Can Bystander Interventions Improve Outcomes From Out-of-Hospital Cardiac Arrest?

Following a statewide educational initiative in North Carolina focused on intervention and resuscitation training, the proportion of patients receiving a combination of bystander-initiated cardiopulmonary resuscitation (CPR) and defibrillation by first responders increased, according to a study published July 21 in the Journal of the American Medical Association (JAMA). This increase was linked with a greater likelihood of survival. Additionally, increased rates of bystander-initiated CPR were associated with a greater chance for favorable neurological outcome.

The study observed 4,961 patients on whom resuscitation was attempted following out-of-hospital cardiac arrest. The patients were identified through the Cardiac Arrest Registry to Enhance Survival (2010 – 2013), and first responders included dispatched police officers, firefighters, rescue squad members or a life-saving crew trained to perform basic life support until arrival of the EMS.

Sweeping positive results were observed as a result of North Carolina’s statewide educational initiative. For the whole study period, a total of 86.3 percent of patients received CPR before EMS arrival – 45.7 percent by bystanders and 40.6 percent by first responders. The combination of bystander CPR and first-responder defibrillation increased from 14.1 percent in 2010 to 23.1 percent in 2013. In the same time frame, survival with favorable neurological outcome increased from 7.1 percent to 9.7 percent; this increase was also associated with bystander initiated CPR. The increased numbers of bystander and first-responder interventions were also associated with higher survival to hospital discharge. Survival following EMS-initiated CPR and defibrillation was 15.2 percent compared to 33.6 percent following bystander-initiated CPR and defibrillation, 24.2 percent following bystander CPR and first-responder defibrillation and 25.2 percent following first-responder CPR and defibrillation.

Similar observations were reflected in the findings of a separate study based in Japan, also published July 21 in JAMA. The study demonstrated that between 2005 and 2012, the rates of bystander chest compression and bystander defibrillation increased. These increased rates were associated with increased odds of neurologically intact survival.

The study was a retrospective descriptive study and used data from Japan’s nationwide out-of-hospital cardiac arrest (OHCA) registry. Researchers recorded the characteristics, prehospital interventions and outcomes of 167,912 patients who suffered bystander-witnessed OHCA of presumed cardiac origin between January 2005 and December 2012.

While the number of bystander-witnessed OHCAs of presumed cardiac origin increased from 17,882 to 23,797, the neurologically intact survival rate also increased from 587 cases to 1710 cases. There were significant observable increases in bystander chest compression, bystander-only defibrillation, bystander defibrillation combined with EMS defibrillation, in addition to a 3.1 percent decrease in EMS-only defibrillation. Performance of bystander chest compression, when compared with no bystander chest compression, was associated with increased neurologically intact survival.

The authors note that moving forward, physicians and researchers alike should recognize the benefits of increased education for professionals and bystanders on intervention and resuscitation techniques. Such initiatives have shown positive impact on patients suffering from cardiac arrest, particularly those suffering from this affliction away from hospital grounds.

“Despite increased knowledge and use of bystander CPR as well as improved survival over time, ongoing efforts are needed to improve outcomes after OHCA,” write Graham Nichol, MD, MPH, and Francis Kim, MD, FACC, of the University of Washington, Seattle, WA, in an editorial comment on the two studies. “Mortality after resuscitation from cardiac arrest continues to be high in many communities. Further improvements in outcomes will require additional coordinated efforts to improve resuscitation care,” they note.

They add that the Institute of Medicine recently released a report that describes multiple steps to improve outcomes after cardiac arrest. “Key recommendations of this report include simple, sustainable high-quality efforts to measure and improve the process and outcome of care, as well as increased training of EMS personnel and leadership and funding for resuscitation research. The current studies … demonstrate the potential benefit these changes can have on resuscitation outcomes. Lay persons can improve outcomes after cardiac arrest in their community by participating in their system of care as well as supporting increased measurement and resuscitation research,” they explain. 

Clinical Topics: Arrhythmias and Clinical EP, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias

Keywords: Cardiopulmonary Resuscitation, Electric Countershock, Heart Arrest, National Academies of Science, Engineering, and Medicine, U.S., Health and Medicine Division, Japan, Leadership, Out-of-Hospital Cardiac Arrest, Registries, Retrospective Studies, Survival Rate

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