Racial and Ethnic Differences in Bystander CPR for Witnessed Cardiac Arrest.

BACKGROUND: Differences in the incidence of cardiopulmonary resuscitation (CPR) provided by bystanders contribute to survival disparities among persons with out-of-hospital cardiac arrest. It is critical to understand whether the incidence of bystander CPR in witnessed out-of-hospital cardiac arrests at home and in public settings differs according to the race or ethnic group of the person with cardiac arrest in order to inform interventions. METHODS: Within a large U.S. registry, we identified 110,054 witnessed out-of-hospital cardiac arrests during the period from 2013 through 2019. We used a hierarchical logistic regression model to analyze the incidence of bystander CPR in Black or Hispanic persons as compared with White persons with witnessed cardiac arrests at home and in public locations. We analyzed the overall incidence as well as the incidence according to neighborhood racial or ethnic makeup and income strata. Neighborhoods were classified as predominantly White (>80% of residents), majority Black or Hispanic (>50% of residents), or integrated, and as high income (an annual median household income of >$80,000), middle income ($40,000-$80,000), or low income (<$40,000). RESULTS: Overall, 35,469 of the witnessed out-of-hospital cardiac arrests (32.2%) occurred in Black or Hispanic persons. Black and Hispanic persons were less likely to receive bystander CPR at home (38.5%) than White persons (47.4%) (adjusted odds ratio, 0.74; 95% confidence interval [CI], 0.72 to 0.76) and less likely to receive bystander CPR in public locations than White persons (45.6% vs. 60.0%) (adjusted odds ratio, 0.63; 95% CI, 0.60 to 0.66). The incidence of bystander CPR among Black and Hispanic persons was less than that among White persons not only in predominantly White neighborhoods at home (adjusted odds ratio, 0.82; 95% CI, 0.74 to 0.90) and in public locations (adjusted odds ratio, 0.68; 95% CI, 0.60 to 0.75) but also in majority Black or Hispanic neighborhoods at home (adjusted odds ratio, 0.79; 95% CI, 0.75 to 0.83) and in public locations (adjusted odds ratio, 0.63; 95% CI, 0.59 to 0.68) and in integrated neighborhoods at home (adjusted odds ratio, 0.78; 95% CI, 0.74 to 0.81) and in public locations (adjusted odds ratio, 0.73; 95% CI, 0.68 to 0.77). Similarly, across all neighborhood income strata, the frequency of bystander CPR at home and in public locations was lower among Black and Hispanic persons with out-of-hospital cardiac arrest than among White persons. CONCLUSIONS: In witnessed out-of-hospital cardiac arrest, Black and Hispanic persons were less likely than White persons to receive potentially lifesaving bystander CPR at home and in public locations, regardless of the racial or ethnic makeup or income level of the neighborhood where the cardiac arrest occurred. (Funded by the National Heart, Lung, and Blood Institute.).

Rural cardiac arrest care and outcomes in Texas.

INTRODUCTION: Out-of-hospital cardiac arrest (OHCA) victims in rural communities have worse outcomes despite higher rates of bystander cardiopulmonary resuscitation (CPR) than urban communities. In this retrospective cohort study we attempt to evaluate selected aspects of the continuum of care, including post-arrest care, for rural OHCA victims, and we investigated factors that could contribute to rural areas having higher rates of bystander CPR. METHODS: We analyzed 2014-2020 Texas Cardiac Arrest Registry to Enhance Survival (TX-CARES) data for adult OHCAs. We linked TX-CARES data to census tract data and stratified OHCAs into urban and rural events. We created a mixed-model logistic regression to compare cardiac arrest characteristics, pre-hospital care, and post-arrest care between rural and urban settings. We adjusted for confounders and modeled census tract as a random intercept. We then compared different regression models evaluating the association between response time and bystander CPR. RESULTS: We included 1202 rural and 28,288 urban cardiac arrests. Comparing rural to urban OHCAs, rates of bystander CPR were significantly higher in rural communities (49.6% v 40.6%, aOR 1.3 95% CI 1.1-1.5). The median response time for rural (11.5 min) was longer than urban (7.3 min). The occurrence of an ambulance response time of <10 min was notably less common in rural communities when compared to urban areas (aOR 0.2, 95% CI 0.2-0.2). For post-arrest care the rates of percutaneous coronary intervention (PCI) were higher in rural than urban communities (aOR 1.7, 95% CI 1.01-2.8). The rates of AED and TTM were similar between urban and rural communities. Survival to hospital discharge was significantly lower in rural communities than urban communities (aOR 0.6, 95% CI 0.4-0.7). Although not significant, rural communities had lower rate of survival with a cognitive performance score (CPC) of 1 or 2 (aOR 0.7, 05% CI 0.6-1.003). We identified no association between response time and bystander CPR. CONCLUSION: Patients in rural areas of Texas have lower survival after OHCA compared to patients in urban areas, despite having significantly greater rates of bystander CPR and PCI. We did not find a link between response time and bystander CPR rates.

Survival after out-of-hospital cardiac arrest, Viet Nam: multicentre prospective cohort study.

OBJECTIVE: To investigate factors associated with survival after out-of-hospital cardiac arrest in Viet Nam. METHODS: We did a multicentre prospective observational study of people (> 18 years) presenting with out-of-hospital cardiac arrest (not caused by trauma) to three tertiary hospitals in Viet Nam from February 2014 to December 2018. We collected data on characteristics, management and outcomes of patients with out-of-hospital cardiac arrest and compared these data by type of transportation to hospital and survival to hospital admission. We assessed factors associated with survival to admission to and discharge from hospital using logistic regression analysis. FINDINGS: Of 590 eligible people with out-of-hospital cardiac arrest, 440 (74.6%) were male and the mean age was 56.1 years (standard deviation: 17.2). Only 24.2% (143/590) of these people survived to hospital admission and 14.1% (83/590) survived to hospital discharge. Most cardiac arrests (67.8%; 400/590) occurred at home, 79.4% (444/559) were witnessed by bystanders and 22.3% (124/555) were given cardiopulmonary resuscitation by a bystander. Only 8.6% (51/590) of the people were taken to hospital by the emergency medical services and 32.2% (49/152) received pre-hospital defibrillation. Pre-hospital defibrillation (odds ratio, OR: 3.90; 95% confidence interval, CI: 1.54-9.90) and return of spontaneous circulation in the emergency department (OR: 2.89; 95% CI: 1.03-8.12) were associated with survival to hospital admission. Hypothermia therapy during post-resuscitation care was associated with survival to discharge (OR: 5.44; 95% CI: 2.33-12.74). CONCLUSION: Improvements are needed in the emergency medical services in Viet Nam such as increasing bystander cardiopulmonary resuscitation and public access defibrillation, and improving ambulance and post-resuscitation care.

The association between scene time interval and neurologic outcome following adult bystander witnessed out-of-hospital cardiac arrest.

OBJECTIVE: To analyze the association between Emergency Medical Services (EMS) scene time interval (STI) and survival with functional neurologic recovery following adult out-of-hospital cardiac arrest (OHCA). METHODS: A retrospective analysis of prospectively collected data from the national Cardiac Arrest Registry to Enhance Survival from January 2013 to December 2018. All adult non-traumatic, EMS-treated, bystander-witnessed OHCA with complete data were included. Patients with STI times >60 min, defined as the time from EMS arrival at the patient's side to the time the transport vehicle left the scene, unwitnessed OHCA, nursing home events, EMS-witnessed OHCA, or patients with termination of resuscitation in the field were excluded. The primary outcome was survival with functional recovery (Cerebral Performance Category [CPC] = 1 or 2). Multivariable logistic regression was used to quantify the association of STI with the primary. RESULTS: 67,237 patients met inclusion criteria with 12,098 (18.0%) surviving with functional recovery. Mean STI (SD) for survivors with CPC 1 or 2 was 19 (8.4) and 22.8 (10.5) for those with poor outcomes (death or CPC 3-4; p < 0.001). For every 1-min increase in STI, the adjusted odds of a poor outcome increased by 3.5%; odds ratio = 1.035; 95% CI (1.027, 1.044); p < 0.001. Restricted cubic spline analysis showed increased risk of poor outcome after approximately 20 min. CONCLUSION: Longer STI times are strongly associated with poor neurologic outcome in bystander-witnessed OHCA patients. After a STI duration of approximately 20 min, the associated risk of a poor neurologic outcome increased more rapidly.

Survival after traumatic out-of-hospital cardiac arrest in Vietnam: a multicenter prospective cohort study.

BACKGROUND: Pre-hospital services are not well developed in Vietnam, especially the lack of a trauma system of care. Thus, the prognosis of traumatic out-of-hospital cardiac arrest (OHCA) might differ from that of other countries. Although the outcome in cardiac arrest following trauma is dismal, pre-hospital resuscitation efforts are not futile and seem worthwhile. Understanding the country-specific causes, risk, and prognosis of traumatic OHCA is important to reduce mortality in Vietnam. Therefore, this study aimed to investigate the survival rate from traumatic OHCA and to measure the critical components of the chain of survival following a traumatic OHCA in the country. METHODS: We performed a multicenter prospective observational study of patients (> 16 years) presenting with traumatic OHCA to three central hospitals throughout Vietnam from February 2014 to December 2018. We collected data on characteristics, management, and outcomes of patients, and compared these data between patients who died before hospital discharge and patients who survived to discharge from the hospital. RESULTS: Of 111 eligible patients with traumatic OHCA, 92 (82.9%) were male and the mean age was 39.27 years (standard deviation: 16.38). Only 5.4% (6/111) survived to discharge from the hospital. Most cardiac arrests (62.2%; 69/111) occurred on the street or highway, 31.2% (29/93) were witnessed by bystanders, and 33.7% (32/95) were given cardiopulmonary resuscitation (CPR) by a bystander. Only 29 of 111 patients (26.1%) were taken by the emergency medical services (EMS), 27 of 30 patients (90%) received pre-hospital advanced airway management, and 29 of 53 patients (54.7%) were given resuscitation attempts by EMS or private ambulance. No significant difference between patients who died before hospital discharge and patients who survived to discharge from the hospital was found for bystander CPR (33.7%, 30/89 and 33.3%, 2/6, P > 0.999; respectively) and resuscitation attempts (56.3%, 27/48, and 40.0%, 2/5, P = 0.649; respectively). CONCLUSION: In this study, patients with traumatic OHCA presented to the ED with a low rate of EMS utilization and low survival rates. The poor outcomes emphasize the need for increasing bystander first-aid, developing an organized trauma system of care, and developing a standard emergency first-aid program for both healthcare personnel and the community.

Disparity in Receipt and Utilization of Telecommunicator CPR Instruction.

Introduction: Telecommunicator Assisted Cardiopulmonary Resuscitation (T-CPR) is independently associated with improved survival and improved functional outcome after adult Out of Hospital Cardiac Arrest (OHCA). The objective of this study was to evaluate whether there are racial and socioeconomic disparities in the provision of T-CPR instruction and subsequent CPR performance. Methods: We performed a retrospective review of a convenience sample of EMS agencies throughout the United States that utilized the Cardiac Arrest Registry to Enhance Survival (CARES) dispatch registry during the period 1/2014-12/2017. Data were collected by dispatch agencies after review of 9-1-1 OHCA audio recordings. Elements related to dispatcher CPR instruction, barriers to bystander CPR (BCPR) performance, patient race (White, Black, Hispanic-Latino, or other) and Utstein data were captured from the CARES database. These data were merged with census tract data from incident locations. The effects of race and income (Socioeconomic status, SES) on outcome were analyzed using multilevel logistic regression. Results: A total of 3,807 cases were identified from 37 dispatch agencies in 6 states. The sample was predominantly White (57.5%) and male (64.9%) with an average age of 60.3 ± 19.9. In the adjusted analysis, there were no differences in the odds of receiving CPR instruction by race (black vs white), OR = 0.96 (95% CI. 0.70, 1.32) or for increased income, (OR = 1.00, 95% CI 0.99, 1.02). There was a significant difference in receipt of T-CPR instruction by patient age, OR = 0.99 (95% CI, 0.98, 0.99). Subsequent utilization of T-CPR instruction to perform BCPR was less likely for patients that had a lower income, OR = 1.03 (95% CI 1.01, 1.05). There was also a decreased rate of BCPR provision by patient age OR = 0.99 (95% CI, 0.99, 1.00), but there was no difference in rate of BCPR provision by race, OR = 0.86 (95% CI 0.61, 1.23). Conclusion: We identified differences in age but not race or SES in the provision of T-CPR instruction by dispatch centers. We also identified decreased CPR provision by age and income after receipt of T-CPR instructions. In this sample, we found no evidence of racial disparities in the provision of T-CPR instruction or subsequent provision of BCPR.

Outcomes for Hemodialysis Patients Given Cardiopulmonary Resuscitation for Cardiac Arrest at Outpatient Dialysis Clinics.

BACKGROUND: Out-of-hospital cardiac arrest, the leading cause of death among patients on hemodialysis, occurs frequently within outpatient dialysis centers. Practice guidelines recommend resuscitation training for all dialysis clinic staff and on-site defibrillator availability, but the extent of staff involvement in cardiopulmonary resuscitation (CPR) efforts and its association with outcomes is unknown. METHODS: We used data from the Cardiac Arrest Registry to Enhance Survival and the Centers for Medicare & Medicaid Services dialysis facility database to identify patients who had cardiac arrest within outpatient dialysis clinics between 2010 and 2016 in the southeastern United States. We compared outcomes of patients who received dialysis staff-initiated CPR with those who did not until the arrival of emergency medical services (EMS). RESULTS: Among 398 OHCA events in dialysis clinics, 66% of all patients presented with a nonshockable initial rhythm. Dialysis staff initiated CPR in 81.4% of events and applied defibrillators before EMS arrival in 52.3%. Staff were more likely to initiate CPR among men and witness cardiac arrests, and were more likely to provide CPR within larger dialysis clinics. Staff-initiated CPR was associated with a three-fold increase in the odds of hospital discharge and favorable neurologic status on discharge. There was no overall association between staff-initiated defibrillator use and outcomes, but there was a nonsignificant trend toward improved survival to hospital discharge in the subgroup with shockable initial cardiac arrest rhythms. CONCLUSIONS: Dialysis staff-initiated CPR was associated with a large increase in survival but was only performed in 81% of cardiac arrest events. Further investigations should focus on understanding the potential facilitators and barriers to CPR in the dialysis setting.

Evaluating Dispatch-Assisted CPR Using the CARES Registry.

OBJECTIVES: Dispatch-assisted cardiopulmonary resuscitation (DA-CPR) has been shown to improve cardiac arrest survival. Recent literature has proposed dispatch metrics for provision of this intervention. Our objectives are to: use the Cardiac Arrest Registry to Enhance Survival (CARES) to compare current practice to proposed DA-CPR guidelines; describe barriers to DA-CPR; and assess the association of DA-CPR with out-of-hospital cardiac arrest (OHCA) survival. METHODS: We reviewed data from structured dispatch reviews of 911 OHCA calls from 1/1/14-12/31/15. Dispatch data including whether dispatch CPR instruction was given, and time intervals to CPR instruction and provision were linked with OHCA data elements from field cardiac arrest process and outcome data. Descriptive data on barriers to dispatch-caller instruction and measures of dispatcher performance were calculated. We compared outcome of patients who received bystander CPR prior to the 911 call (BCPR), after dispatcher CPR instructions (DA-CPR), and not until Emergency Medical Services (EMS) arrival (no BCPR). RESULTS: We identified 3335 cases from 32 dispatch agencies in 9 states that had dispatch and outcome data. CPR was performed prior to the 911 call by a bystander in 496 (14.9%) cases. Of all calls where the dispatcher talked to a bystander, dispatchers recognized cardiac arrest in 82.9% cases (1514/1827), with 31.6% calls recognized in <60 seconds. DA-CPR instructions were initiated in most (1320/1514, 87.2%) cases, and cardiac compressions were initiated in 73.7% (973/1320). DA-CPR was performed < two minutes in 21.4% of cases. In a multivariable analysis, BCPR (CPR prior to EMS arrival without instructions given) was associated with significantly improved patient survival (OR = 1.49, 95% CI 1.09, 2.04), and DA-CPR a non-significant improvement in survival to discharge (OR = 1.19, 95% CI 0.91, 1.56). CONCLUSIONS: Temporal measures of dispatch performance were substantially below proposed national standards. In this population, OHCA was frequently recognized and DA-CPR performed but was not associated with a significant improvement in survival.

Regional Variation in Out-of-Hospital Cardiac Arrest Survival in the United States.

BACKGROUND: Although previous studies have shown marked variation in out-of-hospital cardiac arrest survival across US regions, factors underlying this survival variation remain incompletely explained. METHODS AND RESULTS: Using data from the Cardiac Arrest Registry to Enhance Survival, we identified 96 662 adult patients with out-of-hospital cardiac arrest in 132 US counties. We used hierarchical regression models to examine county-level variation in rates of survival and survival with functional recovery (defined as Cerebral Performance Category score of 1 or 2) and examined the contribution of demographics, cardiac arrest characteristics, bystander cardiopulmonary resuscitation, automated external defibrillator use, and county-level sociodemographic factors in survival variation across counties. A total of 9317 (9.6%) patients survived to discharge, and 7176 (7.4%) achieved functional recovery. At a county level, there was marked variation in rates of survival to discharge (range, 3.4%-22.0%; median odds ratio, 1.40; 95% confidence interval, 1.32-1.46) and survival with functional recovery (range, 0.8%-21.0%; median odds ratio, 1.53; 95% confidence interval, 1.43-1.62). County-level rates of bystander cardiopulmonary resuscitation and automated external defibrillator use were positively correlated with both outcomes (P<0.0001 for all). Patient demographic and cardiac arrest characteristics explained 4.8% and 27.7% of the county-level variation in survival, respectively. Additional adjustment of bystander cardiopulmonary resuscitation and automated external defibrillator explained 41% of the survival variation, and this increased to 50.4% after adjustment of county-level sociodemographic factors. Similar findings were noted in analyses of survival with functional recovery. CONCLUSIONS: Although out-of-hospital cardiac arrest survival varies significantly across US counties, a substantial proportion of the variation is attributable to differences in bystander response across communities.

Effect of Dispatcher-Assisted Cardiopulmonary Resuscitation Program and Location of Out-of-Hospital Cardiac Arrest on Survival and Neurologic Outcome.

STUDY OBJECTIVE: We study the effect of a nationwide dispatcher-assisted cardiopulmonary resuscitation (CPR) program on out-of-hospital cardiac arrest outcomes by arrest location (public and private settings). METHODS: All emergency medical services (EMS)-treated adults in Korea with out-of-hospital cardiac arrests of cardiac cause were enrolled between 2012 and 2013, excluding cases witnessed by EMS providers and those with unknown outcomes. Exposure was bystander CPR categorized into 3 groups: bystander CPR with dispatcher assistance, bystander CPR without dispatcher assistance, and no bystander CPR. The endpoint was good neurologic recovery at discharge. Multivariable logistic regression analysis was performed. The final model with an interaction term was evaluated to compare the effects across settings. RESULTS: A total of 37,924 patients (31.1% bystander CPR with dispatcher assistance, 14.3% bystander CPR without dispatcher assistance, and 54.6% no bystander CPR) were included in the final analysis. The total bystander CPR rate increased from 30.9% in quarter 1 (2012) to 55.7% in quarter 4 (2014). Bystander CPR with and without dispatcher assistance was more likely to result in higher survival with good neurologic recovery (4.8% and 5.2%, respectively) compared with no bystander CPR (2.1%). The adjusted odds ratios for good neurologic recovery were 1.50 (95% confidence interval [CI] 1.30 to 1.74) in bystander CPR with dispatcher assistance and 1.34 (95% CI 1.12 to 1.60) in bystander CPR without it compared with no bystander CPR. For arrests in private settings, the adjusted odds ratios were 1.58 (95% CI 1.30 to 1.92) in bystander CPR with dispatcher assistance and 1.28 (95% CI 0.98 to 1.67) in bystander CPR without it; in public settings, the adjusted odds ratios were 1.41 (95% CI 1.14 to 1.75) and 1.37 (95% CI 1.08 to 1.72), respectively. CONCLUSION: Bystander CPR regardless of dispatcher assistance was associated with improved neurologic recovery after out-of-hospital cardiac arrest. However, for out-of-hospital cardiac arrest cases in private settings, bystander CPR was associated with improved neurologic recovery only when dispatcher assistance was provided.

Cardiac arrest and cardiopulmonary resuscitation outcome reports: update of the Utstein Resuscitation Registry Templates for Out-of-Hospital Cardiac Arrest: a statement for healthcare professionals from a task force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian and New Zealand Council on Resuscitation, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, Resuscitation Council of Asia); and the American Heart Association Emergency Cardiovascular Care Committee and the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation.

Utstein-style guidelines contribute to improved public health internationally by providing a structured framework with which to compare emergency medical services systems. Advances in resuscitation science, new insights into important predictors of outcome from out-of-hospital cardiac arrest, and lessons learned from methodological research prompted this review and update of the 2004 Utstein guidelines. Representatives of the International Liaison Committee on Resuscitation developed an updated Utstein reporting framework iteratively by meeting face to face, by teleconference, and by Web survey during 2012 through 2014. Herein are recommendations for reporting out-of-hospital cardiac arrest. Data elements were grouped by system factors, dispatch/recognition, patient variables, resuscitation/postresuscitation processes, and outcomes. Elements were classified as core or supplemental using a modified Delphi process primarily based on respondents' assessment of the evidence-based importance of capturing those elements, tempered by the challenges to collect them. New or modified elements reflected consensus on the need to account for emergency medical services system factors, increasing availability of automated external defibrillators, data collection processes, epidemiology trends, increasing use of dispatcher-assisted cardiopulmonary resuscitation, emerging field treatments, postresuscitation care, prognostication tools, and trends in organ recovery. A standard reporting template is recommended to promote standardized reporting. This template facilitates reporting of the bystander-witnessed, shockable rhythm as a measure of emergency medical services system efficacy and all emergency medical services system-treated arrests as a measure of system effectiveness. Several additional important subgroups are identified that enable an estimate of the specific contribution of rhythm and bystander actions that are key determinants of outcome.

Out-of-hospital cardiac arrest attended by ambulance services in Ireland: first 2†years' results from a nationwide registry.

BACKGROUND: National data collection provides information on out-of-hospital cardiac arrest (OHCA) incidence, management and outcomes that may not be generalisable from smaller studies. This retrospective cohort study describes the first 2 years' results from the Irish National Out-of-Hospital Cardiac Arrest Register (OHCAR). METHODS: Data on OHCAs attended by emergency medical services (EMS) where resuscitation was attempted (EMS-treated) were collected from ambulance services and entered onto OHCAR. Descriptive analysis of the study population was performed, and regression analysis was performed on the subgroup of adult patients with a bystander-witnessed event of presumed cardiac aetiology and an initial shockable rhythm (Utstein group). RESULTS: 3701 EMS-treated OHCAs were recorded for the study period (1 January 2012-31 December 2013). Incidence was 39/100 000 population/year. In the Utstein group (n=577), compared with the overall group, there was a higher proportion of male patients, public event location, bystander cardiopulmonary resuscitation (CPR) and early defibrillation. Median EMS call-response interval was similar in both groups. A higher proportion of patients in the Utstein group achieved return of spontaneous circulation (35% vs 17%) and survival to hospital discharge (22% vs 6%). After multivariate adjustment for the Utstein group, the following variables were found to be independent predictors of the outcome survival to hospital discharge: public event location (OR 3.1 (95% CI 1.9 to 5.0)); bystander CPR (2.4 (95% CI 1.2 to 4.9)); EMS response of 8 min or less (2.2 (95% CI 1.3 to 3.6)). CONCLUSIONS: This study highlights the role of nationwide registries in quantifying, monitoring and benchmarking OHCA incidence and outcome, providing baseline data upon which service improvement effects can be measured.

Epidemiology and outcomes of out-of-hospital cardiac arrest in a developing country-a multicenter cohort study.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) is one of the leading causes of death and disability worldwide. Overall survival after an OHCA has been reported to be poor and limited studies have been conducted in developing countries. We aimed to investigate the rates of survival from OHCA and explore components of the chain of survival in a developing country. METHODS: We conducted a multicenter prospective cohort study in the emergency departments (ED) of five major public and private sector hospitals of Karachi, Pakistan from January 2013 to April 2013. Twenty-four hour data collection was performed by trained data collectors, using a structured questionnaire. All patients ≥18 years of age, presenting with OHCA of cardiac origin, were included. Patients with do-not-resuscitate status or referred from other hospitals were excluded. Our primary outcome was survival of OHCA patients at the end of ED stay. RESULTS: During the three month period, data was obtained from 310 OHCA patients. The overall survival to ED discharge was 1.6 % which decreased to 0 % at 2-months after discharge. More than half (58.3 %) of these OHCA patients were brought to the hospital in a non-EMS (emergency medical service) vehicle i.e. public or private transportation. Patients utilizing non-EMS transportation reached the hospital earlier with a median time of 23 min compared to patients utilizing any type of ambulances which had a delay of 7 min hospital reaching time (median time 30 min). However, patients utilizing ambulances with life-support facilities, as compared to all other types of pre-hospital transportation, had the shortest time to first life-support intervention (15 min). Most of the patients (92.9 %) had a witnessed cardiac arrest out of which only a small percentage (2.3 %) received bystander CPR (cardio pulmonary resuscitation). Median time from arrest to receiving first CPR was 20 min. Only 1 % of patients were found to have a shockable rhythm on first assessment. CONCLUSION: This study showed that the overall survival of OHCA is null in this population. Lack of bystander CPR and weaker emergency medical services (EMS) leading to a delay in receiving life-support interventions were some of the important observations. Poor survival emphasizes the need to standardize EMS systems, initiate public awareness programs and strengthen links in the chain of survival.

Recent trends in survival from out-of-hospital cardiac arrest in the United States.

BACKGROUND: Despite intensive efforts over many years, the United States has made limited progress in improving rates of survival from out-of-hospital cardiac arrest. Recently, national organizations, such as the American Heart Association, have focused on promoting bystander cardiopulmonary resuscitation, use of automated external defibrillators, and other performance improvement efforts. METHODS AND RESULTS: Using the Cardiac Arrest Registry to Enhance Survival (CARES), a prospective clinical registry, we identified 70 027 U.S. patients who experienced an out-of-hospital cardiac arrest between October 2005 and December 2012. Using multilevel Poisson regression, we examined temporal trends in risk-adjusted survival. After adjusting for patient and cardiac arrest characteristics, risk-adjusted rates of out-of-hospital cardiac arrest survival increased from 5.7% in the reference period of 2005 to 2006 to 7.2% in 2008 (adjusted risk ratio, 1.27; 95% confidence interval, 1.12-1.43; P<0.001). Survival improved more modestly to 8.3% in 2012 (adjusted risk ratio, 1.47; 95% confidence interval, 1.26-1.70; P<0.001). This improvement in survival occurred in both shockable and nonshockable arrest rhythms (P for interaction=0.22) and was also accompanied by better neurological outcomes among survivors (P for trend=0.01). Improved survival was attributable to both higher rates of prehospital survival, where risk-adjusted rates increased from 14.3% in 2005 to 2006 to 20.8% in 2012 (P for trend<0.001), and in-hospital survival (P for trend=0.015). Rates of bystander cardiopulmonary resuscitation and automated external defibrillator use modestly increased during the study period and partly accounted for prehospital survival trends. CONCLUSIONS: Data drawn from a large subset of U.S communities suggest that rates of survival from out-of-hospital cardiac arrest have improved among sites participating in a performance improvement registry.

Association of neighborhood characteristics with bystander-initiated CPR.

BACKGROUND: For persons who have an out-of-hospital cardiac arrest, the probability of receiving bystander-initiated cardiopulmonary resuscitation (CPR) may be influenced by neighborhood characteristics. METHODS: We analyzed surveillance data prospectively submitted from 29 U.S. sites to the Cardiac Arrest Registry to Enhance Survival between October 1, 2005, and December 31, 2009. The neighborhood in which each cardiac arrest occurred was determined from census-tract data. We classified neighborhoods as high-income or low-income on the basis of a median household income threshold of $40,000 and as white or black if more than 80% of the census tract was predominantly of one race. Neighborhoods without a predominant racial composition were classified as integrated. We analyzed the relationship between the median income and racial composition of a neighborhood and the performance of bystander-initiated CPR. RESULTS: Among 14,225 patients with cardiac arrest, bystander-initiated CPR was provided to 4068 (28.6%). As compared with patients who had a cardiac arrest in high-income white neighborhoods, those in low-income black neighborhoods were less likely to receive bystander-initiated CPR (odds ratio, 0.49; 95% confidence interval [CI], 0.41 to 0.58). The same was true of patients with cardiac arrest in neighborhoods characterized as low-income white (odds ratio, 0.65; 95% CI, 0.51 to 0.82), low-income integrated (odds ratio, 0.62; 95% CI, 0.56 to 0.70), and high-income black (odds ratio, 0.77; 95% CI, 0.68 to 0.86). The odds ratio for bystander-initiated CPR in high-income integrated neighborhoods (1.03; 95% CI, 0.64 to 1.65) was similar to that for high-income white neighborhoods. CONCLUSIONS: In a large cohort study, we found that patients who had an out-of-hospital cardiac arrest in low-income black neighborhoods were less likely to receive bystander-initiated CPR than those in high-income white neighborhoods. (Funded by the Centers for Disease Control and Prevention and others.).

Rationale, Methodology, and Implementation of a Dispatcher-assisted Cardiopulmonary Resuscitation Trial in the Asia-Pacific (Pan-Asian Resuscitation Outcomes Study Phase 2).

Abstract Background. Survival outcomes from out-of-hospital cardiac arrest (OHCA) in Asia are poor (2-11%). Bystander cardiopulmonary resuscitation (CPR) rates are relatively low in Asia. Dispatcher-assisted CPR (DA-CPR) has recently emerged as a potentially cost-effective intervention to increase bystander CPR and survival from OHCA. The Pan-Asian Resuscitation Outcomes Study (PAROS), an Asia-Pacific cardiac arrest registry, was set up in 2009, with the aim of understanding OHCA as a disease in Asia and improving OHCA survival. The network has adopted DA-CPR as part of its strategy to improve OHCA survival. Objective. This article aims to describe the conceptualization, study design, potential benefits, and difficulties for implementation of DA-CPR trial in the Asia-Pacific. Methods. Two levels of intervention, basic and comprehensive, will be offered to PAROS participating sites. The basic level consists of implementation of a DA-CPR protocol and training program, while the comprehensive level consists of implementation of the basic level, with the addition of a dispatch quality measurement tool, quality improvement program, and community education program. Sites that are not able to implement the package will contribute control data. The primary outcome of the study is survival to hospital discharge or survival to 30 days post cardiac arrest. DA-CPR and bystander CPR are secondary outcomes. Conclusion. Implementation of DA-CPR requires concerted efforts by EMS leaders and supervisors, dispatchers, hospital stakeholders, policy makers, and the general public. The DA-CPR trial implemented by the PAROS sites, if successful, can serve as a model for other countries considering such an intervention in their EMS systems.

Association of Bystander and First-Responder Intervention With Survival After Out-of-Hospital Cardiac Arrest in North Carolina, 2010-2013.

IMPORTANCE: Out-of-hospital cardiac arrest is associated with low survival, but early cardiopulmonary resuscitation (CPR) and defibrillation can improve outcomes if more widely adopted. OBJECTIVE: To examine temporal changes in bystander and first-responder resuscitation efforts before arrival of the emergency medical services (EMS) following statewide initiatives to improve bystander and first-responder efforts in North Carolina from 2010-2013 and to examine the association between bystander and first-responder resuscitation efforts and survival and neurological outcome. DESIGN, SETTINGS, AND PARTICIPANTS: We studied 4961 patients with out-of-hospital cardiac arrest for whom resuscitation was attempted and who were identified through the Cardiac Arrest Registry to Enhance Survival (2010-2013). First responders were dispatched police officers, firefighters, rescue squad, or life-saving crew trained to perform basic life support until arrival of the EMS. EXPOSURES: Statewide initiatives to improve bystander and first-responder interventions included training members of the general population in CPR and in use of automated external defibrillators (AEDs), training first responders in team-based CPR including AED use and high-performance CPR, and training dispatch centers in recognition of cardiac arrest. MAIN OUTCOMES AND MEASURES: The proportion of bystander and first-responder resuscitation efforts, including the combination of efforts between bystanders and first responders, from 2010 through 2013 and the association between these resuscitation efforts and survival and neurological outcome. RESULTS: The combination of bystander CPR and first-responder defibrillation increased from 14.1% (51 of 362; 95% CI, 10.9%-18.1%) in 2010 to 23.1% (104 of 451; 95% CI, 19.4%-27.2%) in 2013 (P < .01). Survival with favorable neurological outcome increased from 7.1% (82 of 1149; 95% CI, 5.8%-8.8%) in 2010 to 9.7% (129 of 1334; 95% CI, 8.2%-11.4%) in 2013 (P = .02) and was associated with bystander-initiated CPR. Adjusting for age and sex, bystander and first-responder interventions were associated with higher survival to hospital discharge. Survival following EMS-initiated CPR and defibrillation was 15.2% (30 of 198; 95% CI, 10.8%-20.9%) compared with 33.6% (38 of 113; 95% CI, 25.5%-42.9%) following bystander-initiated CPR and defibrillation (odds ratio [OR], 3.12; 95% CI, 1.78-5.46); 24.2% (83 of 343; 95% CI, 20.0%-29.0%) following bystander CPR and first-responder defibrillation (OR, 1.70; 95% CI, 1.06-2.71); and 25.2% (109 of 432; 95% CI, 21.4%-29.6%) following first-responder CPR and defibrillation (OR, 1.77; 95% CI, 1.13-2.77). CONCLUSIONS AND RELEVANCE: Following a statewide educational intervention on rescusitation training, the proportion of patients receiving bystander-initiated CPR and defibrillation by first responders increased and was associated with greater likelihood of survival. Bystander-initiated CPR was associated with greater likelihood of survival with favorable neurological outcome.

Temporal differences in out-of-hospital cardiac arrest incidence and survival.

BACKGROUND: Understanding temporal differences in the incidence and outcomes of out-of-hospital cardiac arrest (OHCA) has important implications for developing preventative strategies and optimizing systems for OHCA care. METHODS AND RESULTS: We studied 18 588 OHCAs of presumed cardiac origin in patients aged ≥18 years who received resuscitative efforts by emergency medical services (EMS) and were enrolled in the Cardiac Arrest Registry to Enhance Survival (CARES) from October 1, 2005, to December 31, 2010. We evaluated temporal variability in OHCA incidence and survival to hospital discharge. There was significant variability in the frequency of OHCA by hour of the day (P<0.001), day of the week (P<0.001), and month of the year (P<0.001), with the highest incidence occurring during the daytime, from Friday to Monday, in December. Survival to hospital discharge was lowest for OHCA that occurred overnight (from 11:01 pm to 7 am; 7.1%) versus daytime (7:01 am to 3 pm; 10.8%) or evening (3:01 pm to 11 pm; 11.3%; P<0.001) and during the winter (8.8%) versus spring (11.1%), summer (11.0%), or fall (10.0%; P<0.001). There was no difference in survival to hospital discharge between OHCAs that occurred on weekends and weekdays (9.5% versus 10.4%, P=0.06). After multivariable adjustment for age, sex, race, witness status, layperson resuscitation, first monitored cardiac rhythm, and emergency medical services response time, compared with daytime and spring, survival to hospital discharge remained lowest for OHCA that occurred overnight (odds ratio, 0.81; 95% confidence interval, 0.70-0.95; P=0.008) and during the winter (odds ratio, 0.81; 95% confidence interval, 0.70-0.94; P=0.006), respectively. CONCLUSIONS: There is significant temporal variability in the incidence of and survival after OHCA. The relative contribution of patient pathophysiology, likelihood of the OHCA being observed, and prehospital and hospital-based resuscitative factors deserves further exploration.

Factors mediating community race and ethnicity differences in initial shockable rhythm for out-of-hospital cardiac arrests in Texas.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) patients from minoritized communities have lower rates of initial shockable rhythm, which is linked to favorable outcomes. We sought to evaluate the importance of initial shockable rhythm on OHCA outcomes and factors that mediate differences in initial shockable rhythm. METHODS: We performed a retrospective study of the 2013-2022 Texas Cardiac Arrest Registry to Enhance Survival (TX-CARES). Using census tract data, we stratified OHCAs into majority race/ethnicity communities: >50% White, >50% Black, and >50% Hispanic/Latino. We compared logistic regression models between community race/ethnicity and OHCA outcome: (1) unadjusted, (2) adjusting for bystander CPR (bCPR), and (3) adjusting for initial rhythm. Using structural equation modeling, we performed mediation analyses between community race/ethnicity, OHCA characteristics, and initial shockable rhythm. RESULTS: We included 22,730 OHCAs from majority White (21.1% initial shockable rhythm), 4,749 from majority Black (15.3% shockable), and 16,054 majority Hispanic/Latino (16.1% shockable) communities. Odds of favorable neurologic outcome were lower for majority Black (0.4 [0.3-0.5]) and Hispanic/Latino (0.6 [0.6-0.7]). While adjusting for bCPR minimally changed outcome odds, adjusting for shockable rhythm increased odds for Black (0.5 [0.4-0.5]) and Hispanic/Latino (0.7 [0.6-0.8]) communities. On mediation analysis for majority Black, the top mediators of initial shockable rhythm were public location (14.6%), bystander witnessed OHCA (11.6%), and female gender (5.7%). The top mediators for majority Hispanic/Latino were bystander-witnessed OHCA (10.2%), public location (3.52%), and bystander CPR (3.49%), CONCLUSION: Bystander-witnessed OHCA and public location were the largest mediators of shockable rhythm for OHCAs from minoritized communities.

The past, present, and future of the Cardiac Arrest Registry to Enhance Survival (CARES).

Background: The Cardiac Arrest Registry to Enhance Survival (CARES) was created in 2004 in collaboration with the Centers for Disease Control and Prevention (CDC) and Emory University School of Medicine's Department of Emergency Medicine. The registry allows local communities to benchmark their performance, enhance the quality of care, and increase survival rates for out-of-hospital cardiac arrest (OHCA). Methods/design: CARES enrolls patients who experience a non-traumatic, EMS-treated OHCA. For each case, data is collected from three sources: 911 call center data, EMS data, and hospital data. CARES data is de-identified and stored in a secured web-based cloud platform and maintains confidentiality throughout the process. CARES data is subjected to an internal auditing system that oversees both local and regional levels. The variables in CARES adhere with the Utstein style reporting system and the National EMS Information System (NEMSIS) standard. Discussion: As of 2023, CARES captures data from a population base of over 178 million people which accounts for 53% of the total U.S. population. Over the past two decades, CARES has consistently been a part of public health surveillance for OHCA and serves as a quality improvement tool to improve cardiac arrest outcomes. Moreover, CARES commits to facilitate observational research on OHCA, continues to modernize its software platform, and comprehensively expands its coverage for the entire U.S.