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

Abstract

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 PARTICIPANTSWe 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)(2011)(2012)(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 MEASURESThe 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. RESULTSThe 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 RELEVANCEFollowing 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.

Relationship Between Emergency Medical Services Response Time and Bystander Intervention in Patients With Out‐of‐Hospital Cardiac Arrest

“…To increase the rates of bystander intervention before the arrival of EMS personnel, several strategies have been implemented in industrialized nations: traditional classroom training, dispatcher‐guided CPR, school‐based instruction, online education, and targeted neighborhood or individualized training 4, 7, 8, 9, 24, 25, 26, 27, 28, 29, 30. Despite these strategies and the increase in rates of bystander intervention, the rate of neurologically intact survival cannot improve if the EMS response time is too long.…”

“…Therefore, appropriate initiatives should be adopted to reduce EMS response time 31, 32, 33. Such initiatives may include the reconfiguration of emergency call systems to enable rapid arrival of lay‐trained volunteers before the arrival of EMS personnel at the scene, or the implementation of educational programs to improve performance of high‐quality bystander CPR with defibrillation 7, 30, 34, 35, 36, 37, 38, 39, 40, 41, 42…”

“…Such initiatives may include first responder systems for early defibrillation and CPR such as police CPR‐AED programs,36, 37 the HeartRescue Project in North Carolina,7 text message alert systems,38 mobile‐phone positioning systems to dispatch lay volunteers who are trained in CPR,30 mobile application–based alert systems for trained responders,39 the PulsePoint Respond mobile device application for the recruitment of citizens to perform basic life support,40 and delivering defibrillators using a drone 41. In Japan, a rural community first responder system involves nonmedical citizens trained in resuscitation 42.…”

“…However, the proportion of patients who receive bystander CPR, following an out‐of‐hospital cardiac arrest (OHCA), is still relatively low in most countries 3. Fortunately, bystander CPR rates in some countries have recently increased to ≈50% 4, 5, 6, 7, 8, 9. In an analysis of OHCA, Hasselqvist‐Ax and colleagues6 reported survival that was more than twice as high among patients who received bystander CPR compared with those who received no CPR before the arrival of emergency medical services (EMS) providers.…”

Association of Bystander and First‐Responder Efforts and Outcomes According to Sex: Results From the North Carolina HeartRescue Statewide Quality Improvement Initiative

“…To reduce the chance that our results were driven by changes in reporting, we included only counties with complete registry enrollment and thus complete county‐wide case ascertainment during 2010–2014 (counties where cases were reported to CARES during the whole study period), as done previously 16, 19. Thus, the study population included all out‐of‐hospital cardiac arrests from 16 counties in North Carolina, covering a total population of ≈3 million inhabitants (30% of the total state population) with demographics varying from urban to rural areas.…”