Resuscitation 82 (2011) 1508–1513
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Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation
Clinical Paper
Good outcome in every fourth resuscitation attempt is achievable—An Utstein
template report from the Stavanger region夽
Thomas Werner Lindner a,b,∗ , Eldar Søreide a,c , Odd Bjarte Nilsen d,e , Mathiesen Wenche Torunn a ,
Hans Morten Lossius c,f
a
Department of Anaesthesiology and Intensive Care, Stavanger University Hospital, Norway
Regional Competence Centre for Emergency Medicine, Stavanger University Hospital, Norway
c
Department of Surgical Sciences, Section for Anaesthesiology, University of Bergen, Norway
d
Norwegian Centre for Movement Disorders, Stavanger University Hospital, Norway
e
Department of Industrial Economics, University of Stavanger, Stavanger, Norway
f
Department of Research, Norwegian Air Ambulance Foundation, Drøbak, Norway
b
a r t i c l e
i n f o
Article history:
Received 13 December 2010
Received in revised form 25 May 2011
Accepted 12 June 2011
Keywords:
Cardiopulmonary resuscitation
Out-of-hospital cardiac arrest
Emergency medical services
Survival to discharge
a b s t r a c t
Aim of the study: Out-of-hospital cardiac arrest (OHCA) is a major cause of death in the western world. We
wanted to study changes in survival over time and factors linked to this in a region which have already
reported high survival rates.
Methods: We used a prospectively collected Utstein template database to identify all resuscitation
attempts in adult patients with OHCA of presumed cardiac origin. We included 846 resuscitation attempts
and compared survival to discharge with good outcome in two time periods (2001–2005 vs. 2006–2008).
Results: We found no significant differences between the two time periods for mean age (71 and 70
years (p = 0.309)), sex distribution (males 70% and 71% (p = 0.708)), location of the OHCA (home 64%
and 63% (p = 0.732)), proportion of shockable rhythms (44% and 47% (p = 0.261)) and rate of return of
spontaneous circulation (38% and 43% (p = 0.136)), respectively. Bystander cardiopulmonary resuscitation
(CPR), however, increased significantly from 60% to 73% (p < 0.0001), as did the overall rate of survival
to discharge from 18% to 25% (p = 0.018). In patients with a shockable first rhythm, rate of survival to
discharge increased significantly from 37% to 48% (p = 0.036). In witnessed arrest with shockable rhythm
survival to discharge increased from 37% to 52% (p = 0.0105).
Conclusion: Overall, good outcome is now achievable in every fourth resuscitation attempt and in every
second resuscitation attempt when patients have a shockable rhythm. The reason for the better outcomes
is most likely multi-factorial and linked to improvements in the local chain of survival.
© 2011 Elsevier Ireland Ltd. All rights reserved.
1. Introduction
Every year, emergency medical system (EMS) personnel attempt
to resuscitate approximately 500,000 out-of-hospital cardiac arrest
(OHCA) victims in Europe and North America.1–3 Substantial variations in short- and long-term survival have been reported.2,4,5
Although differences in bystander cardiopulmonary resuscitation
(CPR) rates and time until defibrillation may explain some of the
differences, the large variations in survival rates are still not fully
夽 A Spanish translated version of the abstract of this article appears as Appendix
in the final online version at doi:10.1016/j.resuscitation.2011.06.016.
∗ Corresponding author at: Department of Anaesthesiology and Intensive Care,
Stavanger University Hospital, Box 8100, N-4068 Stavanger, Norway.
Tel.: +47 99391632; fax: +47 51513903.
E-mail address: [email protected] (T.W. Lindner).
0300-9572/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.resuscitation.2011.06.016
understood.5 To improve the local chains of survival, the European
Resuscitation Council (ERC), as part of the International Liaison
Committee on Resuscitation (ILCOR), have developed internationally recognized guidelines on how to treat OHCA, and the guidelines
are revised on a regular basis.6 The Utstein template for uniform data reporting after OHCA has also been revised to allow
better comparisons of different EMS systems reporting of OHCA
incidence, return of spontaneous circulation (ROSC) and survival
rates.4,5,7–9
In the late 1990s, high survival rates after OHCA were reported
from the Stavanger region.7,10 Since then we have continued our
quality improvement process focusing on bystander CPR, prehospital care as well as the other parts of the chain of survival.7,11–13
We felt it would be of interest to study changes in OHCA
survival in our community and therefore used a prospectively
collected, population-based, Utstein template OHCA database to
study survival and factors linked to survival in adult patients
T.W. Lindner et al. / Resuscitation 82 (2011) 1508–1513
with OHCA of presumed cardiac origin8,9 in the time period
2001–2008.
1509
Response from EMS
to OHCA
n=1628 (100%)
2. Materials and methods
2.1. The EMS and Stavanger University Hospital
During the study period from January 1, 2001 to December 31,
2008 the population in the studied region (5700 km2 ) increased
from approximately 273,000 inhabitants to approximately 314,000
inhabitants.7,14 Stavanger University Hospital (SUH) is the only
receiving hospital for patients after OHCA. The Emergency Dispatch Centre (EDC) at SUH coordinates 18 ambulance units and
one hospital-based, anaesthesiologist-manned rapid response unit
using a helicopter or car as well as general practitioners (GPs) on
call in the local communities.13 All ambulances are staffed with
at least one advanced life support (ALS)-certified paramedic. The
resuscitation guideline changes were implemented shortly after
their approval. The implementation process of the 2005 guidelines included a training period of some weeks. In this period both
guidelines may have been used, but after this only the new guidelines were used as a standard. The Norwegian ALS algorithm from
2000 was similar to the ERC guidelines from 2000 while the ALS
algorithm from 2005 differed from the ERC guidelines.15 The Norwegian ALS algorithm recommended time loops of 3 min duration
between rhythm analyses and defibrillation attempts, with pulse
control performed 1 min after heart rhythm analysis followed by
the administration of 1 mg adrenalin iv if there was no palpable
pulse present.16
The EDC is reached by one nationwide alarm telephone number and dispatch is criteria-based.17 Throughout the whole study
period, the EDC instructed the calling bystander to start CPR, including mouth-to-mouth ventilations. In cases of presumed OHCA, the
EDC activates a response consisting of one or two ambulances, the
anaesthesiologist-manned rapid response unit and the local GP on
call. There were no systematic changes in this response pattern in
the study period. The EDC always tried to get at least one doctor
and one ambulance unit to the scene. If the incident was not primarily identified as OHCA by the EDC, the rapid response unit was
called out later. Resuscitation attempts not leading to sustained
ROSC were as a rule terminated on scene, and transportations to
the hospital with on-going CPR were rare.18
Apart from an increased number of fire brigades equipped
with automated external defibrillators (AED) acting as first responders, there were no major organizational changes to this response
system during the study period. The collaborations between fire
brigades and the EMS began in 2000 and had reached 17 units in
2008.
Public education in basic CPR has been focused on in Norway
both through training of health personnel and lay people in the
school system and voluntary organizations.19,20 Standard courses
in basic CPR are offered and encourage the public to use public access AEDs (PAD).21,22 PADs were first provided in 2001, and
approximately 100 PADs were available in the study area in 2008.
PADs were typically placed in large businesses, public buildings,
schools and shopping malls. The EDC does not, however, have alerting routines for PAD locations.
In-hospital treatment for OHCA survivors has been expanded
to include therapeutic hypothermia (TH) as part of post resuscitation intensive care23 in all unconscious patients from 200211
and emergency percutaneous coronary intervention (PCI) in STelevation myocardial infarction (STEMI) from 2004.12 Prior to the
implementation of TH, comatose survivors of OHCA were treated
with 2–3 days on mechanical ventilation before prognostication
and possible withdrawal of active treatment.7,11
Resuscitation not started
n=373 (23%)
OHCA non-cardiac origin
n=409 (25%)
OHCA of presumed cardiac origin
n=846 (52%)
Study population
Fig. 1. Inclusion of patients with OHCA of presumed cardiac origin from January 1,
2001 to December 31, 2008.
2.2. Patient inclusion and data collection
Since 1996, all EMS missions for an OHCA have been registered
in the hospital-run Utstein registry.7,8 The present study accessed
all prospective collected datasets of individuals 18 years and older
between January 1, 2001 and December 31, 2008. We included
patients with OHCA from presumed cardiac origin according to
the Utstein definition without obtaining post mortems.8,9 The following two groups were excluded from further analysis: patients
with OHCA of non-cardiac origin and patients without resuscitation attempts (Fig. 1). The latter situation occurred when somebody
called the EDC, but the EMS did not perform medical measures
such as airway assistance, chest compressions, drug administration, intubation or defibrillation.
Eight hundred forty-six patients with OHCA of presumed cardiac
origin for whom resuscitation was attempted were included in the
present study (Fig. 1). We compared two time periods (2001–2005
vs. 2006–2008). In the first time period, the 2000 ERC resuscitation
guidelines were used for CPR. TH and emergency PCI were successively implemented.11,12 In the 2006–2008 time period only the
2005 resuscitation guidelines with Norwegian alterations16 were
used and TH and emergency PCI had become standard practice.
Utstein template data were registered separately by both the
ambulance and the rapid response unit.8 For quality assurance, data
were crossed-checked before being entered in the study database.
Missing data for each performed analysis are noted in Section 3.
Good outcome in survivors were assessed using the Cerebral Performance Category (CPC) 1–2.9 The Utstein template database was
approved for scientific use nationally and locally by the Norwegian
Social Science Data Service, the Regional Committee for Research
Ethics and the Central Office for National Registration.
2.3. Statistical analysis
The data were entered into a FilemakerPro9 database (FileMaker, Inc.; USA), and SPSS 15.0 (SPSS, Inc.; USA) was used for
statistical analysis. Figures were constructed using SPSS 15.0 and
Microsoft® Office Excel 2003 (Microsoft Corporation, USA). We
used the chi-square test to examine differences in proportions
for categorical variables. For frequencies less than 5, Yates correction was employed. To examine between-group differences
the independent-samples t-test was conducted for age and the
1510
T.W. Lindner et al. / Resuscitation 82 (2011) 1508–1513
Table 1
Demographic overview of OHCA patients in the two time periods studied (n = 846).
Age year/ mean (SD) (n)
Male sex (%) (n)
Witnessed OHCA (%) (n)
EMS witnessed OHCA (%) (n)
Bystander CPR (%) (n)
Bystander CPR + witnessed (%) in all patients (n)
Bystander CPR + Non witnessed (%) in all patients (n)
Location OHCA (%)
Home
Public/other
EMS
(n)
EMS response time in minutes
Median (IQRa )
(n)
a
Time period
2001–2005
Time period
2006–2008
p-Value
71 (15) (555)
70% (633)
77% (414)
11% (68)
60% (320)
47% (261)
11% (61)
70 (15) (291)
71% (213)
74% (221)
8% (28)
73% (217)
55% (160)
16% (47)
0.309
0.708
0.263
0.601
0.0001
0.0001
0.152
64%
32%
3%
(554)
63%
36%
2%
(291)
0.732
0.453
0.264
8 (5–11)
(501)
9 (6–13)
(289)
Missing data as number
0
0
13
13
13
18
16
1
0.001
56
IQR = Interquartile range.
Table 2
Comparisons of ROSC, survival to discharge and good cerebral outcome (CPC 1–2) rates in the two time periods (2000–2005 vs. 2006–2008) studied.
Time period
2001–2005
Time period
2006–2008
All rhythms (n)
ROSC (%) (n)
Survival to discharge (%) (n)
CPC 1-2 (%) in all survivors (n)
1 Year survival (%) (n)
555
38% (211)
18% (99)
84% (83)
14% (75)
Shockable rhythms (n)
ROSC (%) (n)
Survival to discharge (%) (n)
CPC 1–2 (%) in survivors of shockable rhythms (n)
1 Year survival (%) (n)
237
65% (155)
37% (87)
87% (76)
29% (69)
Mann–Whitney-U-Test for the EMS response time. Multivariate
logistic regression analysis correcting for age, witnessed OHCA,
bystander CPR, time period, shockable rhythm and EMS response
time was used to examine differences in both ROSC and survival to
discharge.
Two-sided p-values less than 0.05 were considered statistically
significant.
3. Results
In the 846 resuscitation attempts studied, age, gender distribution, OHCA location, proportion of OHCAs that were witnessed,
and first reported heart rhythm did not differ significantly
between the two time periods (2001–2005 vs. 2006–2008), but
median EMS response time increased significantly from 8 to 9 min
(Tables 1 and 2). The number of patients receiving bystander CPR
increased from 60% to 73% (p = 0.0001) (Table 1). Bystander CPR
in the subgroup of OHCA patients with witnessed OHCA increased
from 47% to 55% (p = 0.0001) (Table 1).
p-Value
Missing data as number
291
43% (126)
25% (72)
97% (70)
22% (64)
0.136
0.018
0.010
0.040
0
0
9
0
136
66% (90)
48% (65)
99% (64)
43% (60)
0.879
0.036
0.041
0.005
0
0
0
7
7
Sixty-five patients were admitted to hospital with ongoing
resuscitation, 12 achieved ROSC, but no one survived to discharge.
The overall ROSC rate was 40% and did not change over time
(Table 2). The overall survival to discharge and 1-year survival
increased significantly from 18% to 25% (p = 0.018) and 14% to 22%,
respectively (p = 0.040) (Table 2).
Overall 44% of the OHCA victims presented with a shockable rhythm. The rate of shockable rhythm remained unchanged
throughout the study period; 43% vs. 47% (p = 0.261). ROSC rates in
patients with shockable rhythms also remained unchanged (66%)
during the two study periods (Table 2), while survival to discharge and 1-year survival increased significantly from 37% to 48%
(p = 0.036) and 30% to 43% (p = 0.005), respectively (Table 2). In this
patient group, good cerebral outcome (CPC 1–2) upon discharge
also increased from 87% to 99% (p = 0.041) (Table 2). Survival to discharge and 1-year survival improved significantly (p = 0.0105 and
p = 0.0005) in witnessed OHCA with shockable rhythm in the time
period 2006–2008 (Fig. 2). In OHCA victims with witnessed arrest
and shockable rhythm who received bystander CPR, 52% of patients
survived to discharge in the time period 2006–2008 (Fig. 2).
Table 3
Factors associated with ROSC and survival to discharge in OHCA of presumed cardiac origin (n = 747).
ROSC
Shockable rhythm vs. non-shockable rhythm
Witnessed arrest vs. non-witnessed arrest
Bystander CPR vs. no-bystander CPR
Time period 2006–2008 vs. Time period 2001–2005
EMS response time (one additional minute)
Age (one additional year)
Survival to discharge
Odds ratio
95% confidence interval
p
Odds ratio
95% confidence interval
p
6.00
2.90
1.21
1.31
0.99
0.99
4.20–8.56
1.82–4.62
0.83–1.76
0.92–1.88
0.99–1.00
0.98–1.01
0.0001
0.0001
0.323
0.139
0.007
0.482
14.76
2.86
1.87
1.65
0.99
0.96
7.64–28.54
1.32–6.19
1.11–3.16
1.05–2.61
0.99–0.99
0.95–0.98
0.0001
0.008
0.019
0.030
0.0001
0.001
T.W. Lindner et al. / Resuscitation 82 (2011) 1508–1513
Witnessed OHCA
Shockable rhythm
2000-2005
2006-2008
n=215
100%
n=118
100%
66%
Non witnessed OHCA
Non shockable rhythm
Shockable rhythm
2006-2008
2000-2005
2006-2008
2000-2005
2006-2008
n=186
100%
n=86
100%
n=20
100%
n=18
100%
n=103
100%
n=57
100%
ROSC
2006-2008
67%
n.s.
Survival to discharge
ROSC
2000-2005
2006-2008
19%
27%
n.s.
Survival to discharge
2000-2005
2006-2008
2000-2005
2006-2008
37%
52%
p=0.0105
4%
5%
n.s.
One year survival
Non shockable rhythm
2000-2005
ROSC
2000-2005
1511
One year survival
ROSC
2000-2005
2006-2008
65%
44%
n.s.
Survival to discharge
2000-2005
2006-2008
3%
14%
p=0.0077
Survival to discharge
2000-2005
2006-2008
2000-2005
2006-2008
25%
22%
n.s.
1%
2%
n.s.
One year survival
2000-2005
2006-2008
2000-2005
2006-2008
2000-2005
2006-2008
28%
47%
p=0.0005
1%
2%
n.s.
10%
22%
n.s.
One year survival
2000-2005
2006-2008
1%
2%
n.s.
Fig. 2. Distribution and survival of witnessed and non-witnessed OHCA of presumed cardiac origin with and without a shockable rhythm in the two time periods compared
(2000–2005 vs. 2006–2008). n.s. = non significant.
The multivariate analyses revealed that the time period from
2006 to 2008 was associated with an improved survival to discharge (odds ratio (OR) 1.65), as were witnessed OHCA (OR 2.86),
bystander CPR (OR 1.87) and shockable rhythm (OR 14.76) (Table 3).
On the other hand, increased EMS response time and older age
were associated with reduced odds ratios for survival to discharge
(Table 3).
Based on the last 3 years of the study period, the OHCA incidence
in our region was approximately 38/100,000 inhabitants.
4. Discussion
After the introduction of the 2005 CPR guidelines and implementation of major treatment changes, such as post-resuscitation
TH11 and PCI,12 we experienced a significant improvement in overall survival to discharge (25%) in resuscitation attempts of OHCAs
of presumed cardiac origin in the time period 2006–2008. During the same time period, the proportion of OHCA survivors with
good cerebral outcome (CPC 1–2) increased significantly to 97%.
For the group of OHCA victims with a witnessed arrest and a shockable rhythm, survival to discharge with good cerebral outcome was
obtained in every second resuscitation attempt in the latter period.
Although our study design does not allow a specific analysis of which factors contributed the most, our results indicate a
few possible explanations. The rate of shockable rhythm remained
unchanged throughout the study period, but it was lower than
previously reported7 in our region and therefore cannot explain
the outcomes. This decline in shockable rhythms also matches
other reported results.24 The mean age (70 years) of our patients
remained the same throughout the study period and was slightly
higher than recently reported by others.25,26 Therefore, reduced age
cannot explain the improved survival found in our study.
It has previously been shown that an increase in bystander
CPR leads to an increase in survival to discharge.27,28 The rate of
bystander CPR was 73% in the latter time period in our study. We
think this is a major reason for the improved outcomes. Bystander
CPR may preserve the shockable rhythm until the first defibrillation
and ensure minimal cerebral circulation. The increase in bystander
CPR is most likely the result of ongoing national and local focus
on layperson CPR training.19,20,29 This may be of particular importance, as we noticed increased EMS response times. The increase in
EMS response time is most likely due to a rise in traffic during the
8-year study period.
A higher availability of PADs may have increased the probability
that OHCA victims received early defibrillation. We were not able to
extract specific data on the use of first responder AED or PAD from
our database. This could be considered a limitation to our study.
However, the first responders were considered part of the total EMS
response, and although they may have ensured earlier defibrillation
in some cases, we do not think that this measure alone can explain
the improved outcomes.
The impact of ALS procedures on OHCA survival is still debated.
The first time period examined may have included a short time
period where both the 2000 and the 2005 guidelines were used,
but the second time period included only patients where the 2005
resuscitation guidelines with Norwegian alterations were used.
Positive effects of the 2005 resuscitation guidelines on survival
have been demonstrated in populations from Denmark30 and the
1512
T.W. Lindner et al. / Resuscitation 82 (2011) 1508–1513
United States,31 but were not found in studies from New Zealand26
and Netherlands, France and Norway.32–34 The varying survival
rates reported show the challenge in comparing different EMS
systems with varying response factors and post resuscitation treatments. We do not claim that the increase in survival found in our
study is due to the implementation of the 2005 resuscitation guidelines alone, but acknowledge that a combination of factors most
likely was of importance. Still, the quality of CPR is important during ALS. Minimal hands-off time and correct compression depth
and frequency must be maintained.6 We have previously reported
good quality CPR over time in a simulated OHCA situation35
involving double ambulance crews. The dedication to provide
high-quality CPR may therefore have contributed to the improved
survival.
ROSC rate did not change during the study period but survival
to discharge did. Further, 97% of our surviving patients obtained a
CPC of 1 or 2 in the latter period. This strengthens the likelihood
that changes in post-resuscitation care contributed to the increased
survival. We implemented post-cardiac arrest TH in 2002 and postcardiac arrest PCI in 2004.11,12 The full impact of TH was maybe first
reached in the latter time period of the study, although our study
design made it impossible to determine the exact contribution of
TH or PCI to the improved outcomes in the population as a whole.
Further, some patients with an indication may not have received
the treatments, but previous studies from our system indicate high
implementation rates.11,12
We think that our focus on all parts of the local Chain of Survival,
as suggested by Rea and Lange in their review where they named
this “the community based approach to resuscitation”,36 is what
may have caused the significant improvements.
Similar to other studies, we only used a crude measure of good
cerebral outcome (CPC 1–2).25,37 There may therefore have been
differences in the quality of outcome that this study could not
detect. These aspects of post-resuscitation care should also be
examined further.
6. Conclusion
In this study of OHCA of presumed cardiac origin comparing
the time periods from 2001 to 2005 with 2006 to 2008, the overall survival to discharge increased to 25% in the latter period. In
the 2006–2008 time period, every second resuscitation attempt in
patients with a witnessed arrest and a shockable rhythm resulted in
survival to discharge with good cerebral outcome. Our results support the notion that all aspects of the chain of survival are important
when trying to improve resuscitation outcomes.
Conflicts of interest statement
The authors declare no conflicts of interest.
Acknowledgments
The authors would like to thank Astrid Våga and Kristian Lexow
for their help with data collection, and Svein Arne Hapnes for leading the way as the medical director of the EMS system in the
Stavanger region. We would also like to thank all the paramedics,
nurses, doctors and other allied health professionals at SUH for their
relentless work to further improve survival in cardiac arrest victims
inside and outside the hospital.
5. Limitations
References
There are many limitations to a registry-based study like ours,
including those listed above, regarding the contribution of the various factors to the overall improved overall outcomes. To ensure
data quality, one designated research nurse was continuously collecting and cross-checking data entries from different sources to
reduce uncertainty and missing data.
The calculation of survival to discharge rate depends on the
population used as the denominator. Decreasing the denominator could have inflated the survival rates. However, we only
excluded patients for whom such resuscitation measures as airway
assistance, chest compressions, drug administration, intubation or
defibrillation were not performed. When we compared the way we
excluded resuscitation attempts and patients from our analysis to
the exclusions in similar recent studies, we found no discrepancies
that could explain our more positive results.1,25 The most common
reason for not starting resuscitation was obvious signs of death. Presumed OHCA missions to which the EMS responded, but without
starting resuscitation, may reflect the EDC alarm accuracy and the
caller’s uncertainty. The calculated incidence of 38 OHCA/100,000
inhabitants in our population was slightly lower than previously
reported from this region,7 but is still close to the average for the
Norwegian population.3 A recent meta analysis reported a mean
incidence of 54.6 OHCA/100,000 inhabitants,3 with a standard deviation of 26. Altogether, we see no reason to believe our results are
due to selective reporting.
Due to lack of data, we could not include co-morbidity and
chronic medical treatment as factors in the multivariate analysis.
Because co-morbidity has been shown to be an important factor
related to long-term survival this is an obvious limitation in our
study.7 More studies are needed to fully elucidate the interaction between co-morbidity, possible genetic factors and survival
in OHCA victims.
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