Health inequalities in cardiopulmonary resuscitation and use of automated electrical defibrillators in out-of-hospital cardiac arrest

Is there an association between 30-day mortality from out-of-hospital cardiac arrest (OHCA) and deprivation levels within Hampshire? A retrospective cohort study

Introduction

People who live in population-dense areas, work in routine occupations, originate from a non-white background, have lower education attainment and experience a greater level of deprivation have an increased risk of suffering an OHCA and are less likely to receive bystander CPR. This study seeks to understand if these observed inequalities result in reduced survival by examining the relationship between deprivation and survival at 30 days at a UK single county level.

Methods

30-day survival from non-traumatic OHCA in adults over 18 years of age in Hampshire from local ambulance service data (Jan 2019 - March 2023) was combined with indices of multiple deprivation (IMD) based on the home postcode. Multivariable logistic regression models were developed, through bidirectional stepwise regression, to evaluate the effect of deprivation on 30-day survival. Separate models were developed to consider non-linear relationships before a final model incorporated learning from previous iterations.

Results

Overall, 4184 patients were included in the final analysis, with 437 (10%) surviving to 30 days. Age of OHCA patients varied significantly between IMD deciles (p < 0.01), with a trend to younger patients in more deprived deciles. Univariable regression found no relationship between deprivation and survival. However, after controlling for age, sex, shockable rhythm and bystander CPR, increasing deprivation was associated with reduced survival (OR: 1.05, 95% CI 1.01-1.09). Other significant predictors were age, shockable rhythm and bystander CPR.

Conclusion

Increasing deprivation was associated with a reduced 30-day survival after accounting for other measured variables.

An insight regarding the article 'Predictors and rate of survival after out-of-hospital cardiac arrest.'

Advancements in diagnostic and therapeutic approaches have led to a remarkable reduction in the morbidity and mortality rates associated with a variety of diseases. In the context of acute ischemic heart disease, significant milestones have been achieved, beginning with the establishment of cardiac ICUs. These were pivotal in providing specialized care for patients with severe heart conditions. Subsequent to this development, methods to restore blood flow in areas compromised by arterial blockages were introduced. Initially, systemic thrombolysis was the primary method used, but it has since been largely supplanted by primary percutaneous coronary intervention (PCI), also known as primary coronary angioplasty, which is now the preferred treatment due to its effectiveness and safety. The incidence of out-of-hospital cardiac arrest (OHCA) where resuscitation attempts have been made, whether successful or not, is significant and presents a considerable challenge. Unfortunately, the mortality rate among these patients remains distressingly high, and efforts to reduce it are fraught with difficulty. It is crucial to acknowledge that survival from an OHCA does not automatically equate to a favorable clinical outcome, as serious neurological impairments are common sequelae of such events. In addition to mortality rates, the term "survival with favorable neurologic outcome" has emerged as another critical measure of the success of resuscitation efforts. This parameter underscores the importance of not only saving lives but also preserving the quality of life for survivors. The ability to restore both life and cognitive function is a testament to the comprehensiveness of care provided to OHCA patients.

Prehospital critical care beyond advanced life support for out-of-hospital cardiac arrest: A systematic review

Aim

To assess the clinical outcomes of patients with out-of-hospital cardiac arrest attended by prehospital critical care teams compared to non-critical care teams.

Methods

This review was prospectively registered with PROSPERO and the eligibility criteria followed a PICOST framework for ILCOR systematic reviews. Prehospital critical care was defined as any provider with enhanced clinical competencies beyond standard advanced life support algorithms and dedicated dispatch to critically ill patients. MEDLINE, Embase and CINAHL databases were searched from inception to 20 April 2024. Risk of bias was assessed using the ROBINS-I tool and the certainty of evidence by the GRADE approach. Meta-analyses of pooled data from studies at moderate risk of bias were performed using a generic inverse-variance with random-effects.

Results

The search returned 6,444 results and 17 articles were included, reporting 1,192,158 patients. Three studies reported traumatic patients and one reported paediatric patients. All studies were non-randomised and 15 were at moderate risk of bias. Most studies included prehospital physicians (n = 16). For adult non-traumatic patients, the certainty of evidence was low and prehospital critical care was associated with improved survival to hospital admission (OR 1.95, 95% CI 1.35-2.82), survival to hospital discharge (OR 1.34, 95% CI 1.10-1.63), survival at 30 days (OR 1.56, 95% CI 1.38-1.75), and favourable neurological outcome at 30 days (OR 1.48, 95% CI 1.19-1.84). Prehospital critical care was also associated with improved outcomes for traumatic and paediatric patients and the certainty of evidence was very low.

Conclusion

Attendance of prehospital critical care teams to patients with out-of-hospital cardiac arrest is associated with improved outcomes.

Examining the association between ethnicity and out-of-hospital cardiac arrest interventions in Salt Lake City, Utah

Aims

Previous research has reported racial disparities in out-of-hospital cardiac arrest (OHCA) interventions, including bystander CPR and AED use. However, studies on other prehospital interventions are limited. The primary objective of this study was to investigate race/ethnic disparities in out-of-hospital cardiac arrest (OHCA) interventions: EMS response times, medication administration, and decisions for intra-arrest transport. The secondary objective was to evaluate differences in the provision of Bystander CPR (CPR) and application of AED.

Methods

We retrospectively analyzed data from the Salt Lake City Fire Department (2010-2023). We included adults 18 years or older with EMS-treated OHCA. Race/ethnicity was categorized as White people, Asian people, Black people, Hispanic people, and others. We employed multivariable regression analysis to evaluate the association between race/ethnicity and the outcomes of interest.

Results

Unadjusted analyses revealed no significant differences across ethnic groups in EMS response, medication administration, bystander CPR, or intra-arrest transport decisions. However, significant ethnic disparities were observed in Automated External Defibrillator (AED) utilization, Black people having the lowest rate (6.5%) and Asian people the highest (21.8%). The adjusted analysis found no significant association between race/ethnicity and all OHCA intervention measures, nor between race/ethnicity and survival outcomes.

Conclusions

Our multivariable analysis found no statistically significant association between race/ethnicity and EMS response time, epinephrine administration, antiarrhythmic medication use, bystander CPR, AED intervention, or intra-arrest transport. These results imply regional variations in ethnic disparities in OHCA may not be consistent across all areas, warranting further research into disparities in other regions and additional influential factors like neighborhood conditions and socioeconomic status.

A review regarding the article 'Health inequalities in cardiopulmonary resuscitation and use of automated electrical defibrillators in out-of-hospital cardiac arrest'

Out-of-hospital cardiac arrest (OHCA) is a major cause of mortality worldwide, with a high incidence and low survival rate. Prompt cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use are major contributors in the "chain of survival" for OHCA. the response of a community plays a key role in determining the outcomes in OHCA. The outcomes of OHCA are affected by health inequalities in bystander CPR and AED use, due to factors such as differences in sex, ethnicity, and socioeconomic status amongst others. Literature shows patients from lower socio-economic backgrounds are more likely to have risk factors for a cardiac arrest and are therefore more likely to have OHCA. Studies have also reported lower rates of bystander AED use in females compared to males. Targeting deprived areas with tailored training and access to AEDs can be beneficial in improving CPR outcomes in communities. Due to the physical nature of CPR maneuvers, age and frailty of the patient can both impact the outcome of the resuscitation. Environmental factors affecting AED use include availability, visibility, accessibility, support, extra equipment, training materials, staffing, and awareness. Education should focus on areas such as conducting BLS on both male and female patients, recognizing cardiac arrest, tailoring BLS to difference ages as well as provision for training in different languages, including sign language. Like some other countries, CPR training is now being implemented in the school curriculum.

Comment on the. Health inequalities in cardiopulmonary resuscitation and the use of automated external defibrillators (AEDs) in out-of-hospital cardiac arrest (OHCA)

I am writing to express my concerns regarding article on Health inequalities in cardiopulmonary resuscitation and the use of automated external defibrillators (AEDs) in out-of-hospital cardiac arrest (OHCA)1. The article provides a comprehensive overview of the issue, but several points could be expanded upon or clarified.