A before-after interventional trial of dispatcher-assisted cardio-pulmonary resuscitation for out-of-hospital cardiac arrests in Singapore

The Lancet Commission to reduce the global burden of sudden cardiac death: a call for multidisciplinary action

Despite major advancements in cardiovascular medicine, sudden cardiac death (SCD) continues to be an enormous medical and societal challenge, claiming millions of lives every year. Efforts to prevent SCD are hampered by imperfect risk prediction and inadequate solutions to specifically address arrhythmogenesis. Although resuscitation strategies have witnessed substantial evolution, there is a need to strengthen the organisation of community interventions and emergency medical systems across varied locations and health-care structures. With all the technological and medical advances of the 21st century, the fact that survival from sudden cardiac arrest (SCA) remains lower than 10% in most parts of the world is unacceptable. Recognising this urgent need, the Lancet Commission on SCD was constituted, bringing together 30 international experts in varied disciplines. Consistent progress in tackling SCD will require a completely revamped approach to SCD prevention, with wide-sweeping policy changes that will empower the development of both governmental and community-based programmes to maximise survival from SCA, and to comprehensively attend to survivors and decedents' families after the event. International collaborative efforts that maximally leverage and connect the expertise of various research organisations will need to be prioritised to properly address identified gaps. The Commission places substantial emphasis on the need to develop a multidisciplinary strategy that encompasses all aspects of SCD prevention and treatment. The Commission provides a critical assessment of the current scientific efforts in the field, and puts forth key recommendations to challenge, activate, and intensify efforts by both the scientific and global community with new directions, research, and innovation to reduce the burden of SCD worldwide.

Pre-Arrival Care of the Out-of-Hospital Cardiac Arrest Victim

Lay rescuers play a pivotal role in the recognition and initial management of out-of-hospital cardiac arrest. The provision of timely pre-arrival care by lay responders, including cardiopulmonary resuscitation and the use of automated external defibrillator before emergency medical service arrival, is important link in the chain of survival and has been shown to improve outcomes from cardiac arrest. Although physicians are not directly involved in bystander response to cardiac arrest, they play a key role in emphasizing the importance of bystander interventions.

Tele-Instruction Tool for Multiple Lay Responders Providing Cardiopulmonary Resuscitation in Telehealth Emergency Dispatch Services: Mixed Methods Study

BACKGROUND

Telephone-assisted cardiopulmonary resuscitation (T-CPR) has proven to be a crucial intervention in enhancing the ability of lay responders to perform cardiopulmonary resuscitation (CPR) during telehealth emergency services. While the majority of established T-CPR protocols primarily focus on guiding individual rescuers, there is a lack of emphasis on instructing and coordinating multiple lay responders to perform resuscitation collaboratively.

OBJECTIVE

This study aimed to develop an innovative team-based tele-instruction tool to efficiently organize and instruct multiple lay responders on the CPR process and to evaluate the effectiveness and feasibility of the tool.

METHODS

We used a mixed methods design in this study. We conducted a randomized controlled simulation trial to conduct the quantitative analysis. The intervention groups used the team-based tele-instruction tool for team resuscitation, while the control groups did not have access to the tool. Baseline resuscitation was performed during the initial phase (phase I test). Subsequently, all teams watched a team-based CPR education training video and finished a 3-person practice session with teaching followed by a posttraining test (phase II test). In the qualitative analysis, we randomly selected an individual from each team and 4 experts in emergency medical services to conduct semistructured interviews. The purpose of these interviews was to evaluate the effectiveness and feasibility of this tool.

RESULTS

The team-based tele-instruction tool significantly improved the quality of chest compression in both phase I and phase II tests. The average compression rates were more appropriate in the intervention groups compared to the control groups (median 104.5, IQR 98.8-111.8 min-1 vs median 112, IQR 106-120.8 min-1; P=.04 in phase I and median 117.5, IQR 112.3-125 min-1 vs median 111, IQR 105.3-119 min-1; P=.03 in phase II). In the intervention group, there was a delay in the emergency response time compared to that in the control group (time to first chest compression: median 20, IQR 15-24.8 seconds vs median 25, IQR 20.5-40.3 seconds; P=.03; time to open the airway: median 48, IQR 36.3-62 seconds vs median 73.5, IQR 54.5-227.8 seconds; P=.01). However, this delay was partially mitigated after the phase II test. The qualitative results confirmed the compatibility and generalizability of the team-based tele-instruction tool, demonstrating its ability to effectively guide multiple lay responders through teamwork and effective communication with telecommunicators.

CONCLUSIONS

The use of the team-based tele-instruction tool offers an effective solution to enhance the quality of chest compression among multiple lay responders. This tool facilitated the organization of resuscitation teams by dispatchers and enabled efficient cooperation. Further assessment of the widespread adoption and practical application of the team-based tele-instruction tools in real-life rescue scenarios within the telehealth emergency services system is warranted.

The Integration of Live Video Tools to Help Bystanders During an Emergency Call: Protocol for a Mixed Methods Simulation Study

BACKGROUND

Early action by bystanders is particularly important for the survival of individuals in need of emergency care, especially those experiencing a cardiac arrest or an airway obstruction. However, only a few bystanders are willing to perform cardiopulmonary resuscitation. The use of a live video during emergency calls appears to have a positive effect on the number of cardiopulmonary resuscitations performed by bystanders.

OBJECTIVE

The objective of this study is to propose and evaluate the relevance of a living lab methodology involving video calls in simulated life-threatening emergency situations.

METHODS

The first study aimed at analyzing the process of dealing with out-of-hospital cardiac arrest at a dispatch center and identifying the needs of the dispatchers. The second study is a pretest of a living lab. The third study focuses on a living lab in which 16 situations of cardiac arrest and airway obstruction are simulated. The simulation includes both a live video and transmission of a video demonstration of emergency procedures. The measures focus on 3 areas: the impact of video tools, development of collaboration within the community, and evaluation of the method.

RESULTS

The results of the first study show that dispatchers have an interest in visualizing the scene with live video and in broadcasting a live demonstration video when possible. The initial results also show that collaboration within the community is enhanced by the shared simulation and debriefing experiences, clarifying regulation procedures, and improving communication. Finally, an iterative development based on the lessons learned, expectations, and constraints of each previous study promotes the existence of a living lab that aims to determine the place of live video tools in the sequence of care performed by dispatchers.

CONCLUSIONS

Living labs offer the opportunity to grasp previously undetected insights and refine the use of the applications while potentially developing a sense of community among the stakeholders.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/40699.

Effects of cardiopulmonary resuscitation instructions on the outcomes of out-of-hospital cardiac arrest: An analysis of the JAAM-OHCA registry

Aim

To determine whether dispatcher-provided cardiopulmonary resuscitation (CPR) instructions improve the outcomes of out-of-hospital cardiac arrest (OHCA).

Methods

Cases registered in the Japanese Association for Acute Medicine Out-of-Hospital Cardiac Arrest (JAAM-OHCA) Registry between June 2014 and December 2019 were included. Cases in which the dispatcher provided CPR instructions to the bystander were included in the "Instructions" group", and cases without CPR instructions were included in the "No Instructions" group. The primary outcome was the proportion of patients with a favorable neurological outcome, defined as a Glasgow-Pittsburgh cerebral performance category scale of 1 to 2 at 1 month after OHCA.

Results

Overall, 51,199 patients with OHCA were registered in the JAAM-OHCA Registry during the study period. Of these, 33,745 were eligible for the study, with 16,509 in the Instructions group and 17,236 in the No Instructions group. The proportion of patients with a favorable neurological outcome at 1 month after OHCA was inferior in the Instructions group than in the No Instructions group (2.3% versus 3.0%, p < 0.001). After adjustment for patient background characteristics, no association was found between CPR instructions provided by a dispatcher and favorable neurological outcomes at 1 month after OHCA (adjusted odds ratio, 1.000; 95% confidence interval, 0.869-1.151, p = 0.996).

Conclusion

The present study found no clear clinical benefit of dispatcher-provided CPR instructions on the neurological outcomes of cases with OHCA.

Contributions of event rates, pre-hospital deaths, and deaths following hospitalisation to variations in myocardial infarction mortality in 326 districts in England: a spatial analysis of linked hospitalisation and mortality data

BACKGROUND

Myocardial infarction mortality varies substantially within high-income countries. There is limited guidance on what interventions-including primary and secondary prevention, or improvement of care pathways and quality-can reduce myocardial infarction mortality. Our aim was to understand the contributions of incidence (event rate), pre-hospital deaths, and hospital case fatality to the variations in myocardial infarction mortality within England.

METHODS

We used linked data from national databases on hospitalisations and deaths with acute myocardial infarction (ICD-10 codes I21 and I22) as a primary hospital diagnosis or underlying cause of death, from Jan 1, 2015, to Dec 31, 2018. We used geographical identifiers to estimate myocardial infarction event rate (number of events per 100 000 population), death rate (number of deaths per 100 000 population), total case fatality (proportion of events that resulted in death), pre-hospital fatality (proportion of events that resulted in pre-hospital death), and hospital case fatality (proportion of admissions due to myocardial infarction that resulted in death within 28 days of admission) for men and women aged 45 years and older across 326 districts in England. Data were analysed in a Bayesian spatial model that accounted for similarities and differences in spatial patterns of fatal and non-fatal myocardial infarction. Age-standardised rates were calculated by weighting age-specific rates by the corresponding national share of the appropriate denominator for each measure.

FINDINGS

From 2015 to 2018, national age-standardised death rates were 63 per 100 000 population in women and 126 per 100 000 in men, and event rates were 233 per 100 000 in women and 512 per 100 000 in men. After age-standardisation, 15·0% of events in women and 16·9% in men resulted in death before hospitalisation, and hospital case fatality was 10·8% in women and 10·6% in men. Across districts, the 99th-to-1st percentile ratio of age-standardised myocardial infarction death rates was 2·63 (95% credible interval 2·45-2·83) in women and 2·56 (2·37-2·76) in men, with death rates highest in parts of northern England. The main contributor to this variation was myocardial infarction event rate, with a 99th-to-1st percentile ratio of 2·55 (2·39-2·72) in women and 2·17 (2·08-2·27) in men across districts. Pre-hospital fatality was greater than hospital case fatality in every district. Pre-hospital fatality had a 99th-to-1st percentile ratio of 1·60 (1·50-1·70) in women and 1·75 (1·66-1·86) in men across districts, and made a greater contribution to variation in total case fatality than did hospital case fatality (99th-to-1st percentile ratio 1·39 [1·29-1·49] and 1·49 [1·39-1·60]). The contribution of case fatality to variation in deaths across districts was largest in women aged 55-64 and 65-74 years and in men aged 55-64, 65-74, and 75-84 years. Pre-hospital fatality was slightly higher in men than in women in most districts and age groups, whereas hospital case fatality was higher in women in virtually all districts at ages up to and including 65-74 years.

INTERPRETATION

Most of the variation in myocardial infarction mortality in England is due to variation in myocardial infarction event rate, with a smaller role for case fatality. Most variation in case fatality occurs before rather than after hospital admission. Reducing subnational variations in myocardial infarction mortality requires interventions that reduce event rate and pre-hospital deaths.

FUNDING

Wellcome Trust, British Heart Foundation, Medical Research Council (UK Research and Innovation), and National Institute for Health Research (UK).

Clinical effects of a new dispatcher-assisted basic life support training program in a metropolitan city

This study estimates the effect of a new dispatcher-assisted basic life support training program on the survival outcomes of out-of-hospital cardiac arrest (OHCA). Before-and-after intervention trials were conducted in Seoul. Patients who suffered OHCA in a private place from January 2014 to December 2017 were included. The intervention group was 3 districts; the other 22 districts were regarded as the control group. The primary outcome was survival up to hospital discharge. The difference-in-difference (DID) was calculated to evaluate changes in the survival outcomes of the 2 groups over the period. A total of 10,127 OHCA patients were included in the final analysis. OHCA patients in the intervention group were less likely to receive bystander cardiopulmonary resuscitation (57.8% vs 61.1%; P = .02) and showed lower survival outcomes (5.7% vs 6.4% for survival up to hospital discharge; P = .34 and 2.8% vs 3.7% for good neurological recovery; P = .11), but this was not statistically significant. Compared to 2014, good neurological recovery in 2017 was significantly improved in the intervention group (DID for good neurological recovery = 3.2%; 0.6-5.8). There were no statistically significant differences in return of spontaneous circulation and survival up to hospital discharge between the 2 groups (DID for survival to discharge was 1.8% [-1.7 to 5.3] and DID for return of spontaneous circulation was -2.5% [-9.8 to 4.8]). Improvement in neurological recovery was observed in the 3 districts after implementing the new dispatcher-assisted basic life support training program.

Predictive performances of ALS and BLS termination of resuscitation rules in out-of-hospital cardiac arrest for different resuscitation protocols

BACKGROUND

Resuscitation guidance has advanced; however, the predictive performance of the termination of resuscitation (TOR) rule has not been validated for different resuscitation protocols published by the American Heart Association (AHA).

METHODS

A retrospective study validating the basic life support (BLS) and advanced life support (ALS) TOR rules was conducted using an Utstein-style database in Tainan city, Taiwan. Adult patients with nontraumatic out-of-hospital cardiac arrests from January 1, 2015, to December 31, 2015, (using the AHA 2010 resuscitation protocol) and from January 1, 2020, to December 31, 2020, (using the AHA 2015 resuscitation protocol) were included. The characteristics of rule performance were calculated, including sensitivity, specificity, positive predictive value (PPV) and negative predictive value.

RESULTS

Among 1260 eligible OHCA patients in 2015, 757 met the BLS TOR rule and 124 met the ALS TOR rule. The specificity and PPV for predicting unfavorable neurological outcomes were 61.1% and 99.0%, respectively, for the BLS TOR rule and 93.8% and 99.2%, respectively, for the ALS TOR rule. A total of 970 OHCA patients were enrolled in 2020, of whom 438 met the BLS TOR rule and 104 met the ALS TOR rule. The specificity and PPV for predicting unfavorable neurological outcomes were 85.7% and 100%, respectively, for the BLS TOR rule and 99.5% and 100%, respectively, for the ALS TOR rule.

CONCLUSIONS

Both the BLS and ALS TOR rules performed better when using the 2015 AHA resuscitation protocols compared to the 2010 protocols, with increased PPVs and decreased false-positive rates in predicting survival to discharge and good neurological outcomes at discharge. The BLS and ALS TOR rules can perform differently while the resuscitation protocols are updated. As the concepts and practices of resuscitation progress, the BLS and ALS TOR rules should be evaluated and validated accordingly.

The impact of bystander cardiopulmonary resuscitation on patients with out-of-hospital cardiac arrests

Out-of-hospital cardiac arrest (OHCA) is one of the leading causes of death around the world. Bystander cardiopulmonary resuscitation (CPR) is an independent factor to improve OHCA survival. However, the prevalence of bystander CPR remains low worldwide. Community interventions such as mandatory school CPR training or targeting CPR training to family members of high-risk cardiac patients are possible strategies to improve bystander CPR rate. Real-time feedback, hands-on practice with a manikin, and metronome assistance may increase the quality of CPR. Dispatcher-assistance and compression-only CPR for untrained bystanders have shown to increase bystander CPR rate and increase survival to hospital discharge. After return of spontaneous circulation, targeted temperature management should be performed to improve neurological function. This review focuses on the impact of bystander CPR on clinical outcomes and strategies to optimize the prevalence and quality of bystander CPR.

Early recognition of a caller's emotion in out-of-hospital cardiac arrest dispatching: An artificial intelligence approach

AIM

This study aimed to develop an AI model for detecting a caller's emotional state during out-of-hospital cardiac arrest calls by processing audio recordings of dispatch communications.

METHODS

Audio recordings of 337 out-of-hospital cardiac arrest calls from March-April 2011 were retrieved. The callers' emotional state was classified based on the emotional content and cooperative scores. Mel-frequency cepstral coefficients extracted essential information from the voice signals. A support vector machine was utilised for the automatic judgement, and repeated random sub-sampling cross validation (RRS-CV) was applied to evaluate robustness. The results from the artificial intelligence classifier were compared with the consensus of expert reviewers.

RESULTS

The audio recordings were classified into five emotional content and cooperative score levels. The proposed model had an average positive predictive value of 72.97%, a negative predictive value of 93.47%, sensitivity of 38.76%, and specificity of 98.29%. If only the first 10 seconds of the recordings were considered, it had an average positive predictive value of 84.62%, a negative predictive value of 93.57%, sensitivity of 52.38%, and specificity of 98.64%. The artificial intelligence model's performance maintained preferable results for emotionally stable cases.

CONCLUSION

Artificial intelligence models can possibly facilitate the judgement of callers' emotional states during dispatch conversations. This model has the potential to be utilised in practice, by pre-screening emotionally stable callers, thus allowing dispatchers to focus on cases that are judged to be emotionally unstable. Further research and validation are required to improve the model's performance and make it suitable for the general population.

An essential review of Singapore's response to out-of-hospital cardiac arrests: improvements over a ten-year period

Care for patients who experience out-of-hospital cardiac arrest (OHCA) has rapidly evolved in the past decade. Increased sophistication of care in the community, emergency medical services (EMS) and hospital setting is associated with improved patient-centred outcomes. Notably, Utstein survival doubled from 11.6% to 23.1% between 2011 and 2016. These achievements involved collaboration between policymakers, clinicians and researchers, and were made possible by a strategic interplay of policy, research and implementation. We review the development and current state of OHCA in Singapore using primary population-based data from the Pan-Asian Resuscitation Outcomes Study and an unstructured search of research databases. We discuss the roles of important milestones in policy, community, dispatch, EMS and hospital interventions. Finally, we relate these interventions to relevant processes and outcomes, such as the relationship between the strategic implementation of bystander cardiopulmonary resuscitation and placement of automated external defibrillator with return of spontaneous circulation, survival to discharge and survival with favourable neurological outcomes.

Impact of dispatcher-assisted cardiopulmonary resuscitation on neurologically intact survival in out-of-hospital cardiac arrest: a systematic review

Background

Dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) increases neurologically intact survival in out-of-hospital cardiac arrest (OHCA) according to several studies. This systematic review summarizes neurologically intact survival outcomes of DA-CPR in comparison with bystander-initiated CPR and no bystander CPR in OHCA.

Methods

The systematic review was conducted according to the PRISMA guidelines. All studies including adult and/or pediatric OHCAs that compared DA-CPR with bystander-initiated CPR or no bystander CPR were included. Primary outcome was neurologically intact survival at discharge, one-month or longer. Studies were searched for in PubMed (MEDLINE), EMBASE, and the Cochrane Library databases. The risk of bias was evaluated using the Newcastle-Ottawa Scale.

Results

The search string generated 4742 citations of which 33 studies were eligible for inclusion. Due to overlapping study populations, the review included 14 studies. All studies were observational. The study populations were heterogeneous and included adult, pediatric and mixed populations. Some studies reported only witnessed cardiac arrests, arrests of cardiac ethiology, and/or shockable rhythm. The individual studies scored between six and nine on the Newcastle-Ottawa Scale of risk of bias. The median neurologically intact survival at hospital discharge with DA-CPR was 7.0% (interquartile range (IQR): 5.1–10.8%), with bystander-initiated CPR 7.5% (IQR: 6.6–10.2%), and with no bystander CPR 4.4% (IQR: 2.0–9.0%) (four studies). At one-month neurologically intact survival with DA-CPR was 3.1% (IQR: 1.6–3.4%), with bystander-initiated CPR 5.7% (IQR: 5.0–6.0%), and with no bystander CPR 2.5% (IQR: 2.1–2.6%) (three studies).

Conclusion

Both DA-CPR and bystander-initiated CPR increase neurologically intact survival compared with no bystander CPR. However, DA-CPR demonstrates inferior outcomes compared with bystander-initiated CPR. Early CPR is crucial, thus in cases where bystanders have not initiated CPR, DA-CPR provides an opportunity to improve neurologically intact survival following OHCA. Variability in OHCA outcomes across studies and multiple confounding factors were identified.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00875-5.

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.

European Resuscitation Council Guidelines 2021: Systems saving lives

The European Resuscitation Council (ERC) has produced these Systems Saving Lives guidelines, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include chain of survival, measuring performance of resuscitation, social media and smartphones apps for engaging community, European Restart a Heart Day, World Restart a Heart, KIDS SAVE LIVES campaign, lower-resource setting, European Resuscitation Academy and Global Resuscitation Alliance, early warning scores, rapid response systems, and medical emergency team, cardiac arrest centres and role of dispatcher.

Effects of telephone-assisted cardiopulmonary resuscitation on the sex disparity in provision of bystander cardiopulmonary resuscitation in public locations

PURPOSE

Telephone-assisted cardiopulmonary resuscitation (TA-CPR) is an effective community intervention to increase bystander CPR rates. This study evaluated the effect of TA-CPR on the provision of bystander CPR as a function of the patient's sex.

METHODS

Adult (aged ≥ 18 years) patients who collapsed in a public location between January 2013 and December 2017 and received emergency medical service (EMS) treatment for out-of-hospital cardiac arrest (OHCA) of presumed cardiac aetiology were included in the study. The main exposures were TA-CPR and the patients' sex. The primary outcome was the implementation of bystander CPR by laypersons. Multivariable logistic regression analysis was conducted, stratified based on the provision of TA-CPR, to examine the effect on bystander CPR according to patient sex.

RESULTS

In the final analysis, 15,840 patients with OHCAs were included. Patients who received TA-CPR accounted for 32.6% (5167/15,840) of the sample. Overall, 84.4% (814/964) of the women and 86.9% (3653/4203) of the men received bystander CPR in the TA-CPR group (P < 0.001). In the non-TA-CPR group, 40.5% (912/2252) of women and 47.3% (3653/8421) of men received bystander CPR (P < 0.001). In the multivariable logistic regression analysis, there was no significant difference in the odds ratio (OR) of bystander CPR according to patient sex in the TA-CPR group (adjusted OR [AOR], 0.83; 95% confidence interval [CI], 0.68-1.01). Women were less likely to receive bystander CPR if the bystanders are not directed by TA-CPR (AOR: 0.79; 95% CI, 0.70-0.87).

CONCLUSIONS

TA-CPR attenuated the sex disparity in bystander CPR provided in public places.

Impact of dispatcher-assisted cardiopulmonary resuscitation and myResponder mobile app on bystander resuscitation

INTRODUCTION

Bystander cardiopulmonary resuscitation (B-CPR) is associated with improved out-of hospital cardiac arrest survival. Community-level interventions including dispatcher-assisted CPR (DA-CPR) and myResponder were implemented to increase B-CPR. We sought to assess whether these interventions increased B-CPR.

METHODS

The Singapore out-of-hospital cardiac arrest registry captured cases that occurred between 2010 and 2017. Outcomes occurring in 3 time periods (Baseline, DA-CPR, and DA-CPR plus myResponder) were compared. Segmented regression of time-series data was conducted to investigate our intervention impact on the temporal changes in B-CPR.

RESULTS

A total of 13,829 out-of-hospital cardiac arrest cases were included from April 2010 to December 2017. Higher B-CPR rates (24.8% versus 50.8% vs 64.4%) were observed across the 3 time periods. B-CPR rates showed an increasing but plateauing trend. DA-CPR implementation was significantly associated with an increased B-CPR (level odds ratio [OR] 2.26, 95% confidence interval [CI] 1.79-2.88; trend OR 1.03, 95% CI 1.01-1.04), while no positive change was detected with myResponder (level OR 0.95, 95% CI 0.82-1.11; trend OR 0.99, 95% CI 0.98-1.00).

CONCLUSION

B-CPR rates in Singapore have been increasing alongside the implementation of community-level interventions such as DA-CPR and myResponder. DA-CPR was associated with improved odds of receiving B-CPR over time while the impact of myResponder was less clear.

Efficacy of a new dispatcher-assisted cardiopulmonary resuscitation protocol with audio call-to-video call transition

BACKGROUND

Video call based dispatcher-assisted cardiopulmonary resuscitation (V-DACPR) has been suggested to improve the quality of bystander cardiopulmonary resuscitation. In the current system, dispatchers must convert the audio calls to video calls to provide V-DACPR. We aimed to develop new audio call-to-video call transition protocols and test its efficacy and safety compared to conventional DACPR(C-DACPR).

METHODS

This was a randomized controlled simulation trial that compared the quality of bystander chest compression that was performed under three different DACPR protocols: C-DACPR, V-DACPR with rapid transition, and V-DACPR with delayed transition. Adult volunteers excluding healthcare providers were recruited for the trial. The primary outcome of the study was the mean proportion of adequate hand positioning during chest compression.

RESULTS

Simulation results of 131 volunteers were analyzed. The mean proportion of adequate hand positioning was highest in V-DACPR with rapid transition (V-DACPR with rapid transition vs. C-DACPR: 92.7% vs. 82.4%, p = 0.03). The mean chest compression depth was deeper in both V-DACPR groups than in the C-DACPR group (V-DACPR with rapid transition vs. C-DACPR: 40.7 mm vs. 35.9 mm, p = 0.01, V-DACPR with delayed transition vs. C- DACPR: 40.9 mm vs. 35.9 mm, p = 0.01). Improvement in the proportion of adequate hand positioning was observed in the V-DACPR groups (r = 0.25, p < 0.01 for rapid transition and r = 0.19, p < 0.01 for delayed transition).

CONCLUSION

Participants in the V-DACPR groups performed higher quality chest compression with higher appropriate hand positioning and deeper compression depth compared to the C-DACPR group.

Community Socioeconomic Status and Dispatcher-Assisted Cardiopulmonary Resuscitation for Patients with Out-of-Hospital Cardiac Arrest

Few studies have investigated the association between dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) performance and the outcomes of out-of-hospital cardiac arrest (OHCA) among communities with different socioeconomic statuses (SES). A retrospective cohort study was conducted using an Utstein-style population OHCA database in Tainan, Taiwan, between January 2014 and December 2015. SES was defined based on real estate prices. The outcome measures included the achievement of return of spontaneous circulation (ROSC) and the performance of DA-CPR. Statistical significance was set at a two-tailed p-value of less than 0.05. A total of 2928 OHCA cases were enrolled in the high SES (n = 1656, 56.6%), middle SES (n = 1025, 35.0%), and low SES (n = 247, 8.4%) groups. The high SES group had a significantly higher prehospital ROSC rate, ever ROSC rate, and sustained ROSC rate and good neurologic outcomes at discharge (all p < 0.005). The low SES group, compared to the high and middle SES groups, had a significantly longer dispatcher recognition time (p = 0.004) and lower early (≤60 s) recognition rate (p = 0.029). The high SES group, but none of the DA-CPR measures, had significant associations with sustained ROSC in the multivariate regression model. The low SES group was associated with a longer time to dispatcher recognition of cardiac arrest and worse outcomes of OHCA. Strategies to promote public awareness of cardiac arrest could be tailored to neighborhood SES.

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.

myResponder Smartphone Application to Crowdsource Basic Life Support for Out-of-Hospital Cardiac Arrest: The Singapore Experience

OBJECTIVE

The Singapore myResponder is a novel smartphone application developed by the Singapore Civil Defence Force (SCDF) that notifies volunteer first responders of a suspected out-of-hospital cardiac arrest (OHCA) case and locations of Automated External Defibrillators (AED) in the vicinity so that they can assist with resuscitation. We aimed to examine the performance of this application, challenges encountered, and future directions. Methods: We analyzed data from the myResponder app since its launch from April 2015 to July 2019. The number of installations, registered community first responders, suspected OHCA cases, notifications sent by the app, percentage of responders who accepted activation and arrived at scene were reviewed. A subgroup of taxi driving responders (within a 1.5-kilometer response radius) carrying an AED under a subsequent pilot program was also analyzed. Results: By July 2019, 46,689 responders were registered in the myResponder app. There were a total of 19,189 cases created for suspected OHCA, with a median of 358 cases per month (IQR 330-430), in which 10,073 responders accepted activation from myResponder and 4,955 arrived on-scene. A total of 135,599 notifications were sent for these cases, with a median of 7.1 notifications per case (IQR 4.3-8.7). In 2019, the percentages of responders who accepted notification and arrived on scene were 45.8% and 24.1%, respectively. 43% (1110/2581) of responders arrived before EMS crew. Conclusion: The myResponder mobile application is a feasible smart technology solution to improve community response to OHCA, and to increase bystander CPR and AED use. Future directions include increasing the number of active responders, improving response rates, app performance, and better data capture for quality improvement.

The Effectiveness of a New Dispatcher-Assisted Basic Life Support Training Program on Quality in Cardiopulmonary Resuscitation Performance During Training and Willingness to Perform Bystander Cardiopulmonary Resuscitation: A Cluster Randomized Controlled Study

INTRODUCTION

A new dispatcher-assisted basic life support training program, called "Home Education and Resuscitation Outcome Study (HEROS)" was developed with a goal to provide high-quality dispatcher-assisted cardiopulmonary resuscitation (CPR) training, with a focus on untrained home bystanders. This study aimed to determine whether the HEROS program is associated with improved quality in CPR performance during training and willingness to provide bystander CPR compared with other basic life support programs without dispatcher-assisted CPR (non-HEROS).

METHODS

This clustered randomized trial was conducted in 3 district health centers in Seoul. Intervention group was trained with the HEROS program and control group was trained with non-HEROS program. The primary outcome was overall CPR quality, measured as total CPR score. Secondary outcomes were other CPR quality parameters including average compression depth and rate, percentages of adequate depth, and acceptable release. Tertiary outcomes were posttraining survey results. Difference in difference analysis was performed to analyze the outcomes.

RESULTS

Among total 1929 trainees, 907 (47.0%) were trained with HEROS program. Compared with the non-HEROS group, the HEROS group showed higher-quality CPR performances and better maintenance of their CPR quality throughout the course (total scores of 84% vs. 80% for first session and 72% vs. 67% for last session; difference in difference of 12.2 vs. 13.2). Other individual CPR parameters also showed significantly higher quality in the HEROS group. The posttraining survey showed that both groups were highly willing to perform bystander CPR (91.4% in the HEROS vs. 92.3% in the non-HEROS) with only 3.4% of respondents in the HEROS group were not willing to volunteer compared with 6.2% in the non-HEROS group (P < 0.01).

CONCLUSIONS

The HEROS training program helped trainees perform high-quality CPR throughout the course and enhanced their willingness to provide bystander CPR.

Factors associated with return of spontaneous circulation after out-of-hospital cardiac arrest in Poland: a one-year retrospective study

Background

Out-of-hospital cardiac arrest (OHCA) is a common reason for calls for intervention by emergency medical teams (EMTs) in Poland. Regardless of the mechanism, OHCA is a state in which the chance of survival is dependent on rapid action from bystanders and responding health professionals in emergency medical services (EMS). We aimed to identify factors associated with return of spontaneous circulation (ROSC).

Methods

The medical records of 2137 EMS responses to OHCA in the city of Wroclaw, Poland between July 2017 and June 2018 were analyzed.

Results

The OHCA incidence rate for the year studied was 102 cases per 100,000 inhabitants. EMS were called to 2317 OHCA events of which 1167 (50.4%) did not have resuscitation attempted on EMS arrival. The difference between the number of successful and failed cardiopulmonary resuscitations (CPRs) was statistically significant (p < 0.001). Of 1150 patients in whom resuscitation was attempted, ROSC was achieved in 250 (27.8%). Rate of ROSC was significantly higher when CPR was initiated by bystanders (p < 0.001). Patients presenting with asystole or pulseless electrical activity (PEA) had a higher risk of CPR failure (86%) than those with ventricular fibrillation/ventricular tachycardia (VF/VT). Patients with VF/VT had a higher chance of ROSC (OR 2.68, 1.86–3.85) than those with asystole (p < 0.001). The chance of ROSC was 1.78 times higher when the event occurred in a public place (p < 0.001).

Conclusions

The factors associated with ROSC were occurrence in a public place, CPR initiation by witnesses, and presence of a shockable rhythm. Gender, age, and the type of EMT did not influence ROSC. Low bystander CPR rates reinforce the need for further efforts to train the public in CPR.

Dispatcher-Assisted Cardiopulmonary Resuscitation: Disparity between Urban and Rural Areas

Methods

Patients with out-of-hospital cardiac arrest (OHCA) were prospectively registered in Taichung. The 29 districts of Taichung city were divided into urban and rural areas based on whether the population density is more than 1,000 people per square kilometer. Prehospital data were collected according to the Utstein-style template, and telephone auditory records were collected by a dispatch center.

Results

2,716 patients were enrolled during the study period. 88.4% OHCA occurred in urban areas and 11.6% in rural areas. 74.9% after dispatcher assistance, laypersons performed CPR in urban areas and 67.7% in rural areas (p=0.023). The proportion of laypersons continued CPR until an emergency medical technician's (EMT) arrival was higher in the urban areas (59.57% vs 52.27%, p=0.039). Laypersons continued CPR until an EMT' arrival would increase the chance of return of spontaneous circulation in urban and rural areas, with adjusted odds ratio (aOR) of 1.02, 95% confidence interval (CI) of 0.82–1.27, and aOR of 1.49, 95% CI of 0.80–2.80, respectively. Continued laypersons CPR until the EMT' arrival also improved survival with favorable neurological function, with aOR of 1.16, 95% CI of 0.61–2.20 in urban areas and aOR of 2.90 95% CI of 0.18–46.81 in rural areas.

Conclusion

Bystanders in urban areas exhibited higher ratio of acceptance of DACPR. However, after DACPR intervention, prognosis improvement was considerably higher in rural areas than in urban areas.

Impact of Dispatcher-Assisted Bystander Cardiopulmonary Resuscitation with Out-of-Hospital Cardiac Arrest: A Systemic Review and Meta-Analysis

OBJECTIVE

This systemic review and meta-analysis was conducted to explore the impact of dispatcher-assisted bystander cardiopulmonary resuscitation (DA-BCPR) on bystander cardiopulmonary resuscitation (BCPR) probability, survival, and neurological outcomes with out-of-hospital cardiac arrest (OHCA).

METHODS

Electronically searching of PubMed, Embase, and Cochrane Library, along with manual retrieval, were done for clinical trials about the impact of DA-BCPR which were published from the date of inception to December 2018. The literature was screened according to inclusion and exclusion criteria, the baseline information, and interested outcomes were extracted. Two reviewers assessed the methodological quality of the included studies. Pooled odds ratio (OR) and 95% confidence interval (CI) were calculated by STATA version 13.1.

RESULTS

In 13 studies, 235,550 patients were enrolled. Compared with no dispatcher instruction, DA-BCPR tended to be effective in improving BCPR rate (I2 = 98.2%; OR = 5.84; 95% CI, 4.58-7.46; P <.01), return of spontaneous circulation (ROSC) before admission (I2 = 36.0%; OR = 1.17; 95% CI, 1.06-1.29; P <.01), discharge or 30-day survival rate (I2 = 47.7%; OR = 1.25; 95% CI, 1.06-1.46; P <.01), and good neurological outcome (I2 = 30.9%; OR = 1.24; 95% CI, 1.04-1.48; P = .01). However, no significant difference in hospital admission was found (I2 = 29.0%; OR = 1.09; 95% CI, 0.91-1.30; P = .36).

CONCLUSION

This review shows DA-BPCR plays a positive role for OHCA as a critical section in the life chain. It is effective in improving the probability of BCPR, survival, ROSC before admission, and neurological outcome.

Nationwide trends in residential and non-residential out-of-hospital cardiac arrest and differences in bystander cardiopulmonary resuscitation

AIMS

Singapore is highly-urbanized, with >90% of the population living in high-rise apartments. She has implemented several city-wide interventions such as dispatcher-assisted CPR, community CPR training and smartphone activation of volunteers to increase bystander CPR (BCPR) rates for out-of-hospital cardiac arrest (OHCA). These may have different impact on residential and non-residential OHCA. We aimed to evaluate the characteristics, processes-of-care and outcome differences between residential and non-residential OHCA and study the differences in temporal trends of BCPR rates.

METHODS

This was a national, observational study in Singapore from 2010 to 2016, using data from the prospective Pan-Asian Resuscitation Outcomes Study. The primary outcome was survival (to-discharge or to-30-days). Multivariate logistic regression was performed to determine the effect of location-type on survival and a test of statistical interaction was performed to assess the difference in the temporal relationship of BCPR rates between location-type.

RESULTS

8397 cases qualified for analysis, of which 5990 (71.3%) were residential. BCPR and bystander automated external defibrillator (AED) rates were significantly lower in residential as compared to non-residential arrests (41.0% vs 53.6%, p < 0.01; 0.4% vs 10.8%, p < 0.01 respectively). Residential BCPR increased from 15.8% (2010) to 57.1% (2016). Residential cardiac arrests had lower survival-to-discharge (2.9% vs 10.1%, p < 0.01). Multivariate logistic regression analysis showed that location-type had an independent effect on survival, with residential arrests having poorer survival compared to non-residential cardiac arrests (adjusted OR 0.547 [0.435-0.688]). A test of statistical interaction showed a significant interaction effect between year and location-type for bystander CPR, with a narrowing of differences in bystander CPR between residential and non-residential cardiac arrests over the years.

CONCLUSION

Residential cardiac arrests had poorer bystander intervention and survival from 2010 to 2016 in Singapore. BCPR had improved more in residential arrests compared to non-residential arrests over a period of city-wide interventions to improve BCPR.

Getting R-AEDI to save lives in Singapore

Early cardiopulmonary resuscitation (CPR) and defibrillation prior to the arrival of emergency medical services can improve survival from out-of-hospital cardiac arrest (OHCA) with good neurological outcome. However, the rate of local bystander CPR is only 24.3% and bystander defibrillation 2.1%. In 2015, the R-AEDI (Registry for AED Integration) initiative was started to improve OHCA survival rates. R-AEDI alerts volunteers to nearby OHCA cases via the myResponder mobile application. In 2015-2017, 7,682 AEDs were mapped and made accessible via this app. Comprehensive site inspections also resulted in fewer non-functional AEDs, as AED owners were educated on the importance of the maintenance of pads and batteries. The AED heat map allows us to identify areas that are lacking in or require improved public access AED coverage. The online AED registry found in the myResponder app is useful to locate AEDs rapidly during OHCAs. More community education would improve the rate of bystander defibrillation.

Key components of a community response to out-of-hospital cardiac arrest

Out-of-hospital cardiac arrest (OHCA) remains a leading cause of death worldwide, with substantial geographical, ethnic and socioeconomic disparities in outcome. Successful resuscitation efforts depend on the 'chain of survival', which includes immediate recognition of cardiac arrest and activation of the emergency response system, early bystander cardiopulmonary resuscitation (CPR) with an emphasis on chest compressions, rapid defibrillation, basic and advanced emergency medical services and integrated post-cardiac arrest care. Well-orchestrated telecommunicator CPR programmes can improve rates of bystander CPR - a critical link in the chain of survival. High-performance CPR by emergency medical service providers includes minimizing interruptions in chest compressions and ensuring adequate depth of compressions. Developing local, regional and statewide systems with dedicated high-performing cardiac resuscitation centres for post-resuscitation care can substantially improve survival after OHCA. Innovative digital tools for recognizing cardiac arrest where and when it occurs, notifying potential citizen rescuers and providing automated external defibrillators at the scene hold the promise of improving survival after OHCA. Improved implementation of the chain of survival can save thousands of lives each year.

Comparison of the effects of audio-instructed and video-instructed dispatcher-assisted cardiopulmonary resuscitation on resuscitation outcomes after out-of-hospital cardiac arrest

BACKGROUND

This study compared the real-world effects of audio-instructed dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) and video-instructed DA-CPR on resuscitation outcomes after out-of-hospital cardiac arrest (OHCA).

METHODS

A retrospective cohort study was conducted among adult OHCA patients in whom resuscitation was attempted in 2017 in Seoul, Korea. The dispatch center of Seoul introduced video-instructed DA-CPR in 2017, whereas audio-instructed DA-CPR was first implemented in 2010. When more than two bystanders were at the scene and could handle a video-call, the dispatcher call back a video-call and provided CPR instructions. In other situations, standard audio-instructed DA-CPR was provided. The primary outcome was survival to discharge. The secondary outcome was good neurological outcome at hospital discharge. The tertiary outcome was early instruction time interval (ITI, time from call to the initiation of CPR instruction ≤90 s). The study outcomes of audio-instructed DA-CPR (audio group) and video-instructed DA-CPR (video group) were compared. The propensity score matching (PSM) method was used to increase the comparability of the two groups and the logistic regression was performed for the PSM cohort.

RESULTS

A total of 1720 eligible OHCA patients (1489 and 231 in the audio and video groups, respectively) were evaluated. The median ITI was 136 s in the audio group and 122 s in the video group (p = 0.12). The survival to discharge rates were 8.9% in the audio group and 14.3% in the video groups (p < 0.01). Good neurological outcome occurred in 5.8% and 10.4% in the audio and video groups, respectively (p < 0.01). Compared to the audio group, the AORs (95% CIs) for survival to discharge, good neurological outcome and early ITI of the video group were 1.20 (0.74-1.94), 1.28 (0.73-2.26) and 1.00 (0.70-1.43), respectively. The PSM population showed similar results as those of the original cohort.

CONCLUSION

Compared to audio-instructed DA-CPR, video-instructed DA-CPR was not associated with survival improvement in this observational study conducted in one metropolitan city. Randomized controlled trials are needed to compare the effects of video- and audio-instructed DA-CPR.

2019 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the third annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. It addresses the most recent published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. This summary addresses the role of cardiac arrest centers and dispatcher-assisted cardiopulmonary resuscitation, the role of extracorporeal cardiopulmonary resuscitation in adults and children, vasopressors in adults, advanced airway interventions in adults and children, targeted temperature management in children after cardiac arrest, initial oxygen concentration during resuscitation of newborns, and interventions for presyncope by first aid providers. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the certainty of the evidence on the basis of the Grading of Recommendations, Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence to Decision Framework Highlights sections. The task forces also listed priority knowledge gaps for further research.

2019 American Heart Association Focused Update on Systems of Care: Dispatcher-Assisted Cardiopulmonary Resuscitation and Cardiac Arrest Centers: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Survival after out-of-hospital cardiac arrest requires an integrated system of care (chain of survival) between the community elements responding to an event and the healthcare professionals who continue to care for and transport the patient for appropriate interventions. As a result of the dynamic nature of the prehospital setting, coordination and communication can be challenging, and identification of methods to optimize care is essential. This 2019 focused update to the American Heart Association systems of care guidelines summarizes the most recent published evidence for and recommendations on the use of dispatcher-assisted cardiopulmonary resuscitation and cardiac arrest centers. This article includes the revised recommendations that emergency dispatch centers should offer and instruct bystanders in cardiopulmonary resuscitation during out-of-hospital cardiac arrest and that a regionalized approach to post-cardiac arrest care may be reasonable when comprehensive postarrest care is not available at local facilities.

Dispatcher assisted cardiopulmonary resuscitation implementation in Kuwait: A before and after study examining the impact on outcomes of out of hospital cardiac arrest victims

Dispatcher assisted cardiopulmonary resuscitation (DACPR) by Emergency medical services has been shown to improve rates of early out of hospital cardiac arrest (OHCA) recognition and early cardiopulmonary resuscitation (CPR) for OHCA. This study measures the impact of introducing DACPR on OHCA recognition, CPR rates and on patient outcomes in a pilot region in Kuwait.EMS treated OHCA data over 10 months period (February 21-December 31, 2017) before and after the intervention was prospectively collected and analyzed.Comprehensive DACPR in the form of: a standardized dispatch protocol, 1-day training package and quality assurance and improvement measures were applied to Kuwait EMS central Dispatch unit only for pilot region. Primary outcomes: OHCA recognition rate, CPR instruction rate, and Bystander CPR rate. Secondary outcome: survival to hospital discharge.A total of 332 OHCA cases from the EMS archived data were extracted and after exclusion 176 total OHCA cases remain. After DACPR implementation OHCA recognition rate increased from 2% to 12.9% (P = .037), CPR instruction rate increased from 0% to 10.4% (P = .022); however, no significant change was noted for bystander CPR rates or prehospital return of spontaneous circulation. Also, survival to hospital discharge rate did not change significantly (0% before, and 0.8% after, P = .53)In summary, DACPR implementation had positive impacts on Kuwait EMS system operational outcomes; early OHCA recognition and CPR instruction rates in a pilot region of Kuwait. Expanding this initiative to other regions in Kuwait and coupling it with other OHCA system of care interventions are needed to improve OHCA survival rates.

Dispatcher-assisted cardiopulmonary resuscitation for traumatic patients with out-of-hospital cardiac arrest

Background

Resuscitation efforts for traumatic patients with out-of-hospital cardiac arrest (OHCA) are not always futile. Dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) during emergency calls could increase the rate of bystander cardiopulmonary resuscitation (CPR) and thus may enhance survival and neurologic outcomes of non-traumatic OHCA. This study aimed to examine the effectiveness of DA-CPR for traumatic OHCA.

Methods

A retrospective cohort study was conducted using an Utstein-style population database with data from January 1, 2014, to December 31, 2016, in Tainan City, Taiwan. Voice recordings of emergency calls were retrospectively retrieved and reviewed. The primary outcome was an achievement of sustained (≥2 h) return of spontaneous circulation (ROSC); the secondary outcomes were prehospital ROSC, ever ROSC, survival at discharge and favourable neurologic status at discharge. Statistical significance was set at a p-value of less than 0.05.

Results

A total of 4526 OHCA cases were enrolled. Traumatic OHCA cases (n = 560, 12.4%), compared to medical OHCA cases (n = 3966, 87.6%), were less likely to have bystander CPR (10.7% vs. 31.7%, p < 0.001) and initially shockable rhythms (7.1% vs. 12.5%, p < 0.001). Regarding DA-CPR performance, traumatic OHCA cases were less likely to have dispatcher recognition of cardiac arrest (6.3% vs. 42.0%, p < 0.001), dispatcher initiation of bystander CPR (5.4% vs. 37.6%, p < 0.001), or any dispatcher delivery of CPR instructions (2.7% vs. 20.3%, p < 0.001). Stepwise logistic regression analysis showed that witnessed cardiac arrests (aOR 1.70, 95% CI 1.10–2.62; p = 0.017) and transportation to level 1 centers (aOR 1.99, 95% CI 1.27–3.13; p = 0.003) were significantly associated with achievement of sustained ROSC in traumatic OHCA cases, while DA-CPR-related variables were not (All p > 0.05).

Conclusions

DA-CPR was not associated with better outcomes for traumatic OHCA in achieving a sustained ROSC. The DA-CPR program for traumatic OHCAs needs further studies to validate its effectiveness and practicability, especially in the communities where rules for the termination of resuscitation in prehospital settings do not exist.

Isolated right ventricle infarction

We described two patients who were successfully resuscitated from out-of-hospital cardiac arrest. Their ECGs showed ST elevations in V1 and aVR, as well as diffuse ST depression. Their ST elevation in V1 was noted to be greater than in aVR. While one patient was found to have an occlusion of the right ventricular (RV) branch of the right coronary artery, the other was found to have an occlusion of a proximal non-dominant right coronary artery supplying the RV branch. Successful primary percutaneous coronary intervention was performed for each patient with angioplasty and implantation of a drug-eluting stent. Both patients made good physical and neurological recovery.

Impact of the caller’s emotional state and cooperation on out-of-hospital cardiac arrest recognition and dispatcher-assisted cardiopulmonary resuscitation

Objective

This study determined the impact of the caller’s emotional state and cooperation on out-of-hospital cardiac arrest (OHCA) recognition and dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) performance metrics.

Methods

This was a retrospective study using data from November 2015 to October 2016 from the emergency medical service dispatching centre in northern Taiwan. Audio recordings of callers contacting the centre regarding adult patients with non-traumatic OHCA were reviewed. The reviewers assigned an emotional content and cooperation score (ECCS) to the callers. ECCS 1–3 callers were graded as cooperative and ECCS 4–5 callers as uncooperative and highly emotional. The relation between ECCS and OHCA recognition, time to key events and DA-CPR delivery were investigated.

Results

Of the 367 cases, 336 (91.6%) callers were assigned ECCS 1–3 with a good inter-rater reliability (k=0.63). Dispatchers recognised OHCA in 251 (68.4%) cases. Compared with callers with ECCS 1, callers with ECCS 2 and 3 were more likely to give unambiguous responses about the patient’s breathing status (adjusted OR (AOR)=2.6, 95% CI 1.1 to 6.4), leading to a significantly higher rate of OHCA recognition (AOR=2.3, 95% CI 1.1 to 5.0). Thirty-one callers were rated uncooperative (ECCS 4–5) but had shorter median times to OHCA recognition and chest compression (29 and 122 s, respectively) compared with the cooperative caller group (38 and 170 s, respectively). Nevertheless, those with ECCS 4–5 had a significantly lower DA-CPR delivery rate (54.2% vs 85.9%) due to ‘caller refused’ or ‘overly distraught’ factors.

Conclusions

The caller’s high emotional state is not a barrier to OHCA recognition by dispatchers but may prevent delivery of DA-CPR instruction. However, DA-CPR instruction followed by first chest compression is possible despite the caller’s emotional state if dispatchers are able to skilfully reassure the emotional callers.

Dispatcher-assisted cardiopulmonary resuscitation for paediatric out-of-hospital cardiac arrest: A structured evaluation of communication issues using the SACCIA® safe communication typology

AIM

To evaluate communication issues during dispatcher-assisted cardiopulmonary resuscitation (DACPR) for paediatric out-of-hospital cardiac arrest in a structured manner to facilitate recommendations for training improvement.

METHODS

A retrospective observational study evaluated DACPR communication issues using the SACCIA^® Safe Communication typology (Sufficiency, Accuracy, Clarity, Contextualization, Interpersonal Adaptation). Telephone recordings of 31 cases were transcribed verbatim and analysed with respect to encoding, decoding and transactional communication issues.

RESULTS

Sixty SACCIA communication issues were observed in the 31 cases, averaging 1.9 issues per case. A majority of the issues were related to sufficiency (35%) and accuracy (35%) of communication between dispatcher and caller. Situation specific guideline application was observed in CPR practice, (co)counting and methods of compressions.

CONCLUSION

This structured evaluation identified specific issues in paediatric DACPR communication. Our training recommendations focus on situation and language specific guideline application and moving beyond verbal communication by utilizing the smart phone's functions. Prospective efforts are necessary to follow-up its translation into better paediatric DACPR outcomes.

The use of dispatcher assistance in improving the quality of cardiopulmonary resuscitation: A randomised controlled trial

AIMS

The introduction of dispatcher assistance (DA) services has led to increased bystander cardiopulmonary resuscitation (CPR) participation rates. However, the extent to which DA improves CPR quality remains unclear. This study aimed to evaluate the efficacy of DA in improving CPR quality among healthcare professionals and laypersons within a multi-ethnic Southeast Asian population.

METHODS

A parallel, randomised controlled, open label trial was performed. Four hundred and twelve participants were recruited via convenience sampling in a public location. In a simulated cardiac-arrest scenario, the participants were randomised to perform CPR with DA over the phone (DA+) or CPR without DA (DA-). The ratio of participant assignment to DA+ and DA- was 1:1. The primary outcomes were CPR compression depth, compression rate, no-flow time, complete release of pressure between compressions, and hand location. The assessment involved CPR manikins and human assessors.

RESULTS

A larger proportion of participants in DA + achieved the correct compression rate (34.3% vs 18.1%, p < 0.001). There was no difference in the other primary outcomes. A subgroup analysis revealed that healthcare professionals in DA+ had a higher proportion of correct hand location compared to those in DA- (82.1% vs. 53.5%, p < 0.05). There was no significant difference in CPR quality among laypersons with valid CPR certification regardless of whether they received DA.

CONCLUSION

DA should be provided to laypersons without valid CPR certification, as well as healthcare professionals. The identification of gaps in the current DA protocol highlights areas where specific changes can be made to improve CPR quality.

A systematic review and meta-analysis of the effect of dispatcher-assisted CPR on outcomes from sudden cardiac arrest in adults and children

BACKGROUND

Dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) has been reported in individual studies to significantly increase the rate of bystander CPR and survival from cardiac arrest.

METHODS

We undertook a systematic review and meta-analysis to evaluate the impact of DA-CPR programs on key clinical outcomes following out-of-hospital cardiac arrest. We searched the PubMED, EMBASE, CINAHL, ERIC and Cochrane Central Register of Controlled Trials databases from inception until July 2018. Eligible studies compared systems with and without dispatcher-assisted CPR programs. The results of included studies were classified into 3 categories for the purposes of more accurate analysis: comparison of outcomes in systems with DA-CPR programs, case-based comparison of DA-CPR to bystander CPR, and case-based comparisons of DA-CPR to no CPR before EMS arrival. The GRADE system was used to assess certainty of evidence at an outcome level. We used random-effects models to produce summary effect sizes across all outcomes.

RESULTS

Of 5531 citations screened, 33 studies were eligible for inclusion. All included studies were observational. Evidence certainty across all outcomes was assessed as low or very low. In system-level and patient-level comparisons, the provision of DA-CPR compared with no DA-CPR was consistently associated with improved outcome across all analyses. Comparison of DA-CPR to bystander CPR produced conflicting results. Findings were consistent across sensitivity analyses and the pediatric sub-group.

CONCLUSION

These results support the recommendation that dispatchers provide CPR instructions to callers for adults and children with suspected OHCA. Review registration: PROSPERO- CRD42018091427.

Does dispatcher-assisted bystander CPR improve outcomes from adult out-of-hospital cardiac arrest?

This short review addresses the evidence behind dispatcher-assisted CPR (DA-CPR) and whether it contributes to overall survival of out-of-hospital cardiac arrest (OHCA). Six papers directly addressed the review question and were selected for appraisal, including one systematic review. The outcomes of these studies demonstrate variable results from the implementation of DA-CPR strategies. While DA-CPR has some utility as a substitute for spontaneously delivered bystander CPR, available evidence suggests there is scope to improve. Further work should focus on the identification and adoption of more effective protocols.

Comparison of Outcomes and Characteristics of Emergency Medical Services (EMS)-Witnessed, Bystander-Witnessed, and Unwitnessed Out-of-Hospital Cardiac Arrests in Singapore

Objectives: The objective was to compare the survival outcomes of emergency medical services (EMS)-witnessed to bystander-witnessed, and unwitnessed out-of-hospital cardiac arrests (OHCA) in Singapore. Secondary aims are to describe the 5-year trend in survival rates of EMS-witnessed arrests. Methods: This was a retrospective analysis of the Singapore's OHCA registry data from 2011 to 2015. Excluded from the analysis were patients younger than 18 years old, arrests of traumatic etiology, resuscitation not attempted, and cases not conveyed by EMS. The primary outcome was survival to hospital discharge or 30 days post-arrest. Secondary outcomes were return of spontaneous circulation (ROSC) and survival to hospital admission. Results: 8,394 cases were analyzed, with 650 (7.7%) EMS-witnessed arrests, 4480 (53.4%) bystander-witnessed arrests, and 3264 (38.9%) unwitnessed arrests. Among EMS-witnessed arrests, the majority were presumed to be of cardiac etiology (62.8%) and the most common presenting rhythm was pulseless electrical activity (PEA; 57.2%). Survival to discharge or 30^th day post-arrest was higher in EMS-witnessed arrests compared to bystander-witnessed and unwitnessed arrests (11.2% vs. 5.3% and 1.3%, p < 0.001). Survival to discharge for EMS-witnessed cases increased from 2011 (13.2%) to 2015 (18.9%). Conclusions: EMS-witnessed OHCAs were more likely to have favorable outcomes compared to bystander-witnessed and unwitnessed OHCAs. High PEA rates in EMS-witnessed arrests were associated with older patients with underlying preexisting medical conditions. Increasing public awareness on recognition of prodromal symptoms and early activation of EMS could improve post-arrest survival and neurological outcomes of OHCA.

Effect of National Implementation of Telephone CPR Program to Improve Outcomes from Out-of-Hospital Cardiac Arrest: an Interrupted Time-Series Analysis

BACKGROUND

In cardiac arrest, the survival rate increases with the provision of bystander cardiopulmonary resuscitation (CPR), of which the initial response and treatment are critical. Telephone CPR is among the effective methods that might increase the provision of bystander CPR. This study aimed to describe and examine the improvement of neurological outcomes in individuals with out-of-hospital acute cardiac arrest by implementing the nationwide, standardized telephone CPR program.

METHODS

Data from the emergency medical service-based cardiac arrest registry that were collected between 2009 and 2014 were used. The effectiveness of the intervention in the interrupted time-series study was determined via a segmented regression analysis, which showed the risk ratio and risk difference in good neurological outcomes before and after the intervention.

RESULTS

Of 164,221 patients, 148,403 were analyzed. However, patients with unknown sex and limited data on treatment outcomes were excluded. Approximately 64.3% patients were men, with an average age of 63.7 years. The number of bystander CPR increased by 3.3 times (95% confidence interval [CI], 3.1-3.5) after the intervention, whereas the rate of good neurological outcomes increased by 2.6 times (95% CI, 2.3-2.9 [1.6%]; 1.4-1.7). The excess number was identified based on the differences between the observed and predicted trends. In total, 2,127 cases of out-of-hospital cardiac arrest (OHCA) after the intervention period received additional bystander CPR, and 339 cases of OHCA had good neurological outcomes.

CONCLUSION

The nationwide implementation of the standardized telephone CPR program increased the number of bystander CPR and improved good neurological outcomes.

Dispatcher CPR Instructions Across the Age Continuum

Background

Survival rates following out-of-hospital cardiac arrest (OHCA) increase two to three times when cardiopulmonary resuscitation (CPR) is started by bystanders, as compared to starting CPR when Emergency Medical Services (EMS) arrives. Municipalities that have implemented dispatcher-assisted bystander CPR programs have seen increased rates of bystander CPR. Cardiopulmonary resuscitation instructions are given for victims of all ages, but it is unknown if offering instructions results in similar rates of EMS-documented bystander CPR across the age continuum in these municipalities.

Objectives

The aim of this study was to determine if there is a difference in EMS-documented bystander CPR rates based on the age group of the OHCA victim when dispatcher CPR instructions are available in the community.

Methods

This was a three-year, retrospective chart review of OHCA patients in two municipalities within a single county that provided dispatcher-assisted CPR instructions. Bystander CPR and patient age were determined based on EMS documentation. Age was stratified into three groups: child (0-12 years), adult (13-54 years), and geriatric (≥55 years). Chi square was used to compare the rate of bystander CPR in each age group.

Results

During the study period, 1,993 patients were identified as being in OHCA at the time of EMS arrival. The overall bystander CPR rate was 10%. The highest rate of bystander CPR was in the child age group (19%). The lowest rate of bystander CPR was in the geriatric age group (9%). There was a statistically significant difference between age groups (P≤.01).

Conclusions

The rate of EMS-documented bystander CPR was low, even though these municipalities provided dispatcher-assisted CPR instructions. The highest rates of bystander CPR were observed in children (0-12 years). Future investigations should determine why this occurs and if there are opportunities to modify dispatcher coaching based on patient age so that bystander CPR rates improve.

WeinmeisterKL, LernerEB, GuseCE, AteyyahKA, PirralloRG. Dispatcher CPR instructions across the age continuum. Prehosp Disaster Med. 2018;33(3):342–345.

The Pan-Asian Resuscitation Outcomes Study (PAROS) clinical research network: what, where, why and how

Out-of-hospital cardiac arrest (OHCA) is a global health concern with an incidence rate of 50-60 per 100,000 person-years. To improve OHCA survival rates, several cardiac arrest registries have been set up in North America and Europe, such as the Resuscitation Outcomes Consortium, Cardiac Arrest Registry to Enhance Survival, Ontario Prehospital Advanced Life Support and European Registry of Cardiac Arrest. In Asia, however, there was previously no concerted effort in prehospital emergency care research owing to differences in prehospital emergency medical services systems, data collection methods and outcome reporting between countries. Recognising the need for a collaborative prehospital emergency care research group in Asia, researchers from seven countries in the Asia-Pacific region (including Japan, South Korea, Taiwan, Thailand, United Arab Emirates-Dubai, Singapore and Malaysia) established the Pan-Asian Resuscitation Outcomes Study (PAROS) clinical research network in 2010. This paper gives the overview, methodology and research accomplishments of the PAROS network.

The role of dispatch in resuscitation

The role of the dispatch centre has increasingly become a focus of attention in cardiac arrest resuscitation. The dispatch centre is part of the first link in the chain of survival because without the initiation of early access, the rest of the chain is irrelevant. The influence of dispatch can also extend to the initiation of bystander cardiopulmonary resuscitation, early defibrillation and the rapid dispatch of emergency ambulances. The new International Liaison Committee on Resuscitation, the American Heart Association and, especially, the European Resuscitation Council 2015 guidelines have been increasing their emphasis on dispatch as the key to improving out-of-hospital cardiac arrest survival.