Optimizing Outcomes After Out-of-Hospital Cardiac Arrest With Innovative Approaches to Public-Access Defibrillation: A Scientific Statement From the International Liaison Committee on Resuscitation.

Out-of-hospital cardiac arrest is a global public health issue experienced by ≈3.8 million people annually. Only 8% to 12% survive to hospital discharge. Early defibrillation of shockable rhythms is associated with improved survival, but ensuring timely access to defibrillators has been a significant challenge. To date, the development of public-access defibrillation programs, involving the deployment of automated external defibrillators into the public space, has been the main strategy to address this challenge. Public-access defibrillator programs have been associated with improved outcomes for out-of-hospital cardiac arrest; however, the devices are used in <3% of episodes of out-of-hospital cardiac arrest. This scientific statement was commissioned by the International Liaison Committee on Resuscitation with 3 objectives: (1) identify known barriers to public-access defibrillator use and early defibrillation, (2) discuss established and novel strategies to address those barriers, and (3) identify high-priority knowledge gaps for future research to address. The writing group undertook systematic searches of the literature to inform this statement. Innovative strategies were identified that relate to enhanced public outreach, behavior change approaches, optimization of static public-access defibrillator deployment and housing, evolved automated external defibrillator technology and functionality, improved integration of public-access defibrillation with existing emergency dispatch protocols, and exploration of novel automated external defibrillator delivery vectors. We provide evidence- and consensus-based policy suggestions to enhance public-access defibrillation and guidance for future research in this area.

Considerations for the design of overdose education and naloxone distribution interventions: results of a multi-stakeholder workshop.

INTRODUCTION: Opioid overdose epidemic is a public health crisis that is impacting communities around the world. Overdose education and naloxone distribution programs equip and train lay people to respond in the event of an overdose. We aimed to understand factors to consider for the design of naloxone distribution programs in point-of-care settings from the point of view of community stakeholders. METHODS: We hosted a multi-stakeholder co-design workshop to elicit suggestions for a naloxone distribution program. We recruited people with lived experience of opioid overdose, community representatives, and other stakeholders from family practice, emergency medicine, addictions medicine, and public health to participate in a full-day facilitated co-design discussion wherein large and small group discussions were audio-recorded, transcribed and analysed using thematic approaches. RESULTS: A total of twenty-four participants participated in the multi-stakeholder workshop from five stakeholder groups including geographic and setting diversity. Collaborative dialogue and shared storytelling revealed seven considerations for the design of naloxone distribution programs specific to training needs and the provision of naloxone, these are: recognizing overdose, how much naloxone, impact of stigma, legal risk of responding, position as conventional first aid, friends and family as responders, support to call 911. CONCLUSION: To create an naloxone distribution program in emergency departments, family practice and substance use treatment services, stigma is a central design consideration for training and naloxone kits. Design choices that reference the iconography, type, and form of materials associated with first aid have the potential to satisfy the need to de-stigmatize overdose response.

Design details for overdose education and take-home naloxone kits: Codesign with family medicine, emergency department, addictions medicine and community.

INTRODUCTION: Overdose education and naloxone distribution (OEND) programmes equip and train people who are likely to witness an opioid overdose to respond with effective first aid interventions. Despite OEND expansion across North America, overdose rates are increasing, raising questions about how to improve OEND programmes. We conducted an iterative series of codesign stakeholder workshops to develop a prototype for take-home naloxone (THN)-kit (i.e., two doses of intranasal naloxone and training on how to administer it). METHODS: We recruited people who use opioids, frontline healthcare providers and public health representatives to participate in codesign workshops covering questions related to THN-kit prototypes, training on how to use it, and implementation, including refinement of design artefacts using personas and journey maps. Completed over 9 months, the workshops were audio-recorded and transcribed with visible results of the workshops (i.e., sticky notes, sketches) archived. We used thematic analyses of these materials to identify design requirements for THN-kits and training. RESULTS: We facilitated 13 codesign workshops to identify and address gaps in existing opioid overdose education training and THN-kits and emphasize timely response and stigma in future THN-kit design. Using an iterative process, we created 15 prototypes, 3 candidate prototypes and a final prototype THN-kit from the synthesis of the codesign workshops. CONCLUSION: The final prototype is available for a variety of implementation and evaluation processes. The THN-kit offers an integrated solution combining ultra-brief training animation and physical packaging of nasal naloxone to be distributed in family practice clinics, emergency departments, addiction medicine clinics and community settings. PATIENT OR PUBLIC CONTRIBUTION: The codesign process was deliberately structured to involve community members (the public), with multiple opportunities for public contribution. In addition, patient/public participation was a principle for the management and structuring of the research team.

Paediatric health care access in community health centres is associated with survival for critically ill children who undergo inter-facility transport: A province-wide observational study.

BACKGROUND: Diverse settlement makes inter-facility transport of critically ill children a necessary part of regionalized health care. There are few studies of outcomes and health care services use of this growing population. METHODS: A retrospective study evaluated the frequency of transports, health care services use, and outcomes of all critically ill children who underwent inter-facility transport to a paediatric intensive care unit (PICU) in Ontario from 2004 to 2012. The primary outcome was PICU mortality. Secondary outcomes were 24-hour and 6-month mortality, PICU and hospital lengths of stay, and use of therapies in the PICU. RESULTS: The 4,074 inter-facility transports were for children aged median (IQR) 1.6 (0.1 to 8.3) years. The rate of transports increased from 15 to 23 per 100,000 children. There were 233 (5.7%) deaths in PICU and an additional 78 deaths (1.9%) by 6 months. Length of stay was median (IQR) 2 (1 to 5) days in PICU and 7 (3 to 14) days in the receiving hospital. Lower PICU mortality was independently associated with prior acute care contact (odds ratio [OR]=0.3, 95% confidence interval [CI]: 0.2 to 0.6) and availability of paediatric expertise at the referral hospital (OR=0.7, 95% CI: 0.5 to 1.0). CONCLUSIONS: We found that in Ontario, children undergoing inter-facility transport to PICUs are increasing in number, consume significant acute care resources, and have a high PICU mortality. Access to paediatric expertise is a potentially modifiable factor that can impact mortality and warrants further evaluation.

2017 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Summary.

The International Liaison Committee on Resuscitation has initiated a near-continuous review of cardiopulmonary resuscitation science that replaces the previous 5-year cyclic batch-and-queue approach process. This is the first of an annual series of International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations summary articles that will include the cardiopulmonary resuscitation science reviewed by the International Liaison Committee on Resuscitation in the previous year. The review this year includes 5 basic life support and 1 pediatric Consensuses on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Each of these includes a summary of the science and its quality based on Grading of Recommendations, Assessment, Development, and Evaluation criteria and treatment recommendations. Insights into the deliberations of the International Liaison Committee on Resuscitation task force members are provided in Values and Preferences sections. Finally, the task force members have prioritized and listed the top 3 knowledge gaps for each population, intervention, comparator, and outcome question.

Early versus later rhythm analysis in patients with out-of-hospital cardiac arrest.

BACKGROUND: In a departure from the previous strategy of immediate defibrillation, the 2005 resuscitation guidelines from the American Heart Association-International Liaison Committee on Resuscitation suggested that emergency medical service (EMS) personnel could provide 2 minutes of cardiopulmonary resuscitation (CPR) before the first analysis of cardiac rhythm. We compared the strategy of a brief period of CPR with early analysis of rhythm with the strategy of a longer period of CPR with delayed analysis of rhythm. METHODS: We conducted a cluster-randomized trial involving adults with out-of-hospital cardiac arrest at 10 Resuscitation Outcomes Consortium sites in the United States and Canada. Patients in the early-analysis group were assigned to receive 30 to 60 seconds of EMS-administered CPR and those in the later-analysis group were assigned to receive 180 seconds of CPR, before the initial electrocardiographic analysis. The primary outcome was survival to hospital discharge with satisfactory functional status (a modified Rankin scale score of ≤3, on a scale of 0 to 6, with higher scores indicating greater disability). RESULTS: We included 9933 patients, of whom 5290 were assigned to early analysis of cardiac rhythm and 4643 to later analysis. A total of 273 patients (5.9%) in the later-analysis group and 310 patients (5.9%) in the early-analysis group met the criteria for the primary outcome, with a cluster-adjusted difference of -0.2 percentage points (95% confidence interval, -1.1 to 0.7; P=0.59). Analyses of the data with adjustment for confounding factors, as well as subgroup analyses, also showed no survival benefit for either study group. CONCLUSIONS: Among patients who had an out-of-hospital cardiac arrest, we found no difference in the outcomes with a brief period, as compared with a longer period, of EMS-administered CPR before the first analysis of cardiac rhythm. (Funded by the National Heart, Lung, and Blood Institute and others; ROC PRIMED ClinicalTrials.gov number, NCT00394706.).

Predicting neurologic outcome after targeted temperature management for cardiac arrest: systematic review and meta-analysis.

OBJECTIVES: Targeted temperature management improves survival and neurologic outcomes for adult out-of-hospital cardiac arrest survivors but may alter the accuracy of tests for predicting neurologic outcome after cardiac arrest. DATA SOURCES: We systematically searched Medline, Embase, CINAHL, and CENTRAL from database inception to September 2012. STUDY SELECTION: Citations were screened for studies that examined diagnostic tests to predict poor neurologic outcome or death following targeted temperature management in adult cardiac arrest survivors. DATA EXTRACTION: Data on study outcomes and quality were abstracted in duplicate. We constructed contingency tables for each diagnostic test and calculated sensitivity, specificity, and positive and negative likelihood ratios. DATA SYNTHESIS: Of 2,737 citations, 20 studies (n = 1,845) met inclusion criteria. Meta-analysis showed that three tests accurately predicted poor neurologic outcome with low false-positive rates: bilateral absence of pupillary reflexes more than 24 hours after a return of spontaneous circulation (false-positive rate, 0.02; 95% CI, 0.01-0.06; summary positive likelihood ratio, 10.45; 95% CI, 3.37-32.43), bilateral absence of corneal reflexes more than 24 hours (false-positive rate, 0.04; 95% CI, 0.01-0.09; positive likelihood ratio, 6.8; 95% CI, 2.52-18.38), and bilateral absence of somatosensory-evoked potentials between days 1 and 7 (false-positive rate, 0.03; 95% CI, 0.01-0.07; positive likelihood ratio, 12.79; 95% CI, 5.35-30.62). False-positive rates were higher for a Glasgow Coma Scale motor score showing extensor posturing or worse (false-positive rate, 0.09; 95% CI, 0.06-0.13; positive likelihood ratio, 7.11; 95% CI, 5.01-10.08), unfavorable electroencephalogram patterns (false-positive rate, 0.07; 95% CI, 0.04-0.12; positive likelihood ratio, 8.85; 95% CI, 4.87-16.08), myoclonic status epilepticus (false-positive rate, 0.05; 95% CI, 0.02-0.11; positive likelihood ratio, 5.58; 95% CI, 2.56-12.16), and elevated neuron-specific enolase (false-positive rate, 0.12; 95% CI, 0.06-0.23; positive likelihood ratio, 4.14; 95% CI, 1.82-9.42). The specificity of available tests improved when these were performed beyond 72 hours. Data on neuroimaging, biomarkers, or combination testing were limited and inconclusive. CONCLUSION: Simple bedside tests and somatosensory-evoked potentials predict poor neurologic outcome for survivors of cardiac arrest treated with targeted temperature management, and specificity improves when performed beyond 72 hours. Clinicians should use caution with these predictors as they carry the inherent risk of becoming self-fulfilling.

Expanding paramedic scope of practice in the community: a systematic review of the literature.

BACKGROUND: Paramedics are an important health human resource and are uniquely mobile in most communities across Canada. In the last dozen years, challenges in the delivery of health care have prompted governments from around the globe to consider expanding the role paramedics play in health systems. Utilizing paramedics for the management of urgent, low-acuity illnesses and injuries has been coined "community paramedicine," but the role, safety, and effectiveness of this concept are poorly understood. OBJECTIVE: We undertook a systematic review of the international literature to describe existing community paramedic programs. METHOD: We used the Cochrane methodology for systematic reviews. An international group of experts developed a search strategy and a health information specialist executed this search in Medline, Embase, and CINAHL starting January 1, 2000. We included all research articles in the English language that reported a research methodology. We excluded commentaries and letters to the editor. Two investigators independently screened citations in a hierarchical manner and abstracted data. RESULTS: Of 3,089 titles, 10 articles were included in the systematic review and one additional paper was author-nominated. The nature of the 11 articles was heterogeneous, and only one randomized controlled trial (RCT) was found. This trial showed community paramedicine to be beneficial to patients and health systems. The other articles drew conclusions favoring community paramedicine. CONCLUSION: Community paramedicine research to date is lacking, but programs in the United Kingdom, Australia, and Canada are perceived to be promising, and one RCT shows that paramedics can safely practice with an expanded scope and improve system performance and patient outcomes. Further research is required to fully understand how expanding paramedic roles affect patients, communities, and health systems.

Optimizing outcomes after out-of-hospital cardiac arrest with innovative approaches to public-access defibrillation: A scientific statement from the International Liaison Committee on Resuscitation.

Out-of-hospital cardiac arrest is a global public health issue experienced by ≈3.8 million people annually. Only 8% to 12% survive to hospital discharge. Early defibrillation of shockable rhythms is associated with improved survival, but ensuring timely access to defibrillators has been a significant challenge. To date, the development of public-access defibrillation programs, involving the deployment of automated external defibrillators into the public space, has been the main strategy to address this challenge. Public-access defibrillator programs have been associated with improved outcomes for out-of-hospital cardiac arrest; however, the devices are used in <3% of episodes of out-of-hospital cardiac arrest. This scientific statement was commissioned by the International Liaison Committee on Resuscitation with 3 objectives: (1) identify known barriers to public-access defibrillator use and early defibrillation, (2) discuss established and novel strategies to address those barriers, and (3) identify high-priority knowledge gaps for future research to address. The writing group undertook systematic searches of the literature to inform this statement. Innovative strategies were identified that relate to enhanced public outreach, behavior change approaches, optimization of static public-access defibrillator deployment and housing, evolved automated external defibrillator technology and functionality, improved integration of public-access defibrillation with existing emergency dispatch protocols, and exploration of novel automated external defibrillator delivery vectors. We provide evidence- and consensus-based policy suggestions to enhance public-access defibrillation and guidance for future research in this area.

Pediatric timing of epinephrine doses: A systematic review.

AIM: To evaluate the optimal timing and doses of epinephrine for Infants and children suffering in-hospital or out-of-hospital cardiac arrest. METHODS: We searched Medline, EMBASE, and Cochrane Controlled Register of Trials (CENTRAL) for human randomized clinical trials and observational studies including comparative cohorts. Two investigators reviewed relevance of studies, extracted the data, conducted meta-analyses and assessed the risk of bias using the GRADE and CLARITY frameworks. Authors of the eligible studies were contacted to obtain additional data. Critically important outcomes included return of spontaneous circulation, survival to hospital discharge and survival with good neurological outcome. RESULTS: We identified 7 observational studies suitable for meta-analysis and no randomized clinical trials. The overall certainty of evidence was very low. For the critically important outcomes, the earlier administration of epinephrine was favorable for both in-hospital and out-of-hospital cardiac arrest. Because of a limited number of eligible studies and the presence of severe confounding factors, we could not determine the optimal interval of epinephrine administration. CONCLUSIONS: Earlier administration of the first epinephrine dose could be more favorable in non-shockable pediatric cardiac arrest. The optimal interval for epinephrine administration remains unclear.

Mixed methods feasibility study for the surviving opioid overdose with naloxone education and resuscitation (SOONER) trial.

AIM: We plan to conduct a randomised clinical trial among people likely to witness opioid overdose to compare the educational effectiveness of point-of-care naloxone distribution with best-available care, by observing participants' resuscitation skills in a simulated overdose. This mixed methods feasibility study aims to assess the effectiveness of recruitment and retention strategies and acceptability of study procedures. METHODS: We implemented candidate-driven recruitment strategies with verbal consent and destigmatizing study materials in a family practice, emergency department, and addictions service. People ≥16 years of age who are likely to witness overdose were randomized to point-of-care naloxone distribution or referral to an existing program. We evaluated participant skills as a responder to a simulated overdose 3-14 days post-recruitment. Retention strategies included flexible scheduling, reminders, cash compensation and refreshments. The primary outcome was recruitment and retention feasibility, defined as the ability to recruit 28 eligible participants in 28 days, with <50% attrition at the outcome simulation. Acceptability of study procedures and motivations for participation were assessed in a semi-structured interview. RESULTS: We enrolled 30 participants over 24 days, and retained 21 participants (70%, 95%CI 56.7-100). The most common motivation for participation was a desire to serve the community or loved ones in distress. Participants reported that study procedures were acceptable and that the outcome simulation provided a supportive and affirming environment. CONCLUSION: The planned trial is ready for implementation. Recruitment and retention is feasible and study processes are acceptable for people who are likely to witness overdose. (Registration: NCT03821649).

Healthcare costs and resource utilization associated with treatment of out-of-hospital cardiac arrest.

BACKGROUND: The management of out-of-hospital cardiac arrest (OHCA) patients requires the coordination of prehospital, in-hospital and post-discharge teams. Data reporting a comprehensive analysis of all costs associated with treating OHCA are scarce. We aimed to describe the total costs (and their components) related to the management of OHCA patients. PATIENT AND METHODS: We performed an analysis on a merged database of the Toronto Regional RescuNet Epistry database (prehospital data) and administrative population-based databases in Ontario. All non-traumatic OHCA patients over 18 years of age treated by the EMS between January 1, 2006, and March 31, 2014, were included in this study. The primary outcome was per patient longitudinal cumulative healthcare costs, from time of collapse to a maximum follow-up until death or 30 days after the event. We included all available cost sectors, from the perspective of the health system payer. We used multivariable generalized linear models with a logarithmic link and a gamma distribution to determine predictors of healthcare costs. RESULTS: 25,826/44,637 patients were treated by EMS services for an OHCA (mostly male 64.4%, mean age 70.1). 11,727 (45%) were pronounced dead on scene, 8359 (32%) died in the emergency department, 3640 (14%) were admitted to hospital but died before day-30, and 2100 (8.1%) were still alive at day-30. Total cost was $690 [interquartile range (IQR) $308, $1742] per patient; ranging from $290 [IQR $188, $390] for patients who were pronounced on scene to $39,216 [IQR 21,802, 62,093] for patients who were still alive at day-30. In-hospital costs accounted for 93% of total costs. After adjustment for age and gender, rate of patient survival was the main driver of total costs: the rate ratio was 3.88 (95% confidence interval 3.80, 3.95), 49.46 and 148.89 for patients who died in the ED, patients who died after the ED but within 30 days, and patients who were still alive at day-30 compared to patients who were pronounced dead on scene, respectively. Factors independently associated with costs were the number of prehospital teams (rate ratio (RR) 5.50 [5.32, 5.67] for being treated by 4 teams vs. 1), the need for hospital transfer (RR 2.38 [2.01, 2.82]), coronary angiography (RR 1.43 [1.27, 1.62]) and targeted temperature management (RR 1.25 [1.09, 1.44]). CONCLUSION: Survival is the main driver of total costs of treating OHCA patients in a large Canadian health system. Inpatient costs accounted for the majority of the total costs; potentially modifiable factors include the number of prehospital teams that arrive to the scene of the arrest and the need for between-hospital transfers after successful resuscitation.

Costs related to cardiac arrest management: a systematic review protocol.

BACKGROUND: Each year, about 500,000 people suffer a cardiac arrest (either out-of-hospital or in-hospital) in the USA. Although significant improvements in survival have occurred through the implementation of complex high-quality protocols of care, global costs related to such management are not clearly described. METHODS: We will undertake a systematic review of the published literature on costs related to the acute phase of cardiac arrest management (from collapse to hospital discharge). The search will cover the period 1991 to present, and we will include studies written in English or in French involving patients with cardiac arrest of all ages, settings (in- and out-of-hospital arrest), countries, and etiology (including traumatic). The primary outcome will include estimates of costs related to cardiac arrest patients' management in various categories (e.g., resuscitation process, in-hospital management as well as rehabilitation and long-term care facilities) and perspectives (e.g., hospital, societal, or third-payer perspective). Study selection will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and data quality will be assessed by questions adapted from the Drummond economic evaluation checklist. DISCUSSION: This review will provide an estimate of costs related to cardiac arrest management according to the different components of such a management as well as total costs. SYSTEMATIC REVIEW REGISTRATION: International Prospective Register of Systematic Reviews PROSPERO CRD42016046993.

Evaluation of prehospital insertion of the laryngeal mask airway by primary care paramedics with only classroom mannequin training.

INTRODUCTION: The laryngeal mask airway (LMAtrade mark airway) provides adequate ventilation and offers a suitable alternative for airway management in patients with cardiac arrest if primary care paramedics do not have intubation skills or are unable to intubate. Training in the use of the LMA usually occurs in the operating room. OBJECTIVE: To describe the use of the LMA by paramedics in prehospital adult non-traumatic cardiac arrest patients after classroom mannequin training. The study took place in a suburban rural emergency medical service. METHODS: This is a 2-phase observational study of the effect of paramedic training for LMA insertion using a mannequin and the success rate in the prehospital setting. All paramedics successfully completed classroom mannequin training. All subsequent prehospital adult non-traumatic cardiac arrest patients from mid-February 1999 to Mar. 31, 2000, were eligible. Subjective assessment of chest expansion, ease of ventilation and auscultation defined adequacy of ventilation. Data collected included the number of insertion attempts, reasons for failure, ease of insertion, adverse events and reasons for not attempting intubation. Statistical analysis comprised descriptive frequencies, chi-squared tests for comparison of categorical variables and analysis of variance for continuous variables. RESULTS: 208 paramedics (100%) successfully completed training. The mean number of attempts was 1, and only 4 (2.1%) paramedics required a second attempt with a mannequin. The paramedics' perception of ease of use comparing the LMA with a bag valve mask (BVM) was evenly distributed across the 3 descriptors: 70 (39%) scored the LMA as easier to use, 57 (31%) as more difficult, and 54 (30%) stated there would be no difference. Of the 291 arrests during the study period, insertion of the LMA was attempted in 283 (97.3%) and was successful in 199 (70%) patients. The LMA became dislodged in 5 (2.5%) cases and was removed in 12 (6%) to clear vomit from the airway. The overall success rate was 182 (64%). The incidence of regurgitation prior to attempted insertion of the LMA was 28% (79 patients). Success rates did not vary significantly with the incidence of vomiting prior to insertion (p = 0.11). The majority of the paramedics evaluated LMA insertion as Very easy 49/220 (22.3%) or Easy 87/220 (39.6%). Paramedic evaluation of ease of use varied with success (p = 0.001). CONCLUSIONS: This study reports a 100% training success rate with a mannequin and a 64% success with LMA insertion and ventilation in the field by paramedics among adult out-of-hospital non-traumatic cardiac arrest patients.

The Canadian National EMS Research Agenda: a mixed methods consensus study.

INTRODUCTION: Research is essential for the development of evidence-based emergency medical services (EMS) systems of care. When resources are scarce and gaps in evidence are large, a national agenda may inform the growth of EMS research in Canada. This mixed methods consensus study explores current barriers and existing strengths within Canadian EMS research, provides recommendations, and suggests EMS topics for future study. METHODS: Purposeful sampling was employed to invite EMS research stakeholders from various roles across the country. Study phases consisted of 1) baseline interviews of a subsample, 2) roundtable discussion, and 3) an online Delphi survey, in which participants scored each statement for importance. Consensus was defined a priori and met if 80% scored a statement as "important" or "very important." RESULTS: Fifty-three stakeholders participated, representing researchers (37.7%), EMS administrators (24.6%), clinicians/providers (20.7%), and educators (17.0%). Participation rates were as follows: interviews, 13 of 13 (100%); roundtable, 47 of 53 (89%); survey round 1, 50 of 53 (94%); survey round 2, 47 of 53 (89%); and survey round 3, 40 of 53 (75%). A total of 141 statements were identified as important: 20 barriers, 54 strengths/opportunities, 31 recommendations, and 36 suggested topics for future research. Like statements were synthesized, resulting in barriers (n  =  10), strengths/opportunities (n  =  24), and recommendations (n  =  19), which were categorized as time, opportunities, and funding; education and mentorship; culture of research and collaboration; structure, process, and outcome of research; EMS and paramedic practice; and the future of the EMS Research Agenda. CONCLUSION: Consensus-based key messages from this agenda should be considered when designing, funding, and publishing EMS research and will advance EMS research locally, regionally, and nationally.

Developing a Canadian emergency medical services research agenda: a baseline study of stakeholder opinions.

PURPOSE: This study forms the first phase in the development of the Canadian National EMS Research Agenda. The purpose was to understand the current state of emergency medical services (EMS) research through the barriers and opportunities perceived by key stakeholders in the Canadian system and to identify the recommendations this group had for moving forward. METHODS: This qualitative study was conducted in the spring of 2011 using one-on-one semistructured telephone interviews. Purposeful sampling was used to recruit a cross section of EMS research stakeholders, representing a breadth of geographic regions and roles. Data were collected until thematic saturation was reached. A constant comparative approach was used to develop a basic coding framework and identify emerging themes. RESULTS: Twenty stakeholders were invited to participate, and saturation was reached after 13 interviews. Thematic saturation was used to ensure that the findings were grounded in the data. Four major themes were identified: 1) the need for additional research education within EMS; 2) the importance of creating an infrastructure to support pan-Canadian research collaboration; 3) addressing the complexities of involving EMS providers in research; and 4) considerations for a national research agenda. CONCLUSION: This hypothesis-generating study reveals key areas regarding EMS research in Canada and through the guidance it provides is a first step in the development of a comprehensive national research agenda. Our intention is to collate the identified themes with the results of a larger roundtable discussion and Delphi survey and, in doing so, guide development of a Canadian national EMS research agenda.

Wide variability in drug use in out-of-hospital cardiac arrest: a report from the resuscitation outcomes consortium.

BACKGROUND: Despite the publication and dissemination of the Advanced Cardiac Life Support guidelines, variability in the use of drugs during resuscitation from out-of-hospital cardiac arrest may exist between different Emergency Medical Services throughout North America. The purpose of this study was to characterize the use of such drugs and evaluate their relationship to cardiac arrest outcomes. METHODS AND RESULTS: The Resuscitation Outcomes Consortium Registry-Cardiac Arrest collects out-of-hospital cardiac arrest data from 264 Emergency Medical Services agencies in 11 geographical locations in the U.S. and Canada. Multivariable logistic regression was used to assess the association between drug use, characteristics of the cardiac arrest and a pulse at emergency department arrival and survival to discharge. A total of 16,221 out-of-hospital cardiac arrests were attended by 74 Emergency Medical Services agencies. There was a considerable variability in the administration of amiodarone and lidocaine for the treatment of shock resistant ventricular tachycardia/ventricular fibrillation. For non-shockable rhythms, atropine use ranged from 29 to 95% and sodium bicarbonate use ranged from 0.2 to 73% across agencies in the 89% of agencies that used the drug. Epinephrine use ranged from 57 to 98% within agencies. Neither lidocaine nor amiodarone was associated with a survival benefit while there was an inverse relationship between the administration of epinephrine, atropine and sodium bicarbonate and survival to hospital discharge. CONCLUSIONS: There is considerable variability among Emergency Medical Services agencies in their use of pharmacological therapy for out-of-hospital cardiac arrests which may be resolved by performing large randomized trials examining effects on survival.

Patient safety in emergency medical services: executive summary and recommendations from the Niagara Summit.

Emergency medical services (EMS) personnel care for patients in challenging and dynamic environments that may contribute to an increased risk for adverse events. However, little is known about the risks to patient safety in the EMS setting. To address this knowledge gap, we conducted a systematic review of the literature, including nonrandomized, noncontrolled studies, conducted qualitative interviews of key informants, and, with the assistance of a pan-Canadian advisory board, hosted a 1-day summit of 52 experts in the field of EMS patient safety. The intent of the summit was to review available research, discuss the issues affecting prehospital patient safety, and discuss interventions that might improve the safety of the EMS industry. The primary objective was to define the strategic goals for improving patient safety in EMS. Participants represented all geographic regions of Canada and included administrators, educators, physicians, researchers, and patient safety experts. Data were collected through electronic voting and qualitative analysis of the discussions. The group reached consensus on nine recommendations to increase awareness, reduce adverse events, and suggest research and educational directions in EMS patient safety: increasing awareness of patient safety principles, improving adverse event reporting through creating nonpunitive reporting systems, supporting paramedic clinical decision making through improved research and education, policy changes, using flexible algorithms, adopting patient safety strategies from other disciplines, increasing funding for research in patient safety, salary support for paramedic researchers, and access to graduate training in prehospital research.