Community trends in CPR training and use: the Minnesota Heart Survey

Disparities in Emergency Medical Services Care Delivery in the United States: A Scoping Review

BACKGROUND

Emergency medical services (EMS) often serve as the first medical contact for ill or injured patients, representing a critical access point to the health care delivery continuum. While a growing body of literature suggests inequities in care within hospitals and emergency departments, limited research has comprehensively explored disparities related to patient demographic characteristics in prehospital care.

OBJECTIVE

We aimed to summarize the existing literature on disparities in prehospital care delivery for patients identifying as members of an underrepresented race, ethnicity, sex, gender, or sexual orientation group.

METHODS

We conducted a scoping review of peer-reviewed and non-peer-reviewed (gray) literature. We searched PubMed, CINAHL, Web of Science, Proquest Dissertations, Scopus, Google, and professional websites for studies set in the U.S. between 1960 and 2021. Each abstract and full-text article was screened by two reviewers. Studies written in English that addressed the underrepresented groups of interest and investigated EMS-related encounters were included. Studies were excluded if a disparity was noted incidentally but was not a stated objective or discussed. Data extraction was conducted using a standardized electronic form. Results were summarized qualitatively using an inductive approach.

RESULTS

One hundred forty-five full-text articles from the peer-reviewed literature and two articles from the gray literature met inclusion criteria: 25 studies investigated sex/gender, 61 studies investigated race/ethnicity, and 58 studies investigated both. One study investigated sexual orientation. The most common health conditions evaluated were out-of-hospital cardiac arrest (n = 50), acute coronary syndrome (n = 36), and stroke (n = 31). The phases of EMS care investigated included access (n = 55), pre-arrival care (n = 46), diagnosis/treatment (n = 42), and response/transport (n = 40), with several studies covering multiple phases. Disparities were identified related to all phases of EMS care for underrepresented groups, including symptom recognition, pain management, and stroke identification. The gray literature identified public perceptions of EMS clinicians' cultural competency and the ability to appropriately care for transgender patients in the prehospital setting.

CONCLUSIONS

Existing research highlights health disparities in EMS care delivery throughout multiple health outcomes and phases of EMS care. Future research is needed to identify structured mechanisms to eliminate disparities, address clinician bias, and provide high-quality equitable care for all patient populations.

The Price of a Helping Hand: Modeling the Outcomes and Costs of Bystander CPR

OBJECTIVE

Early, high-quality, minimally interrupted bystander cardio-pulmonary resuscitation (BCPR) is essential for out-of-hospital cardiac arrest survival. However, rates of bystander intervention remain low in many geographic areas. Community CPR programs have been initiated to combat these low numbers by teaching compression-only CPR to laypersons. This study examined bystander CPR and the cost-effectiveness of a countywide CPR program to improve out-of-hospital cardiac arrest survival.

METHODS

A 2-year retrospective review of emergency medical services (EMS) run reports for adult nontraumatic cardiac arrests was performed using existing prehospital EMS quality assurance data. The incidence and success of bystander CPR to produce prehospital return of spontaneous circulation and favorable neurologic outcomes at hospital discharge were analyzed. The outcomes were paired with cost data for the jurisdiction's community CPR program to develop a cost-effectiveness model.

RESULTS

During the 23-month study period, a total of 371 nontraumatic adult out-of-hospital cardiac arrests occurred, with a 33.4% incidence of bystander CPR. Incremental cost-effectiveness analysis for the community CPR program demonstrated a total cost of $22,539 per quality-adjusted life-year (QALY). A significantly increased proportion of those who received BCPR also had an automated external defibrillator (AED) applied. There was no correlation between witnessed arrest and performance of BCPR. A significantly increased proportion of those who received BCPR were found to be in a shockable rhythm when the initial ECG was performed. In the home setting, the chances of receiving BCPR were significantly smaller, whereas in the public setting a nearly equal number of people received and did not receive BCPR. Witnessed arrest, AED application, public location, and shockable rhythm on initial ECG were all significantly associated with positive ROSC and neurologic outcomes. A home arrest was significantly associated with worse neurologic outcome.

CONCLUSIONS

Cost-effectiveness analysis demonstrates that a community CPR outreach program is a cost-effective means for saving lives when compared to other healthcare-related interventions. Bystander CPR showed a clear trend toward improving the neurologic outcome of survivors. The findings of this study indicate a need for additional research into the economic effects of bystander CPR.

Rates of cardiopulmonary resuscitation training in the United States

IMPORTANCE

Prompt bystander cardiopulmonary resuscitation (CPR) improves the likelihood of surviving an out-of-hospital cardiac arrest. Large regional variations in survival after an out-of-hospital cardiac arrest have been noted.

OBJECTIVES

To determine whether regional variations in county-level rates of CPR training exist across the United States and the factors associated with low rates in US counties.

DESIGN, SETTING, AND PARTICIPANTS

We used a cross-sectional ecologic study design to analyze county-level rates of CPR training in all US counties from July 1, 2010, through June 30, 2011. We used CPR training data from the American Heart Association, the American Red Cross, and the Health & Safety Institute. Using multivariable logistic regression models, we examined the association of annual rates of adult CPR training of citizens by these 3 organizations (categorized as tertiles) with a county's geographic, population, and health care characteristics.

EXPOSURE

Completion of CPR training.

MAIN OUTCOME AND MEASURES

Rate of CPR training measured as CPR course completion cards distributed and CPR training products sold by the American Heart Association, persons trained in CPR by the American Red Cross, and product sales data from the Health & Safety Institute. RESULTS During the study period, 13.1 million persons in 3143 US counties received CPR training. Rates of county training ranged from 0.00% to less than 1.29% (median, 0.51%) in the lower tertile, 1.29% to 4.07% (median, 2.39%) in the middle tertile, and greater than 4.07% or greater (median, 6.81%) in the upper tertile. Counties with rates of CPR training in the lower tertile were more likely to have a higher proportion of rural areas (adjusted odds ratio, 1.12 [95% CI, 1.10-1.15] per 5-percentage point [PP] change), higher proportions of black (1.09 [1.06-1.13] per 5-PP change) and Hispanic (1.06 [1.02-1.11] per 5-PP change) residents, a lower median household income (1.18 [1.04-1.34] per $10 000 decrease), and a higher median age (1.28 [1.04-1.58] per 10-year change). Counties in the South, Midwest, and West were more likely to have rates of CPR training in the lower tertile compared with the Northeast (adjusted odds ratios, 7.78 [95% CI, 3.66-16.53], 5.56 [2.63-11.75], and 5.39 [2.48-11.72], respectively).

CONCLUSIONS AND RELEVANCE

Annual rates of US CPR training are low and vary widely across communities. Counties located in the South, those with higher proportions of rural areas and of black and Hispanic residents, and those with lower median household incomes have lower rates of CPR training than their counterparts. These data contribute to known geographic disparities in survival of cardiac arrest and offer opportunities for future community interventions.

First-aid training and capabilities of the lay public: a potential alternative source of emergency medical assistance following a natural disaster

Basic first-aid skills can be useful in treating minor injuries that commonly result from natural disasters in the United States. Yet there has been insufficient research on training and competence in first-aid skills among community residents. This study utilises panel data for 414 adults in Los Angeles, California, who were interviewed within three years of the 1994 Northridge earthquake and re-interviewed in 1999 after the El Ninõ winter of 1997-98. Descriptive, bivariate and multivariate analyses were performed. Results showed that 24 percent of the members of the sample had received first-aid training since their Northridge earthquake interview. First-aid training, particularly recent training, was associated with greater perceived first-aid skills, as well as with increased expected and actual employment of those skills. With the appropriate training and skill retention, lay members of the public can potentially contribute to a post-disaster medical response.

Cost-effectiveness of training unselected laypersons in cardiopulmonary resuscitation and defibrillation

PURPOSE

The cost-effectiveness of cardiopulmonary resuscitation (CPR) and defibrillation training for laypersons unselected for risk of encountering cases of cardiac arrest is not known. We compared the costs and health benefits of alternative resuscitation training strategies for adults without professional first-responder duties who are at average risk of encountering cases of out-of-hospital cardiac arrest.

METHODS

We constructed a cost-effectiveness analytic model. Data on cardiac arrest epidemiology and the effectiveness of CPR/defibrillation training were obtained from the medical literature. Instructional costs were determined from a survey of training programs. Downstream cardiac arrest survivor quality-adjusted life expectancy and long-term health care costs were derived from prior studies. We compared three strategies for training unselected laypersons: CPR/defibrillation training alone, training combined with home defibrillator purchase, and no training. The main outcome measures were total instructional costs for trainees combined with health care costs for additional cardiac arrest survivors, and quality-adjusted survival for additional patients resuscitated by trainees.

RESULTS

CPR/defibrillation training yielded 2.7 quality-adjusted hours of life at a cost of 62 US dollars per trainee (202,400 US dollars per quality-adjusted life-year [QALY] gained). Training laypersons in CPR/defibrillation with subsequent defibrillator purchase cost 2,489,700 US dollars per QALY. In contrast, CPR/defibrillation training cost less than 75,000 US dollars per QALY if trainees lived with persons older than 75 years or with persons who had cardiac disease, or if total training costs were less than 10 US dollars.

CONCLUSION

Training unselected laypersons in CPR/defibrillation is costly compared with other public health initiatives. Conversely, training laypersons selected by occupation, low training costs, or having high-risk household companions is substantially more efficient.

Cardiopulmonary Resuscitation Programs Revisited: Results of a Community Study Among Older African Americans

Early cardiopulmonary resuscitation (CPR) performed by a layperson and prompt defibrillation in the field are critical links in the chain of survival of out-of-hospital sudden cardiac arrest. It has been suggested that minorities, women, and elderly persons are often left out of CPR training programs. To examine knowledge and attitudes toward CPR and automatic external defibrillation among African Americans, the author and colleagues conducted home interviews in a population sample of 425 older men and women in Miami-Dade County, FL. It was found that 25% of the participants did not know what CPR was. Only 18% of men and 28% of women had ever taken CPR classes. Mean age the time of CPR training was for men 36 years and for women 46 years. About 74% of all subjects did not know whom to contact for CPR training, and fewer than 5% knew about the American Heart Association Heartsaver Program (including automatic external defibrillation performed by laypersons). The majority of participants suggested churches or community organizations as organizers of CPR training. This study shows that there is a major need for improving knowledge and intensifying CPR training programs among older African Americans. Community organizations and churches may play a critical role in reaching this goal.

Doctor-based basic cardiopulmonary resuscitation course: an alternative to the conventional approach

United Christian Hospital initiated a doctor-based cardiopulmonary resuscitation (CPR) Program. It is a two-hour, focused, adult CPR course, suitable for adults of different age groups and of different educational levels. The course was rated highly by the participants. Most trainees acquired CPR knowledge and skills, and had confidence to perform CPR. This type of training could improve the rate of bystander CPR for out-of-hospital cardiac arrest patients in this region. Avoiding the complexity and pass-fail psychology that is used in the traditional CPR training curriculum, it can be an alternative to the traditional four-hour instructor-based Basic Life Support (BLS) course.

Simple CPR: A randomized, controlled trial of video self-instructional cardiopulmonary resuscitation training in an African American church congregation

STUDY OBJECTIVE

Despite the proven efficacy of cardiopulmonary resuscitation (CPR), only a small fraction of the population knows how to perform it. As a result, rates of bystander CPR and rates of survival from cardiac arrest are low. Bystander CPR is particularly uncommon in the African American community. Successful development of a simplified approach to CPR training could boost rates of bystander CPR and save lives. We conducted the following randomized, controlled study to determine whether video self-instruction (VSI) in CPR results in comparable or better performance than traditional CPR training.

METHODS

This randomized, controlled trial was conducted among congregational volunteers in an African American church in Atlanta, GA. Subjects were randomly assigned to receive either 34 minutes of VSI or the 4-hour American Heart Association "Heartsaver" CPR course. Two months after training, blinded observers used explicit criteria to assess CPR performance in a simulated cardiac arrest setting. A recording manikin was used to measure ventilation and chest compression characteristics. Participants also completed a written test of CPR-related knowledge and attitudes.

RESULTS

VSI trainees displayed a comparable level of performance to that achieved by traditional trainees. Observers scored 40% of VSI trainees competent or better in performing CPR, compared with only 16% of traditional trainees (absolute difference 24%, 95% confidence interval 8% to 40%). Data from the recording manikin confirmed these observations. VSI trainees and traditional trainees achieved comparable scores on tests of CPR-related knowledge and attitudes.

CONCLUSION

Thirty-four minutes of VSI can produce CPR of comparable quality to that achieved by traditional training methods. VSI provides a simple, quick, consistent, and inexpensive alternative to traditional CPR instruction, and may be used to extend CPR training to historically underserved populations.

Neighborhoods matter: a population-based study of provision of cardiopulmonary resuscitation

STUDY OBJECTIVE

Cardiorespiratory resuscitation (CPR) nonprovision-the failure of bystanders to provide CPR to cardiac arrest victims-remains a well-documented public health problem associated with significant mortality. Multivariate data on failure to provide CPR are limited. Given the established independent contributions of neighborhoods to explaining many behaviors, we asked the following questions: Do neighborhood characteristics affect the likelihood of CPR nonprovision? In particular, we sought to identify the characteristics of areas that have had the most success in providing CPR.

METHODS

We performed multivariable logistic regression analysis of a prospectively collected cohort of 4,379 cardiac arrests linked at an individual level to neighborhood data from the US Census. These arrests represent all out-of-hospital cardiac arrests in the City of Chicago in 1987 and 1988.

RESULTS

In multivariate analysis, patients who had cardiac arrests who lived in neighborhoods where cardiac arrests were more common were significantly more likely to receive CPR. Patients with arrests in racially integrated neighborhoods were most likely to be provided with CPR, followed by those in predominately white neighborhoods, with the lowest rates of CPR provision in predominately black neighborhoods. Neither the socioeconomic status, number of elderly, nor the occupational characteristics of the neighborhood appeared to influence CPR provision. At the individual level, in-home arrests and arrests among middle-aged black residents (relative to older black and all white residents) were less likely to receive CPR.

CONCLUSION

Substantial variation in rates of CPR nonprovision exists between neighborhoods; the variation is associated with neighborhood characteristics. Combining individual and neighborhood data allows identification of important factors associated with the failure to provide CPR.

Randomized, controlled trial of video self-instruction versus traditional CPR training

STUDY OBJECTIVE

We conducted a prospective, randomized, controlled trial to test the hypothesis that a 34-minute video self-instruction (VSI) training program for adult CPR would yield comparable or better CPR performance than the current community standard, the American Heart Association Heartsaver course.

METHODS

Incoming freshman medical students were randomly assigned to VSI or the Heartsaver CPR course. Two to 6 months after training, we tested subjects to determine their ability to perform CPR in a simulated cardiac arrest setting. Blinded observers used explicit criteria to assess our primary outcome, CPR performance skill. In addition, we assessed secondary outcomes including sequential performance of individual skills, ventilation and chest compression characteristics, and written tests of CPR-related knowledge and attitudes.

RESULTS

VSI trainees displayed superior overall performance compared with traditional trainees. Twenty of 47 traditional trainees (43%) were judged not competent in their performance of CPR, compared with only 8 of 42 VSI trainees (19%; absolute difference, 24%; 95% confidence interval, 5% to 42%).

CONCLUSION

In a group of incoming freshman medical students, we found that a half-hour of VSI resulted in superior overall CPR performance compared with that in traditional trainees. If validated by further research, VSI may provide a simple, quick, and inexpensive alternative to traditional CPR instruction for health care workers and, perhaps, the general population.

Community cardiac awareness teaching in a rural area: the potential for a health promotion message

Little information has been published on the uptake of cardiopulmonary resuscitation (CPR) training in rural areas or on the potential to associate a health promotion message with skills training. This paper describes CPR instructor and community training programmes in Ireland. Public interest in these programmes has been strongest in rural areas, which have constituted the main focus of activity to date. High-quality training of lay instructors has been a specific target of the programmes, which have included a significant health promotion message. In the pilot rural area, almost 2% of adults aged between 15 and 64 years attended a course during the first year of operation. However, the self-reported risk factor profile of participants suggests significant under-estimation of risk factors such as obesity, hypertension or raised blood cholesterol. While general population teaching programmes can attract large numbers of participants, even in isolated rural areas, the perceived relevance of an associated health promotion message may be very low.