Association of National Initiatives to Improve Cardiac Arrest Management With Rates of Bystander Intervention and Patient Survival After Out-of-Hospital Cardiac Arrest

Abstract

IMPORTANCE Out-of-hospital cardiac arrest is a major health problem associated with poor outcomes. Early recognition and intervention are critical for patient survival. Bystander cardiopulmonary resuscitation (CPR) is one factor among many associated with improved survival.OBJECTIVE To examine temporal changes in bystander resuscitation attempts and survival during a 10-year period in which several national initiatives were taken to increase rates of bystander resuscitation and improve advanced care. DESIGN, SETTING, AND PARTICIPANTSPatients with out-of-hospital cardiac arrest for which resuscitation was attempted were identified between 2001 and 2010 in the nationwide Danish Cardiac Arrest Registry. Of 29 111 patients with cardiac arrest, we excluded those with presumed noncardiac cause of arrest (n = 7390) and those with cardiac arrests witnessed by emergency medical services personnel (n = 2253), leaving a study population of 19 468 patients.MAIN OUTCOMES AND MEASURES Temporal trends in bystander CPR, bystander defibrillation, 30-day survival, and 1-year survival. RESULTSThe median age of patients was 72 years; 67.4% were men. Bystander CPR increased significantly during the study period, from 21.1% (95% CI, 18.8%-23.4%) in 2001 to 44.9% (95% CI, 42.6%-47.1%) in 2010 (P < .001), whereas use of defibrillation by bystanders remained low (1.1% [95% CI, 0.6%-1.9%] in 2001 to 2.2% [95% CI, 1.5%-2.9%] in 2010; P = .003). More patients achieved survival on hospital arrival (7.9% [95% CI, 6.4%-9.5%] in 2001 to 21.8% [95% CI, 19.8%-23.8%] in 2010; P < .001). Also, 30-day survival improved (3.5% [95% CI, 2.5%-4.5%] in 2001 to 10.8% [95% CI, 9.4%-12.2%] in 2010; P < .001), as did 1-year survival (2.9% [95% CI, 2.0%-3.9%] in 2001 to 10.2% [95% CI, 8.9%-11.6%] in 2010; P < .001). Despite a decrease in the incidence of out-of-hospital cardiac arrests during the study period (40.4 to 34.4 per 100 000 persons in 2001 and 2010, respectively; P = .002), the number of survivors per 100 000 persons increased significantly (P < .001). For the entire study period, bystander CPR was positively associated with 30-day survival, regardless of witnessed status (30-day survival for nonwitnessed cardiac arrest, 4.3% [95% CI, 3.4%-5.2%] with bystander CPR and 1.0% [95% CI, 0.8%-1.3%] without; odds ratio, 4.38 [95% CI, 3.17-6.06]). For witnessed arrest the corresponding values were 19.4% (95% CI, 18.1%-20.7%) vs 6.1% (95% CI, 5.4%-6.7%); odds ratio, 3.74 (95% CI, 3.26-4.28). CONCLUSIONS AND RELEVANCEIn Denmark between 2001 and 2010, an increase in survival following out-of-hospital cardiac arrest was significantly associated with a concomitant increase in bystander CPR. Because of the co-occurrence of other related initiatives, a causal relationship remains uncertain.

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.…”

“…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

“…However, for women, these improvements seem to be attenuated in the transition from the prehospital setting to hospital admission. Previous studies have suggested that prehospital treatment strategies (early CPR and defibrillation) may be more suited to male patients with initial shockable heart rhythm 24, 25, 26. Although bystander CPR has been associated with improved outcomes among patients with nonshockable heart rhythm, survival in this population is markedly lower and limited increase in survival has been shown following improvements in prehospital treatment compared with those having a shockable heart rhythm 24, 25, 26.…”

Survival After Out‐of‐Hospital Cardiac Arrest in Children

“…One additional important finding in our study was the lack of improvement in survival over the course of the 9‐year study period. Given updated guidelines regarding a renewed focus on delivery of high‐quality and bystander CPR, advances in hospital care of patients sustaining an OHCA, and improved access to AEDs, this lack of survival improvement is somewhat surprising, especially since OHCA survival has been shown to improve among adults during the same time period and even within the CARES registry 19, 20, 21, 22…”