Prospective assessment of integrating the existing emergency medical system with automated external defibrillators fully operated by volunteers and laypersons for out-of-hospital cardiac arrest: the Brescia Early Defibrillation Study (BEDS)

AIMS: There are few data on the outcomes of cardiac arrest (CA) victims when the defibrillation capability of broad rural and urban territories is fully operated by volunteers and laypersons. METHODS AND RESULTS: In this study, we investigated whether a programme based on diffuse deployment of automated external defibrillators (AEDs) operated by 2186 trained volunteers and laypersons across the County of Brescia, Italy (area: 4826 km(2); population: 1 112 628), would safely and effectively impact the current survival among victims of out-of-hospital CA. Forty-nine AEDs were added to the former emergency medical system that uses manual EDs in the emergency department of 10 county hospitals and in five medically equipped ambulances. The primary endpoint was survival free of neurological impairment at 1-year follow-up. Data were analysed in 692 victims before and in 702 victims after the deployment of the AEDs. Survival increased from 0.9% (95% CI 0.4-1.8%) in the historical cohort to 3.0% (95% CI 1.7-4.3%) (P=0.0015), despite similar intervals from dispatch to arrival at the site of collapse [median (quartile range): 7 (4) min vs. 6 (6) min]. Increase of survival was noted both in the urban [from 1.4% (95% CI 0.4-3.4 %) to 4.0% (95% CI 2.0-6.9 %), P=0.024] and in the rural territory [from 0.5% (95% CI 0.1-1.6%) to 2.5% (95% CI 1.3-4.2%), P=0.013]. The additional costs per quality-adjusted life year saved amounted to euro39 388 (95% CI euro16 731-49 329) during the start-up phase of the study and to euro23 661 (95% CI euro10 327-35 528) at steady state. CONCLUSION: Diffuse implementation of AEDs fully operated by trained volunteers and laypersons within a broad and unselected environment proved safe and was associated with a significantly higher long-term survival of CA victims

The use of trained volunteers in the response to out-of-hospital cardiac arrest – the GoodSAM Experience

In England, fewer than 1 in 10 out-of-hospital cardiac arrest victims survive to hospital discharge. This could be substantially improved by increasing bystander cardiopulmonary resuscitation and Automated External Defibrillator use. GoodSAM is a mobile-phone, app-based system, alerting trained individuals to nearby cardiac arrests. ‘Responders’ can be notified by bystanders using the GoodSAM ‘Alerter’ function. In London, when a 999 call-handler identifies cardiac arrest, in addition to dispatching the usual professional resources, London Ambulance Service automatically activates nearby GoodSAM responders. This article discusses the development of GoodSAM, its integration with London Ambulance Service, and the plans for future expansion

Dispatch of lay responders to out-of-hospital cardiac arrests

Background and aim Out-of-hospital cardiac arrest (OHCA) remains a major public-health problem affecting around 300 000 Europeans each year. If treatment is not started within a couple of minutes the chances of survival are slim. One important predictor of survival is the time from call to start of treatment. To reduce this time frame, different strategies, in addition to emergency medical services (EMS), such as widespread deployment of automated external defibrillators (AEDs) and dispatch of fire fighters and police officers have been implemented. The aim of this thesis is to study the implementation and effects of a third additional resource, lay responders dispatched by the emergency dispatch center. The aim of study 1 was to evaluate the technical function and performance of a lay responder system during a run-in phase. The aim of study 2 was to measure the travelling speed and response time of the dispatched lay responders. In study 3 the aim was to investigate the emotional response, both positive and negative, wellbeing and post-traumatic stress disorder, among dispatched lay responders. In study 4 the aim was to investigate if lay responders instructed to fetch a public AED by using a smartphone application could increase the bystander use of AEDs before arrival of EMS, fire fighters and police officers. Methods and results In study 1 data from the smartphone application were collected and linked to cardiac arrest data from the Swedish Register for Cardiopulmonary Resuscitation (SRCR). During six months in 2016 the system was activated 685 times. 224 of these cases were EMS treated OHCAs. After exclusion of EMS-witnessed cases (n=11) and cases with missing survey data (n=15), 198 cases remained in the analytical sample. The results showed that dispatched lay responders reached the scene in 116 cases (58%), in 51 (26%) cases before the EMS. An AED was attached 17 times (9%) and defibrillated 4 times (2%). The median Euclidian distance to travel to perform CPR was 560 meters (IQR=332-860) compared with 1280 (IQR=748-1776) among for those who were directed to fetch an AED. In study 2, data on lay responder movement were collected from the smartphone application. During the 7-month study period 1406 suspected OHCAs were included. In these calls, 9058 lay responders accepted the mission and 2176 reached the scene of the suspected cardiac arrest (the study population). Among all cases the median travelling speed was 2.3 meters/sec (IQR=1.4–4.0) while the response time was 6.2 minutes, and the travelling distance was 956 meters (IQR=480–1661). In the most densely populated areas the median travelling speed was 1.8 meters/sec compared with 3.1 in the least densely populated areas. In study 3 we included 886 unexposed and 1389 exposed lay-responders. The lay responders were divided into 3 groups; unexposed, exposed-1 (who tried, but failed to reach the scene before EMS) and exposed-2 (who either reached the scene before EMS or performed CPR). Using the two dimensions of the Swedish Core Affect Scales (SCAS), valence and activation the results suggested that exposed lay responders showed higher activation (Exp-1=7.5, Exp-2=7.6) than unexposed lay responders (7.0) (p<0.001). Exposed lay responders had lower valence (Exp-1=6.3, Exp-2=6.3) compared with unexposed lay responders (6.8) (p<0.001). PCL-6 mean scores were highest in the unexposed group (10.4) compared with the exposed group (Exp-1=8.8, Exp-2=9.2) (p=0.007). There were no differences in the WHO wellbeing index, (Un-Exp: 77.7; Exp-1: 77.8; Exp-2: 78.2) (p=0.963). In Study 4, cases of suspected OHCA were randomly assigned to either an intervention group, where the majority of lay responders (4/5) were guided to the nearest AED, or to a control group, where all lay responders were directed to perform CPR. Data from the smartphone application system were linked to data from the SRCR. During the 13-month study period 2553 suspected OHCAs were randomized. Among these, 815 (32%) were EMS-treated. The AED attachment rate was 13.2% in the intervention group compared with 9.4 in the control group (p=0.087). In both groups combined, 29.3% of all bystanders attached AEDs, and 35.3% of all cases of bystander CPR were performed by a dispatched lay responder. Conclusions The conclusion from the first run-in study (study 1) was that it is feasible to dispatch lay responders to suspected OHCAs but that further system improvements are needed to reduce the time to defibrillation. The results from study 2 suggested that lay responders travel faster than previously estimated and that the travelling speed is dependent on population density, information that may be used for simulation studies as well as in configurations in app-based systems. Study 3 showed that lay responders rated the experience as high-energy and mostly positive. No indication of harm was seen, as the lay responders had low post-traumatic stress scores and high levels of general wellbeing at follow-up. Study 4 revealed that smartphone dispatch of lay responders to public AEDs did not increase the AED attachment rate before arrival of the EMS or first responders, versus smartphone dispatch to perform CPR. If dispatched lay responders arrived prior to the EMS, the likelihood of bystander AED use and CPR was increased

Dead Zones: An Analysis of South Dakota’s Rural EMS System

Emergency Medical Services is a key component of South Dakota’s rural healthcare network. However, research suggests that rural EMS agencies are ill-equipped to provide high quality emergency medical care. Delays or difficulty in delivery of care is exacerbated by sparsely spread resources. Evaluations of rural EMS agencies show that lack of volunteers and insufficient funding due to current reimbursement models are threatening the continued operation of rural EMS agencies. A survey conducted in 2016 by South Dakota Department of Health’s EMS Program and SafeTech Solutions, LLP, a national EMS consulting firm revealed that South Dakota’s EMS agencies are struggling to maintain a staffed agency. The results of this study confirm the discrepancies between the delivery of care in urban vs rural settings and bring into question the reliability of rural EMS agencies. Some rural states have piloted innovative programs to address the issue and integrate their rural EMS system into a larger healthcare network. But these are small measures, limited in scope to the grand scale of the rural crisis. It is hoped that more research brings policy change to the volunteer EMS model in order to address the issue that rural EMS agencies are facing

Increased bystander intervention when volunteer responders attend out-of-hospital cardiac arrest

AIM: The primary aim was to investigate the association between alarm acceptance compared to no-acceptance by volunteer responders, bystander intervention, and survival in out-of-hospital cardiac arrest. MATERIALS AND METHODS: This retrospective observational study included all suspected out-of-hospital cardiac arrests (OHCAs) with activation of volunteer responders in the Capital Region of Denmark (1 November 2018 to 14 May 2019), the Central Denmark Region (1 November 2018 to 31 December 2020), and the Northern Denmark Region (14 February 2020 to 31 December 2020). All OHCAs unwitnessed by Emergency Medical Services (EMS) were analyzed on the basis on alarm acceptance and arrival before EMS. The primary outcomes were bystander cardio-pulmonary resuscitation (CPR), bystander defibrillation and secondary outcome was 30-day survival. A questionnaire sent to all volunteer responders was used with respect to their arrival status. RESULTS: We identified 1,877 OHCAs with volunteer responder activation eligible for inclusion and 1,725 (91.9%) of these had at least one volunteer responder accepting the alarm (accepted). Of these, 1,355 (79%) reported arrival status whereof 883 (65%) arrived before EMS. When volunteer responders accepted the alarm and arrived before EMS, we found increased proportions and adjusted odds ratio for bystander CPR {94 vs. 83%, 4.31 [95% CI (2.43–7.67)] and bystander defibrillation [13 vs. 9%, 3.16 (1.60–6.25)]} compared to cases where no volunteer responders accepted the alarm. CONCLUSION: We observed a fourfold increased odds ratio for bystander CPR and a threefold increased odds ratio for bystander defibrillation when volunteer responders accepted the alarm and arrived before EMS

Activation of Citizen Responders to Out-of-Hospital Cardiac Arrest During the COVID-19 Outbreak in Denmark 2020

BACKGROUND: Little is known about how COVID‐19 influenced engagement of citizen responders dispatched to out‐of‐hospital cardiac arrest (OHCA) by a smartphone application. The objective was to describe and analyze the Danish Citizen Responder Program and bystander interventions (both citizen responders and nondispatched bystanders) during the first COVID‐19 lockdown in 2020. METHODS AND RESULTS: All OHCAs from January 1, 2020, to June 30, 2020, with citizen responder activation in 2 regions of Denmark were included. We compared citizen responder engagement for OHCA in the nonlockdown period (January 1, 2020, to March 10, 2020, and April 21, 2020, to June 30, 2020) with the lockdown period (March 11, 2020, to April 20, 2020). Data are displayed in the order lockdown versus nonlockdown period. Bystander cardiopulmonary resuscitation rates did not differ in the 2 periods (99% versus 92%; P=0.07). Bystander defibrillation (9% versus 14%; P=0.4) or return‐of‐spontaneous circulation (23% versus 23%; P=1.0) also did not differ. A similar amount of citizen responders accepted alarms during the lockdown (6 per alarm; interquartile range, 6) compared with the nonlockdown period (5 per alarm; interquartile range, 5) (P=0.05). More citizen responders reported performing chest‐compression‐only cardiopulmonary resuscitation during lockdown compared with nonlockdown (79% versus 59%; P=0.0029), whereas fewer performed standardized cardiopulmonary resuscitation, including ventilations (19% versus 38%; P=0.0061). Finally, during lockdown, more citizen responders reported being not psychologically affected by attending an OHCA compared with nonlockdown period (68% versus 56%; P<0.0001). Likewise, fewer reported being mildly affected during lockdown (26%) compared with nonlockdown (35%) (P=0.003). CONCLUSIONS: The COVID‐19 lockdown in Denmark was not associated with decreased bystander‐initiated resuscitation in OHCAs attended by citizen responders