We sought to assess how much of the variation in OHCA survival between emergency medical services (EMS) across the globe is explained by differences in the Utstein factors. We also assessed how accurately the Utstein factors predict OHCA survival.

METHODS

We performed a retrospective analysis of patient-level prospectively collected data from 12 OHCA registries from 12 countries for the period 1 Jan 2006 through 31 Dec 2011. We used generalized linear mixed models to examine the variation in survival between EMS agencies (n=232).

RESULTS

Twelve registries contributed 86,759 cases. Patient arrest characteristics, EMS treatment and patient outcomes varied across registries. Overall survival to hospital discharge was 10% (range, 6% to 22%). Overall survival with Cerebral Performance Category of 1 or 2 (available for 8/12 registries) was 8% (range, 2% to 20%). The area-under-the-curve for the Utstein model was 0.85 (Wald CI: 0.85-0.85). The Utstein factors explained 51% of the EMS agency variation in OHCA survival.

CONCLUSIONS

The Utstein factors explained 51% of the variation in survival to hospital discharge among multiple large geographically separate EMS agencies. This suggests that quality improvement and public health efforts should continue to target modifiable Utstein factors to improve OHCA survival. Further study is required to identify the reasons for the variation that is incompletely understood.

Apples to apples: can differences in out-of-hospital cardiac arrest incidence and outcomes between Sweden and Ireland be explained by core Utstein variables?

BACKGROUND

Variation in reported incidence and outcome based on aggregated data is a persistent feature of out-of-hospital cardiac arrest (OHCA) epidemiology.

OBJECTIVE

To investigate the extent to which patient-level analysis using core 'Utstein' variables explains inter-country variation between Sweden and the Republic of Ireland.

METHODS

A retrospective cross-sectional comparative study was performed, including all Swedish and Irish OHCA cases attended by Emergency Medical Services (EMS-attended OHCA) where resuscitation was attempted from 1st January 2012 to 31st December 2014. Incidence rates per 100,000 population were adjusted for age and gender. Two subgroups were extracted: (1) Utstein - adult patients, bystander-witnessed collapse, presumed medical aetiology, initial shockable rhythm and (2) Emergency Medical Service (EMS)-witnessed events. Multivariable logistic regression analysis was used to identify predictors of survival following multiple imputations of data.

RESULTS

Five thousand eight hundred eighty six Irish and 15,303 Swedish patients were included. Swedish patients were older than Irish patients (median age 71 vs. 66 years respectively). Adjusted incidence was significantly higher in Sweden compared to the Republic of Ireland (52.9 vs. 43.1 per 100,000 population per year). Proportionate survival in Sweden was greater for both subgroups and all age categories. Regression analysis of the Utstein subgroup predicted approximately 17% of variation in outcome, but there was a large unexplained 'country effect' for survival in favour of Sweden (OR 4.40 (95% CI 2.55-7.56)).

CONCLUSIONS

Using patient level data, a proportion of inter-country variation was explained, but substantial variation was not explained by the core Utstein variables. Researchers and policy makers should be aware of the potential for unmeasured differences when comparing OHCA incidence and outcomes between countries.

Review of 14 drowning publications based on the Utstein style for drowning

BACKGROUND

The Utstein style for drowning (USFD) was published in 2003 with the aim of improving drowning research. To support a revision of the USFD, the current study aimed to generate an inventory of the use of the USFD parameters and compare the findings of the publications that have used the USFD.

METHODS

A search in Pubmed, Embase, the Cochrane Library, Web of Science and Scopus was performed to identify studies that used the USFD and were published between 01-10-2003 and 22-03-2015. We also searched in Pubmed, Embase, the Cochrane Library, Web of Science, and Scopus for all publications that cited the two publications containing the original ILCOR advisory statement introducing and recommending the USFD. In total we identified 14 publications by groups that explicitly used elements of the USFD for collecting and reporting their data.

RESULTS

Of the 22 core and 19 supplemental USFD parameters, 6-19 core (27-86%) and 1-12 (5-63%) supplemental parameters were used; two parameters (5%) have not been used in any publication. Associations with outcome were reported for nine core (41%) and five supplemental (26%) USFD parameters. The USFD publications also identified non-USFD parameters related to outcome: initial cardiac rhythm, time points and intervals during resuscitation, intubation at the drowning scene, first hospital core temperature, serum glucose and potassium, the use of inotropic/vasoactive agents and the Paediatric Index of Mortality 2-score.

CONCLUSIONS

Fourteen USFD based drowning publications have been identified. These publications provide valuable information about the process and quality of drowning resuscitation and confirm that the USFD is helpful for a structured comparison of the outcome of drowning resuscitation.

Medical versus non medical etiology in out-of-hospital cardiac arrest-Changes in outcome in relation to the revised Utstein template

INTRODUCTION

The Utstein-style recommendations for reporting etiology and outcome in out-of-hospital cardiac arrest (OHCA) from 2004 have recently been revised. Among other etiologies a medical category is now introduced, replacing the cardiac category from Utstein template 2004.

AIM

The aim of this study is to describe characteristics and temporal trends from reporting OHCA etiology according to the revised Utstein template 2014 in regards to patient characteristics and 30-day survival rates.

METHODS

This registry study is based on consecutive OHCA cases reported from the Emergency medical services (EMS) to the Swedish Registry of Cardiopulmonary Resuscitation (SRCR) 1992-2014. Characteristics, including a presumed cardiac etiology in Utstein template 2004, were transcribed to a medical etiology in Utstein template 2014.

RESULTS

Of a total of n=70,846 cases, 92% were categorized as having a medical etiology and 8% as having a non-medical cause. Using the new classifications, the 30-day survival rate has significantly increased over a 20-year period from 4.7% to 11.0% in the medical group and from 3% to 9.9% in the non-medical group (p≤0.001). Trauma was the most common cause in OHCA of a non-medical etiology (26%) with a 30-day survival rate of 3.4% whilst drowning and drug overdose had the highest survival rates (14% and 10% respectively).

CONCLUSION

Based on Utstein 2014 categories of etiology, overall survival after OHCA with a medical etiology has more than doubled in a 20-year period and tripled for non-medical cases. Patients with a medical etiology found in a shockable rhythm have the highest chance of survival. There is great variability in characteristics among non-medical cases.

Characterizing cardiac arrest in children undergoing cardiac surgery: A single-center study

OBJECTIVES

To characterize cardiac arrest in children undergoing cardiac surgery using single-center data from the Society of Thoracic Surgeons and Pediatric Advanced Life Support Utstein-Style Guidelines.

METHODS

Patients aged 18 years or less having a cardiac arrest for 1 minute or more during the same hospital stay as heart operation qualified for inclusion (2002-2014). Patients having a cardiac arrest both before or after heart operation were included. Heart operations were classified on the basis of the first cardiovascular operation of each hospital admission (the index operation). The primary outcome was survival to hospital discharge.

RESULTS

A total of 3437 children undergoing at least 1 heart operation were included. Overall rate of cardiac arrest among these patients was 4.5% (n = 154) with survival to hospital discharge of 84 patients (66.6%). Presurgery cardiac arrest was noted among 28 patients, with survival of 21 patients (75%). Among the 126 patients with postsurgery cardiac arrest, survival was noted among 84 patients (66.6%). Regardless of surgical case complexity, the median days between heart operation and cardiac arrest, duration of cardiac arrest, and survival after cardiac arrest were similar. The independent risk factors associated with improved chances of survival included shorter duration of cardiac arrest (odds ratio, 1.12; 95% confidence interval, 1.05-1.20; P = .01) and use of defibrillator (odds ratio, 4.51; 95% confidence interval, 1.08-18.87; P = .03).

CONCLUSIONS

This single-center study demonstrates that characterizing cardiac arrest in children undergoing cardiac surgery using definitions from 2 societies helps to increase data granularity and understand the relationship between cardiac arrest and heart operation in a better way.

Survival to Discharge After Cardiac Arrest Attended by a Doctor-Paramedic Helicopter Emergency Medical Service: An Utstein-style Multiservice Review of 1085 Activations

BACKGROUND

The presentation of outcomes after cardiac arrest presented by emergency medical service and in-hospital teams in the Utstein style allows for comparative analysis of populations and systems. Essex and Herts Air Ambulance Trust (EHAAT) and the East Anglian Air Ambulance (EAAA) are doctor-plus-paramedic prehospital care teams that respond to a large number of medical cardiac arrests.

OBJECTIVE

To report the outcomes of medical cardiac arrests according to the Utstein style.

METHODS

Retrospective database analysis and hospital follow-up of all cardiac arrests attended by either service over a 31-month period. Traumatic cardiac arrests were excluded.

PRIMARY OUTCOME

survival and cerebral performance category at discharge from the hospital.

RESULTS

There were 429 patients attended by the two services; 193 patients achieved return of spontaneous circulation, which was sustained at the time of handover to the hospital team. Of 140 patients for whom complete follow-up was available, the overall survival rate was 50.7%, 86% of whom had a Cerebral Performance Category of 1 or 2. The overall survival-to-discharge rate for all patients attended was 11.7%.

CONCLUSION

Benchmarking of performance is essential to understand reasons for variability, and to allow individual systems to reflect on their own practices. We have described 31 months of data that pertain to medical cardiac arrest cases attended by our services and demonstrated a comparable survival rate to discharge with good neurological outcome.

Cardiac arrest and cardiopulmonary resuscitation outcome reports: update of the Utstein Resuscitation Registry Templates for Out-of-Hospital Cardiac Arrest: a statement for healthcare professionals from a task force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian and New Zealand Council on Resuscitation, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, Resuscitation Council of Asia); and the American Heart Association Emergency Cardiovascular Care Committee and the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation

Utstein-style guidelines contribute to improved public health internationally by providing a structured framework with which to compare emergency medical services systems. Advances in resuscitation science, new insights into important predictors of outcome from out-of-hospital cardiac arrest, and lessons learned from methodological research prompted this review and update of the 2004 Utstein guidelines. Representatives of the International Liaison Committee on Resuscitation developed an updated Utstein reporting framework iteratively by meeting face to face, by teleconference, and by Web survey during 2012 through 2014. Herein are recommendations for reporting out-of-hospital cardiac arrest. Data elements were grouped by system factors, dispatch/recognition, patient variables, resuscitation/postresuscitation processes, and outcomes. Elements were classified as core or supplemental using a modified Delphi process primarily based on respondents' assessment of the evidence-based importance of capturing those elements, tempered by the challenges to collect them. New or modified elements reflected consensus on the need to account for emergency medical services system factors, increasing availability of automated external defibrillators, data collection processes, epidemiology trends, increasing use of dispatcher-assisted cardiopulmonary resuscitation, emerging field treatments, postresuscitation care, prognostication tools, and trends in organ recovery. A standard reporting template is recommended to promote standardized reporting. This template facilitates reporting of the bystander-witnessed, shockable rhythm as a measure of emergency medical services system efficacy and all emergency medical services system-treated arrests as a measure of system effectiveness. Several additional important subgroups are identified that enable an estimate of the specific contribution of rhythm and bystander actions that are key determinants of outcome.

Effects of epinephrine administration in out-of-hospital cardiac arrest based on a propensity analysis

BACKGROUND

Epinephrine administration has been advocated for cardiopulmonary resuscitation (CPR) for decades. Despite the fact that epinephrine administration during CPR is internationally accepted, the effects of the prehospital epinephrine administration still remain controversial. We investigated the effects of epinephrine administration on patients with out-of-hospital cardiac arrest based on a propensity analysis with regard to the 'CPR time'.

METHODS

From April 1, 2007, to December 31, 2009, 633 out-of-hospital cardiac arrest patients with bystander witnesses were included in the present study. To rule out any survival bias, we used the propensity scores, which included CPR time. CPR time was defined as the time span from when the emergency medical technicians started CPR until either the return of spontaneous circulation or arrival at the hospital. After performing propensity score matching, the epinephrine and no-drug groups each included 141 patients. The primary study endpoint was a favorable neurological outcome at 30 days after cardiac arrest.

RESULTS

After propensity score matching, the frequency of the return of spontaneous circulation before arrival at the hospital in the matched epinephrine group was higher than that in the matched no-drug group (27% vs. 13%, P = 0.002). However, the frequency of a favorable neurological state did not differ between the two groups. With regard to the frequency of a favorable neurological state in the patients, the adjusted odds ratio of the time span from cardiac arrest to the first epinephrine administration was 0.917 (95% confidence interval 0.850-0.988, P = 0.023) per minute.

CONCLUSIONS

In patients with witnessed out-of-hospital cardiac arrest, prehospital epinephrine administration was associated with increase of the return of spontaneous circulation before arrival at the hospital. Moreover, the early administration of epinephrine might improve the overall neurological outcome.