Bystander and First-Responder Intervention After Cardiac Arrest

Study Questions:

Did statewide initiatives to improve bystander and first-responder efforts in North Carolina affect survival and neurological outcome after out-of-hospital cardiac arrest (OHCA)?


The Cardiac Arrest Registry to Enhance Survival was used to identify 4,961 individuals with OHCA for whom resuscitation was attempted between 2010 and 2013. Statewide initiatives to improve bystander and first-responder interventions included training members of the general population in cardiopulmonary resuscitation (CPR) and in use of automated external defibrillators (AEDs), training first responders in team-based CPR including AED use and high-performance CPR, and training dispatch centers in recognition of cardiac arrest. First responders were dispatched police officers, firefighters, rescue squad, or life-saving crew trained to perform basic life support until arrival of the emergency medical service (EMS).


The combination of bystander CPR and first-responder defibrillation increased from 14.1% in 2010 to 23.1% in 2013 (p < 0.01). Survival with favorable neurological outcome increased from 7.1% to 9.7% over the same time period (p = 0.02), and was associated with bystander-initiated CPR. Bystander and first-responder interventions were associated with higher survival to hospital discharge. Survival following EMS-initiated CPR and defibrillation was 15.2% compared with 33.6% following bystander-initiated CPR and defibrillation, 24.2% following bystander CPR and first-responder defibrillation, and 25.2% following first-responder CPR and defibrillation.


More patients received bystander-initiated CPR and defibrillation by first responders after a statewide initiative. This was associated with greater likelihood of survival. Bystander-initiated CPR was associated with increased survival and favorable neurological outcomes.


Putting all potential confounders aside, the authors of this study offer a cogent argument that initiatives to improve rates of CPR and defibrillation in the community will save lives and lessen the disability. Similar findings were noted in another article in the same issue of JAMA from Japan. Despite the major improvements demonstrated in both studies, the penetration of chest compression CPR and defibrillation in many communities remains dismally low. I would speculate that there are few areas in the US health care system with a greater potential for improvement. The recent Institute of Medicine report, titled “Strategies to Improve Cardiac Arrest Survival: A Time to Act” (, offers eight evidence-based recommendations to improve the treatment of cardiac arrest in the United States. It should become our to-do-list. We must engage the public and the policy makers to give cardiac arrest the attention it demands.

Clinical Topics: Arrhythmias and Clinical EP, Prevention, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Arrhythmias, Cardiac, Cardiopulmonary Resuscitation, Defibrillators, Implantable, Electric Countershock, Emergency Medical Services, Heart Arrest, Out-of-Hospital Cardiac Arrest, Resuscitation, Secondary Prevention, Survival

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