The impact of a pre-hospital critical care team on survival from out-of-hospital cardiac arrest

Influence of the Type of Physician on Survival from Emergency-Medical-Service-Witnessed Cardiac Arrest: An Observational Study

Out-of-hospital cardiac arrest resuscitation by non-emergency dedicated physicians may not be positively associated with survival, as these physicians have less experience and exposure than specialised dedicated personnel. The aim of this study was to compare the survival results of the teams led by emergency dedicated physicians (EDPhy) with those of the teams led by non-emergency dedicated physicians (N-EDPhy) and with a team of basic life support (BLS) emergency technicians (EMTs) used as the control group. A retrospective, multicentre study of emergency-medical-service-witnessed cardiac arrest from medical causes in adults was performed. The records from 2006 to 2016 in a database of a regional emergency system were analysed and updated up to 31 December 2021. Two groups were studied: initial shockable and non-shockable rhythms. In total, 1359 resuscitation attempts were analysed, 281 of which belonged to the shockable group, and 1077 belonged to the non-shockable rhythm group. Any onsite return of spontaneous circulation, patients admitted to the hospital alive, global survival, and survival with a cerebral performance category (CPC) of 1-2 (good and moderate cerebral performance) were studied, with both of the latter categories considered at 30 days, 1 year (primary outcome), and 5 years. The shockable and non-shockable rhythm group (and CPC 1-2) survivals at 1 year were, respectively, as follows: EDPhy, 66.7 % (63.4%) and 14.0% (12.3%); N-EDPhy, 16.0% (16.0%) and 1.96 % (1.47%); and EMTs 32.0% (29.7%) and 1.3% (0.84%). The crude ORs were EDPhy vs. N-EDPhy, 10.50 (5.67) and 8.16 (4.63) (all p < 0.05); EDPhy vs. EMTs, 4.25 (2.65) and 12.86 (7.80) (p < 0.05); and N-EDPhy vs. EMTs, 0.50 (0.76) (p < 0.05) and 1.56 (1.32) (p > 0.05). The presence of an EDPhy was positively related to all the survival and CPC rates.

Prospective Evaluation of Cardiopulmonary Resuscitation Performed in Dogs and Cats According to the RECOVER Guidelines. Part 1: Prognostic Factors According to Utstein-Style Reporting

Factors associated with positive cardiopulmonary resuscitation (CPR) outcomes defined according to the veterinary Utstein-style CPR reporting guidelines have not been described since implementation of the Reassessment Campaign on Veterinary Resuscitation (RECOVER) CPR clinical guidelines in 2012. The aims of this study were to assess factors associated with positive CPR outcomes at a U.S. veterinary teaching hospital, to re-evaluate these factors since implementation of the RECOVER guidelines compared to reported factors prior to their publication, and to identify potential additional factors since guideline publication. One-hundred and seventy-two dogs and 47 cats that experienced cardiopulmonary arrest (CPA) and had CPR performed were prospectively included in this observational study. Supervising clinicians were asked to complete a data form on CPR events immediately following completion of CPR efforts. Multivariable logistic regression was used to evaluate the effect of twenty hospital, animal, and arrest variables on the three patient outcomes “any return of spontaneous circulation (ROSC),” “sustained ROSC,” and survival to hospital discharge. Cats had significantly higher odds to achieve any ROSC [OR (95%CI) 2.72 (1.12–6.61), p = 0.028] and survive to hospital discharge than dogs [OR (95%CI) 4.87 (1.52–15.58), p = 0.008]. Patients had significantly lower odds of achieving any ROSC if CPA occurred during nighttime hours [OR (95%CI) nighttime = 0.52 (0.27–0.98), p = 0.043], and higher odds if CPA was witnessed [OR (95%CI) 3.45 (1.57–7.55), p = 0.002], if less people were involved in CPR efforts [OR (95%CI) 0.8 (0.66–0.96), p = 0.016], if pulses were palpable during CPR [OR (95%CI) 9.27 (4.16–20.63), p < 0.0005], and if an IV catheter was already in place at the time of CPA [OR (95%CI) 5.07 (2.12–12.07), p = 0.0003]. Odds for survival to hospital discharge were significantly higher if less people were involved in CPR efforts [OR (95%CI) 0.65 (0.46–0.91), p = 0.013] and for patients of the anesthesia service [OR (95%CI) 14.82 (3.91–56.17), p = 0.00007]. Overall, factors associated with improved CPR outcomes have remained similar since incorporation of RECOVER guidelines into daily practice. Witnessed CPA events and high-quality CPR interventions were associated with positive patient outcomes, emphasizing the importance of timely recognition and initiation of CPR efforts. An optimal CPR team size has yet to be determined.

Response time in the emergency services. Systematic review

The growth of the urban population raises concern about municipal public managers in the sense of providing emergency medical services (EMS) that are aligned with the needs of prehospital emergency medical care demanded by the population. The literature review aims at presenting the response time of emergency medical services in several parts of the world and discussing some factors that interfere in the result of this indicator such as GDP (Gross Domestic Product) percentage spent on health and life expectancy of countries. The study will also show that in some of the consulted articles, authors suggest to EMS recommendations for decreasing the response time using simulations, heuristics and metaheuristics. Response time is a basic indicator of emergency medical services, in such a way that researchers use the descriptive statistics to evaluate this parameter. Europe and the USA outstand in the publication of studies that present this information. Some articles use stochastic and mathematical methods to suggest models that simulate scenarios of response time reduction and suggest such proposals to the local EMS. Countries in which the response time was identified have a high index of human development and life expectancy between 74.7 and 83.7 years.

Impact of prehospital physician-led cardiopulmonary resuscitation on neurologically intact survival after out-of-hospital cardiac arrest: A nationwide population-based observational study

AIM

The impact of prehospital physician care for out-of-hospital cardiac arrest (OHCA) on long-term neurological outcome is unclear. We aimed to determine the association between emergency medical services (EMS) physician-led cardiopulmonary resuscitation (CPR) versus paramedic-led CPR and neurologically intact survival after OHCA.

METHODS

We assessed 613,251 patients using All-Japan Utstein Registry data from 2011 to 2015 retrospectively. The main outcome measure was 1-month neurologically intact survival after OHCA, defined as Cerebral Performance Category 1 or 2 (CPC 1-2).

RESULTS

Before propensity score matching, the 1-month CPC 1-2 rate was significantly higher in EMS physician-led CPR than in paramedic-led CPR [5.7% (1114/19,551) vs. 2.5% (14,859/593,700), P < 0.001; adjusted odds ratio (aOR), 1.50; 95% confidence interval (CI), 1.40-1.61]. After propensity score matching, EMS physician-led CPR showed more favourable neurological outcomes than paramedic-led CPR [6.0% (996/16,612) vs. 4.6% (766/16,612), P < 0.001; aOR, 1.44; 95% CI, 1.29-1.60]. In most subgroup analyses after matching, physician-led CPR had higher 1-month CPC 1-2 rates than paramedic-led CPR did; however, 1-month CPC 1-2 rates were similar between the two CPR configurations for patients aged <18 years (5.6% vs. 8.2%, P = 0.10; aOR, 0.82; 95% CI, 0.46-1.47) and those who received bystander defibrillation (26.3% vs. 21.5%; P = 0.10; aOR, 1.07; 95% CI, 0.74-1.53).

CONCLUSION

Within the limitations of this retrospective observational research, EMS physician-led CPR for OHCA was associated with improved 1-month neurologically intact survival compared with paramedic-led CPR. However, neurologically intact survival was similar for patients aged <18 years and those receiving bystander defibrillation.

Variations in stakeholders' priorities and views on randomisation and funding decisions in out-of-hospital cardiac arrest: An exploratory study

BACKGROUND AND AIMS

Prehospital critical care for out-of-hospital cardiac arrest (OHCA) is a complex and largely unproven intervention. During research to examine this intervention, we noted significant differences in stakeholders' views about research, randomisation, and the funding of prehospital critical care for OHCA. We aimed to answer the following questions: What are stakeholders' priorities for prehospital research? What are stakeholders' views on randomisation of prehospital critical care? How do stakeholders consider allocation of resources in prehospital care?

METHODS

We undertook an explanatory qualitative framework analysis of interviews and focus group with 5 key stakeholder groups: patients and public, air ambulance charities, ambulance service commissioners, prehospital researchers, and prehospital critical care providers.

RESULTS

We undertook 3 focus group discussions with a total of 23 participants and 8 interviews with a total of 9 participants. Despite sharing a common appreciation of the concepts of scientific enquiry, fairness, and beneficence, the 5 relevant stakeholder groups displayed divergent views of research and funding strategies regarding the intervention of prehospital critical care for the condition of OHCA. The reasons for this divergence could largely be explained through the different personal experiences and situational contexts of each stakeholder group. Many aspects of the strategies suggested by the stakeholder groups only partially aligned with principles of traditional evidence-based medicine, but were held with strong conviction.

DISCUSSION

Analysis of the views of 5 stakeholder groups regarding research and the funding of prehospital critical care for OHCA revealed shared values but a variety of different strategies to achieve these. This knowledge can help researchers in similar fields in the planning and presentation of their research, to maximise impact on decision making.

Systematic review of the effectiveness of prehospital critical care following out-of-hospital cardiac arrest

BACKGROUND

Improving survival after out-of-hospital cardiac arrest (OHCA) is a priority for modern emergency medical services (EMS) and prehospital research. Advanced life support (ALS) is now the standard of care in most EMS. In some EMS, prehospital critical care providers are also dispatched to attend OHCA. This systematic review presents the evidence for prehospital critical care for OHCA, when compared to standard ALS care.

METHODS

We searched the following electronic databases: PubMed, EmBASE, CINAHL Plus and AMED (via EBSCO), Cochrane Database of Systematic Reviews, DARE, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, NIHR Health Technology Assessment Database, Google Scholar and ClinicalTrials.gov. Search terms related to cardiac arrest and prehospital critical care. All studies that compared patient-centred outcomes between prehospital critical care and ALS for OHCA were included.

RESULTS

The review identified six full text publications that matched the inclusion criteria, all of which are observational studies. Three studies showed no benefit from prehospital critical care but were underpowered with sample sizes of 1028-1851. The other three publications showed benefit from prehospital critical care delivered by physicians. However, an imbalance of prognostic factors and hospital treatment in these studies systematically favoured the prehospital critical care group.

CONCLUSION

Current evidence to support prehospital critical care for OHCA is limited by the logistic difficulties of undertaking high quality research in this area. Further research needs an appropriate sample size with adjustments for confounding factors in observational research design.

Prehospital critical care for out-of-hospital cardiac arrest: An observational study examining survival and a stakeholder-focused cost analysis

Background

Survival rates from out-of-hospital cardiac arrest (OHCA) remain low, despite remarkable efforts to improve care. A number of ambulance services in the United Kingdom (UK) have developed prehospital critical care teams (CCTs) which attend critically ill patients, including OHCA. However, current scientific evidence describing CCTs attending OHCA is sparse and research to date has not demonstrated clear benefits from this model of care.

Methods

This prospective, observational study will describe the effect of CCTs on survival from OHCA, when compared to advanced-life-support (ALS), the current standard of prehospital care in the UK. In addition, we will describe the association between individual critical care interventions and survival, and also the costs of CCTs for OHCA.

To examine the effect of CCTs on survival from OHCA, we will use routine Utstein variables data already collected in a number of UK ambulance trusts. We will use propensity score matching to adjust for imbalances between the CCT and ALS groups. The primary outcome will be survival to hospital discharge, with the secondary outcome of survival to hospital admission.

We will record the critical care interventions delivered during CCT attendance at OHCA. We will describe frequencies and aim to use multiple logistic regression to examine possible associations with survival.

Finally, we will undertake a stakeholder-focused cost analysis of CCTs for OHCA. This will utilise a previously published Emergency Medical Services (EMS) cost analysis toolkit and will take into account the costs incurred from use of a helicopter and the proportion of these costs currently covered by charities in the UK.

Discussion

Prehospital critical care for OHCA is not universally available in many EMS. In the UK, it is variable and largely funded through public donations to charities. If this study demonstrates benefit from CCTs at an acceptable cost to the public or EMS commissioners, it will provide a rationale to increase funding and service provision. If no clinical benefit is found, the public and charities providing these services can consider concentrating their efforts on other areas of prehospital care.

Trial registration

ISRCTN registry ID ISRCTN18375201.