Self-Assessment Feedback Form Improves Quality of Out-of-Hospital CPR

Objective: Various continuous quality improvement (CQI) approaches have been used to improve quality of cardiopulmonary resuscitation (CPR) delivered at the scene of out-of-hospital cardiac arrest. We evaluated a post-event, self-assessment, CQI feedback form to determine its impact on delivery of CPR quality metrics. Methods: This before/after retrospective review evaluated data from a CQI program in a midsized urban emergency medical services (EMS) system using CPR quality metrics captured by Zoll Medical Inc. X-series defibrillator ECG files in adult patients (≥18 years old) with non-traumatic out-of-hospital cardiac arrest. Two 9-month periods, one before and one after implementation of the feedback form on December 31, 2013 were evaluated. Metrics included the mean and percentage of goal achievement for chest compression depth (goal: >5 centimeters [cm]; >90%/episode), rate (goal: 100–120 compressions/minute [min]), chest compression fraction (goal: ≥75%), and preshock pause (goal: <10?seconds [sec]). The feedback form was distributed to all EMS providers involved in the resuscitation within 72?hours for self-review. Results: A total of 439 encounters before and 621 encounters after were evaluated including basic life support (BLS) and advanced life support (ALS) providers. The Before Group consisted of 408 patients with an average age of 61?±?17 years, 61.8% male. The After Group consisted of 556 patients with an average age of 61?±?17 years, 58.3% male. Overall, combining BLS and ALS encounters, the mean CPR metric values before and after were: chest compression depth (5.0?cm vs. 5.5?cm; p?<?0.001), rate (109.6/min vs 114.8/min; p?<?0.001), fraction (79.2% vs. 86.4%; p?<?0.001), and preshock pause (18.8?sec vs. 11.8?sec; p?<?0.001), respectively. Overall, the percent goal achievement before and after were: chest compression depth (48.5% vs. 66.6%; p?<?0.001), rate (71.8% vs. 71.7%, p?=?0.78), fraction (68.1% vs. 91.0%; p?<?0.001), and preshock pause (24.1% vs. 59.5%; p?<?0.001), respectively. The BLS encounters and ALS encounters had similar statistically significant improvements seen in all metrics. Conclusion: This post-event, self-assessment CQI feedback form was associated with significant improvement in delivery of out-of-hospital CPR depth, fraction and preshock pause time.     

A composite model of survival from out-of-hospital cardiac arrest using the Cardiac Arrest Registry to Enhance Survival (CARES)

ObjectiveUsing CARES data, to develop a composite multivariate logistic regression model of survival for projecting survival rates for out-of-hospital arrests of presumed cardiac etiology (OHCA).MethodsThis is an analysis of 25,975 OHCA cases (from October 1, 2005 to December 31, 2011) occurring before EMS/first responder arrival and involving attempted resuscitation by responders from 125 EMS agencies.ResultsThe survival-at-hospital discharge rate was 9% for all cases, 16% for bystander-witnessed cases, 4% for unwitnessed cases, and 32% for bystander-witnessed pVT/VF cases. The model was estimated separately for each set of cases above. Generally, our first equation showed that joint presence of a presenting rhythm of pVT/VF and return of spontaneous circulation in the pre-hospital setting (PREHOSPROSC) is a substantial direct predictor of patient survival (e.g., 55% of such cases survived). Bystander AED use, and, for witnessed cases, bystander CPR and response time are significant but less sizable direct predictors of survival. Our second equation shows that these variables make an additional, indirect contribution to survival by affecting the probability of joint presence of pVT/VF and PREHOSPROSC. The model yields survival rate projections for various improvement scenarios; for example, if all cases had involved bystander AED use (vs. 4% currently), the survival rate would have increased to 14%. Approximately one-half of projected increases come from indirect effects that would have been missed by the conventional single-equation approach.ConclusionThe composite model describes major connections among predictors of survival, and yields specific projections for consideration when allocating scarce resources to impact OHCA survival.     

A study of police operated dispatch to acute coronary syndrome cases arising from 112 emergency calls in Aarhus county, Denmark

Background

The accuracy of the Danish police operated "112" emergency call system was studied. Dispatch of the anaesthesiologist staffed mobile emergency care unit (MECU) to acute coronary syndrome (ACS) cases was used as an indicator of accuracy of dispatch to life threatening emergencies.

Methods

This was an observational cohort study of patients given a 112 system report of heart attack and patients with a provisional diagnosis of ACS made on scene by the MECU. Sensitivity, specificity, and positive predictive value with 95% confidence intervals (CI) were calculated.

Results

There were 341 reports of “heart attack” and 205 patients with ACS. Sensitivity was 75% (95% CI 68% to 80%) specificity 90% (89% to 92%) and positive predictive value 45% (40% to 50%).

Conclusion

The accuracy of 112 dispatch of the MECU was found to be moderate. We suggest more training of dispatch staff and medical supervision.     

CPR: R ESUSCITATION OF THE A RRESTED H EART

A case report of seizure due to photic stimulation from sunlight shining through spinning helicopter rotor blades is discussed. A review of photosensitive epilepsy is provided with particular emphasis on the effects andfrequencies of photic stimulation required to induce symptoms. The frequencies of flashing light produced by spinning helicopter rotor blades commonly used in air medical transport range from 24 to 27 flashes per second. These frequencies are well within the range reported in the literature to produce symptoms in the laboratory setting. The literature provides only a few case reports of individuals sustaining a seizure after photic stimulation from spinning turboprop or helicopter blades. Symptoms range from mild discomfort andheadache to profound spatial disorientation andseizures andmay be an underrecognized but preventable complication of air medical transport.     

Prehospital Cardiac Arrest in a Paramedic First-responder System Using the Utstein Style

Objectives. To describe the characteristics of patients found to have cardiac arrest andto evaluate the characteristics predictive of survival after cardiac arrest in a paramedic first-responder model. Methods. All patients who suffered out-of-hospital cardiac arrest in the city of Reading, Ohio, from January 1998 to December 2003 were recorded in the Utstein style. The number andincidence rate of witnessed arrests, initial rhythms, rate of bystander cardiopulmonary resuscitation (CPR), and30-day mortality rate were retrospectively collected. Demographics, time to hospital, andresponse times were evaluated as predictors of survival. Results. Of those patients initially found to be in cardiac arrest, 14.3% were discharged alive. Witnessed arrests were more likely to result in live discharge of the patient. Whether bystander CPR was performed was not found to affect survival, nor was initial rhythm, although no patients initially found in asystole were discharged alive. No demographic characteristics or response times were predictive of survival. Conclusion. The rates of survival in this paramedic first-response system are favorable compared with basic emergency medical technician first-response systems. Further study using direct comparison methodology is warranted to confirm these findings.     

Feasibility of Out-of-Hospital Cardiac Arrest Ultrasound by EMS Physicians

Introduction: Point-of-care ultrasound (POCUS) has been suggested as a useful tool to predict survival and guide interventions in out-of-hospital cardiac arrest (OHCA). While POCUS has been deployed in prehospital settings, a minimal amount of data exists on prehospital use, particularly by personnel with limited ultrasound experience. We aimed to characterize the feasibility and barriers to prehospital POCUS during OHCA by emergency medicine services (EMS) physicians in training. Methods: We deployed the SonoSite iViz portable ultrasound device for use by EMS physicians for OHCA in an urban EMS system. All physicians received POCUS education as part of their graduate medical training and were provided an instructional video on use of the SonoSite iViz device. POCUS use was limited to identifying cardiac motion during pulse checks, without interrupting resuscitation, and the results could be used to supplement management at the physicians’ discretion. Data were recorded prospectively by saving images on the device and through a custom electronic form within the patient care report. The primary measure was the frequency of use of POCUS during OHCA. Secondarily, we characterized agreement by expert (ultrasound fellowship trained) faculty (using a kappa statistic) and identified reported barriers to the use of prehospital POCUS. Results: From November 2016 to March 2017, 348 physician field responses were reviewed, including 127 cases of OHCA. There were 106 patients remaining in arrest on physician arrival, with 56 (52.8%) cases of POCUS use. Still or video images were recorded in 48 cases; video in 34 cases. From video images, agreement in identifying cardiac motion between the EMS physician and expert reviewer occurred in 91% of cases (K?=?0.82). Reasons cited for not using POCUS included return of circulation soon before or after arrival, prioritizing clinical interventions, not having the ultrasound device, mechanical failure, and cessation of resuscitation per advanced directives. Conclusion: Use of POCUS by EMS physicians to detect cardiac activity in OHCA is feasible and correlates with expert interpretation. Several avoidable barriers were identified and should be considered in the future implementation of prehospital POCUS. Larger studies are needed to determine what role POCUS may play in prehospital cardiac arrest management.     

The Accuracy of Predicting Cardiac Arrest by Emergency Medical Services Dispatchers: The Calling Party Effect

OBJECTIVES: To analyze the accuracy of paramedic emergency medical services (EMS) dispatchers in predicting cardiac arrest and to assess the effect of the caller party on dispatcher accuracy in an advanced life support, public utility model EMS system, with greater than 90,000 calls and greater than 60,000 transports per year. METHODS: This was a retrospective analysis from January 1, 2000, through June 30, 2000, of 911 calls with dispatcher-assigned presumptive patient condition (PPC) or field diagnosis of cardiac arrest. Sensitivity and positive predictive value (PPV) of the PPC code for cardiac arrest by calling parties were calculated. Homogeneity of sensitivity and PPV of the PPC code for cardiac arrest by calling parties was studied with chi-square analysis. Relevant proportions, relative risk ratios, and associated 95% confidence intervals (95% CIs) were calculated. Student's t-test was used to compare quality assurance scores between calling parties. RESULTS: There were 506 patients included in the study. Overall sensitivity for dispatcher-assigned PPC of cardiac arrest was 68.3% (95% CI = 63.3% to 73.0%) with a PPV of 65.0% (95% CI = 60.0% to 69.7%). There was a significant difference in the PPV for the EMS dispatcher diagnosis of cardiac arrest depending on the type of caller (chi(2) = 17.34, p < 0.001). CONCLUSIONS: A higher level of medical training may improve dispatch accuracy for predicting cardiac arrest. The type of calling party influenced the PPV of dispatcher-assigned condition.     

Probabilistic Linkage of Prehospital and Outcomes Data in Out-of-hospital Cardiac Arrest

Abstract

Objective. Lack of longitudinal patient outcome data is an important barrier in emergency medical services (EMS) research. We aimed to demonstrate the feasibility of linking prehospital data from the California EMS Information Systems (CEMSIS) database to outcomes data from the California Office of Statewide Health Planning and Development (OSHPD) database for patients with out-of-hospital cardiac arrest (OHCA). Methods. We included patients age 18 years or older who sustained nontraumatic OHCA and were included in the 2010–2011 CEMSIS databases. The CEMSIS database is a unified EMS data collection system for California. The OSHPD database is a comprehensive data collection system for patient-level inpatient and emergency department encounters in California. OHCA patients were identified in the CEMSIS database using cardiac rhythm, procedures, medications, and provider impression. Probabilistic linkage blocks were created using in-hospital death or one of the following primary or secondary diagnoses (ICD-9-CM) in the OSHPD databases: cardiac arrest (427.5), sudden death (798), ventricular tachycardia (427.1), ventricular fibrillation (427.4), and acute myocardial infarction (410.xx). Blocking variables included incident date, gender, date of birth, age, and/or destination facility. Due to the volume of cases, match thresholds were established based on clerical record review for each block individually. Match variables included incident date, destination facility, date of birth, sex, race, and ethnicity. Results. Of the 14,603 cases of OHCA we identified in CEMSIS, 91 (0.6%) duplicate records were excluded. Overall, 46% of the data used in the linkage algorithm were missing in CEMSIS. We linked 4,961/14,512 (34.2%) records. Linkage rates varied significantly by local EMS agency, ranging from 1.4 to 61.1% (OR for linkage 0.009–0.76; p < 0.0001). After excluding the local EMS agency with the outlying low linkage rate, we linked 4,934/12,596 (39.2%) records. Conclusion. Probabilistic linkage of CEMSIS prehospital data with OSHPD outcomes data was severely limited by the completeness of the EMS data. States and EMS agencies should aim to overcome data limitations so that more effective linkages are possible.     

A Failed Attempt to Improve Quality of Out-of-Hospital CPR Through Performance Evaluation

Introduction. Quality of CPR performed by professionals has been reported to be substandard even with automated corrective feedback. Our hypothesis was that providing CPR performance evaluation (CPR-PE) to three ambulance services would facilitate local education andimplementation of CPR guidelines and, consequently, improve CPR quality.

Methods: Quality of CPR in 85 consecutive cases of adult out-of-hospital cardiac arrests after CPR-PE was compared to 39 cases prior to CPR-PE. Real-time automated verbal andvisual feedback on CPR performance was given in all cases. No general implementation strategy was provided because the sites were expected to use the CPR-PEs in development of local strategies. Because the strategies were expected to vary, the sites were analyzed separately.

Results: No significant improvement was seen in quality of CPR after CPR-PE. No chest compressions were given 40% of the time before versus 41% after CPR-PE. The median (95% confidence interval) percentage of chest compressions within the recommended depth range (38–51 mm) was 35% (27–57) before versus 51% (42–60) after CPR-PE (p = 0.12). In site-specific analysis, chest compressions within guideline depth increased from 31% to 61% after CPR-PE (p = 0.05) in one site.

Conclusions: Overall our attempt to improve CPR-quality was unsuccessful. Quality improvement likely requires a full range of implementation strategies to change current attitudes andpractices.     

Outcomes of sudden cardiac arrest treated with defibrillation by emergency medical technicians (emt-ds) or paramedics in a two-tiered urban ems system

Objective. Controversy exists as to the effectiveness of de-fibrillation by emergency medical technicians (EMT-Ds) in reducing mortality from cardiac arrest in two-tiered EMS systems. This study was performed to assess the impact of EMT-Ds on outcome of sudden cardiac death in a small, urban, modified two-tiered EMS system. Methods. This was a retrospective, unmatched case-control study comparing the outcomes of patients suffering sudden cardiac death treated by EMT-Ds with paramedic (EMT-P) backup with the outcomes of patients treated by EMT-Ps as first responders. Outcomes were defined as survival to the following endpoints: hospital admission, hospital discharge, and discharge with normal neurologic function (neurologic survival). Differences between groups were considered significant if p ≤ 0.05 by Fisher's exact test or t-test. Results. Three hundred twenty-two patients suffered out-of hospital sudden cardiac deaths over a three-year period and met study inclusion criteria. There were no significant differences in mean age, sex distribution, or incidence of ventricular fibrillation as the presenting rhythm between the groups. Rates of survival to admission, survival to discharge, and neurologic survival were 25.8%, 8.1%, and 5.6%, respectively. Corresponding survival rates for 46 patients treated first by EMT-Ds were 19.6%, 8.7%, and 4.3%. For 276 patients treated by EMT-Ps as first responders, the rates were 26.8%, 8.0%, and 5.8%. There were no significant differences in survival rates between the two response modes, despite a significantly shorter response interval for EMT-Ds (3.6 ± 1.8 min, vs 4.6 ± 2.0 min for EMT-Ps). There were likewise no significant differences in survival rates between the two response modes when only patients in ventricular fibrillation or ventricular tachycardia were considered. There were no significant differences in survival rates grouped by presenting rhythm, with the exception of 9.6% neurologic survival in witnessed ventricular fibrillation as compared with 0% in asystole. Conclusion. EMT defibrillation had no impact on outcome of sudden cardiac death in this small, urban, two-tiered EMS system. Survival rates were similar to those reported for other such systems. However, power to detect significant differences was low, and further study is indicated. Controlled multicenter trials are recommended.     

Prevalence of automated external defibrillators at cardiac arrest high-risk sites

Objective

Automated external defibrillators (AEDs) distributed throughout communities may improve survival from cardiac arrest. The purpose of this study was to determine if AEDs were present at high-risk locations for cardiac arrest in King County, Washington.

Methods

The authors compiled a list of sites based on a five-year study that identified public sites with the highest incidence of cardiac arrests in King County. They conducted a structured telephone survey with the manager, director, or owner of those high-risk sites.

Results

Of the 263 identified high-risk cardiac arrest sites, we obtained information for 228 (87%) sites. Overall, 87 of 228 (38%) high-risk sites had one or more AEDs. The AED dissemination varied greatly by type of site. The airport, the two county jails, the five public sports venues, and the nine ferries/train terminals each reported at least one AED on site. In contrast, none of the 13 shelters and 19% of health clubs/gyms reported an AED on site. Nearly half (44%) of sites without AEDs cited cost as a factor preventing them from purchasing AEDs in the future.

Conclusion

Although AEDs have diffused into high-risk sites in this community, the diffusion appears to vary by the type of site.     

Service factors and health status of survivors of out-of-hospital cardiac arrest

To determine how emergency service factors affect the health status of survivors of out-of-hospital cardiac arrest, 424 survivors were studied six months later. The principal research tool was the Sickness Impact Profile (SIP), a behaviorally-based instrument for measuring sickness-related dysfunction. Time to initiation of care and time to definitive care were significantly related to dysfunction. The critical time intervals can be influenced by the manner in which communities provide emergency care.     

Out-of-hospital Care of Critical Drug Overdoses Involving Cardiac Arrest

OBJECTIVES: Death from acute drug poisoning, also termed drug overdose, is a substantial public health problem. Little is known regarding the role of emergency medical services (EMS) in critical drug poisonings. This study investigates the involvement and potential mortality benefit of EMS for critical drug poisonings, characterized by cardiovascular collapse requiring cardiopulmonary resuscitation (CPR). METHODS: The study population was composed of death events caused by acute drug poisoning, defined as poisoning deaths and deaths averted (persons successfully resuscitated from out-of-hospital cardiac arrest by EMS) in King County, Washington, during the year 2000. RESULTS: Eleven persons were successfully resuscitated and 234 persons died from cardiac arrest caused by acute drug poisoning, for a total of 245 cardiac events. The EMS responded to 79.6% (195/245), attempted resuscitation in 34.7% (85/245), and successfully resuscitated 4.5% (11/245) of all events. Among the 85 persons for whom EMS attempted resuscitation, opioids, cocaine, and alcohol were the predominant drugs involved, although over half involved multiple drug classes. Among the 11 persons successfully resuscitated, return of circulation was achieved in six following EMS cardiopulmonary resuscitation alone, in one following CPR and defibrillation, and in the remaining four after additional advanced life support. CONCLUSIONS: In this community, EMS was involved in the majority of acute drug poisonings characterized by cardiovascular collapse and may potentially lower total mortality by approximately 4.5%. The results show that, in some survivors, return of spontaneous circulation may be achieved with CPR alone, suggesting a different pathophysiology in drug poisoning compared with cardiac arrest due to heart disease.     

Evaluation of the outcome of out-of-hospital cardiac arrest resuscitation efforts in Denizli, Turkey

The objective of this study was to evaluate the outcomes and associated factors for short-term success and long-term survival rates of resuscitated non-traumatic out-of-hospital cardiac arrest (OHCAs) in Denizli, Turkey. All non-traumatic OHCA patients from the Emergency Departments of the Pamukkale University and City Hospitals between the dates of January 1, 2004 and March 1, 2005 were included in this study. A successful outcome was defined as the return of spontaneous circulation or breathing, or evidence of a palpable pulse or a measurable blood pressure. Information on post-resuscitation long-term survival up to 9 months also was obtained by telephone. A total of 222 adults experiencing OHCAs were resuscitated. The number of successful outcomes was 85 (38.3%); 25 (11.2%) were discharged alive; and 21 (9.4%) were alive at the 9-month follow-up. The predicted mean arrest time was 11.7 min (95% confidence interval 10.27-13.2). Type of transportation to the Emergency Department (ambulance, 32.1% vs. private vehicle, 44.5%; p = 0.057), place of arrest (home, 32.6% vs. other, 44.0%; p = 0.08), first rhythm at the scene (asystole, 22.9% vs. ventricular fibrillation-pulseless ventricular tachycardia, 48.0%, vs. pulseless electrical activity, 12.5%; p = 0.056), and advanced cardiac life support starting time (the first 8 min, 46.8% vs. later than 8 min, 32.0%; p = 0.025) had an effect on outcome. Intensive public education for diagnosis and appropriate reporting of OHCA, the importance of bystander cardiopulmonary resuscitation, and the use of automated external defibrillators have an impact on the potential to increase the number of survivors.     

Ability of the Medical Priority Dispatch System Protocol to Predict the Acuity of “Unknown Problem” Dispatch Response Levels

Objective. To determine if Medical Priority Dispatch System's (MPDS's) Protocol 32–Unknown Problem interrogation-based differential dispatch coding distinguishes the acuity of patients as found at the scene by responders, when little (if any) clinical information is known. Methods. “Unknown problem” situations (i.e., all cases not fitting into any other chief complaint group) constitute 5–8% of all calls to dispatch centers. From the total patient encounters (n = 599,107) in the aggregate data of one year (September 2005 to August 2006), we examined 3,947 (0.7%) encounters initially coded as “unknown problem” by the London Ambulance Service Communications Center for the scene presence of cardiac arrest (CA) andparamedic-determined high-acuity (blue-in [BI]/“lights andsiren”) findings. Odds ratios (ORs) with 95% confidence intervals (95% CIs) andp-values were used to assess the degree of associations between determinant codes andcase outcomes (i.e., CA/BI). Results. Statistically significant association between clinical dispatch determinant codes andcase outcomes was observed in the “life status questionable” (LSQ; DELTA-1 [D-1]) andthe “standing, sitting, moving, or talking” (BRAVO-1 [B-1]) code pair for the CA outcome (OR [95% CI]: 0.11 [0, 0.63], p = 0.005) andfor the BI outcome (OR [95% CI]: 0.47 [0.28, 0.77], p = 0.003). The LSQ andall three code pairs (i.e., B-1; “community alarm notifications” [B-2]; and“unknown status” [B-3]) also demonstrated significant associations both with the CA outcome (OR [95% CI]: 0.43 [0.23, 0.81], p = 0.010) andwith the BI outcome (OR [95% CI]: 0.74 [0.56, 0.97], p = 0.033). All the determinant code levels yielded significant association between BI andCA cases. Conclusion. This dispatch protocol for unknown problems successfully differentiates dispatch coding of low-acuity andnon-CA patients only when specific situational information such as the patient's standing, sitting, moving, or talking can be determined during the interrogation process. Also, emergency medical dispatcher (EMD) reliance on caller-volunteered information to identify predefined critical situations does not appear to add to the protocol's ability to differentiate high-acuity andCA patients. LSQ proved to be a better predictor of both CA andBI outcomes, when compared with the BRAVO-level determinant codes within the “unknown problem” chief complaint. The B-3 (completely unknown) determinant code is a better predictor of severe outcomes than nearly all of the clinically similar BRAVO determinant codes in the entire MPDS protocol. Hence, the B-3 coding should be considered—in terms of its predictability for severe outcome—as falling somewhere between a typical DELTA anda typical BRAVO determinant code.