The Effects of Public Access Defibrillation on Survival After Out-of-Hospital Cardiac Arrest: A Systematic Review of Observational Studies

Current summary of the evidence in drone-based emergency medical services care

Interventions for many medical emergencies including cardiac arrests, strokes, drug overdoses, seizures, and trauma, are critically time-dependent, with faster intervention leading to improved patient outcomes. Consequently, a major focus of emergency medical services (EMS) systems and prehospital medicine has been improving the time until medical intervention in these time-sensitive emergencies, often by reducing the time required to deliver critical medical supplies to the scene of the emergency. Medical indications for using unmanned aerial vehicles, or drones, are rapidly expanding, including the delivery of time-sensitive medical supplies. To date, the drone-based delivery of a variety of time-critical medical supplies has been evaluated, generating promising data suggesting that drones can improve the time interval to intervention through the rapid delivery of automatic external defibrillators (AEDs), naloxone, antiepileptics, and blood products. Furthermore, the improvement in the time until intervention offered by drones in out-of-hospital emergencies is likely to improve patient outcomes in time-dependent medical emergencies. However, barriers and knowledge gaps remain that must be addressed. Further research demonstrating functionality in real-world scenarios, as well as research that integrates drones into the existing EMS structure will be necessary before drones can reach their full potential. The primary aim of this review is to summarize the current evidence in drone-based Emergency Medical Services Care to help identify future research directions.

Effect of a low-cost instruction card for automated external defibrillator operation in lay rescuers: a randomized simulation study

BACKGROUND

To evaluate whether a simplified self-instruction card can help potential rescue providers use automated external defibrillators (AEDs) more accurately and quickly.

METHODS

From June 1, 2018, to November 30, 2019, a prospective longitudinal randomized controlled simulation study was conducted among 165 laypeople (18-65 years old) without prior AED training. A self-instruction card was designed to illuminate key AED operation procedures. Subjects were randomly divided into the card (n=83) and control (n=82) groups with age stratification. They were then individually evaluated in the same simulated scenario to use AED with (card group) or without the self-instruction card (control group) at baseline, post-training, and at the 3-month follow-up.

RESULTS

At baseline, the card group reached a significantly higher proportion of successful defibrillation (31.1% vs. 15.9%, P=0.03), fully baring the chest (88.9% vs. 63.4%, P<0.001), correct electrode placement (32.5% vs. 17.1%, P=0.03), and resuming cardiopulmonary resuscitation (CPR) (72.3% vs. 9.8%, P<0.001). At post-training and follow-up, there were no significant differences in key behaviors, except for resuming CPR. Time to shock and time to resume CPR were shorter in the card group, while time to power-on AED was not different in each phase of tests. In the 55-65 years group, the card group achieved more skill improvements over the control group compared to the other age groups.

CONCLUSION

The self-instruction card could serve as a direction for first-time AED users and as a reminder for trained subjects. This could be a practical, cost-effective way to improve the AED skills of potential rescue providers among different age groups, including seniors.

Rapid-cycle deliberate practice versus after-event debriefing clinical simulation in cardiopulmonary resuscitation: a cluster randomized trial

INTRODUCTION

Rapid-cycle deliberate practice (RCDP) is a simulation-based educational strategy that consists of repeating a simulation scenario a number of times to acquire a planned competency. When the objective of a cycle is achieved, a new cycle initiates with increased skill complexity. There have been no previous randomized studies comparing after-event debriefing clinical manikin-based simulation to RCDP in adult cardiopulmonary resuscitation (CPR).

METHODS

We invited physicians from the post-graduate program on Emergency Medicine of the Hospital Israelita Albert Einstein. Groups were randomized 1:1 to RCDP or after-event debriefing simulation prior to the first station of CPR training. During the first 5 min of the pre-intervention scenario, both groups participated in a simulated case of an out-of-hospital cardiac arrest without facilitator interference; after the first 5 min, each scenario was then facilitated according to group allocation (RCDP or after-event debriefing). In a second scenario of CPR later in the day with the same participants, there was no facilitator intervention, and the planned outcomes were evaluated. The primary outcome was the chest compression fraction during CPR in the post-intervention scenario. Secondary outcomes comprised time for recognition of the cardiac arrest, time for first verbalization of the cardiac arrest initial rhythm, time for first defibrillation, and mean pre-defibrillation pause.

RESULTS

We analyzed data of three courses conducted between June 2018 and July 2019, with 76 participants divided into 9 teams. Each team had a median of 8 participants. In the post-intervention scenario, the RCDP teams had a significantly higher chest compression fraction than the after-event debriefing group (80.0% vs 63.6%; p = 0.036). The RCDP group also demonstrated a significantly lower time between recognition of the rhythm and defibrillation (6 vs 25 s; p value = 0.036).

CONCLUSION

RCDP simulation strategy is associated with significantly higher manikin chest compression fraction during CPR when compared to an after-event debriefing simulation.

[AED drones on the rise? : Use of drones to improve public access defibrillation]

BACKGROUND

The poor availability of automatic external defibrillators (AED) and the modest knowledge of lay persons in handling these devices has led to an insufficient spread of public access defibrillation in Germany.

OBJECTIVE

This article examines whether the automated deployment of AED drones to out-of-hospital cardiac arrest can help to remedy this situation.

METHODS

Narrative literature review, evaluation of statistics, analysis of relevant media reports, and discussion of key research.

RESULTS

The present investigations are mainly located in the experimental field and demonstrate the feasibility and safety of drone use, as well as shorter times to first defibrillation, which is confirmed by initial clinical studies. Mathematical models also indicate cost-effectiveness of airborne AED delivery compared to ground dispatch. Integration into the chain of survival appears to be possible but adaptations to existing emergency medical service structures and close cooperation with regional first responder and AED schemes as well as local authorities is required to optimise patient benefit and efficiency.

CONCLUSION

The use of AED drones could probably contribute to improving public access defibrillation in Germany. This applies to both rural and urban regions. The technological requirements are met but flight regulations still have to be amended. In order to explore the full potential of this novel technology, further field trials are required to achieve smooth integration into existing emergency medical services.

Sports-related sudden cardiac arrest in young adults

AIMS

Data on sports-related sudden cardiac arrest (SrSCA) among young adults in the general population are scarce. We aimed to determine the overall SrSCA incidence, characteristics, and outcomes in young adults.

METHODS AND RESULTS

Prospective cohort study of all cases of SrSCA between 2012 and 2019 in Germany and Paris area, France, involving subjects aged 18-35 years. Detection of SrSCA was achieved via multiple sources, including emergency medical services (EMS) reporting and web-based screening of media releases. Cases and aetiologies were centrally adjudicated. Overall, a total of 147 SrSCA (mean age 28.1 ± 4.8 years, 95.2% males) occurred, with an overall burden of 4.77 [95% confidence interval (CI) 2.85-6.68] cases per million-year, including 12 (8.2%) cases in young competitive athletes. While bystander cardiopulmonary resuscitation (CPR) was initiated in 114 (82.6%), automated external defibrillator (AED) use by bystanders occurred only in a minority (7.5%). Public AED use prior to EMS arrival (odds ratio 6.25, 95% CI 1.48-43.20, P = 0.02) was the strongest independent predictor of survival at hospital discharge (38.1%). Among cases that benefited from both immediate bystander CPR and AED use, survival rate was 90.9%. Coronary artery disease was the most frequent aetiology (25.8%), mainly through acute coronary syndrome (86.9%).

CONCLUSION

Sports-related sudden cardiac arrest in the young occurs mainly in recreational male sports participants. Public AED use remains disappointingly low, although survival may reach 90% among those who benefit from both bystander CPR and early defibrillation. Coronary artery disease is the most prevalent cause of SrSCA in young adults.

[The new 2021 resuscitation guidelines and the importance of lay resuscitation]

Lay resuscitation is one of the most important measures to increase the survival rate of patients after out-of-hospital cardiac arrest. While European countries, and especially Scandinavian countries, achieve lay resuscitation rates of over 80%, the rate in Germany is only around 40%. The 2021 Resuscitation Guidelines updated by the European Resuscitation Council give special weight to Systems Saving Lives and focus on resuscitation by laypersons. The Systems Saving Lives emphasize the interplay between all actors involved in the chain of survival and thereby specify the link between the emergency service and the general population.Based on the BIG FIVE survival strategies after cardiac arrest, five key strategies are outlined that can achieve the greatest improvement in survival. These are (1) increasing lay resuscitation rates through campaigns and KIDS SAVE LIVES school-based resuscitation training, (2) implementing telephone resuscitation in dispatch centers, (3) first responder systems, (4) advanced life support, and (5) specialized cardiac arrest centers.

The Role of Drones in Out-of-Hospital Cardiac Arrest: A Scoping Review

Drones may be able to deliver automated external defibrillators (AEDs) directly to bystanders of out-of-hospital cardiac arrest (OHCA) events, improving survival outcomes by facilitating early defibrillation. We aimed to provide an overview of the available literature on the role and impact of drones in AED delivery in OHCA. We conducted this scoping review using the PRISMA-ScR and Arksey and O'Malley framework, and systematically searched five bibliographical databases (Medline, EMBASE, Cochrane CENTRAL, PsychInfo and Scopus) from inception until 28 February 2022. After excluding duplicate articles, title/abstract screening followed by full text review was conducted by three independent authors. Data from the included articles were abstracted and analysed, with a focus on potential time savings of drone networks in delivering AEDs in OHCA, and factors that influence its implementation. Out of the 26 included studies, 23 conducted simulations or physical trials to optimise drone network configuration and evaluate time savings from drone delivery of AEDs, compared to the current emergency medical services (EMS), along with 1 prospective trial conducted in Sweden and 2 qualitative studies. Improvements in response times varied across the studies, with greater time savings in rural areas. However, emergency call to AED attachment time was not reduced in the sole prospective study and a South Korean study that accounted for weather and topography. With growing interest in drones and their potential use in AED delivery spurring new research in the field, our included studies demonstrate the potential advantages of unmanned aerial vehicle (UAV) network implementation in controlled environments to deliver AEDs faster than current EMS. However, for these time savings to translate to reduced times to defibrillation and improvement in OHCA outcomes, careful evaluation and addressing of real-world delays, challenges, and barriers to drone use in AED delivery is required.

Visual assessment of interactions among resuscitation activity factors in out-of-hospital cardiopulmonary arrest using a machine learning model

Aim

The evaluation of the effects of resuscitation activity factors on the outcome of out-of-hospital cardiopulmonary arrest (OHCA) requires consideration of the interactions among these factors. To improve OHCA success rates, this study assessed the prognostic interactions resulting from simultaneously modifying two prehospital factors using a trained machine learning model.

Methods

We enrolled 8274 OHCA patients resuscitated by emergency medical services (EMS) in Nara prefecture, Japan, with a unified activity protocol between January 2010 and December 2018; patients younger than 18 and those with noncardiogenic cardiopulmonary arrest were excluded. Next, a three-layer neural network model was constructed to predict the cerebral performance category score of 1 or 2 at one month based on 24 features of prehospital EMS activity. Using this model, we evaluated the prognostic impact of continuously and simultaneously varying the transport time and the defibrillation or drug-administration time in the test data based on heatmaps.

Results

The average class sensitivity of the prognostic model was more than 0.86, with a full area under the receiver operating characteristics curve of 0.94 (95% confidence interval of 0.92–0.96). By adjusting the two time factors simultaneously, a nonlinear interaction was obtained between the two adjustments, instead of a linear prediction of the outcome.

Conclusion

Modifications to the parameters using a machine-learning-based prognostic model indicated an interaction among the prognostic factors. These findings could be used to evaluate which factors should be prioritized to reduce time in the trained region of machine learning in order to improve EMS activities.

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.

•

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

•

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.

•

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

•

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

Lay rescuer use of automated external defibrillators in infants, children and adolescents: A systematic review

Importance

Automated external defibrillator (AED) use is increasing, but use in children is uncommon. A growing literature of use in children by lay rescuers warrants review.

Objective

A systematic review of AED effectiveness in children experiencing out-of-hospital cardiac arrest (OHCA).

Data Sources

PubMed, EMBASE, Cochrane Register of Controlled Trials.

Study Selection

Children, ages 0-18, experiencing OHCA with an AED applied by a lay rescuer. Control population: children with no AED application.

Data Extraction and Synthesis

Results are reported according to PRISMA guidelines. Two authors independently reviewed all titles and abstracts of references identified by the search strategy, then generated a subset which all authors reviewed.

Main Outcomes and Measures

Critical outcomes were survival with Cerebral Performance Category (CPC) 1-2 at hospital discharge or 30 days and survival to hospital discharge.

Results

Population: age categories: <1 year, 1-12 years, 13-18 years. Lay rescuer AED application resulted in improved survival with CPC 1-2 at hospital discharge or 30 days to hospital discharge in age groups 1-12 and 13-18 years (RR 3.84 [95 % CI 2.69-5.5], RR 3.75 [95 %CI 2.97-4.72]), respectively and hospital discharge in both groups(RR 3.04 [95 % CI 2.18-4.25], RR 3.38 [95 % CI 2.17-4.16]), respectively. AED use with CPR improved CPC 1-2 at hospital discharge and hospital discharge (RR 1.49 [95 % CI 1.11-1.97], RR 1.55[1.12-2.12]).

Conclusions

AED application by lay rescuers is associated with improved survival with a CPC of 1-2 at 30 days, and improved survival to hospital discharge for children 1-18 years. There are limited data for children < 1 year.

Evolution of European Resuscitation and End-of-Life Practices from 2015 to 2019: A Survey-Based Comparative Evaluation

BACKGROUND

In concordance with the results of large, observational studies, a 2015 European survey suggested variation in resuscitation/end-of-life practices and emergency care organization across 31 countries. The current survey-based study aimed to comparatively assess the evolution of practices from 2015 to 2019, especially in countries with "low" (i.e., average or lower) 2015 questionnaire domain scores.

METHODS

The 2015 questionnaire with additional consensus-based questions was used. The 2019 questionnaire covered practices/decisions related to end-of-life care (domain A); determinants of access to resuscitation/post-resuscitation care (domain B); diagnosis of death/organ donation (domain C); and emergency care organization (domain D). Responses from 25 countries were analyzed. Positive or negative responses were graded by 1 or 0, respectively. Domain scores were calculated by summation of practice-specific response grades.

RESULTS

Domain A and B scores for 2015 and 2019 were similar. Domain C score decreased by 1 point [95% confidence interval (CI): 1-3; p = 0.02]. Domain D score increased by 2.6 points (95% CI: 0.2-5.0; p = 0.035); this improvement was driven by countries with "low" 2015 domain D scores. In countries with "low" 2015 domain A scores, domain A score increased by 5.5 points (95% CI: 0.4-10.6; p = 0.047).

CONCLUSIONS

In 2019, improvements in emergency care organization and an increasing frequency of end-of-life practices were observed primarily in countries with previously "low" scores in the corresponding domains of the 2015 questionnaire.

Trends in maintenance status and usability of public automated external defibrillators during a 5-year on-site inspection

This study aimed to assess the trend of the maintenance status and usability of public automated external defibrillators (AEDs). Public AEDs installed in Seoul from 2013 to 2017 were included. An inspector checked the maintenance status and usability of the AEDs annually using a checklist. During the study period, 23,619 AEDs were inspected. Access to the AEDs was improved, including the absence of obstacles near the AEDs (from 90.2% in 2013 to 99.1% in 2017, p < 0.0001) and increased AED signs (from 34.3% in 2013 to 91.3% in 2017, p < 0.0001). The rate of AEDs in normal operation (from 94.0% in 2013 to 97.6% in 2017, p < 0.0001), good battery status (from 95.6% in 2013 to 96.8% in 2017, p = 0.0016), and electrode availability increased (from 97.1% in 2013 to 99.0% in 2017, p < 0.0001); the rate of electrode validity decreased (from 90.0% in 2013 to 87.2% in 2017, p < 0.0001). The overall rate of the non-ready-to-use AEDs and AEDs with less than 24-h usability accounted for 15.4% and 44.1% of the total number of AEDs, respectively. Although most AEDs had a relatively good maintenance status, a significant proportion of public AEDs were not available for 24-h use. Invalid electrodes and less than 24-h accessibility were the main reasons that limited the 24-h usability of public AEDs.

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.

Public Access Defibrillators and Socioeconomic Factors on the Small—Scale Spatial Level in Berlin

BACKGROUND

The use of a public access defibrillator (PAD) increases the probability of surviving an out-of-hospital cardiac arrest (OHCA). No strategies exist, however, for the optimal distribution of PADs in an urban area in order to meet existing needs and ensure equal access for all potential users. It thus seems likely that the accessibility of PADs on the spatial level varies widely as a function of living circumstances.

METHODS

This cross-sectional study is based on registry data concerning PAD (2022, n = 776) and OHCA (2018-2020, n = 4051), along with data on socioeconomic factors on the spatial level in Berlin (12 districts and 137 subdistricts). Associations of socioeconomic factors with the number of PADs per 10 000 inhabitants and the PAD coverage rate of sites of previous OHCAs were investigated.

RESULTS

The median number of PADs per 10 000 inhabitants ranged from 0.46 to 2.67 at the district level, and only five districts had a median PAD coverage rate of sites of previous OHCAs above 0%, after aggregation of the analyses at the subdistrict level. Subdistricts with a more favorable economic status and a greater income disparity had a higher PAD density. Socially disadvantaged subdistricts had no association with PAD density.

CONCLUSION

There are large deficits in the distribution of PADs at the small-scale spatial level in Berlin with respect to the goals of meeting existing needs and ensuring equal access for all potential users. The findings presented here will be of importance for the planning of future PAD programs so that the distributional efficiency and fairness of PAD in urban areas can be improved.

Optimizing Outcomes After Out-of-Hospital Cardiac Arrest With Innovative Approaches to Public-Access Defibrillation: A Scientific Statement From the International Liaison Committee on Resuscitation

Out-of-hospital cardiac arrest is a global public health issue experienced by ≈3.8 million people annually. Only 8% to 12% survive to hospital discharge. Early defibrillation of shockable rhythms is associated with improved survival, but ensuring timely access to defibrillators has been a significant challenge. To date, the development of public-access defibrillation programs, involving the deployment of automated external defibrillators into the public space, has been the main strategy to address this challenge. Public-access defibrillator programs have been associated with improved outcomes for out-of-hospital cardiac arrest; however, the devices are used in <3% of episodes of out-of-hospital cardiac arrest. This scientific statement was commissioned by the International Liaison Committee on Resuscitation with 3 objectives: (1) identify known barriers to public-access defibrillator use and early defibrillation, (2) discuss established and novel strategies to address those barriers, and (3) identify high-priority knowledge gaps for future research to address. The writing group undertook systematic searches of the literature to inform this statement. Innovative strategies were identified that relate to enhanced public outreach, behavior change approaches, optimization of static public-access defibrillator deployment and housing, evolved automated external defibrillator technology and functionality, improved integration of public-access defibrillation with existing emergency dispatch protocols, and exploration of novel automated external defibrillator delivery vectors. We provide evidence- and consensus-based policy suggestions to enhance public-access defibrillation and guidance for future research in this area.

Optimizing outcomes after out-of-hospital cardiac arrest with innovative approaches to public-access defibrillation: A scientific statement from the International Liaison Committee on Resuscitation

Out-of-hospital cardiac arrest is a global public health issue experienced by ≈3.8 million people annually. Only 8% to 12% survive to hospital discharge. Early defibrillation of shockable rhythms is associated with improved survival, but ensuring timely access to defibrillators has been a significant challenge. To date, the development of public-access defibrillation programs, involving the deployment of automated external defibrillators into the public space, has been the main strategy to address this challenge. Public-access defibrillator programs have been associated with improved outcomes for out-of-hospital cardiac arrest; however, the devices are used in <3% of episodes of out-of-hospital cardiac arrest. This scientific statement was commissioned by the International Liaison Committee on Resuscitation with 3 objectives: (1) identify known barriers to public-access defibrillator use and early defibrillation, (2) discuss established and novel strategies to address those barriers, and (3) identify high-priority knowledge gaps for future research to address. The writing group undertook systematic searches of the literature to inform this statement. Innovative strategies were identified that relate to enhanced public outreach, behavior change approaches, optimization of static public-access defibrillator deployment and housing, evolved automated external defibrillator technology and functionality, improved integration of public-access defibrillation with existing emergency dispatch protocols, and exploration of novel automated external defibrillator delivery vectors. We provide evidence- and consensus-based policy suggestions to enhance public-access defibrillation and guidance for future research in this area.

Timing and Identification of the Cause and Treatment of a Cardiac Arrest: A Potential Survival Benefit

OBJECTIVE

The aim of this study was to evaluate how mobile medical teams (MMTs) search for the etiology of a cardiac arrest (CA) and to investigate the association between the discovery of etiology and patient outcome.

SUBJECTS AND METHODS

Resuscitations of all adult patients who experienced an in- or out-of-hospital CA between 2016 and 2018 were video recorded. All video recordings were reviewed. The time to start of "cause analysis" and time to treatment by the MMT were analyzed. Also, investigations performed during etiologic evaluation were examined: heteroanamnesis, medical history-taking, clinical examinations, technical investigations, and the use of the 4Hs and 4Ts method.

RESULTS

Of the 139 CA events included in this study, the MMTs performed etiologic evaluation in only 75% of the resuscitations, and in 20% of the evaluations, they did not use the recommended 4Hs and 4Ts method. Medical history-taking and heteroanamnesis were performed in the large majority, but often without clear cause. A presumptive etiology was found in 46.8% of out-of-hospital CAs and 65.2% of in-hospital CAs. A significant association was found between return of spontaneous circulation and the discovery of presumable etiology for out-of-hospital CAs (p < 0.001). The median time to treatment was 492 s (recommended: 130-250 s) for nonshockable rhythms and 422 s (recommended: 270-390 s) for shockable rhythms, up to twice the time advised according to the guidelines.

CONCLUSION

The current approach for etiologic evaluation is not ideal. Further research is needed to establish a more structured and simplified approach.

Accessibilité aux soins en situation d’urgence : des déterminants complexes, un besoin d’outils novateurs

Les délais d’accès aux soins sont directement associés au pronostic de nombreuses situations et pathologies urgentes telles que l’arrêt cardiaque extrahospitalier, l’accident vasculaire cérébral, l’infarctus du myocarde ou le traumatisme grave. Ils représentent ainsi un critère de qualité et d’efficacité du système préhospitalier. Or, les déterminants de l’accessibilité aux soins urgents, donc des délais de prise en charge préhospitalière jusqu’au soin définitif, sont multiples, intriquant notamment des dimensions organisationnelles, géographiques et socioéconomiques, captées par différentes définitions de l’accessibilité aux soins. La mesure de l’accessibilité aux soins urgents est donc complexe et nécessite l’emploi de méthodes spécifiques. Ses déterminants sont sujets à d’importantes disparités territoriales, tant sur le plan national que local, qui conduisent à de fortes inégalités de santé en situation urgente. L’organisation du système de soins préhospitaliers doit ainsi prendre en compte l’ensemble des définitions de l’accessibilité en vie réelle, afin de répondre à des objectifs de performance ajustés aux enjeux particuliers des pathologies traceuses les plus urgentes. Les prochaines évolutions organisationnelles et technologiques en médecine d’urgence devraient permettre de mieux appréhender les déterminants de l’accessibilité à toutes les phases de la prise en charge préhospitalière, vers un rééquilibrage de l’inadéquation entre les besoins réels et l’offre possible de soins urgents.

Association between nationwide introduction of public-access defibrillation and sudden cardiac death in Japan: An interrupted time-series analysis

BACKGROUND

The effectiveness of public-use of automated external defibrillators in reducing the number of sudden cardiac death (SCD) cases at the national level is largely unknown. Our study aimed to evaluate whether the nationwide introduction of public-access-defibrillation (PAD) in 2004 affected the trend of annual sudden cardiac death (SCD) rates in Japan.

METHODS

The number of nationwide SCDs occurring in people aged five years and older was extracted from Japanese demographic statistics (1995-2015). Segmented regression analysis was performed on the interrupted time series data stratified by age and sex to evaluate changes in trends of rates of annual SCDs after the PAD introduction in Japan.

RESULTS

After the PAD introduction in 2004, we observed a significant decrease in trends of annual SCD rates for those aged 5-19 years (the ratio of trends between pre and post PAD introduction (RT) = 0.886, 95%CI: 0.801 to 0.980), 20-34 years (RT = 0.932; 95%CI: 0.906, 0.958), 35-49 years (RT = 0.953; 95%CI: 0.929, 0.977) and 50-64 years (RT = 0.971; 95%CI: 0.971, 0.991). However, the decrease was not observed for those aged 65 years and older. In the age and sex stratified analysis, there was a significant decrease in RT among males aged 5-64 years, and among females 35-49 years.

CONCLUSION

The nationwide trend of annual rate of SCDs between 5 and 64 years old significantly decreased after the introduction of PAD in 2004 in Japan. Further, the reduction was more evident in males.

Maximum expected survival rate model for public access defibrillator placement

AIM

Mathematical optimization of automated external defibrillator (AED) placement has demonstrated potential to improve survival of out-of-hospital cardiac arrest (OHCA). Existing models mostly aim to improve accessibility based on coverage radius and do not account for detailed impact of delayed defibrillation on survival. We aimed to predict OHCA survival based on time to defibrillation and developed an AED placement model to directly maximize the expected survival rate.

METHODS

We stratified OHCAs occurring in Singapore (2010-2017) based on time to defibrillation and developed a regression model to predict the Utstein survival rate. We then developed a novel AED placement model, the maximum expected survival rate (MESR) model. We compared the performance of MESR with a maximum coverage model developed for Canada that was shown to be generalizable to other settings (Denmark). The survival gain of MESR was assessed through 10-fold cross-validation for placement of 20 to 1000 new AEDs in Singapore. Statistical analysis was performed using χ² and McNemar's tests.

RESULTS

During the study period, 15,345 OHCAs occurred. The power-law approximation with R² of 91.33% performed best among investigated models. It predicted a survival of 54.9% with defibrillation within the first two minutes after collapse that was reduced by more than 60% without defibrillation within the first 4 minutes. MESR outperformed the maximum coverage model with P-value < 0.05 (<0.0001 in 22 of 30 experiments).

CONCLUSION

We developed a novel AED placement model based on the impact of time to defibrillation on OHCA outcomes. Mathematical optimization can improve OHCA survival.

Analysis of the Way and Correctness of Using Automated External Defibrillators Placed in Public Space in Polish Cities-Continuation of Research

Immediate resuscitation is required for any sudden cardiac arrest. To improve the survival of the patient, a device to be operated by witnesses of the event-automated external defibrillator (AED)-has been produced. The aim of this study is to analyze the way and correctness of use of automated external defibrillators placed in public spaces in Polish cities. The data analyzed (using Excel 2019 and R 3.5.3 software) are 120 cases of use of automated external defibrillators, placed in public spaces in the territory of Poland in 2008-2018. The predominant location of AED use is in public transportation facilities, and the injured party is the traveler. AED use in non-hospital settings is more common in male victims aged 50-60 years. Owners of AEDs inadequately provide information about their use. The documentation that forms the basis of the emergency medical services intervention needs to be refined. There is no mention of resuscitation performed by a witness of an event or of the use of an AED. In addition, Poland lacks the legal basis for maintaining a register of automated external defibrillators. There is a need to develop appropriate documents to determine the process of reporting by the owners of the use of AEDs in out-of-hospital conditions (OHCA).

Development of a Performance Assessment Scale for Simulated Dispatcher-Assisted Cardiopulmonary Resuscitation (Telephone-CPR): A Multi-Center Randomized Simulation-Based Clinical Trial

INTRODUCTION

Dispatchers should be trained to interrogate bystanders with strict protocols to elicit information focused on recognizing cardiac arrest and should provide telephone cardiopulmonary resuscitation (CPR) instructions in all cases of suspected cardiac arrest. While an objective assessment of training outcomes is needed, there is no performance assessment scale for simulated dispatcher-assisted CPR.

STUDY OBJECTIVE

The aim of the study was to create a valid and reliable performance assessment scale for simulated dispatcher-assisted CPR.

METHODS

In this prospective, randomized, controlled, multi-centric simulation-based trial (registration number TCTR20210130002), the scale was developed according to the European Resuscitation Council (ERC) and American Heart Association (AHA) Guidelines 2015 and revised by experts. The performance of 48 dispatchers' telephone-CPR and of 48 bystanders carrying out CPR on a manikin was assessed by two independent evaluators using the scale and using a SkillReporter (PC) software to provide CPR objective performance. Continuous variables were described as mean (SD) and categorical variables as numbers and percentage (%). Comparative analysis between two groups used a Student t-test or a non-parametric test of Mann-Whitney. The internal structure of the scale was evaluated, including internal consistency using α Cronbach coefficient, and reproducibility using intraclass correlation coefficient (ICC) and linear correlation coefficient (R2) calculation.

RESULTS

The scale included three different parts: two sections for dispatchers' (32 items) and bystanders' CPR performance (15 items) assessment, and a third part recording times. There was excellent internal consistency (α Cronbach coefficient = 0.77) and reproducibility (ICC = 0.93; R² = 0.86). For dispatchers' performance assessment, α Cronbach coefficient = 0.76; ICC = 0.91; R2 = 0.84. For bystanders' performance assessment, α Cronbach coefficient = 0.75; ICC = 0.93; R2 = 0.87. Reproducibility was excellent for nine items, good for 19 items, and moderate for 19 items. No item had poor reproducibility. There was no significant difference between dispatch doctors' and medical dispatch assistants' performances (33.0 [SD = 4.7] versus 32.3 [SD = 3.2] out of 52, respectively; P = .70) or between trained and untrained bystanders to follow the instructions (14.3 [SD = 2.0] versus 13.9 [SD = 1.8], respectively; P = .64). Objective performance (%) was significantly higher for trained bystanders than for untrained bystanders (67.4 [SD = 14.5] versus 50.6 [SD = 19.3], respectively; P = .03).

CONCLUSION

The scale was valid and reliable to assess performance for simulated dispatcher-assisted CPR. To the authors' knowledge, no other valid performance tool currently exists. It could be used in simulated telephone-CPR training programs to improve performance.

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

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

Surviving sudden cardiac arrest-successes, challenges, and opportunities

Sudden cardiac arrest (SCA) is the most common cause of death in the world. This manuscript highlights the various challenges in prevention and early management of SCA and also discusses the current state of SCA awareness. The manuscript also outlines the various national and international initiatives in improving SCA awareness and their impact on improving outcomes in SCA. Various campaigns have strived for widespread dissemination of cardiopulmonary resuscitation training and advocated for broader public access defibrillator availability. Finally, the manuscript describes future directions including harnessing technology with voice command and artificial intelligence to allow lay person deliver effective CPR, to improve EMS response times, and to allow wider CPR knowledge dissemination in schools and places of employment. Future research should be focused on optimizing SCA outcomes among vulnerable populations and minorities. Advancements in resuscitation science and use of big data for improvement of EMS services will improve outcomes in SCA.

Adrenaline to improve survival in out-of-hospital cardiac arrest: the PARAMEDIC2 RCT

BACKGROUND

Adrenaline has been used as a treatment for cardiac arrest for many years, despite uncertainty about its effects on long-term outcomes and concerns that it may cause worse neurological outcomes.

OBJECTIVES

The objectives were to evaluate the effects of adrenaline on survival and neurological outcomes, and to assess the cost-effectiveness of adrenaline use.

DESIGN

This was a pragmatic, randomised, allocation-concealed, placebo-controlled, parallel-group superiority trial and economic evaluation. Costs are expressed in Great British pounds and reported in 2016/17 prices.

SETTING

This trial was set in five NHS ambulance services in England and Wales.

PARTICIPANTS

Adults treated for an out-of-hospital cardiac arrest were included. Patients were ineligible if they were pregnant, if they were aged < 16 years, if the cardiac arrest had been caused by anaphylaxis or life-threatening asthma, or if adrenaline had already been given.

INTERVENTIONS

Participants were randomised to either adrenaline (1 mg) or placebo in a 1 : 1 allocation ratio by the opening of allocation-concealed treatment packs.

MAIN OUTCOME MEASURES

The primary outcome was survival to 30 days. The secondary outcomes were survival to hospital admission, survival to hospital discharge, survival at 3, 6 and 12 months, neurological outcomes and health-related quality of life through to 6 months. The economic evaluation assessed the incremental cost per quality-adjusted life-year gained from the perspective of the NHS and Personal Social Services. Participants, clinical teams and those assessing patient outcomes were masked to the treatment allocation.

RESULTS

From December 2014 to October 2017, 8014 participants were assigned to the adrenaline (n = 4015) or to the placebo (n = 3999) arm. At 30 days, 130 out of 4012 participants (3.2%) in the adrenaline arm and 94 out of 3995 (2.4%) in the placebo arm were alive (adjusted odds ratio for survival 1.47, 95% confidence interval 1.09 to 1.97). For secondary outcomes, survival to hospital admission was higher for those receiving adrenaline than for those receiving placebo (23.6% vs. 8.0%; adjusted odds ratio 3.83, 95% confidence interval 3.30 to 4.43). The rate of favourable neurological outcome at hospital discharge was not significantly different between the arms (2.2% vs. 1.9%; adjusted odds ratio 1.19, 95% confidence interval 0.85 to 1.68). The pattern of improved survival but no significant improvement in neurological outcomes continued through to 6 months. By 12 months, survival in the adrenaline arm was 2.7%, compared with 2.0% in the placebo arm (adjusted odds ratio 1.38, 95% confidence interval 1.00 to 1.92). An adjusted subgroup analysis did not identify significant interactions. The incremental cost-effectiveness ratio for adrenaline was estimated at £1,693,003 per quality-adjusted life-year gained over the first 6 months after the cardiac arrest event and £81,070 per quality-adjusted life-year gained over the lifetime of survivors. Additional economic analyses estimated incremental cost-effectiveness ratios for adrenaline at £982,880 per percentage point increase in overall survival and £377,232 per percentage point increase in neurological outcomes over the first 6 months after the cardiac arrest.

LIMITATIONS

The estimate for survival with a favourable neurological outcome is imprecise because of the small numbers of patients surviving with a good outcome.

CONCLUSIONS

Adrenaline improved long-term survival, but there was no evidence that it significantly improved neurological outcomes. The incremental cost-effectiveness ratio per quality-adjusted life-year exceeds the threshold of £20,000-30,000 per quality-adjusted life-year usually supported by the NHS.

FUTURE WORK

Further research is required to better understand patients' preferences in relation to survival and neurological outcomes after out-of-hospital cardiac arrest and to aid interpretation of the trial findings from a patient and public perspective.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN73485024 and EudraCT 2014-000792-11.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 25. See the NIHR Journals Library website for further project information.

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

Background

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

Methods and Results

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

Conclusions

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

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.

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.

Use of a Simple Ultrasound Device to Identify the Optimal Area of Compression for Out-of-Hospital Cardiac Arrest

Background Despite automated defibrillation and compression-first resuscitation, out-of-hospital cardiac arrest (OHCA) survival remains low. Resuscitation guidelines recommend that chest compressions should be done over the lower half of the sternum, but evidence indicates that this is often associated with outflow obstruction. Emerging studies suggest that compression directly over the left ventricle (LV) may improve survival and outcomes, but rapid and reliable localization of the LV is a major obstacle for those first responding to OHCA. This study aimed to determine if a simplified, easy-to-use ultrasound device (bladder scanner) can reliably locate the heart when applied over the intercostal spaces of the anterior thorax in supine patients. Furthermore, we sought to describe the association between largest scan volumes and underlying cardiac anatomy with particular attention to the long axis of the LV. Methodology We recruited healthy male and female volunteers over 40 years of age. Using a bladder scanner to evaluate the left sternal border and mid-clavicular lines, we determined the maximal scan volumes at 10 intercostal spaces for each participant. Cardiac ultrasound was then used to evaluate the corresponding underlying cardiac anatomy and determine the area overlying the long-axis view of the LV. Descriptive statistics (means with standard deviations [SD], medians with interquartile ranges, and frequencies with proportions) were used to quantify demographic information, typical scan volumes across the chest, the frequencies of the best long-axis LV view location. This was then repeated for left sternal border assessments only. Kappa was determined when evaluating agreement between the largest left sternal border scan volume and the best long-axis LV view location. Results The long-axis LV was the predominant structure underlying the largest scan volume in 39/51 (76.5%) patients. When limited to left sternal border volumes only, the long axis of the LV was underlying the maximum volume intercostal space in 46/51 (90.2%; 95% confidence interval [CI]: 78.6%, 96.7%). The largest left sternal border scan volumes were located over the best long-axis LV view in 39/51 (76.5%, 95% CI: 62.5%, 87.2%) of the study participants with a Kappa statistic of 0.68 (95% CI: 0.52, 0.84; p < 0.0001).  Conclusions In this cross-sectional study of healthy volunteers, an easy-to-use ultrasound device (bladder scanner) was able to reliably localize the heart. Largest scan volumes over the left sternal border showed substantial agreement with the intercostal space overlying the long axis of the LV. Further investigations are warranted to determine if such localization is reliable in cardiac arrest patients.

Mismatches Between the Number of Installed Automated External Defibrillators and the Annual Rate of Automated External Defibrillator Use Among Places

AIM

In South Korea, the law concerning automated external defibrillators (AEDs) states that they should be installed in specific places including apartment complexes. This study was conducted to investigate the current status and effectiveness of installation and usage of AEDs in South Korea.

METHODS

Installation and usage of AEDs in South Korea is registered in the National Emergency Medical Center (NEMC) database. Compared were the installed number, usage, and annual rate of AED use according to places of installation. All data were obtained from the NEMC database.

RESULTS

After excluding AEDs installed in ambulances or fire engines (n = 2,003), 36,498 AEDs were registered in South Korea from 1998 through 2018. A higher number of AEDs were installed in places required by the law compared with those not required by the law (20,678 [56.7%] vs. 15,820 [43.3%]; P <.001). Among them, 11,318 (31.0%) AEDs were installed in apartment complexes. The overall annual rate of AED use was 0.38% (95% CI, 0.33-0.44). The annual rate of AED use was significantly higher in places not required by the law (0.62% [95% CI, 0.52-0.72] versus 0.21% [95% CI, 0.16-0.25]; P <.001). The annual rate of AED use in apartment complexes was 0.13% (95% CI, 0.08-0.17).

CONCLUSION

There were significant mismatches between the number of installed AEDs and the annual rate of AED use among places. To optimize the benefit of AEDs in South Korea, changes in the policy for selecting AED placement are needed.

Experiences and Psychological Influences in Lay Rescuers Performing Bystander Cardiopulmonary Resuscitation: A Qualitative Study

BACKGROUND

Bystander-initiated cardiopulmonary resuscitation (CPR) and the use of automated external defibrillation (AED) is pivotal in the community chain of survival, but little is known regarding the bystander experience of performing CPR and AED, and their psychological infl uence from the incidents in the Asian community. This qualitative study was conducted to explore the experiences of lay rescuers who had performed CPR and AED in public locations in Taiwan.

METHODS

Lay rescuers who had provided initial CPR and defi brillation with AED in public locations across Taiwan in 2015 were selectively recruited from Taiwan Public AED Registry for a semi-structured interview.

RESULTS

Nine participants were included in the study, and event-to-interview duration was within 1 year (n = 4) and 1-2 years (n = 5). The major fi ndings from the study were: (1) the lay rescuers possessed helping traits and high motivation; (2) the lay rescuers reported certain aspects of rescue reality that differed much from prior training and expectations, including diffi culty in the depth of chest compression, and uncertainties in real emergency situations; (3) the lay rescuers gained positive personal fulfi llment in sharing their experience and receiving positive feedback from others, and were willing to help next time, although they experienced a short-term negative psychological impact from the event.

CONCLUSIONS

This study provides valuable information on strategies to increase layperson CPR rates and effectiveness in CPR training. Measures should be taken to increase layperson's confi dence and situation awareness, reduce training-reality discrepancy, build up a support system to avoid negative psychological effects, and prepare lay rescuers for the next resuscitation.

Cost-effectiveness of a novel smartphone application to mobilize first responders after witnessed OHCA in Belgium

Background

EVapp (Emergency Volunteer Application) is a Belgian smartphone application that mobilizes volunteers to perform cardiopulmonary resuscitation (CPR) and defibrillation with publicly available automatic external defibrillators (AED) after an emergency call for suspected out of hospital cardiac arrest (OHCA). The aim is to bridge the time before the arrival of the emergency services.

Methods

An accessible model was developed, using literature data, to simulate survival and cost-effectiveness of nation-wide EVapp implementation. Initial validation was performed using field data from a first pilot study of EVapp implementation in a city in Flanders, covering 2.5 years of implementation.

Results

Simulation of nation-wide EVapp implementation resulted in an additional yearly 910 QALY gained over the current baseline case scenario (worst case 632; best case 3204). The cost per QALY associated with EVapp implementation was comparable to the baseline scenario, i.e., 17 vs 18 k€ QALY⁻¹.

Conclusions

EVapp implementation was associated with a positive balance on amount of QALY gained and cost of QALY. This was a consequence of both the lower healthcare costs for patients with good neurological outcome and the more efficient use of yet available resources, which did not outweigh the costs of operation.

Can Mobile Videocall Assist Laypersons' Use of Automated External Defibrillators? A Randomized Simulation Study and Qualitative Analysis

Objective

To investigate the feasibility of mobile videocall guidance to facilitate AED use by laypersons. Design, setting, and participants. A total of 90 laypersons were randomized into three groups: the mobile video call-guided, voice call-guided, and non-guided groups. Participants were exposed to simulated cardiac arrest to use an AED, and guided by video calls, voice calls, or were not guided. We recorded the simulation experiments as a videoclip, and other researchers who were blinded to the simulation assessed the performance according to the prespecified checklist after simulations. Outcomes measure and analysis. We compared the performance score and time intervals from AED arrival to defibrillation among the three groups and analyzed the common errors.

Results

There was no significant difference among the three groups in terms of baseline characteristics. Performance scores in the checklist for using AED were higher in the mobile video call-guided group, especially in the category of "Power on AED" and "Correctly attaches pads" than in the other groups. However, the time interval to defibrillation was significantly longer in the mobile video call-guided group.

Conclusions

Mobile video call guidance might be an alternative method to facilitate AED use by laypersons. Therefore, further well-designed research is needed to evaluate the feasibility of this approach in OHCA.

Improving bystander defibrillation in out-of-hospital cardiac arrests at home

Aims:

Most out-of-hospital cardiac arrests occur at home with dismal bystander defibrillation rates. We investigated automated external defibrillator coverage of home arrests, and the proportion potentially reachable with an automated external defibrillator before emergency medical service arrival according to different bystander activation strategies.

Methods and results:

Cardiac arrests in homes (private/nursing/senior homes) in Copenhagen, Denmark (2008–2016) and registered automated external defibrillators (2007–2016), were identified. Automated external defibrillator coverage (distance from arrest to automated external defibrillator) and accessibility at the time of arrest were examined according to route distance to nearest automated external defibrillator and emergency medical service response time. The proportion of arrests reachable with an automated external defibrillator by bystander was calculated using two-way (from patient to automated external defibrillator and back) and one-way (from automated external defibrillator to patient) potential activation strategies. Of 1879 home arrests, automated external defibrillator coverage ≤100 m was low (6.3%) and a two-way bystander could potentially only retrieve an accessible automated external defibrillator before emergency medical service in 31.1% (n=37) of cases. If a bystander only needed to travel one-way to bring an automated external defibrillator (≤100 m, ≤250 m and ≤500 m), 45.4% (n=54/119), 37.1% (n=196/529) and 29.8% (n=350/1174) could potentially be reached before the emergency medical service based on current automated external defibrillator accessibility.

Conclusions:

Few home arrests were reachable with an automated external defibrillator before emergency medical service if bystanders needed to travel from patient to automated external defibrillator and back. However, nearly one-third of arrests ≤500 m of an automated external defibrillator could be reached before emergency medical service arrival if the bystander only needed to travel one-way from the automated external defibrillator to the patient.

Adult Basic Life Support: International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

This 2020 International Consensus on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care Science With Treatment Recommendations on basic life support summarizes evidence evaluations performed for 20 topics that were prioritized by the Basic Life Support Task Force of the International Liaison Committee on Resuscitation. The evidence reviews include 16 systematic reviews, 3 scoping reviews, and 1 evidence update. Per agreement within the International Liaison Committee on Resuscitation, new or revised treatment recommendations were only made after a systematic review.

Systematic reviews were performed for the following topics: dispatch diagnosis of cardiac arrest, use of a firm surface for CPR, sequence for starting CPR (compressions-airway-breaths versus airway-breaths-compressions), CPR before calling for help, duration of CPR cycles, hand position during compressions, rhythm check timing, feedback for CPR quality, alternative techniques, public access automated external defibrillator programs, analysis of rhythm during chest compressions, CPR before defibrillation, removal of foreign-body airway obstruction, resuscitation care for suspected opioid-associated emergencies, drowning, and harm from CPR to victims not in cardiac arrest.

The topics that resulted in the most extensive task force discussions included CPR during transport, CPR before calling for help, resuscitation care for suspected opioid-associated emergencies, feedback for CPR quality, and analysis of rhythm during chest compressions. After discussion of the scoping reviews and the evidence update, the task force prioritized several topics for new systematic reviews.

Part 7: Systems of Care: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Survival after cardiac arrest requires an integrated system of people, training, equipment, and organizations working together to achieve a common goal. Part 7 of the 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care focuses on systems of care, with an emphasis on elements that are relevant to a broad range of resuscitation situations. Previous systems of care guidelines have identified a Chain of Survival, beginning with prevention and early identification of cardiac arrest and proceeding through resuscitation to post-cardiac arrest care. This concept is reinforced by the addition of recovery as an important stage in cardiac arrest survival. Debriefing and other quality improvement strategies were previously mentioned and are now emphasized. Specific to out-of-hospital cardiac arrest, this Part contains recommendations about community initiatives to promote cardiac arrest recognition, cardiopulmonary resuscitation, public access defibrillation, mobile phone technologies to summon first responders, and an enhanced role for emergency telecommunicators. Germane to in-hospital cardiac arrest are recommendations about the recognition and stabilization of hospital patients at risk for developing cardiac arrest. This Part also includes recommendations about clinical debriefing, transport to specialized cardiac arrest centers, organ donation, and performance measurement across the continuum of resuscitation situations.

Adult Basic Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

This2020 International Consensus on Cardiopulmonary Resuscitation(CPR)and Emergency Cardiovascular Care Science With Treatment Recommendationson basic life support summarizes evidence evaluations performed for 22 topics that were prioritized by the Basic Life Support Task Force of the International Liaison Committee on Resuscitation. The evidence reviews include 16 systematic reviews, 5 scoping reviews, and 1 evidence update. Per agreement within the International Liaison Committee on Resuscitation, new or revised treatment recommendations were only made after a systematic review.

Systematic reviews were performed for the following topics: dispatch diagnosis of cardiac arrest, use of a firm surface for CPR, sequence for starting CPR (compressions-airway-breaths versus airway-breaths-compressions), CPR before calling for help, duration of CPR cycles, hand position during compressions, rhythm check timing, feedback for CPR quality, alternative techniques, public access automated external defibrillator programs, analysis of rhythm during chest compressions, CPR before defibrillation, removal of foreign-body airway obstruction, resuscitation care for suspected opioid-associated emergencies, drowning, and harm from CPR to victims not in cardiac arrest.

The topics that resulted in the most extensive task force discussions included CPR during transport, CPR before calling for help, resuscitation care for suspected opioid-associated emergencies, feedback for CPR quality, and analysis of rhythm during chest compressions. After discussion of the scoping reviews and the evidence update, the task force prioritized several topics for new systematic reviews.

The general public's ability to operate automated external defibrillator: A controlled simulation study

BACKGROUND

Automated external defibrillators (AEDs) enable laypeople to provide early defibrillations to patients undergoing cardiac arrest, but scant information is available on the general public's ability to use AEDs. This study assessed the ability of laypeople to operate AEDs, the effect of a 15-minute training, and whether skills differed by age.

METHODS

From May 1 to December 31, 2018, a prospective simulation study was conducted with 94 laypeople aged 18-65 years (32 aged 18-24 years, 34 aged 25-54 years, and 28 aged 55-65 years) with no prior AED training. The participants' AED skills were assessed individually pre-training, post-training, and at a three-month follow-up using a simulated cardiac arrest scenario. The critical actions and time intervals were evaluated during the AED operating process.

RESULTS

Only 14 (14.9%) participants (eight aged 18-24 years, four aged 25-54 years, and two aged 55-65 years) successfully delivered defibrillations before training. AED operation errors were more likely to occur among the participants aged 55-65 years than among other age groups. After training, the proportion of successful defibrillations increased significantly (18-24 years old: 25.0% vs. 71.9%, P<0.01; 25-54 years old: 11.8% vs. 70.6%, P<0.01; 55-65 years old: 7.1% vs. 67.9%, P<0.01). After three months, 26.1% of the participants aged 55-65 years successfully delivered defibrillations, which was significantly lower than that of participants aged 18-24 years (54.8%) and 25-54 years (64.3%) (P=0.02). There were no differences in time measures among three age groups in each test.

CONCLUSIONS

The majority of untrained laypeople cannot effectively operate AEDs. More frequent training and refresher courses are crucial to improve AED skills.

"Sorry, what did you say?" Communicating defibrillator retrieval and use in OHCA emergency calls

BACKGROUND

The defibrillator prompt, which directs callers to retrieve a defibrillator during out-of-hospital cardiac arrest, is crucial to the emergency call because it can save lives. We evaluated communicative effectiveness of the prompt instated by the Medical Priority Dispatch System™ Version 13, namely: if there is a defibrillator (AED) available, send someone to get it now, and tell me when you have it.

METHODS

Using Conversation Analysis and descriptive statistics, we examined linguistic features of the defibrillator sequences (call-taker prompt and caller response) in 208 emergency calls where non-traumatic out-of-hospital cardiac arrest was confirmed by the emergency medical services, and they attempted resuscitation, in the first six months of 2019. Defibrillator sequence durations were measured to determine impact on time to CPR prompt. The proportion of cases where bystanders retrieved defibrillators was also assessed.

RESULTS

There was low call-taker adoption of the Medical Priority Dispatch System™ Version 13 prompt (99/208) compared to alternative prompts (86/208) or no prompt (23/208). Caller responses to the Version 13 prompt tended to be longer, more ambiguous or unrelated, and have more instances of repair (utterances to address comprehension trouble). Defibrillators were rarely brought to the scene irrespective of defibrillator prompt utilised.

CONCLUSION

While the Version 13 prompt aims to ensure the use of an available automatic external defibrillator, its effectiveness is undermined by the three-clause composition of the prompt and exclusion of a question structure. We recommend testing of a re-phrased defibrillator prompt in order to maximise comprehension and caller action.

Sustaining improvement of dispatcher-assisted cardiopulmonary resuscitation for out-of-hospital cardiac arrest patients in Japan: An observational study

OBJECTIVES

We aimed to estimate the relationship between the promotion of bystander cardiopulmonary resuscitation (CPR) with dispatcher-assistance over time and good cerebral function after out-of-hospital cardiac arrests (OHCAs).

METHODS

This was a retrospective observational study, using a nationwide OHCA database in Japan. The eligible 267,193 witnessed cardiogenic OHCA patients between 2005 and 2016 were analysed. Multivariable logistic regression models were performed to estimate the effect of dispatcher-assisted bystander CPR per year. In addition, we calculated the number of patients with good cerebral function, which was attributed to dispatcher-assisted bystander CPR.

RESULTS

Dispatcher-assisted bystander CPR was performed to 84,076 (31.5%), those without dispatcher-assistance were 48,389 (18.1%), and non-bystander CPR were 134,728 (50.4%). The adjusted odds ratio (AOR) of dispatcher-assisted bystander CPR vs. non-bystander CPR was significantly related to good cerebral function, regardless of the year (AOR, 1.47, 1.62; 95%CI, 1.19-1.80, 1.42-1.85, 2005 and 2016, respectively). The association of dispatcher-assisted bystander CPR with good cerebral function tended to increase (AOR, 1.11, 2.97; 95%CI, 0.99-1.24, 2.69-3.28, 2006 and 2016, based on 2005, respectively). Estimating the number of patients with good cerebral function who attributed to dispatcher-assisted bystander CPR was a significant increase from 41 in 2005 to 580 in 2016 (p < .0001, r = 0.98). Furthermore, chest compression consistently contributed to higher number of patients with good cerebral function than that with a combination of chest compression and shock with public-access-defibrillation.

CONCLUSION

We found that the increased dispatcher-assisted bystander CPR rate was related to good cerebral function at 1-month post OHCA. Chest compression without public-access-defibrillation was most helpful to that number, explaining the effects of dispatcher-assistance and sustaining improvement.

Updated Approaches to Cardiac Electrical Stimulation and Pacing in Pediatrics

Cardiac electrical stimulation is a rarely used but required skill for pediatric emergency physicians. Children who are in cardiac arrest or who demonstrate evidence of hypoperfusion because of cardiac reasons require rapid diagnosis and intervention to minimize patient morbidity and mortality. Both hospital- and community-based personnel must have sufficient access to, and knowledge of, appropriate equipment to provide potentially lifesaving defibrillation, cardioversion, or cardiac pacing. In this review, we will discuss the primary clinical indications for cardioelectrical stimulation in pediatric patients, including the use of automated external defibrillators, internal defibrillators, and pacemakers. We discuss the types of devices that are currently available, emergency management of internal defibrillation and pacemaker devices, and the role of advocacy in improving delivery of emergency cardiovascular care of pediatric patients in the community.