What change in outcomes after cardiac arrest is necessary to change practice? Results of an international survey

Background: Efficient trials of interventions for patients with out-of-hospital cardiac arrest (OHCA) should have adequate but not excess power to detect a difference in outcomes. The minimum clinically important difference (MCID) is the threshold value in outcomes observed in a trial at which providers should choose to adopt a treatment. There has been limited assessment of MCID for outcomes after OHCA. Therefore, we conducted an international survey of individuals interested in cardiac resuscitation to define the MCID for a range of outcomes after OHCA. Methods: A brief survey instrument was developed and modified by consensus. Included were open-ended responses. The survey included an illustrative example of a hypothetical randomized study with distributions of outcomes based on those in a public use datafile from a previous trial. Elicited information included the minimum significant difference required in an outcome to change clinical practice. The population of interest was emergency physicians or other practitioners of acute cardiovascular research. Results: Usable responses were obtained from 160 respondents (50% of surveyed) in 46 countries (79% of surveyed). MCIDs tended to increase as baseline outcomes increased. For a population of patients with 25% survival to discharge and 20% favorable neurologic status at discharge, the MCID were median 5 (interquartile range [IQR] 3, 10) percent for survival to discharge; median 5 (IQR 2, 10) percent for favorable neurologic status at discharge, median 4 (IQR 2, 9) days of ICU-free survival and median 4 (IQR 2, 8) days of hospital-free survival. Conclusion: Reported MCIDs for outcomes after OHCA vary according to the outcome considered as well as the baseline rate of achieving it. MCIDs of ICU-free survival or hospital-free survival may be useful to accelerate the rate of evidence-based change in resuscitation care. (C) 2016 Elsevier Ireland Ltd. All rights reserved.Peer reviewe

Higher chance of survival in patients with out-of-hospital cardiac arrest attributed to poisoning

Aim of the study: Description and comparison of cohort characteristics and outcome of adult patients with out-of-hospital cardiac arrest (OHCA) attributed to poisoning (P-OHCA) versus patients with OHCA attributed to other medical causes (NP-OHCA). Methods: We included all patients who received cardiopulmonary resuscitation after OHCA between January 2011 and December 2020 from German emergency medical services with good data quality in the German Resuscitation Registry. Exclusion criteria: patients < 18 years of age or OHCA attributed to trauma, drowning, intracranial bleeding or exsanguination. Results: Patients with P-OHCA (n = 574) were significantly younger compared to NP-OHCA (n = 40,146) (median age of 43 (35-54) years vs. 73 (62-82) years; p < 0.001). Cardiac arrest in P-OHCA patients was significantly less often witnessed by bystanders (41.8 % vs. 66.2 %, p < 0.001). Asystole was the predominant initial rhythm in P-OHCA patients (73.5% vs. 53.7%, p < 0.001) while ventricular fibrillation (VF) and pulseless electrical activity (PEA) were less common (9.2% vs. 25.1% and 16.2 % vs. 20.5%, p < 0.001). P-OHCA had a higher chance of survival with good neurological outcome at hospital discharge (15.2 vs. 8.8 % p < 0.001) and poisoning was an independent protective prognostic factor in multivariate analysis (OR 2.47, 95%-CI [1.71-3.57]). P-OHCA patients with initial PEA survival with good neurological outcome was comparable to initial VF (34.3 % vs. 37.7%). Conclusion: Patients in the P-OHCA group had a significantly higher chance of survival with good neurological outcome and PEA as initial rhythm was as favourable as initial VF. Therefore, in P-OHCA patients resuscitation efforts should be extended

The Effect of Ambulance Response Time on Survival Following Out-of-Hospital Cardiac Arrest An Analysis from the German Resuscitation Registry

Background: Out of hospital cardiac arrest (OHCA) is one of the more common causes of death in Germany. Ambulance response time is an important planning parameter for emergency medical services (EMS) systems. We studied the effect of ambulance response time on survival after resuscitation from OHCA. Methods: We analyzed data from the German Resuscitation Registry for the years 2010-2016. First, we used a multivariate logistic regression analysis to determine the effect of ambulance response time (defined as the interval from the alarm to the arrival of the first rescue vehicle) on the hospital-discharge rate (in percent), depending on various factors, including resuscitation by bystanders. Second, we compared faster and slower EMS systems (defined as those arriving on the scene within 8 minutes in more than 75% of cases or in a significant independent effect on the survival rate. In drawing conclusions from these findings, one should bear in mind that this was a retrospective registry study, with the corresponding limitations

Application of mechanical cardiopulmonary resuscitation devices and their value in out-of-hospital cardiac arrest: A retrospective analysis of the German Resuscitation Registry

Background Cardiac arrest is an event with a limited prognosis which has not substantially changed since the first description of cardiopulmonary resuscitation (CPR) in 1960. A promising new treatment approach may be mechanical CPR devices (mechanical CPR). Methods In a retrospective analysis of the German Resuscitation Registry between 2007-2014, we examined the outcome after using mechanical CPR on return of spontaneous circulation (ROSC) in adults with out-of-hospital cardiac arrest (OHCA). We compared mechanical CPR to manual CPR. According to preclinical risk factors, we calculated the predicted ROSC-after-cardiac-arrest (RACA) score for each group and compared it to the rate of ROSC observed. Using multivariate analysis, we adjusted the influence of the devices' application on ROSC for epidemiological factors and therapeutic measures. Results We included 19,609 patients in the study. ROSC was achieved in 51.5% of the mechanical CPR group (95%-CI 48.2-54.8%, ROSC expected 42.5%) and in 41.2% in the manual CPR group (95%-CI 40.4-41.9%, ROSC expected 39.2%). After multivariate adjustment, mechanical CPR was found to be an independent predictor of ROSC (OR 1.77; 95%-CI 1.48-2.12). Duration of CPR is a key determinant for achieving ROSC. Conclusions Mechanical CPR was associated with an increased rate of ROSC and when adjusted for risk factors appeared advantageous over manual CPR. Mechanical CPR devices may increase survival and should be considered in particular circumstances according to a physicians' decision, especially during prolonged resuscitation

Chest compression quality management and return of spontaneous circulation: A matched-pair registry study

Aims: Investigating the effects of any intervention during cardiac arrest remains difficult. The ROSC after cardiac arrest score was introduced to facilitate comparison of rates of return of spontaneous circulation (ROSC) between different ambulance services. To study the influence of chest compression quality management (including training, real-time feedback devices, and debriefing) in comparison with conventional cardiopulmonary resuscitation (CPR), a matched-pair analysis was conducted using data from the German Resuscitation Registry, with the calculated ROSC after cardiac arrest score as the baseline. Methods and results: Matching for independent ROSC after cardiac arrest score variables yielded 319 matched cases from the study period (January 2007-March 2011). The score predicted a 45% ROSC rate for the matched pairs. The observed ROSC increased significantly with chest compression quality management, to 52% (P = 0.013; 95% CI, 46-57%). No significant differences were seen in the conventional CPR group (47%; 95% CI, 42-53%). The difference between the observed ROSC rates was not statistically significant. Conclusions: Chest compression quality management leads to significantly higher ROSC rates than those predicted by the prognostic score (ROSC after cardiac arrest score). Matched-pair analysis shows that with conventional CPR, the observed ROSC rate was not significantly different from the predicted rate. Analysis shows a trend toward a higher ROSC rate for chest compression quality management in comparison with conventional CPR. It is unclear whether a single aspect of chest compression quality management or the combination of training, real-time feedback, and debriefing contributed to this result. (C) 2012 Elsevier Ireland Ltd. All rights reserved

EuReCa ONE-27 Nations, ONE Europe, ONE Registry: a prospective observational analysis over one month in 27 resuscitation registries in Europe - the EuReCa ONE study protocol

Background: There is substantial variation in the incidence, likelihood of attempted resuscitation and outcomes from out-of-hospital cardiac arrest (OHCA) across Europe. A European, multi-centre study provides the opportunity to uncover differences throughout Europe and may help find explanations for these differences. Results may also have potential to support the development of quality benchmarking between European Emergency Medical Services (EMS). Methods/Design: This prospective European study involves 27 different countries. It provides a common Utstein-based dataset, data collection tool and a common data collection period for all participants. Study research questions will address the following: OHCA incidence in different European regions; incidence of cardiopulmonary resuscitation (CPR); initial presenting rhythm in patients where bystanders or EMS start CPR or any other resuscitation intervention; proportion of patients with any return of spontaneous circulation (ROSC); patient status at the end of pre-hospital treatment i.e. ROSC at handover to hospital, ongoing CPR, dead; proportion of patients still alive 30 days after OHCA; proportion of patients discharged alive from hospital. All patients who suffered an OHCA during October 2014 and were attended and/or treated by an EMS and documented in one of the participating registries will be included in the study. Each National Coordinator is responsible for data collection and quality control in his/her country and will transfer unprocessed anonymised data via secure electronic transfer. Descriptive analysis will be performed at European, national and registry level. For endpoints like ROSC, admission or survival, multivariate logistic regression analysis will be performed. Discussion: Documenting differences in epidemiology, treatment and outcome in out-of-hospital cardiac arrest throughout Europe is a first step in finding explanations for these differences. Study results might also support the development of quality benchmarking between Emergency Medical Services (EMS) which in turn will facilitate initiatives to improve OHCA outcome in Europe