Good outcome in every fourth resuscitation attempt is achievable—An Utstein template report from the Stavanger region

doi:10.1016/j.resuscitation.2011.06.016

Resuscitation

Volume 82, Issue 12, December 2011, Pages 1508-1513

https://doi.org/10.1016/j.resuscitation.2011.06.016 Get rights and content

Abstract

Aim of the study

Out-of-hospital cardiac arrest (OHCA) is a major cause of death in the western world. We wanted to study changes in survival over time and factors linked to this in a region which have already reported high survival rates.

Methods

We used a prospectively collected Utstein template database to identify all resuscitation attempts in adult patients with OHCA of presumed cardiac origin. We included 846 resuscitation attempts and compared survival to discharge with good outcome in two time periods (2001–2005 vs. 2006–2008).

Results

We found no significant differences between the two time periods for mean age (71 and 70 years (p = 0.309)), sex distribution (males 70% and 71% (p = 0.708)), location of the OHCA (home 64% and 63% (p = 0.732)), proportion of shockable rhythms (44% and 47% (p = 0.261)) and rate of return of spontaneous circulation (38% and 43% (p = 0.136)), respectively. Bystander cardiopulmonary resuscitation (CPR), however, increased significantly from 60% to 73% (p < 0.0001), as did the overall rate of survival to discharge from 18% to 25% (p = 0.018). In patients with a shockable first rhythm, rate of survival to discharge increased significantly from 37% to 48% (p = 0.036). In witnessed arrest with shockable rhythm survival to discharge increased from 37% to 52% (p = 0.0105).

Conclusion

Overall, good outcome is now achievable in every fourth resuscitation attempt and in every second resuscitation attempt when patients have a shockable rhythm. The reason for the better outcomes is most likely multi-factorial and linked to improvements in the local chain of survival.

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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Out of hospital cardiac arrest (OHCA) has very high mortality.1 In the UK, 10% of cases survive to hospital discharge2 whereas 25% is reported in the best performing European centres.3 Prompt, effective bystander cardiopulmonary resuscitation (CPR) is the most important factor determining survival from OHCA, increasing survival almost 4-fold.4,5
Prompt, effective cardio-pulmonary resuscitation (CPR) increases survival in out-of-hospital cardiac arrest. However, CPR is often not provided, even by people with training. Low confidence, perceptions of risks and high emotion can prevent initiation of CPR. Behaviour-change techniques may be helpful in increasing CPR rates.
To pilot a text-message behavioural intervention designed to increase intentions to initiate CPR, explore participant responses and pilot methods for future randomised controlled trial of effectiveness.
A ‘before and after’ pilot study plus qualitative interviews was undertaken. Participants were lay-people who had undertaken CPR training in previous 2 years.
Participants were sent an intervention, comprising 35 text-messages containing 14 behaviour-change techniques, to their mobile phone over 4–6 weeks.
Primary outcome: intentions to initiate CPR assessed in response to 4 different scenarios.
Secondary outcomes: theory-based determinants of intention (attitudes, subjective norms, perceived behavioural control and self-efficacy) and self-rated competence.
20 participants (6 female, 14 male), aged 20–84 provided baseline data. 17 received the full suite of 35 text messages.15 provided follow-up data. Intentions to perform CPR in scenarios where CPR was indicated were high at baseline and increased (18.1 ± 3.2–19.5 ± 1.8/21) after the intervention, as did self-efficacy and self-rated competency. Self-efficacy, attitudes, perceived behavioural control and subjective norms were positively correlated with intentions. Qualitative data suggest the intervention was perceived as useful. Additional options for delivery format and pace were suggested.
Pilot-testing suggests a text-message intervention delivered after CPR training is acceptable and may be helpful in increasing/maintaining intentions to perform CPR.
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Sudden cardiac arrest (SCA) is a common event, affecting almost 400,000 individuals annually in North America. Initiation of cardiopulmonary resuscitation (CPR) and early defibrillation using an automated external defibrillator (AED) are critical for survival, yet many bystanders are reluctant to intervene. Digital technologies, including mobile devices, social media, and crowdsourcing might help play a role to improve survival from SCA. In this article we review the current digital tools and strategies available to increase rates of bystander recognition of SCA, prompt immediate activation of emergency medical services (EMS), initiate high-quality CPR, and to locate, retrieve, and operate AEDs. Smartphones can help to educate and connect bystanders with EMS dispatchers, through text messaging or video calling, to encourage the initiation of CPR and retrieval of the closest AED. Wearable devices and household smart speakers could play a future role in continuous vital signs monitoring in individuals at risk of lethal arrhythmias and send an alert to either chosen contacts or EMS. Machine learning algorithms and mathematical modelling might aid EMS dispatchers with better recognition of SCA as well as policymakers with where to best place AEDs for optimal accessibility. There are challenges with the use of digital tech, including the need for government regulation and issues with data ownership, accessibility, and interoperability. Future research will include smart cities, e-linkages, new technologies, and using social media for mass education. Together or in combination, these emerging digital technologies might represent the next leap forward in SCA survival.
L'arrêt cardiaque soudain (ACS) est un événement courant, qui touche près de 400 000 personnes chaque année en Amérique du Nord. La mise en place de la réanimation cardiorespiratoire (RCR) et de la défibrillation précoce à l'aide d'un défibrillateur externe automatisé (DEA) sont essentielles à la survie, mais de nombreux passants hésitent à intervenir. Les technologies numériques, notamment les appareils mobiles, les médias sociaux et la création participative pourraient contribuer à améliorer la survie après un ACS. Dans cet article, nous passons en revue les outils numériques actuels et les stratégies disponibles pour augmenter les taux d'identification d'un ACS par les passants, l'activation immédiate des services médicaux d'urgence (SMU), le déclenchement d'une RCR de qualité et la localisation, la récupération et le fonctionnement des DEA. Les téléphones intelligents peuvent contribuer à éduquer les témoins d'un ACS et à les mettre en relation avec les répartiteurs des SMU, par le biais de messages texte ou d'appels vidéo, afin d'encourager le déclenchement de la RCR et la récupération du DEA le plus proche. Les dispositifs portables et les haut-parleurs domestiques intelligents pourraient à l'avenir jouer un rôle dans la surveillance continue des signes vitaux chez les personnes présentant un risque d'arythmies mortelles et envoyer une alerte à des contacts prédéfinis ou aux SMU. Les algorithmes d'apprentissage automatique et la modélisation mathématique pourraient aider les répartiteurs des SMU à mieux reconnaître les ACS et les décideurs à déterminer où placer les DEA pour une accessibilité optimale. L'utilisation des technologies numériques présente des défis, notamment la nécessité d'une réglementation gouvernementale et des questions de propriété, d'accessibilité et d'interopérabilité des données. Les futures recherches porteront sur les villes intelligentes, les liens électroniques, les nouvelles technologies et l'utilisation des médias sociaux pour l'éducation de masse. Ensemble ou en combinaison, ces technologies numériques émergentes pourraient représenter le prochain bond en avant quant à la survie à un ACS.
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All 28 countries provided data, covering a total population of 178,879,118. A total of 37,054 OHCA were confirmed, with CPR being started in 25,171 cases. The bystander cardiopulmonary resuscitation (CPR) rate ranged from 13% to 82% between countries (average: 58%). In one third of cases (33%) ROSC was achieved and 8% of patients were discharged from hospital alive. Survival to hospital discharge was higher in patients when a bystander performed CPR with ventilations, compared to compression-only CPR (14% vs. 8% respectively).
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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.

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Clinical PaperGood outcome in every fourth resuscitation attempt is achievable—An Utstein template report from the Stavanger region☆

Abstract

Aim of the study

Methods

Results

Conclusion

Introduction

Section snippets

The EMS and Stavanger University Hospital

Results

Discussion

Limitations

Conclusion

Conflicts of interest statement

Acknowledgments

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Int J Cardiol

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Ann Emerg Med

Resuscitation

Resuscitation

Clinical Paper
Good outcome in every fourth resuscitation attempt is achievable—An Utstein template report from the Stavanger region☆