European Registry of Cardiac Arrest – Study-THREE (EuReCa THREE) – an international, prospective, multi-centre, three-month survey of epidemiology, treatment and outcome of patients with out-of-hospital cardiac arrest in Europe – the study protocol

Background The aim of the European Registry of Cardiac Arrest (EuReCa) network is to provide high quality evidence on epidemiology of out-of-hospital cardiac arrest (OHCA) in Europe by supporting and developing cardiac arrest registries and performing European-wide studies. To date, the EuReCa ONE and EuReCa TWO studies have involved around 28 countries, with population covered increasing from the first to the second study. The aim of the EuReCa THREE study is to build on previous work and to support the promotion of quality data collection on OHCA throughout Europe. Methods/design EuReCa THREE will be the third prospective cohort study on epidemiology of OHCA and will involve around 30 European countries. The study will be conducted between 1st September and 30th November 2022. Data will be collected on cardiac arrest cases attended, resuscitation attempted, patient and cardiac arrest event characteristics and outcomes (including return of spontaneous circulation, status on hospital arrival and discharge). A particular focus for EuReCa THREE will be to describe key time intervals in OHCA management; time from call to EMS arrival on scene, time from cardiac arrest to start CPR, time from EMS arrival to delivery of patient to hospital. EuReCa THREE was registered with the German Registry of Clinical Trials Registration Number: DRKS00028591 searchable via WHO meta-registry (https://apps.who.int/trialsearch/). Discussion The EuReCa THREE study will increase our knowledge on longitudinal OHCA epidemiology and provide new knowledge on crucial time intervals in OHCA management in Europe. However, the primary aim of building a network to support quality data on OHCA, remains the central tenant of the EuReCa project

EuReCa ONE—27 Nations, ONE Europe, ONE Registry A prospective one month analysis of out-of-hospital cardiac arrest outcomes in 27 countries in Europe

AbstractIntroductionThe aim of the EuReCa ONE study was to determine the incidence, process, and outcome for out of hospital cardiac arrest (OHCA) throughout Europe.MethodsThis was an international, prospective, multi-centre one-month study. Patients who suffered an OHCA during October 2014 who were attended and/or treated by an Emergency Medical Service (EMS) were eligible for inclusion in the study. Data were extracted from national, regional or local registries.ResultsData on 10,682 confirmed OHCAs from 248 regions in 27 countries, covering an estimated population of 174 million. In 7146 (66%) cases, CPR was started by a bystander or by the EMS. The incidence of CPR attempts ranged from 19.0 to 104.0 per 100,000 population per year. 1735 had ROSC on arrival at hospital (25.2%), Overall, 662/6414 (10.3%) in all cases with CPR attempted survived for at least 30 days or to hospital discharge.ConclusionThe results of EuReCa ONE highlight that OHCA is still a major public health problem accounting for a substantial number of deaths in Europe.EuReCa ONE very clearly demonstrates marked differences in the processes for data collection and reported outcomes following OHCA all over Europe. Using these data and analyses, different countries, regions, systems, and concepts can benchmark themselves and may learn from each other to further improve survival following one of our major health care events

Statistical and geographic analysis of out-of-hospital cardiac arrest using registry data

Background: Out-of-hospital cardiac arrest (OHCA) is the most critical health event that occurs in the community. When the heart stops pumping blood, if resuscitation is not started, biological death will occur within minutes. It is known that patient-level factors significantly affect OHCA incidence and outcome however, area-level variation is often observed. The aim of this thesis was to investigate if area-level grouping or area-level characteristics could be identified that influence OHCA incidence and outcome, and their impact quantified. Methods: Using data from the Irish OHCA registry, descriptive and geographical analysis of OHCA incidence was performed. Cases were geocoded to Electoral Division (ED) level and combined with national census data, and area-level deprivation data, and classified by urban-rural category. The impact of urban-rural grouping was quantified using multilevel linear regression. To adjust for the impact of a small number of cases at ED-level, and the spatial properties of EDs, Bayesian conditional autoregression (CAR) was used to estimate the relative risk of OHCA. Swedish and Irish registry data was compared using logistic regression to identify the predictors of outcome, and to quantify variation measured. Finally, multilevel logistic regression analyses of outcomes in international airports was performed to allow for a differing effect of predictor variables between countries. Results: The incidence of OHCA where resuscitation was performed was higher in City and Town EDs (51/100,000 population per year; 95% confidence interval [CI], 46 to 55) than in Rural EDs (35/100,000 population per year; 95% CI, 28 to 42). However, urban-rural grouping accounted for only 2% of variation. Bayesian CAR modelling showed that a one-point increase in relative deprivation was associated with an 11% increased risk of OHCA that occurred at home. Logistic regression analysis of the Utstein comparator group (adults, bystander-witnessed, initial shockable rhythm, presumed medical cause) explained only 17% of outcome variation between Sweden and Ireland, with a 4-fold ‘country effect’ in favour of Sweden. Country-level differences in survival in international airports were also evident, particularly when adjusted for age, gender, and attempted bystander defibrillation (median odds ratio 3.0; 95% credible interval, 1.6 to 14.3]). Conclusions: Findings did not support changes in provision of resuscitation services based on area-level differences, and only a small proportion of between-country variation was explained by routinely collected variables. As patient-level factors are likely to explain the greater proportion of variation in OHCA outcome, it is recommended that there is international collaboration to ensure comparability of data collection and data interpretation, and to promote comprehensive case capture and maximise data quality. It is also recommended that more explanatory variables are incorporated into OHCA registry data collection. Finally, improvements in survival cannot be achieved without cooperation from local communities, but community preparedness should include: discussion on the inevitability of cardiac arrest as part of life; the prospect of patient survival; and, the need for innovative thinking to make sure that pre-hospital resuscitation is initiated efficiently and effectively

The spatial distribution of out-of-hospital cardiac arrest and the chain of survival in Ireland: a multi-class urban-rural analysis

Abstract: Cardiac arrest occurs when the heart suddenly ceases to pump blood around the body. To optimise survival from out-of-hospital cardiac arrest (OHCA), knowledge of the spatial distribution of OHCA and the availability of resuscitation, or ‘Chain of Survival’, is required. Thus, this study aims to describe OHCA incidence and Chain of Survival availability in a manner that can help inform pre-hospital planning in the Republic of Ireland. In view of Ireland’s heterogeneous settlement pattern, we analyse the association between varying degrees of rurality, OHCA incidence and the availability of the Chain of Survival. In addition to population density, settlement size, proximity to urban centres and land use is taken into account which results in six classes: city; town; accessible village; remote village; accessible rural; remote rural. Results show that, when adjusted for age and sex, the incidence of adult OHCA decreases with increasing rurality. Furthermore, while distance to the nearest ambulance station and call-response interval is greater with increasing rurality, the lowest levels of bystander cardiopulmonary resuscitation occur in the most urban class. To the best of our knowledge, this is one of the very first whole-country geographic descriptions of OHCA to be performed internationally. It is also the first OHCA study to use a multi-class urban-rural classification that considers rurality as more than a function of population densit

Apples to apples : can differences in out-of-hospital cardiac arrest incidence and outcomes between Sweden and Ireland be explained by core Utstein variables?

BACKGROUND: Variation in reported incidence and outcome based on aggregated data is a persistent feature of out-of-hospital cardiac arrest (OHCA) epidemiology. OBJECTIVE: To investigate the extent to which patient-level analysis using core 'Utstein' variables explains inter-country variation between Sweden and the Republic of Ireland. METHODS: A retrospective cross-sectional comparative study was performed, including all Swedish and Irish OHCA cases attended by Emergency Medical Services (EMS-attended OHCA) where resuscitation was attempted from 1st January 2012 to 31st December 2014. Incidence rates per 100,000 population were adjusted for age and gender. Two subgroups were extracted: (1) Utstein - adult patients, bystander-witnessed collapse, presumed medical aetiology, initial shockable rhythm and (2) Emergency Medical Service (EMS)-witnessed events. Multivariable logistic regression analysis was used to identify predictors of survival following multiple imputations of data. RESULTS: Five thousand eight hundred eighty six Irish and 15,303 Swedish patients were included. Swedish patients were older than Irish patients (median age 71 vs. 66 years respectively). Adjusted incidence was significantly higher in Sweden compared to the Republic of Ireland (52.9 vs. 43.1 per 100,000 population per year). Proportionate survival in Sweden was greater for both subgroups and all age categories. Regression analysis of the Utstein subgroup predicted approximately 17% of variation in outcome, but there was a large unexplained 'country effect' for survival in favour of Sweden (OR 4.40 (95% CI 2.55-7.56)). CONCLUSIONS: Using patient level data, a proportion of inter-country variation was explained, but substantial variation was not explained by the core Utstein variables. Researchers and policy makers should be aware of the potential for unmeasured differences when comparing OHCA incidence and outcomes between countries

Out-of-hospital cardiac arrest attended by ambulance services in Ireland: first 2 years' results from a nationwide registry

Background National data collection provides information on out-of-hospital cardiac arrest (OHCA) incidence, management and outcomes that may not be generalisable from smaller studies. This retrospective cohort study describes the first 2 years' results from the Irish National Out-of-Hospital Cardiac Arrest Register (OHCAR).Methods Data on OHCAs attended by emergency medical services (EMS) where resuscitation was attempted (EMS-treated) were collected from ambulance services and entered onto OHCAR. Descriptive analysis of the study population was performed, and regression analysis was performed on the subgroup of adult patients with a bystander-witnessed event of presumed cardiac aetiology and an initial shockable rhythm (Utstein group).Results 3701 EMS-treated OHCAs were recorded for the study period (1 January 2012-31 December 2013). Incidence was 39/100 000 population/year. In the Utstein group (n=577), compared with the overall group, there was a higher proportion of male patients, public event location, bystander cardiopulmonary resuscitation (CPR) and early defibrillation. Median EMS call-response interval was similar in both groups. A higher proportion of patients in the Utstein group achieved return of spontaneous circulation (35% vs 17%) and survival to hospital discharge (22% vs 6%). After multivariate adjustment for the Utstein group, the following variables were found to be independent predictors of the outcome survival to hospital discharge: public event location (OR 3.1 (95% CI 1.9 to 5.0)); bystander CPR (2.4 (95% CI 1.2 to 4.9)); EMS response of 8 min or less (2.2 (95% CI 1.3 to 3.6)).Conclusions This study highlights the role of nationwide registries in quantifying, monitoring and benchmarking OHCA incidence and outcome, providing baseline data upon which service improvement effects can be measured.peer-reviewe

Out-of-hospital cardiac arrest in the home: can area characteristics identify at-risk communities in the republic of ireland?

Background: Internationally, the majority of out-of-hospital cardiac arrests where resuscitation is attempted (OHCAs) occur in private residential locations i.e. at home. The prospect of survival for this patient group is universally dismal. Understanding of the area-level factors that affect the incidence of OHCA at home may help national health planners when implementing community resuscitation training and services. Methods: We performed spatial smoothing using Bayesian conditional autoregression on case data from the Irish OHCA register. We further corrected for correlated findings using area level variables extracted and constructed for national census data. Results: We found that increasing deprivation was associated with increased case incidence. The methodology used also enabled us to identify specific areas with higher than expected case incidence. Conclusions: Our study demonstrates novel use of Bayesian conditional autoregression in quantifying area level risk of a health event with high mortality across an entire country with a diverse settlement pattern. It adds to the evidence that the likelihood of OHCA resuscitation events is associated with greater deprivation and suggests that area deprivation should be considered when planning resuscitation services. Finally, our study demonstrates the utility of Bayesian conditional autoregression as a methodological approach that could be applied in any country using registry data and area level census data

General practitioner contribution to out-of-hospital cardiac arrest outcome: a national registry study

Background: There is a wide variation in reported survival from out-of-hospital cardiac arrest (OHCA). One factor in this variation may be the contribution of general practitioners to pre-hospital resuscitation. Studies using self-reported data describe increased survival proportions when general practitioners are involved. Objectives: This study aims to investigate the contribution of general practitioner involvement in out-of-hospital cardiac arrest events. Design and Setting: A retrospective observational study using data collected from ambulance records in the Republic of Ireland to describe general practitioner (GP) contribution to pre-hospital resuscitation attempts (n = 2369). Analysis is limited to patients with presumed cardiac cause and first arrest rhythm recorded as shockable (n = 510). Results: When a GP is present at scene (n = 199) patients are less likely to achieve return of spontaneous circulation (ROSC) (P < 0.001) or be transported to hospital (P < 0.001). When GPs participate in resuscitation (n = 92), patients are more likely to have collapsed in a public place (P < 0.01), receive bystander CPR (P < 0.001) and survive to hospital discharge (P < 0.001). Multiple logistic analysis of survival suggests that GP participation in resuscitation increases the odds of survival (4.6; 95% CI 1.6 - 13.3) and having collapsed in a public place increases chances of survival (5.8; 95% CI 2.1 - 15.7). Conclusion: Our analysis suggests that in this subgroup, GP participation in OHCA resuscitation attempts is associated with improved patient survival. Furthermore, resuscitation is more likely to be ceased at scene when a GP is present, highlighting the role that GPs play in the compassionate management of death in unviable circumstances