Clinical PaperGood outcome in every fourth resuscitation attempt is achievable—An Utstein template report from the Stavanger region☆
Introduction
Every year, emergency medical system (EMS) personnel attempt to resuscitate approximately 500,000 out-of-hospital cardiac arrest (OHCA) victims in Europe and North America.1, 2, 3 Substantial variations in short- and long-term survival have been reported.2, 4, 5 Although differences in bystander cardiopulmonary resuscitation (CPR) rates and time until defibrillation may explain some of the differences, the large variations in survival rates are still not fully understood.5 To improve the local chains of survival, the European Resuscitation Council (ERC), as part of the International Liaison Committee on Resuscitation (ILCOR), have developed internationally recognized guidelines on how to treat OHCA, and the guidelines are revised on a regular basis.6 The Utstein template for uniform data reporting after OHCA has also been revised to allow better comparisons of different EMS systems reporting of OHCA incidence, return of spontaneous circulation (ROSC) and survival rates.4, 5, 7, 8, 9
In the late 1990s, high survival rates after OHCA were reported from the Stavanger region.7, 10 Since then we have continued our quality improvement process focusing on bystander CPR, prehospital care as well as the other parts of the chain of survival.7, 11, 12, 13 We felt it would be of interest to study changes in OHCA survival in our community and therefore used a prospectively collected, population-based, Utstein template OHCA database to study survival and factors linked to survival in adult patients with OHCA of presumed cardiac origin8, 9 in the time period 2001–2008.
Section snippets
The EMS and Stavanger University Hospital
During the study period from January 1, 2001 to December 31, 2008 the population in the studied region (5700 km2) increased from approximately 273,000 inhabitants to approximately 314,000 inhabitants.7, 14 Stavanger University Hospital (SUH) is the only receiving hospital for patients after OHCA. The Emergency Dispatch Centre (EDC) at SUH coordinates 18 ambulance units and one hospital-based, anaesthesiologist-manned rapid response unit using a helicopter or car as well as general practitioners
Results
In the 846 resuscitation attempts studied, age, gender distribution, OHCA location, proportion of OHCAs that were witnessed, and first reported heart rhythm did not differ significantly between the two time periods (2001–2005 vs. 2006–2008), but median EMS response time increased significantly from 8 to 9 min (Table 1, Table 2). The number of patients receiving bystander CPR increased from 60% to 73% (p = 0.0001) (Table 1). Bystander CPR in the subgroup of OHCA patients with witnessed OHCA
Discussion
After the introduction of the 2005 CPR guidelines and implementation of major treatment changes, such as post-resuscitation TH11 and PCI,12 we experienced a significant improvement in overall survival to discharge (25%) in resuscitation attempts of OHCAs of presumed cardiac origin in the time period 2006–2008. During the same time period, the proportion of OHCA survivors with good cerebral outcome (CPC 1–2) increased significantly to 97%. For the group of OHCA victims with a witnessed arrest
Limitations
There are many limitations to a registry-based study like ours, including those listed above, regarding the contribution of the various factors to the overall improved overall outcomes. To ensure data quality, one designated research nurse was continuously collecting and cross-checking data entries from different sources to reduce uncertainty and missing data.
The calculation of survival to discharge rate depends on the population used as the denominator. Decreasing the denominator could have
Conclusion
In this study of OHCA of presumed cardiac origin comparing the time periods from 2001 to 2005 with 2006 to 2008, the overall survival to discharge increased to 25% in the latter period. In the 2006–2008 time period, every second resuscitation attempt in patients with a witnessed arrest and a shockable rhythm resulted in survival to discharge with good cerebral outcome. Our results support the notion that all aspects of the chain of survival are important when trying to improve resuscitation
Conflicts of interest statement
The authors declare no conflicts of interest.
Acknowledgments
The authors would like to thank Astrid Våga and Kristian Lexow for their help with data collection, and Svein Arne Hapnes for leading the way as the medical director of the EMS system in the Stavanger region. We would also like to thank all the paramedics, nurses, doctors and other allied health professionals at SUH for their relentless work to further improve survival in cardiac arrest victims inside and outside the hospital.
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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2011.06.016.