Improvement in Non-Traumatic, Out-Of-Hospital Cardiac Arrest Survival in Detroit From 2014 to 2016

Validation of the Termination of Resuscitation Rules in Detroit

Background and objective The termination of resuscitation (TOR) criteria - which recommends termination when a non-traumatic arrest in an adult is unwitnessed by emergency medical services (EMS), no shocks are administered, and no return of spontaneous circulation (ROSC) occurs - guide physicians in determining the viability of continuing cardiopulmonary resuscitation (CPR) and transporting patients to the hospital. We examined the level of compliance with the current basic life support (BLS) TOR rule and assessed alternative sets of rules to retrospectively derive improved TOR guidelines for out-of-hospital cardiac arrests (OHCA) in Detroit. Methods This was a retrospective study involving non-traumatic OHCA cases in Detroit from January 1, 2017, to December 31, 2019, which spans the time frame before and after the BLS TOR rule was officially implemented (June 1, 2018). Data were extracted from the Detroit Cardiac Arrest Registry (DCAR). Patients younger than 18 years of age, those with arrests of traumatic origin, or those with no resuscitation attempted were excluded. Results A total of 1,306 individuals were included in our analysis: 656 OHCA cases before the implementation of the BLS TOR rule in Detroit and 650 OHCA after the implementation. BLS TOR criteria were applied to the pre-TOR implementation data with a resulting specificity of 79% (95% CI: 50.7-80.8) and positive predictive value (PPV) of 97.3% (95% CI: 95.5-98.6). Survival to hospital discharge when termination was recommended was projected at 2.9% (13/444). The overall transportation rate was 85% (559/656). Post-TOR implementation, specificity was 88.9% (95% CI: 78.6-99.1) and PPV was 99.1% (95% CI: 98.3-99.9). Survival to hospital discharge was 0.88% (4/453) with a 69% (451/650) overall transportation rate. Post-hoc addition of age or EMS time to the patient side increased transportation rates to 81% (529/650) and 88% (571/650), respectively, and decreased false positive terminations to 0.84% (2/237) and 0% (0/148), respectively. Conclusions Overall survival and futile transportation rates decreased when TOR was applied since the implementation of the BLS TOR rule in Detroit. The addition of EMS time to the patient side or patient age to current TOR guidelines suggested improved performance. Although the additional criteria resulted in higher transportation rates, these factors may be useful for physicians to consider when deciding to transport patients. However, further derivation and validation are needed to create optimal TOR guidelines.

Characteristics, outcomes, and prognostic factors in patients with hanging-induced out-of-hospital cardiac arrest: An analysis of a nationwide registry in Japan

AIM

To investigate the characteristics, outcomes, and prognostic factors of patients with hanging-induced out-of-hospital cardiac arrest (OHCA).

METHODS

We analysed data from a population-based Japanese nationwide OHCA registry (2021-2022), comparing patients aged ≥18 years with hanging-induced OHCA to those with other OHCA causes. The primary outcome was 1-month favourable neurological outcomes. Prognostic factors for hanging-induced OHCA were identified using multivariable logistic regression analysis.

RESULTS

Of 263,426 OHCAs, 7,878 (3.0 %) were hanging-induced, with an incidence of 3.1 per 100,000 person-years. Patients with hanging-induced OHCA were younger (median age; 58 vs. 81 years), more frequently males (60.2 % vs. 57.5 %), and less likely to have a witness (1.7 % vs. 42.1 %) and initial shockable rhythm (0.4 % vs. 5.9 %). The chance of 1-month favourable neurological outcomes was significantly lower in patients with hanging-induced OHCA than those with other OHCA causes (0.4 % vs. 2.5 %). Factors associated with favourable neurological outcomes included younger age, witnessed arrest, initial non-asystole cardiac rhythm, and prehospital return of spontaneous circulation (ROSC). Patients with initial non-asystole rhythm and prehospital ROSC had an 11.1 % probability of favourable neurological outcomes, whereas 97.1 % of patients lacking these characteristics had only a 0.1 % probability.

CONCLUSIONS

Prognosis following hanging-induced OHCAs was significantly worse compared to OHCAs of other causes. While some patients with initial non-asystole rhythm and prehospital ROSC may benefit from cardiopulmonary resuscitation, most lack these favourable features and have an exceedingly low chance of achieving favourable neurological outcomes at 1-month post-arrest.

Systematic Review on the Worldwide Disparities in the Frequency and Results of Emergency Medical Services (EMS) and Response to Out-of-Hospital Cardiac Arrest (OHCA)

This systematic analysis aimed to analyze the key patterns and tendencies regarding bystander interventions, emergency medical service (EMS) systems, dispatcher support, regional and temporal differences, and the influence of national efforts on survival rates in out-of-hospital cardiac arrest (OHCA). The studies published between 2010 and 2024 examining outcomes of OHCA, interventions by bystanders, and variables linked to OHCA were included in this research. The inclusion process was done under Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), where publications (n = 24) from various geographical locations, including a wide range of research methodologies, were included for this research. The thematic analysis used for the data analysis shows that bystander cardiopulmonary resuscitation (CPR) enhances the chances of survival. The effectiveness of the EMS system, the assistance offered by dispatchers, and the inclusion of doctors in ambulance services are essential components in the management of OHCA. Regional and temporal variations highlight disparities in resuscitation protocols, emphasizing the need for adaptable approaches. Observations from statewide endeavors emphasize the impact of these activities in fostering a culture of prompt bystander intervention. This systematic review presents a comprehensive analysis of research conducted globally, providing a thorough insight into the variables that influence survival rates in instances of OHCA. The review recognizes the importance of bystander CPR and effective EMS services, while also bringing novel perspectives, such as gender disparities and geographical variations that contribute to the existing body of research. Despite possible variances in the studies and biases, the findings underscore the need for tailored therapies and ongoing research to optimize strategies for controlling OHCA and improving survival rates.

Fifteen-year secular changes in the care and outcomes of patients with out-of-hospital cardiac arrest in Japan: a nationwide, population-based study

AIMS

Countries have implemented initiatives to improve the outcomes of patients with out-of-hospital cardiac arrest (OHCA). However, secular changes in care and outcomes at the national level have not been extensively investigated. This study aimed to determine 15-year secular changes in the outcomes of such patients in Japan.

METHODS AND RESULTS

Using population-based data of patients with OHCA, covering all populations in Japan (2005-19), patients for whom resuscitation was attempted were identified. The primary outcome was a favourable neurological outcome (Cerebral Performance Category 1 or 2: sufficient cerebral function for independent activities of daily life and work in a sheltered environment). Secular changes in outcomes were determined using a mixed-level multivariate logistic regression analysis. Overall, 1 764 440 patients (42.4% women; median age, 78 years) were examined. The incidence, median age, and proportion of patients who received bystander cardiopulmonary resuscitation (CPR) and dispatcher instructions for resuscitation increased significantly during the study period (P  < 0.001). A significant trend was noted toward improved outcomes over time (P for trend < 0.001); favourable neurological outcome proportions 1 month after arrest increased from 1.7-3.0% (odds ratio, 1.03 per 1-incremental year). A remarkable increase was noted in favourable neurological outcomes in younger patients and patients with initial shockable cardiac rhythm, while improvement varied among prefectures.

CONCLUSION

In Japan, collaborative efforts have yielded commendable achievements in the care and outcomes of patients with OHCA over 15 years through to 2019, while the improvement depended on patient characteristics. Further initiatives are needed to improve OHCA outcomes.

Association between sex and survival after out-of-hospital cardiac arrest: A systematic review and meta-analysis

The current literature on sex differences in 30-day survival following out-of-hospital cardiac arrest (OHCA) is conflicting, with 3 recent systematic reviews reporting opposing results. To address these contradictions, this systematic literature review and meta-analysis aimed to synthesize the literature on sex differences in survival after OHCA by including only population-based studies and through separate meta-analyses of crude and adjusted effect estimates. MEDLINE and Embase databases were systematically searched from inception to March 23, 2022 to identify observational studies reporting sex-specific 30-day survival or survival until hospital discharge after OHCA. Two meta-analyses were conducted. The first included unadjusted effect estimates of the association between sex and survival (comparing males vs females), whereas the second included effect estimates adjusted for possible mediating and/or confounding variables. The PROSPERO registration number was CRD42021237887, and the search identified 6712 articles. After the screening, 164 potentially relevant articles were identified, of which 26 were included. The pooled estimate for crude effect estimates (odds ratio [OR], 1.42; 95% confidence interval [CI], 1.22-1.66) indicated that males have a higher chance of survival after OHCA than females. However, the pooled estimate for adjusted effect estimates shows no difference in survival after OHCA between males and females (OR, 0.93; 95% CI, 0.84-1.03). Both meta-analyses involved high statistical heterogeneity between studies: crude pooled estimate I2 = 95.7%, adjusted pooled estimate I2 = 91.3%. There does not appear to be a difference in survival between males and females when effect estimates are adjusted for possible confounding and/or mediating variables in non-selected populations.

How Can Out-of-Hospital Cardiac Arrest (OHCA) Data Collection in Slovenia Be Improved?

Background and Objectives: The prevalence of out-of-hospital cardiac arrest (OHCA) has been established as a significant contributor to mortality rates in developed nations. Due to the challenges associated with conducting controlled randomized trials, there exists a necessity for the collection of high-quality data to enhance the comprehension of the impact of interventions. Several nations have initiated efforts to gather information pertaining to out-of-hospital cardiac arrest (OHCA). The Republic of Slovenia has been collecting data from interventions; however, the variables and data attributes have not yet been standardized to comply with international standards. This lack of conformity poses a challenge in making comparisons or drawing inferences. The aim of this study is to identify how to better gather OHCA data in Slovenia. Materials and methods: The Utstein resuscitation registry protocol (UP) was compared to the Slovenian data points that must be gathered in accordance with the Rules on Emergency Medical Service (REMS) during interventions. In addition, we have proposed alternative measures of digitization to enhance pre-hospital data. Results: Missing data points and attribute mismatches were detected in Slovenia. Eight data points necessitated by the UP are gathered in several databases (hospitals, the National Institute of Public Health, dispatch services, intervention reports from first responders, and defibrillator files), but not in the mandated protocols based on REMS. Two data points have variables that do not match those of the UP. A total of 16 data points according to UP are currently not being collected in Slovenia. The advantages and potential drawbacks of digitizing emergency medical services have been discussed. Conclusions: The study has identified gaps in the methods employed for collecting data on OHCA in Slovenia. The assessment conducted serves as a basis for enhancing the process of data collection, integrating quality control measures across the nation, and establishing a nationwide registry for out-of-hospital cardiac arrest (OHCA) in Slovenia.

Treatment and outcome variation in out-of-hospital cardiac arrest among four urban hospitals in Detroit

AIMS

To determine whether out-of-hospital cardiac arrest (OHCA) post-resuscitation management and outcomes differ between four Detroit hospitals.

INTRODUCTION

Significant variation exists in treatment/outcomes from OHCA. Disparities between hospitals serving a similar population is not well known.

METHODS

Retrospective OHCA data was collected from the Detroit-Cardiac Arrest Registry (DCAR) between January 2014 to December 2019. Four hospitals were compared on two treatments (angiography, do not resuscitate (DNR)) and two outcomes (cerebral performance category (CPC) ≤ 2, in-hospital death). Models for death and CPC were tested with and without coronary angiography and DNR status.

RESULTS

999 patients at hospitals A - D differed (p < 0.05) before multivariable adjustment by age, race, witnessed arrest, dispatch-emergency department (ED) time, TTM, coronary angiography, DNR order, and in-hospital death. Rates of death and CPC ≤ 2 were worse in Hospital A (82.8%, 10%, respectively) compared to others (69.1%, 14.1%). After multivariable adjustment, Hospital A performed angiography less compared to B (OR = 0.17) and was more likely to initiate new DNR status than B (OR = 2.9), C (OR = 16.1), or D (OR = 3.6). CPC ≤ 2 were worse in Hospital A compared to B (OR = 0.27) and D (OR = 0.35). After sensitivity analysis, CPC ≤ 2 odds did not differ for A versus B (OR = 0.58, adjusted for angiography) or D (OR = 0.65, adjusted for DNR). Odds of death, despite angiography and DNR differences, were worse in Hospital A compared to B (OR = 1.87) and D (OR = 1.81).

CONCLUSION

Differing rates of DNR and coronary angiography was associated with observed disparities in favorable neurologic outcome, but not death, between four Detroit hospitals.

Racial/ethnic and gender disparities of the impact of the COVID-19 pandemic in out-of-hospital cardiac arrest (OHCA) in Texas

INTRODUCTION

Prior research shows a greater disease burden, lower BCPR rates, and worse outcomes in Black and Hispanic patients after OHCA. Female OHCA patients have lower rates of BCPR compared to men and other survival outcomes vary. The influence of the COVID-19 pandemic on OHCA incidence and outcomes in different health disparity populations is unknown.

METHODS

We used data from the Texas Cardiac Arrest Registry to Enhance Survival (CARES). We determined the association of both prehospital characteristics and survival outcomes with the pandemic period in each study group through Pearson's χ2 test or Fisher's exact tests. We created mixed multivariable logistic regression models to compare odds of cardiac arrest care and outcomes between 2019 and 2020 for the study groups.

RESULTS

Black OHCA patients (aOR = 0.73; 95% CI: 0.65 - 0.82) had significantly lower odds of BCPR compared to White OHCA patients, were less likely to achieve ROSC (aOR = 0.86; 95% CI: 0.74 - 0.99) or have a good CPC score (aOR = 0.47; 95% CI: 0.29 - 0.75). Compared to White patients with OHCA, Hispanic persons were less likely to have a field TOR (aOR = 0.86; 95% CI: 0.75 - 0.99) or receive BCPR (aOR = 0.78; 95% CI: 0.69 - 0.87). Female OHCA patients had higher odds of surviving to hospital admission compared to males (aOR = 1.29; 95% CI: 1.15 - 1.44).

CONCLUSION

Many OHCA outcomes worsened for Black and Hispanic patients. While some aspects of care worsened for women, their odds of survival improved compared to males.

The impact of COVID-19 on incidence and outcomes from out-of-hospital cardiac arrest (OHCA) in Texas

INTRODUCTION

Emerging research demonstrates lower rates of bystander cardiopulmonary resuscitation (BCPR), public AED (PAD), worse outcomes, and higher incidence of OHCA during the COVID-19 pandemic. We aim to characterize the incidence of OHCA during the early pandemic period and the subsequent long-term period while describing changes in OHCA outcomes and survival.

METHODS

We analyzed adult OHCAs in Texas from the Cardiac Arrest Registry to Enhance Survival (CARES) during March 11-December 31 of 2019 and 2020. We stratified cases into pre-COVID-19 and COVID-19 periods. Our prehospital outcomes were bystander cardiopulmonary resuscitation (BCPR), public AED use (PAD), sustained ROSC, and prehospital termination of resuscitation (TOR). Our hospital survival outcomes were survival to hospital admission, survival to hospital discharge, good neurological outcomes (CPC Score of 1 or 2) and Utstein bystander survival. We created a mixed effects logistic regression model analyzing the association between the pandemic on outcomes, using EMS agency as the random intercept.

RESULTS

There were 3619 OHCAs (45.0% of overall study population) in 2019 compared to 4418 (55.0% of overall study population) in 2020. Rates of BCPR (46.2% in 2019 to 42.2% in 2020, P < 0.01) and PAD (13.0% to 7.3%, p < 0.01) decreased. Patient survival to hospital admission decreased from 27.2% in 2019 to 21.0% in 2020 (p < 0.01) and survival to hospital discharge decreased from 10.0% in 2019 to 7.4% in 2020 (p < 0.01). OHCA patients were less likely to receive PAD (aOR = 0.5, 95% CI [0.4, 0.8]) and the odds of field termination increased (aOR = 1.5, 95% CI [1.4, 1.7]).

CONCLUSIONS

Our study adds state-wide evidence to the national phenomenon of long-term increased OHCA incidence during COVID-19, worsening rates of BCPR, PAD use and survival outcomes.

Effects of the COVID-19 pandemic on out-of-hospital cardiac arrest care in Detroit

Introduction

In response to the COVID-19 pandemic in Detroit, an earlier termination of resuscitation protocol was initiated in March 2020. To characterize pre-hospital cardiac arrest careduring COVID-19 in Detroit, we analyzed out-of-hospital cardiac arrest (OHCA) rate of ROSC (return of spontaneous circulation) and patient characteristics before and during the COVID-19 pandemic.

Methods

OHCA data was analyzed between March 10th, 2020 – April 30th, 2020 and March 10th, 2019 – April 30th, 2019. ROSC, patient demographics, arrest location, initial rhythms, bystander CPR and field termination were compared before and during the pandemic. Descriptive statistics were utilized to compare arrest characteristics between years, and the odds of achieving vs. not achieving ROSC. 2020 vs. 2019 as a predictor for ROSC was assessed with logistic regression.

Results

471 patients were included. Arrests increased to 291 during the pandemic vs. 180 in 2019 (62% increase). Age (mean difference + 6; 95% CI: +2.4 to +9.5), arrest location (nursing home OR = 2.42; 95% CI: 1.42–4.31; public place OR = 0.47; 95% CI: 0.25–0.88), BLS response (OR = 0.68; 95% CI: 0.47–0.99), and field termination of resuscitation (OR = 2.36; 95% CI: 1.36–4.07) differed significantly in 2020 compared to 2019. No significant difference was found in the confounder-adjusted odds of ROSC in 2020 vs 2019 (OR = 0.61; 95% CI: 0.34–1.11).

Conclusion

OHCA increased by 62% during COVID-19 in Detroit, without a significant change in prehospital ROSC. The rate of ROSC remained similar despite the implementation of an early termination of resuscitation protocol in response to COVID-19.

Implementation of a National 5-Year Plan for Prehospital Emergency Care in Singapore and Impact on Out-of-Hospital Cardiac Arrest Outcomes From 2011 to 2016

Background

Outcomes of patients from out‐of‐hospital cardiac arrest (OHCA) vary widely globally because of differences in prehospital systems of emergency care. National efforts had gone into improving OHCA outcomes in Singapore in recent years including community and prehospital initiatives. We aimed to document the impact of implementation of a national 5‐year Plan for prehospital emergency care in Singapore on OHCA outcomes from 2011 to 2016.

Methods and Results

Prospective, population‐based data of OHCA brought to Emergency Departments were obtained from the Pan‐Asian Resuscitation Outcomes Study cohort. The primary outcome was Utstein (bystander witnessed, shockable rhythm) survival‐to‐discharge or 30‐day postarrest. Mid‐year population estimates were used to calculate age‐standardized incidence. Multivariable logistic regression was performed to identify prehospital characteristics associated with survival‐to‐discharge across time. A total of 11 465 cases qualified for analysis. Age‐standardized incidence increased from 26.1 per 100 000 in 2011 to 39.2 per 100 000 in 2016. From 2011 to 2016, Utstein survival rates nearly doubled from 11.6% to 23.1% (P=0.006). Overall survival rates improved from 3.6% to 6.5% (P<0.001). Bystander cardiopulmonary resuscitation rates more than doubled from 21.9% to 56.3% and bystander automated external defibrillation rates also increased from 1.8% to 4.6%. Age ≤65 years, nonresidential location, witnessed arrest, shockable rhythm, bystander automated external defibrillation, and year 2016 were independently associated with improved survival.

Conclusions

Implementation of a national prehospital strategy doubled OHCA survival in Singapore from 2011 to 2016, along with corresponding increases in bystander cardiopulmonary resuscitation and bystander automated external defibrillation. This can be an implementation model for other systems trying to improve OHCA outcomes.

Sex differences in survival after out-of-hospital cardiac arrest: a meta-analysis

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is a leading cause of sudden cardiac death worldwide. Researchers have found significant pathophysiological differences between females and males and clinically significant sex differences related to medical services. However, conflicting results exist and there is no uniform agreement regarding sex differences in survival and prognosis after OHCA. Therefore, we investigated the relationship between the prognosis of OHCA and sex factors.

METHODS

We comprehensively searched the PubMed, Embase, and Cochrane databases and obtained a total of 1042 articles, from which 33 studies were selected for inclusion. The pooled odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using a random-effects model.

RESULTS

The meta-analysis included 1,268,664 patients. Compared with males, females were older (69.7 years vs. 65.4 years, p < 0.05) and more frequently suffered OHCA without witnesses (58.39% vs 62.70%, p < 0.05). Females were less likely to receive in-hospital interventions than males. There was no significant difference between females and males in the survival from OHCA to hospital admission (OR 0.99, 95% CI 0.89-1.1). However, females had lower chances for survival from hospital admission to discharge (OR 0.59, 95% CI 0.48-0.73), overall survival to hospital discharge (OR 0.73, 95% CI 0.62-0.86), and favorable neurological outcomes (OR 0.62, 95% CI 0.47-0.83) compared with males.

CONCLUSIONS

Our results indicate that the overall discharge survival rate of females is lower than that of males, and females face a poor prognosis of the nervous system. This is likely related to the pathophysiological characteristics of females, more conservative treatment measures compared with males, and different post-resuscitation care. However, these findings should be interpreted with caution due to the presence of several confounding factors.

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.

2015 Guidelines for Cardiopulmonary Resuscitation and survival after adult and paediatric out-of-hospital cardiac arrest

AIMS

To evaluate whether the introduction of the 2015 Guidelines for Cardiopulmonary Resuscitation were associated with a change in outcomes after out-of-hospital cardiac arrest (OHCA).

METHODS AND RESULTS

Patients with OHCA were divided into adults (≥18 years) and paediatric cases (<18 years). An interrupted time-series analysis was used to compare survival before (pre-guidelines 1 January 2013 to 31 October 2015) and after (post-guidelines 1 May 2016 to 31 December 2018) introduction of the 2015 guidelines. We fitted a regression model after dividing the time-period into segments with separate intercept and slope estimates. We included 309 499 adults and 8668 children with OHCA. There was no difference in the change in survival to hospital discharge with a favourable functional outcome per year between the two periods for adults {slope difference: -0.07% [95% confidence interval (CI) -0.30 to 0.16], P = 0.55} and paediatric cases [slope difference: -0.01% (95% CI -1.35 to 1.32), P = 0.98]. Likewise, we found no immediate change in survival to hospital discharge with a favourable functional outcome between the two periods for adults [0.20% (95% CI -0.21 to 0.61), P = 0.33] and paediatric cases [-1.08 (95% CI -3.44 to 1.27), P = 0.37].

CONCLUSION

Publication of the 2015 Guidelines for Cardiopulmonary Resuscitation was not associated with an increase in survival to hospital discharge with a favourable functional outcome after OHCA. Outcomes for OHCA have not improved the last 6 years in the USA.