Incidence and Survival of Out-of-Hospital Cardiac Arrest in Public Housing Areas in 3 European Capitals.

BACKGROUND: Strategies to reach out-of-hospital cardiac arrests (called cardiac arrest) in residential areas and reduce disparities in care and outcomes are warranted. This study investigated incidences of cardiac arrests in public housing areas. METHODS: This register-based cohort study included cardiac arrest patients from Amsterdam (the Netherlands) from 2016 to 2021, Copenhagen (Denmark) from 2016 to 2021, and Vienna (Austria) from 2018 to 2021. Using Poisson regression adjusted for spatial correlation and city, we compared cardiac arrest incidence rates (number per square kilometer per year and number per 100 000 inhabitants per year) in public housing and other residential areas and examined the proportion of cardiac arrests within public housing and adjacent areas (100-m radius). RESULTS: Overall, 9152 patients were included of which 3038 (33.2%) cardiac arrests occurred in public housing areas and 2685 (29.3%) in adjacent areas. In Amsterdam, 635/1801 (35.3%) cardiac arrests occurred in public housing areas; in Copenhagen, 1036/3077 (33.7%); and in Vienna, 1367/4274 (32.0%). Public housing areas covered 42.4 (12.6%) of 336.7 km2 and 1 024 470 (24.6%) of 4 164 700 inhabitants. Across the capitals, we observed a lower probability of 30-day survival in public housing versus other residential areas (244/2803 [8.7%] versus 783/5532 [14.2%]). The incidence rates and rate ratio of cardiac arrest in public housing versus other residential areas were incidence rate, 16.5 versus 4.1 n/km2 per year; rate ratio, 3.46 (95% CI, 3.31-3.62) and incidence rate, 56.1 versus 36.8 n/100 000 inhabitants per year; rate ratio, 1.48 (95% CI, 1.42-1.55). The incidence rates and rate ratios in public housing versus other residential areas were consistent across the 3 capitals. CONCLUSIONS: Across 3 European capitals, one-third of cardiac arrests occurred in public housing areas, with an additional third in adjacent areas. Public housing areas exhibited consistently higher cardiac arrest incidences per square kilometer and 100 000 inhabitants and lower survival than other residential areas. Public housing areas could be a key target to improve cardiac arrest survival in countries with a public housing sector.

Ventilation during cardiopulmonary resuscitation with mechanical chest compressions: How often are two insufflations being given during the 3-second ventilation pauses?

BACKGROUND: Mechanical chest compression devices in 30:2 mode provide 3-second pauses to allow for two insufflations. We aimed to determine how often two insufflations are provided in these ventilation pauses, in order to assess if prehospital providers are able to ventilate out-of-hospital cardiac arrest (OHCA) patients successfully during mechanical chest compressions. METHODS: Data from OHCA cases of the regional ambulance service of Utrecht, The Netherlands, were prospectively collected in the UTrecht studygroup for OPtimal registry of cardIAc arrest database (UTOPIA). Compression pauses and insufflations were visualized on thoracic impedance and waveform capnography signals recorded by manual defibrillators. Ventilation pauses were analyzed for number of insufflations, duration of the subintervals of the ventilation cycles, and ratio of successfully providing two insufflations over the course of the resuscitation. Generalized linear mixed effects models were used to accurately estimate proportions and means. RESULTS: In 250 cases, 8473 ventilation pauses were identified, of which 4305 (51%) included two insufflations. When corrected for non-independence of the data across repeated measures within the same subjects with a mixed effects analysis, two insufflations were successfully provided in 45% of ventilation pauses (95% CI: 40-50%). In 19% (95% CI: 16-22%) none were given. CONCLUSION: Providing two insufflations during pauses in mechanical chest compressions is mostly unsuccessful. We recommend developing strategies to improve giving insufflations when using mechanical chest compression devices. Increasing the pause duration might help to improve insufflation success.

A national multi centre pre-hospital ECPR stepped wedge study; design and rationale of the ON-SCENE study.

BACKGROUND: The likelihood of return of spontaneous circulation with conventional advanced life support is known to have an exponential decline and therefore neurological outcome after 20 min in patients with a cardiac arrest is poor. Initiation of venoarterial ExtraCorporeal Membrane Oxygenation (ECMO) during resuscitation might improve outcomes if used in time and in a selected patient category. However, previous studies have failed to significantly reduce the time from cardiac arrest to ECMO flow to less than 60 min. We hypothesize that the initiation of Extracorporeal Cardiopulmonary Resuscitation (ECPR) by a Helicopter Emergency Medical Services System (HEMS) will reduce the low flow time and improve outcomes in refractory Out of Hospital Cardiac Arrest (OHCA) patients. METHODS: The ON-SCENE study will use a non-randomised stepped wedge design to implement ECPR in patients with witnessed OHCA between the ages of 18-50 years old, with an initial presentation of shockable rhythm or pulseless electrical activity with a high suspicion of pulmonary embolism, lasting more than 20, but less than 45 min. Patients will be treated by the ambulance crew and HEMS with prehospital ECPR capabilities and will be compared with treatment by ambulance crew and HEMS without prehospital ECPR capabilities. The primary outcome measure will be survival at hospital discharge. The secondary outcome measure will be good neurological outcome defined as a cerebral performance categories scale score of 1 or 2 at 6 and 12 months. DISCUSSION: The ON-SCENE study focuses on initiating ECPR at the scene of OHCA using HEMS. The current in-hospital ECPR for OHCA obstacles encompassing low survival rates in refractory arrests, extended low-flow durations during transportation, and the critical time sensitivity of initiating ECPR, which could potentially be addressed through the implementation of the HEMS system. When successful, implementing on-scene ECPR could significantly enhance survival rates and minimize neurological impairment. TRIAL REGISTRATION: Clinicaltyrials.gov under NCT04620070, registration date 3 November 2020.

Smartwatch based automatic detection of out-of-hospital cardiac arrest: Study rationale and protocol of the HEART-SAFE project.

Out-of-hospital cardiac arrest (OHCA) is a leading cause of mortality. Immediate detection and treatment are of paramount importance for survival and good quality of life. The first link in the 'chain of survival' after OHCA - the early recognition and alerting of emergency medical services - is at the same time the weakest link as it entirely depends on witnesses. About one half of OHCA cases are unwitnessed, and victims of unwitnessed OHCA have virtually no chance of survival with good neurologic outcome. Also in case of a witnessed cardiac arrest, alerting of emergency medical services is often delayed for several minutes. Therefore, a technological solution to automatically detect cardiac arrests and to instantly trigger an emergency response has the potential to save thousands of lives per year and to greatly improve neurologic recovery and quality of life in survivors. The HEART-SAFE consortium, consisting of two academic centres and three companies in the Netherlands, collaborates to develop and implement a technical solution to reliably detect OHCA based on sensor signals derived from commercially available smartwatches using artificial intelligence. In this manuscript, we describe the rationale, the envisioned solution, as well as a protocol outline of the work packages involved in the development of the technology.

Tracheal Intubation during Advanced Life Support Using Direct Laryngoscopy versus Glidescope® Videolaryngoscopy by Clinicians with Limited Intubation Experience: A Systematic Review and Meta-Analysis.

The use of the Glidescope® videolaryngoscope might improve tracheal intubation performance in clinicians with limited intubation experience, especially during cardiopulmonary resuscitation (CPR). The objective of this systematic review and meta-analysis is to compare direct laryngoscopy to Glidescope® videolaryngoscopy by these clinicians. PubMed/Medline and Embase were searched from their inception to 7 July 2020 for randomized controlled trials, including simulation studies. Studies on adult patients or adult-sized manikins were included when direct laryngoscopy was compared to Glidescope® videolaryngoscopy by clinicians with limited experience in tracheal intubation (<10 intubations per year). The primary outcome was the intubation first-pass success rate. Secondary outcomes were time to successful intubation and chest compression interruption duration during intubation. The risk of bias was assessed with the Cochrane risk of bias tool. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE). We included 4 clinical trials with 525 patients and 20 manikin trials with 2547 intubations. Meta-analyses favored Glidescope® videolaryngoscopy over direct laryngoscopy regarding first-pass success (clinical trials: risk ratio [RR] = 1.61; 95% confidence interval [CI]: 1.16−2.23; manikin trials: RR = 1.17; 95% CI: 1.09−1.25). Clinical trials showed a shorter time to achieve successful intubation when using the Glidescope® (mean difference = 17.04 s; 95% CI: 8.51−25.57 s). Chest compression interruption duration was decreased when using the Glidescope® videolaryngoscope. The certainty of evidence ranged from very low to moderate. When clinicians with limited intubation experience have to perform tracheal intubation during advanced life support, the use of the Glidescope® videolaryngoscope improves intubation and CPR performance compared to direct laryngoscopy.

Manual chest compression pause duration for ventilations during prehospital advanced life support - An observational study to explore optimal ventilation pause duration for mechanical chest compression devices.

AIM: Mechanical chest compression devices in the 30:2 mode generally provide a pause of three seconds to give two insufflations without evidence supporting this pause duration. We aimed to explore the optimal pause duration by measuring the time needed for two insufflations, during advanced life support with manual compressions. METHODS: Prospectively collected data in the AmsteRdam REsuscitation STudies (ARREST) registry were analysed, including thoracic impedance signal and waveform capnography from manual defibrillators of the Amsterdam ambulance service. Compression pauses were analysed for number of insufflations, time interval from start of the compression pause to the end of the second insufflation, chest compression pause duration and ventilation subintervals. RESULTS: During 132 out-of-hospital cardiac arrests, 1619 manual chest compression pauses to ventilate were identified. In 1364 (84%) pauses, two insufflations were given. In 28% of these pauses, giving two insufflations took more than three seconds. The second insufflation is completed within 3.8 seconds in 90% and within 5 seconds in 97.5% of these pauses. An increasing likelihood of achieving two insufflations is seen with increasing compression pause duration up to five seconds. CONCLUSION: The optimal chest compression pause duration for mechanical chest compression devices in the 30:2 mode to provide two insufflations, appears to be five seconds, warranting further studies in the context of mechanical chest compression. A 5-second pause will allow providers to give two insufflations with a very high success rate. In addition, a 5-second pause can also be used for other interventions like rhythm checks and endotracheal intubation.

Learning about stress from building, drilling and flying: a scoping review on team performance and stress in non-medical fields.

BACKGROUND: Teamwork is essential in healthcare, but team performance tends to deteriorate in stressful situations. Further development of training and education for healthcare teams requires a more complete understanding of team performance in stressful situations. We wanted to learn from others, by looking beyond the field of medicine, aiming to learn about a) sources of stress, b) effects of stress on team performance and c) concepts on dealing with stress. METHODS: A scoping literature review was undertaken. The three largest interdisciplinary databases outside of healthcare, Scopus, Web of Science and PsycINFO, were searched for articles published in English between 2008 and 2020. Eligible articles focused on team performance in stressful situations with outcome measures at a team level. Studies were selected, and data were extracted and analysed by at least two researchers. RESULTS: In total, 15 articles were included in the review (4 non-comparative, 6 multi- or mixed methods, 5 experimental studies). Three sources of stress were identified: performance pressure, role pressure and time pressure. Potential effects of stress on the team were: a narrow focus on task execution, unclear responsibilities within the team and diminished understanding of the situation. Communication, shared knowledge and situational awareness were identified as potentially helpful team processes. Cross training was suggested as a promising intervention to develop a shared mental model within a team. CONCLUSION: Stress can have a significant impact on team performance. Developing strategies to prevent and manage stress and its impact has the potential to significantly increase performance of teams in stressful situations. Further research into the development and use of team cognition in stress in healthcare teams is needed, in order to be able to integrate this 'team brain' in training and education with the specific goal of preparing professionals for team performance in stressful situations.

Optimizing airway management and ventilation during prehospital advanced life support in out-of-hospital cardiac arrest: A narrative review.

Airway management and ventilation are essential components of cardiopulmonary resuscitation to achieve oxygen delivery in order to prevent hypoxic injury and increase the chance of survival. Weighing the relative benefits and downsides, the best approach is a staged strategy; start with a focus on high-quality chest compressions and defibrillation, then optimize mask ventilation while preparing for advanced airway management with a supraglottic airway device. Endotracheal intubation can still be indicated, but has the largest downsides of all advanced airway techniques. Whichever stage of airway management, ventilation and chest compression quality should be closely monitored. Capnography has many advantages and should be used routinely. Optimizing ventilation strategies, harmonizing ventilation with mechanical chest compression devices, and implementation in complex and stressful environments are challenges we need to face through collaborative innovation, research, and implementation.

Impact of perceived inappropiate cardiopulmonary resuscitation on emergency clinicians' intention to leave the job: Results from a cross-sectional survey in 288 centres across 24 countries.

INTRODUCTION: Cardiopulmonary resuscitation (CPR) in patients with a poor prognosis increases the risk of perception of inappropriate care leading to moral distress in clinicians. We evaluated whether perception of inappropriate CPR is associated with intention to leave the job among emergency clinicians. METHODS: A cross-sectional multi-centre survey was conducted in 24 countries. Factors associated with intention to leave the job were analysed by conditional logistic regression models. Results are expressed as odds ratios with 95% confidence intervals. RESULTS: Of 5099 surveyed emergency clinicians, 1836 (36.0%) were physicians, 1313 (25.7%) nurses, 1950 (38.2%) emergency medical technicians. Intention to leave the job was expressed by 1721 (33.8%) clinicians, 3403 (66.7%) often wondered about the appropriateness of a resuscitation attempt, 2955 (58.0%) reported moral distress caused by inappropriate CPR. After adjustment for other covariates, the risk of intention to leave the job was higher in clinicians often wondering about the appropriateness of a resuscitation attempt (1.43 [1.23-1.67]), experiencing associated moral distress (1.44 [1.24-1.66]) and who were between 30-44 years old (1.53 [1.21-1.92] compared to <30 years). The risk was lower when the clinician felt valued by the team (0.53 [0.42-0.66]), when the team leader acknowledged the efforts delivered by the team (0.61 [0.49-0.75]) and in teams that took time for debriefing (0.70 [0.60-0.80]). CONCLUSION: Resuscitation attempts perceived as inappropriate by clinicians, and the accompanying moral distress, were associated with an increased likelihood of intention to leave the job. Interprofessional collaboration, teamwork, and regular interdisciplinary debriefing were associated with a lower risk of intention to leave the job. ClinicalTrials.gov; No.: NCT02356029.

Rationale and Strategies for Development of an Optimal Bundle of Management for Cardiac Arrest.

OBJECTIVES: To construct a highly detailed yet practical, attainable roadmap for enhancing the likelihood of neurologically intact survival following sudden cardiac arrest. DESIGN SETTING AND PATIENTS: Population-based outcomes following out-of-hospital cardiac arrest were collated for 10 U.S. counties in Alaska, California, Florida, Ohio, Minnesota, Utah, and Washington. The 10 identified emergency medical services systems were those that had recently reported significant improvements in neurologically intact survival after introducing a more comprehensive approach involving citizens, hospitals, and evolving strategies for incorporating technology-based, highly choreographed care and training. Detailed inventories of in-common elements were collated from the ten 9-1-1 agencies and assimilated. For reference, combined averaged outcomes for out-of-hospital cardiac arrest occurring January 1, 2017, to February 28, 2018, were compared with concurrent U.S. outcomes reported by the well-established Cardiac Arrest Registry to Enhance Survival. INTERVENTIONS: Most commonly, interventions and components from the ten 9-1-1 systems consistently included extensive public cardiopulmonary resuscitation training, 9-1-1 system-connected smart phone applications, expedited dispatcher procedures, cardiopulmonary resuscitation quality monitoring, mechanical cardiopulmonary resuscitation, devices for enhancing negative intrathoracic pressure regulation, extracorporeal membrane oxygenation protocols, body temperature management procedures, rapid cardiac angiography, and intensive involvement of medical directors, operational and quality assurance officers, and training staff. MEASUREMENTS AND MAIN RESULTS: Compared with Cardiac Arrest Registry to Enhance Survival (n = 78,704), the cohorts from the 10 emergency medical services agencies examined (n = 2,911) demonstrated significantly increased likelihoods of return of spontaneous circulation (mean 37.4% vs 31.5%; p < 0.001) and neurologically favorable hospital discharge, particularly after witnessed collapses involving bystander cardiopulmonary resuscitation and shockable cardiac rhythms (mean 10.7% vs 8.4%; p < 0.001; and 41.6% vs 29.2%; p < 0.001, respectively). CONCLUSIONS: The likelihood of neurologically favorable survival following out-of-hospital cardiac arrest can improve substantially in communities that conscientiously and meticulously introduce a well-sequenced, highly choreographed, system-wide portfolio of both traditional and nonconventional approaches to training, technologies, and physiologic management. The commonalities found in the analyzed systems create a compelling case that other communities can also improve out-of-hospital cardiac arrest outcomes significantly by conscientiously exploring and adopting similar bundles of system organization and care.

Cardiopulmonary Resuscitation in Adults Over 80: Outcome and the Perception of Appropriateness by Clinicians.

OBJECTIVES: To determine the prevalence of clinician perception of inappropriate cardiopulmonary resuscitation (CPR) regarding the last out-of-hospital cardiac arrest (OHCA) encountered in an adult 80 years or older and its relationship to patient outcome. DESIGN: Subanalysis of an international multicenter cross-sectional survey (REAPPROPRIATE). SETTING: Out-of-hospital CPR attempts registered in Europe, Israel, Japan, and the United States in adults 80 years or older. PARTICIPANTS: A total of 611 clinicians of whom 176 (28.8%) were doctors, 123 (20.1%) were nurses, and 312 (51.1%) were emergency medical technicians/paramedics. RESULTS AND MEASUREMENTS: The last CPR attempt among patients 80 years or older was perceived as appropriate by 320 (52.4%) of the clinicians; 178 (29.1%) were uncertain about the appropriateness, and 113 (18.5%) perceived the CPR attempt as inappropriate. The survival to hospital discharge for the "appropriate" subgroup was 8 of 265 (3.0%), 1 of 164 (.6%) in the "uncertain" subgroup, and 2 of 107 (1.9%) in the "inappropriate" subgroup (P = .23); 503 of 564 (89.2%) CPR attempts involved non-shockable rhythms. CPR attempts in nursing homes accounted for 124 of 590 (21.0%) of the patients and were perceived as appropriate by 44 (35.5%) of the clinicians; 45 (36.3%) were uncertain about the appropriateness; and 35 (28.2%) perceived the CPR attempt as inappropriate. The survival to hospital discharge for the nursing home patients was 0 of 107 (0%); 104 of 111 (93.7%) CPR attempts involved non-shockable rhythms. Overall, 36 of 543 (6.6%) CPR attempts were undertaken despite a known written do not attempt resuscitation decision; 14 of 36 (38.9%) clinicians considered this appropriate, 9 of 36 (25.0%) were uncertain about its appropriateness, and 13 of 36 (36.1%) considered this inappropriate. CONCLUSION: Our findings show that despite generally poor outcomes for older patients undergoing CPR, many emergency clinicians do not consider these attempts at resuscitation to be inappropriate. A professional and societal debate is urgently needed to ensure that first we do not harm older patients by futile CPR attempts. J Am Geriatr Soc 68:39-45, 2019.

Perception of inappropriate cardiopulmonary resuscitation by clinicians working in emergency departments and ambulance services: The REAPPROPRIATE international, multi-centre, cross sectional survey.

INTRODUCTION: Cardiopulmonary resuscitation (CPR) is often started irrespective of comorbidity or cause of arrest. We aimed to determine the prevalence of perception of inappropriate CPR of the last cardiac arrest encountered by clinicians working in emergency departments and out-of-hospital, factors associated with perception, and its relation to patient outcome. METHODS: A cross-sectional survey was conducted in 288 centres in 24 countries. Factors associated with perception of CPR and outcome were analyzed by Cochran-Mantel-Haenszel tests and conditional logistic models. RESULTS: Of the 4018 participating clinicians, 3150 (78.4%) perceived their last CPR attempt as appropriate, 548 (13.6%) were uncertain about its appropriateness and 320 (8.0%) perceived inappropriateness; survival to hospital discharge was 370/2412 (15.3%), 8/481 (1.7%) and 8/294 (2.7%) respectively. After adjusting for country, team and clinician's characteristics, the prevalence of perception of inappropriate CPR was higher for a non-shockable initial rhythm (OR 3.76 [2.13-6.64]; P < .0001), a non-witnessed arrest (2.68 [1.89-3.79]; P < .0001), in older patients (2.94 [2.18-3.96]; P < .0001, for patients >79 years) and in case of a "poor" first physical impression of the patient (3.45 [2.36-5.05]; P < .0001). In accordance, non-shockable and non-witnessed arrests were both associated with lower survival to hospital discharge (0.33 [0.26-0.41]; P < 0.0001 and 0.25 [0.15-0.41]; P < 0.0001, respectively), as were older patient age (0.25 [0.14-0.44]; P < 0.0001 for patients >79 years) and a "poor" first physical impression (0.26 [0.19-0.35]; P < 0.0001). CONCLUSIONS: The perception of inappropriate CPR increased when objective indicators of poor prognosis were present and was associated with a low survival to hospital discharge. Factoring clinical judgment into the decision to (not) attempt CPR may reduce harm inflicted by excessive resuscitation attempts.

Understanding the prehospital physician controversy. Step 2: analysis of on-scene treatment by ambulance nurses and helicopter emergency medical service physicians.

OBJECTIVE: In our previous study, we identified the similarities and differences in competencies of ambulance nurses and helicopter emergency medical service (HEMS) physicians in the Netherlands. This ensuing study aims to quantify the frequency with which the additional therapeutic competencies of the HEMS physician are utilized and to determine whether this is the main reason for usefulness as perceived by ambulance nurses and HEMS physicians. MATERIALS AND METHODS: A prospective observational study was carried out over a 2-month period, with one HEMS station covering six ambulance regions. Provider registration was recorded, supplemented by interviews of ambulance nurses and HEMS physicians. Competencies were categorized depending on whether the competency was specific for the nurse or physician, mutual or mutual with a qualitative difference. RESULTS: A total of 225 HEMS dispatches resulted in 117 cases with HEMS on-scene in the study region and 78 patients were included. In 35 (45%) patients, the HEMS physician provided additional treatment: in 19 (24%) patients, a physician-specific therapeutic competency, in nine (12%) patients, a mutual competency with a qualitative difference and in seven (9%) patients, both categories. The presence of the HEMS physician was considered more useful by both ambulance nurses (89 vs. 60%) and HEMS physicians (97 vs. 81%) when additional treatment was provided by the HEMS physician. CONCLUSION: HEMS physicians provide additional treatment in 45% of patients. The additional treatment increases the perceived usefulness of the HEMS physician. The presence of the HEMS physician was also considered useful when the physician did not provide any additional treatment, possibly because of diagnostic competence and clinical decision-making.

Understanding the prehospital physician controversy. Step 1: comparing competencies of ambulance nurses and prehospital physicians.

OBJECTIVE: In many European countries prehospital care by emergency medical services (EMS) is supplemented by physician-staffed services. There is ongoing controversy on the benefits of a prehospital physician. Possible advantages are additional competencies of the physician. Similarities and differences in competencies of EMS providers and physicians have however never been studied. This study aims to compare competencies of ambulance nurses and helicopter EMS physicians in the Netherlands to gain better insight into the controversy of the prehospital physician. METHODS: In this descriptive study, a quantitative inventory was made of the diagnostic, therapeutic, and clinical judgment competencies of the ambulance nurse and physician, based on analysis of protocols, registration, equipment, and personal interviews. RESULTS: We identified 438 mutual competencies of the ambulance nurse and physician and 62 physician-specific competencies. The ambulance nurse masters 278 diagnostic, 131 therapeutic, and 29 clinical judgment competencies. The physician masters 285 diagnostic, 175 therapeutic, and 40 clinical judgment competencies. Seventy-one percent of the physician-specific competencies are therapeutic and related to advanced life support. CONCLUSION: The ambulance nurse and physician have various mutual competencies. In addition, the physician can provide specific competencies on the scene. Knowing the exact overlap and differences in competencies is the first step to understand the prehospital physician controversy. Our results can be used as a tool for the next step in research on prehospital care by EMS providers and physicians and to improve prehospital care.