Do dispatcher instructions facilitate bystander-initiated cardiopulmonary resuscitation and improve outcomes in patients with out-of-hospital cardiac arrest? A comparison of family and non-family bystanders

Objectives

Bystander-initiated cardiopulmonary resuscitation (CPR) has been reported to increase the possibility of survival in patients with out-of-hospital cardiopulmonary arrest (OHCA). We evaluated the effects of CPR instructions by emergency medical dispatchers on the frequency of bystander CPR and outcomes, and whether these effects differed between family and non-family bystanders.

Methods

We conducted a retrospective cohort study, using Utstein-style records of OHCA taken in a rural area of Japan between January 2004 and December 2009.

Results

Of the 559 patients with non-traumatic OHCA witnessed by laypeople, 231 (41.3%) were given bystander CPR. More OHCA patients received resuscitation when the OHCA was witnessed by non-family bystanders than when it was witnessed by family members (61.4% vs. 34.2%). The patients with non-family-witnessed OHCA were more likely to be given conventional CPR (chest compression plus rescue breathing) or defibrillation with an AED than were those with family-witnessed OHCA. Dispatcher instructions significantly increased the provision of bystander CPR regardless of who the witnesses were. Neurologically favorable survival was increased by CPR in non-family-witnessed, but not in family-witnessed, OHCA patients. No difference in survival rate was observed between the cases provided with dispatcher instructions and those not provided with the instructions.

Conclusions

Dispatcher instructions increased the frequency of bystander CPR, but did not improve the rate of neurologically favorable survival in patients with witnessed OHCA. Efforts to enhance the frequency and quality of resuscitation, especially by family members, are required for dispatcher-assisted CPR.     

Comparison of Medical Priority Dispatch (MPD) and Criteria Based Dispatch (CBD) relating to cardiac arrest calls

Background

Prompt emergency medical service (EMS) system activation with rapid delivery of pre-hospital treatment is essential for patients suffering out-of-hospital cardiac arrest (OHCA). The two most commonly used dispatch tools are Medical Priority Dispatch (MPD) and Criteria Based Dispatch (CBD). We compared cardiac arrest call processing using these two dispatch tools in two different dispatch centres.

Methods

Observational study of adult EMS confirmed (non-EMS witnessed) OHCA calls during one year in Richmond, USA (MPD) and Oslo, Norway (CBD). Patients receiving CPR prior to call, interrupted calls or calls where the caller did not have access to the patients were excluded from analysis. Dispatch logs, ambulance records and digitalized dispatcher and caller voice recordings were compared.

Results

The MPDS-site processed 182 cardiac arrest calls and the CBD-site 232, of which 100 and 140 calls met the inclusion criteria, respectively. The recognition of cardiac arrest was not different in the MPD and CBD systems; 82% vs. 77% (p = 0.42), and pre-EMS arrival CPR instructions were offered to 81% vs. 74% (p = 0.22) of callers, respectively. Time to ambulance dispatch was median (95% confidence interval) 15 (13, 17) vs. 33 (29, 36) seconds (p < 0.001) and time to chest compression delivery; 4.3 (3.7, 4.9) vs. 3.7 (3.0, 4.1) min for the MPD and CBD systems, respectively (p = 0.05).

Conclusion

Pre-arrival CPR instructions were offered faster and more frequently in the CBD system, but in both systems chest compressions were delayed 3–4 min. Earlier recognition of cardiac arrest and improved CPR instructions may facilitate earlier lay rescuer CPR.     

In patients with out-of-hospital cardiac arrest, does the provision of dispatch cardiopulmonary resuscitation instructions as opposed to no instructions improve outcome: a systematic review of the literature

Context

Early bystander cardiopulmonary resuscitation (CPR) provides an essential bridge to successful defibrillation from sudden cardiac arrest (SCA) and there is a need to increase the prevalence and quality of bystander CPR. Emergency medical dispatchers can give CPR instructions to a bystander calling for an ambulance enabling even an inexperienced bystander to start CPR. The impact of these instructions has not been evaluated.

Objectives

To determine if, in adult and pediatric patients with out-of-hospital cardiac arrest, the provision of dispatch CPR instructions as opposed to no instructions improves outcome.

Methods

Two independent reviewers used standardized forms and procedures to review papers published between January, 1985 and December, 2009. Findings were peer-reviewed by the International Liaison Committee on Resuscitation.

Data synthesis

We identified 665 citations; five met the inclusion criteria. One retrospective cohort study reported improved survival with dispatch CPR instructions than without it. Three studies, two observational and one with retrospective controls showed trends toward increased survival after dispatcher-assisted CPR was implemented and one showed trend toward decreased survival. There were no randomised studies addressing the topic. No studies addressing dispatch CPR instructions in the pediatric population were found.

Conclusion

There is limited evidence supporting the survival benefit of dispatch-assisted CPR instructions. All studies comparing survival outcomes when CPR is provided with or without the assistance of dispatch-assisted CPR instructions lack the statistical power to draw significant conclusions. Since it has been demonstrated that such instructions can improve bystander CPR rates, it is reasonable to recommend they should be provided to all callers reporting a victim in cardiac arrest.     

Association of neighborhood characteristics with incidence of out-of-hospital cardiac arrest and rates of bystander-initiated CPR: Implications for community-based education intervention

Objective

A 10-fold regional variation in survival after out-of-hospital cardiac arrest (OHCA) has been reported in the United States, which partly relates to variability in bystander cardiopulmonary resuscitation (CPR) rates. In order for resources to be focused on areas of greatest need, we conducted a geospatial analysis of variation of CPR rates.

Methods

Using 2010–2011 data from Durham, Mecklenburg, and Wake counties in North Carolina participating in the Cardiac Arrest Registry to Enhance Survival (CARES) program, we included all patients with OHCA for whom resuscitation was attempted. Geocoded data and logistic regression modeling were used to assess incidence of OHCA and patterns of bystander CPR according to census tracts and factors associated herewith.

Results

In total, 1466 patients were included (median age, 65 years [interquartile range 25]; 63.4% men). Bystander CPR by a layperson was initiated in 37.9% of these patients. High-incidence OHCA areas were characterized partly by higher population densities and higher percentages of black race as well as lower levels of education and income. Low rates of bystander CPR were associated with population composition (percent black: OR, 3.73; 95% CI, 2.00–6.97 per 1% increment in black patients; percent elderly: 3.25; 1.41–7.48 per 1% increment in elderly patients; percent living in poverty: 1.77, 1.16–2.71 per 1% increase in patients living in poverty).

Conclusions

In 3 counties in North Carolina, areas with low rates of bystander CPR can be identified using geospatial data, and education efforts can be targeted to improve recognition of cardiac arrest and to augment bystander CPR rates.     

Aspects on the increase in bystander CPR in Sweden and its association with outcome

Aim

To describe changes in the proportion of bystanders performing cardiopulmonary resuscitation (CPR) in out of hospital cardiac arrest (OHCA) in Sweden and to study the impact of bystander CPR on ventricular fibrillation and on survival during various times.

Patients and methods

All patients who suffered from OHCA in Sweden in whom CPR was attempted and who were included in the Swedish cardiac arrest register (SCAR) between 1992 and 2005. Crew witnessed cases were excluded.

Results

In all 34,125 patients were included in the survey. Among witnessed OHCA the proportion of patients receiving bystander CPR increased from 40% in 1992 to 55% in 2005 (p < 0.0001). In non-witnessed OHCA the corresponding proportion increased from 22% to 44% (p < 0.0001). There was a significant increase in bystander CPR regardless of age, sex and place. The increase was only found when CPR was performed by lay persons (21% in 1992 to 40% in 2005; p < 0.0001). Bystander CPR was associated with an increased proportion of patients found in a shockable rhythm and a lower number of shocks to receive return of spontaneous circulation. Bystander CPR was associated with a similar increase in survival early and late in the evaluation.

Conclusion

There was a marked increase in bystander CPR in OHCA, when performed by lay persons, during the last 14 years in Sweden. Bystander CPR was associated with positive effects both on ventricular fibrillation and survival.     

Chest compression-only cardiopulmonary resuscitation performed by lay rescuers for adult out-of-hospital cardiac arrest due to non-cardiac aetiologies

Objective

Bystander CPR improves survival in patients with out-of-hospital cardiac arrest (OHCA). For adult sudden collapse, bystander chest compression-only CPR (COCPR) is recommended in some circumstances by the American Heart Association and European Resuscitation Council. However, adults who arrest from non-cardiac causes may also receive COCPR. Because rescue breathing may be more important for individuals suffering OHCA secondary to non-cardiac causes, COCPR is not recommended for these cases. We evaluated the relationship of lay rescuer COCPR and survival after OHCA from non-cardiac causes.

Methods

Analysis of a statewide Utstein-style registry of adult OHCA, during a large scale campaign endorsing COCPR for OHCA from presumed cardiac cause. The relationship between lay rescuer CPR (both conventional CPR and COCPR) and survival to hospital discharge was evaluated.

Results

Presumed non-cardiac aetiologies of OHCA accounted for 15% of all cases, and lay rescuer CPR was provided in 29% of these cases. Survival to hospital discharge occurred in 3.8% after conventional CPR, 2.7% after COCPR, and 4.0% after no CPR (p = 0.85). The proportion of patients receiving COCPR was much lower in the cohort of OHCA from respiratory causes (8.3%) than for those with presumed cardiac OHCA (18.0%; p < 0.001).

Conclusions

In the setting of a campaign endorsing lay rescuer COCPR for cardiac OHCA, bystanders were less likely to perform COCPR on OHCA victims who might benefit from rescue breathing.     

Direction of first bystander call for help is associated with outcome from out-of-hospital cardiac arrest

Background

Preventable bystander delays following out-of-hospital cardiac arrest (OHCA) are common, and include bystanders inappropriately directing their calls for help.

Methods

We retrospectively extracted Utstein-style data from the Victorian Ambulance Cardiac Arrest Registry (VACAR) for adult OHCA occurring in Victoria, Australia, between July 2002 and June 2012. Emergency medical service (EMS) witnessed events were excluded. Cases were assigned into two groups on the basis of the first bystander call for help being directed to EMS. Study outcomes were: likelihood of receiving EMS treatment; survival to hospital, and; survival to hospital discharge.

Results

A total of 44 499 adult OHCA cases attended by EMS were identified, of which first bystander calls for help were not directed to EMS in 2842 (6.4%) cases. Calls to a relative, friend or neighbour accounted for almost 60% of the total emergency call delays. Patient characteristics and survival outcomes were consistently less favourable when calls were directed to others. First bystander call to others was independently associated with older age, male gender, arrest in private location, and arrest in a rural region. The risk-adjusted odds of treatment by EMS (OR 1.33, 95% CI 1.20–1.48), survival to hospital (OR 1.64, 95% CI 1.37–1.96) and survival to hospital discharge (OR 1.64, 95% CI 1.13–2.36) were significantly improved if bystanders called EMS first.

Conclusion

The frequency of inappropriate bystander calls following OHCA was low, but associated with a reduced likelihood of treatment by EMS and poorer survival outcomes.     

Multiple cluster analysis for the identification of high-risk census tracts for out-of-hospital cardiac arrest (OHCA) in Denver,Colorado

Background

Prior research has shown that high-risk census tracts for out-of-hospital cardiac arrest (OHCA) can be identified. High-risk neighborhoods are defined as having a high incidence of OHCA and a low prevalence of bystander cardiopulmonary resuscitation (CPR). However, there is no consensus regarding the process for identifying high-risk neighborhoods.

Objective

We propose a novel summary approach to identify high-risk neighborhoods through three separate spatial analysis methods: Empirical Bayes (EB), Local Moran's I (LISA), and Getis Ord Gi* (Gi*) in Denver, Colorado.

Methods

We conducted a secondary analysis of prospectively collected Emergency Medical Services data of OHCA from January 1, 2009 to December 31, 2011 from the City and County of Denver, Colorado. OHCA incidents were restricted to those of cardiac etiology in adults ≥18 years. The OHCA incident locations were geocoded using Centrus. EB smoothed incidence rates were calculated for OHCA using Geoda and LISA and Gi* calculated using ArcGIS 10.

Results

A total of 1102 arrests in 142 census tracts occurred during the study period, with 887 arrests included in the final sample. Maps of clusters of high OHCA incidence were overlaid with maps identifying census tracts in the below the Denver County mean for bystander CPR prevalence. Five census tracts identified were designated as Tier 1 high-risk tracts, while an additional 7 census tracts where designated as Tier 2 high-risk tracts.

Conclusion

This is the first study to use these three spatial cluster analysis methods for the detection of high-risk census tracts. These census tracts are possible sites for targeted community-based interventions to improve both cardiovascular health education and CPR training.     

New treatment bundles improve survival in out-of-hospital cardiac arrest patients: A historical comparison

Introduction

Before the introduction of the new international cardiac arrest treatment guidelines in 2005, patients with out-of-hospital cardiac arrest (OHCA) of cardiac origin in Northern Italy had very poor prognosis. Since 2006, a new bundle of care comprising use of automated external defibrillators (AEDs) and therapeutic hypothermia (TH) was started, while extracorporeal CPR program (ECPR) for selected refractory CA and dispatcher-assisted cardio-pulmonary resuscitation (CPR) was started in January 2010.

Objectives

We hypothesized that a program of bundled care might improve outcome of OHCA patients.

Methods

We analyzed data collected in the OHCA registry of the MB area between September 2007 and August 2011 and compared this with data from 2000 to 2003.

Results

Between 2007 and 2011, 1128 OHCAs occurred in the MB area, 745 received CPR and 461 of these had a CA of presumed cardiac origin. Of these, 125 (27%) achieved sustained ROSC, 60 (13%) survived to 1 month, of whom 51 (11%) were discharged from hospital with a good neurological outcome (CPC ≤ 2), and 9 with a poor neurological outcome (CPC > 2).Compared with data from the 2000 to 2003 periods, survival increased from 5.6% to 13.01% (p < 0.0001). In the 2007–2011 group, low-flow time and bystander CPR were independent markers of survival.

Conclusions

OHCA survival has improved in our region. An increased bystander CPR rate associated with dispatcher-assisted CPR was the most significant cause of increased survival, but duration of CA remains critical for patient outcome.     

Dispatcher-assisted bystander cardiopulmonary resuscitation in a metropolitan city: A before–after population-based study

Background

The goal of this study was to determine the effects of dispatcher-assisted bystander cardiopulmonary resuscitation (DA-CPR) on outcomes of out-of-hospital cardiac arrest (OHCA).

Methods

All EMS in a metropolitan city with a population of 10 million are dispatched by a single, centralized, and physician-supervised center. Data on patients with adult OHCA with cardiac etiology were collected from the dispatch center registry and from EMS run sheets and hospital medical record review from 2009 to 2011. A standardized DA-CPR protocol (aligned with the 2010 AHA guidelines) we implemented as an intervention in January 2011. The end points were survival to discharge, good neurological outcome, and bystander CPR rate. Multivariate logistic analysis was used to compare between intervention group (2011) and historical control group (2009–2010).

Results

Of 8.144 eligible patients, bystander CPR was performed for the patients in 5.7% (148/2600) of cases in 2009, 6.7% (190/2857) in 2010, and 12.4% (334/2686) in 2011 (p < 0.001). The survival to discharge rates was 7.1% (2009), 7.1% (2010), and 9.4% (2011) (p = 0.001). Good neurological outcomes occurred in 2.1% (2009), 2.0% (2010), and 3.6% (2011) of cases (p < 0.001). The adjusted ORs (95% CIs) for survival to discharge compared with 2009 were 1.33 (1.07–1.66) in 2011 and 1.12 (0.89–1.41) in 2010. The adjusted ORs (95% CIs) for good neurological outcomes were 1.67 (1.13–2.45) in 2011 and 1.13 (0.74–1.72) in 2010.

Conclusions

An EMS intervention using the DA-CPR protocol was associated with a significant increase in bystander CPR and an improved survival and neurologic outcome after OHCA.     

Changing EMS dispatcher CPR instructions to 400 compressions before mouth-to-mouth improved bystander CPR rates

Background

To examine the impact of changing dispatcher CPR instructions (400 compressions: 2 breaths, followed by 100:2 ratio) on rates of bystander CPR and survival in adults with presumed cardiac out-of-hospital arrest (OHCA) in Melbourne, Australia.

Methods

The Victorian Ambulance Cardiac Arrest Registry (VACAR) was searched for OHCA where Emergency Medical Services (EMS) attempted CPR between August 2006 and August 2009. OHCA included were: (1) patients aged ≥18 years old; (2) presumed cardiac etiology; and (3) not witnessed by EMS.

Results

For the pre- and post-study periods, 1021 and 2101 OHCAs met inclusion criteria, respectively. Rates of bystander CPR increased overall (45-55%, p < 0.001) and by initial rhythm (shockable 55-70%, p < 0.001 and non-shockable 40-46%, p = 0.01). In VF/VT OHCA, there were improvements in the number of patients arriving at hospital with a return of spontaneous circulation (ROSC) (48-56%, p = 0.02) and in survival to hospital discharge (21-29%, p = 0.002), with improved outcomes restricted to patients receiving bystander CPR. After adjusting for factors associated with survival, the period of time following the change in CPR instructions was a significant predictor of survival to hospital discharge in VF/VT patients (OR 1.57, 95% CI: 1.15-2.20, p = 0.005).

Conclusion

Following changes to dispatcher CPR instructions, significant increases were seen in rates of bystander CPR and improvements were seen in survival in VF/VT patients who received bystander CPR, after adjusting for factors associated with survival.     

Adult Out-of-Hospital Cardiac Arrest Based on Chain of Survival in Taoyuan County,Northern Taiwan

Background

Most out-of-hospital cardiac arrest (OHCA) studies have been conducted in developed countries or metropolitan areas, and few in developing countries or rural areas.

Objectives

The aims of this study were to determine the weak links in the chain of survival and to estimate the outcomes of OHCA patients in Taoyuan, a nonmetropolitan area in Taiwan.

Methods

A retrospective review and analysis of OHCA data was conducted. The three outcomes were whether a return of spontaneous circulation (ROSC) was achieved, whether the patient survived to admission, or whether the patient survived to hospital discharge.

Results

From April to December 2008, 1048 OHCA patients were resuscitated, and 712 (67.9%) adult cardiac patients were used in this study. Among these 712 patients, 17.8% achieved ROSC (95% confidence interval [CI] 15.2–20.8%), 16.3% survived to admission (95% CI 13.6–19.0%), and 1.4% survived to discharge (95% CI 0.5–2.3%). Factors significantly associated with the three outcomes were witness status, response time to emergency medical services, and whether the patient had a shockable rhythm. Bystander cardiopulmonary resuscitation (CPR) did not add a notable benefit to the outcomes of OHCA.

Conclusions

The survival rate of OHCA patients in nonmetropolitan Taiwan was very low (1.4%). Lower witnessed rate, lower bystander CPR rate, and longer response interval in remote areas are the main causes of inferior survival rate.     

Implementation of the ALERT algorithm,a new dispatcher-assisted telephone cardiopulmonary resuscitation protocol,in non-Advanced Medical Priority Dispatch System (AMPDS) Emergency Medical Services centres

Objectives

Early bystander cardiopulmonary resuscitation (CPR) is a key factor in improving survival from out-of-hospital cardiac arrest (OHCA). The ALERT (Algorithme Liégeois d’Encadrement à la Réanimation par Téléphone) algorithm has the potential to help bystanders initiate CPR. This study evaluates the effectiveness of the implementation of this protocol in a non-Advanced Medical Priority Dispatch System area.

Methods

We designed a before and after study based on a 3-month retrospective assessment of victims of OHCA in 2009, before the implementation of the ALERT protocol in Liege emergency medical communication centre (EMCC), and the prospective evaluation of the same 3 months in 2011, immediately after the implementation.

Results

At the moment of the call, dispatchers were able to identify 233 OHCA in the first period and 235 in the second. Victims were predominantly male (59%, both periods), with mean ages of 64.1 and 63.9 years, respectively. In 2009, only 9.9% victims benefited from bystander CPR, this increased to 22.5% in 2011 (p < 0.0002). The main reasons for protocol under-utilisation were: assistance not offered by the dispatcher (42.3%), caller physically remote from the victim (20.6%). Median time from call to first compression, defined here as no flow time, was 253 s in 2009 and 168 s in 2011 (NS). Ten victims were admitted to hospital after ROSC in 2009 and 13 in 2011 (p = 0.09).

Conclusion

From the beginning and despite its under-utilisation, the ALERT protocol significantly improved the number of patients in whom bystander CPR was attempted.     

Increased survival after EMS witnessed cardiac arrest. Observations from the Resuscitation Outcomes Consortium (ROC) Epistry—Cardiac arrest

Background

Out of hospital cardiac arrest (OHCA) is common and lethal. It has been suggested that OHCA witnessed by EMS providers is a predictor of survival because advanced help is immediately available. We examined EMS witnessed OHCA from the Resuscitation Outcomes Consortium (ROC) to determine the effect of EMS witnessed vs. bystander witnessed and unwitnessed OHCA.

Methods

Data were analyzed from a prospective, population-based cohort study in 10 U.S. and Canadian ROC sites. Individuals with non-traumatic OHCA treated 04/01/06-03/31/07 by EMS providers with defibrillation or chest compressions were included. Cases were grouped into EMS-witnessed, bystander witnessed, and unwitnessed and further stratified for bystander CPR. Multiple logistic regressions evaluated the odds ratio (OR) for survival to discharge relative to the EMS-witnessed group after adjusting for age, sex, public/private location of collapse, ROC site, and initial ECG rhythm. Of 9991 OHCA, 1022 (10.2%) of EMS-witnessed, 3369 (33.7%) bystander witnessed, and 5600 (56.1%) unwitnessed.

Results

The most common initial rhythm in the EMS-witnessed group was PEA which was higher than in the bystander- and unwitnessed groups (p < 0.001). The adjusted OR (95% CI) of survival compared to the EMS-witnessed group was 0.41, (0.36, 0.46) in bystander witnessed with bystander CPR, 0.37 (0.33, 0.43) in bystander witnessed without bystander CPR, 0.17 (0.14, 0.20) in unwitnessed with bystander CPR and 0.21 (0.18, 0.24) in unwitnessed cases without bystander CPR.

Conclusions

Immediate application of prehospital care for OHCA may improve survival. Efforts should be made to educate patients to access 9-1-1 for prodromal symptoms.     

Bystander CPR in south east Scotland increases over 16 years

Background

Out-of-hospital cardiac arrest (OHCA) remains a leading cause of mortality and serious neurological disability across Europe. Without immediate bystander cardiopulmonary resuscitation (CPR), chances of survival are minimal. Despite community initiatives to increase the number of trained CPR providers, the effectiveness of these measures remains unknown and the proportion of OHCA patients receiving bystander CPR in the United Kingdom yet to be established. We sought to identify the change in the rate of bystander CPR in south east Scotland over a 16-year period.

Methods

Retrospective cohort study of all adult non-traumatic OHCA in south east Scotland from 1 January 1992 to 31 December 2007 using the Heartstart Scotland database.

Results

7928 OHCA were included. The proportion of patients receiving bystander CPR increased from 34% in 1992 to 52% in 2007 (p for trend <0.0001). The rate of CPR from bystanders, spouses and from relatives increased significantly over the study period. Patients arresting at home received significantly less bystander CPR than those arresting away from home (39% vs 52%, p < 0.0001) regardless of age or sex.

Conclusion

There has been a significant increase in bystander CPR in south east Scotland during the 16-year period. Bystander CPR is associated with an increased rate of survival and targeted CPR training for relatives of patients at risk of sudden cardiac death may be beneficial.     

Delayed Visceral Bleeding from Liver Injury After Cardiopulmonary Resuscitation

Background

Visceral injury is a life-threatening complication of cardiopulmonary resuscitation (CPR); however, the clinical significance has been masked by the lethal outcome of out-of-hospital cardiac arrest (OHCA).

Objective

The objective is to share our experience of successful treatment of OHCA patients with serious, CPR-related visceral complications.

Case Reports

We report two cases of cardiac-origin OHCA with liver injury exacerbated by heparinization during mechanical circulatory support. Although both patients presented with delayed massive liver bleeding (intrahepatic or peritoneal) that compromised hemodynamic status, one patient was successfully treated by selective transcatheter arterial embolization and the other by a surgical procedure.

Conclusion

Preventive measures such as careful CPR, as well as interventional or surgical repair after the early diagnosis of visceral injury, are required to improve the outcome in some cases of OHCA.     

Bystander-initiated CPR in an Asian metropolitan: Does the socioeconomic status matter?

Objectives

To determine the association of neighborhood socioeconomic status (SES) with bystander-initiated cardiopulmonary resuscitation (CPR) and patient outcomes of out of hospital cardiac arrests (OHCAs) in an Asian metropolitan area.

Methods

We performed a retrospective study in a prospectively collected cohort from the Utstein registry of adult non-traumatic OHCAs in Taipei, Taiwan. Average real estate value was assessed as the first proxy of SES. Twelve administrative districts in Taipei City were categorized into low versus high SES areas to test the association. The primary outcome was bystander-initiated CPR, and the secondary outcome was patient survival status. Factors associated with bystander-initiated CPR were adjusted for in multivariate analysis. The mean household income was assessed as the second proxy of SES to validate the association.

Results

From January 1, 2008 to December 30, 2009, 3573 OHCAs received prehospital resuscitation in the community. Among these, 617 (17.3%) cases received bystander CPR. The proportion of bystander CPR in low-SES vs. high-SES areas was 14.5% vs. 19.6% (p < 0.01). Odds ratio of receiving bystander-initiated CPR in low-SES areas was 0.72 (95% confidence interval: [0.60–0.88]) after adjusting for age, gender, witnessed status, public collapse, and OHCA unrecognized by the online dispatcher. Survival to discharge rate was significantly lower in low-SES areas vs. high-SES areas (4.3% vs. 6.8%; p < 0.01). All results above remained consistent in the analyses by mean household income.

Conclusions

Patients who experienced an OHCA in low-SES areas were less likely to receive bystander-initiated CPR, and demonstrated worse survival outcomes.     

The continuous quality improvement project for telephone-assisted instruction of cardiopulmonary resuscitation increased the incidence of bystander CPR and improved the outcomes of out-of-hospital cardiac arrests

Review

In 2007, the Ishikawa Medical Control Council initiated the continuous quality improvement (CQI) project for telephone-assisted cardiopulmonary resuscitation (telephone-CPR), which included instruction on chest-compression-only CPR, education on how to recognise out-of-hospital cardiac arrests (OHCAs) with agonal breathing, emesis and convulsion, recommendations for on-line or redialling instructions and feedback from emergency physicians. This study aimed to investigate the effect of this project on the incidence of bystander CPR and the outcomes of OHCAs.

Materials and methods

The baseline data were prospectively collected on 4995 resuscitation-attempted OHCAs, which were recognised or witnessed by citizens rather than emergency medical technicians during the period of February 2004 to March 2010. The incidence of telephone-CPR and bystander CPR, as well as the outcomes of the OHCAs, was compared before and after the project.

Results

The incidence of telephone-CPR and bystander CPR significantly increased after the project (from 42% to 62% and from 41% to 56%, respectively). The incidence of failed telephone-CPR due to human factors significantly decreased from 30% to 16%. The outcomes of OHCAs significantly improved after the projects. A multiple logistic regression analysis revealed that the CQI project is one of the independent factors associated with one-year (1-Y) survival with favourable neurological outcomes (odds ratio = 1.81, 95% confidence interval = 1.20–2.76).

Conclusions

The CQI project for telephone-CPR increased the incidence of bystander CPR and improved the outcome of OHCAs. A CQI project appeared to be essential to augment the effects of telephone-CPR.