One-year survival after prehospital cardiac arrest: The Utstein style applied to a rural-suburban system

doi:10.1016/0735-6757(94)90190-2

The American Journal of Emergency Medicine

Volume 12, Issue 1, January 1994, Pages 17-20

https://doi.org/10.1016/0735-6757(94)90190-2 Get rights and content

Abstract

To evaluate the recently published Utstein algorithm (Ann Emerg Med 1991;20:861), the authors conducted a retrospective review of all advanced life support (ALS) trip sheets and hospital records of patients with prehospital cardiac arrests between January 1988 and December 1989. Telephone follow-up was used to determine 1-year survival rates. Of 713 arrests in the 24-month study period, 601 were of presumed cardiac etiology. Approximately 599 of these charts were available for analysis. One hundred ninety-three (32.2%) of these had return of spontaneous circulation (ROSC), 36 (6.0%) survived to hospital discharge, and 24 were alive at 1-year follow-up (4.0% of total or 67% of survivors to discharge). The Utstein style was found to be a useful algorithmic format for reporting prehospital cardiac arrest data in a manner that should allow direct comparison between emergency medical service (EMS) systems. Existing prehospital record-keeping practices (trip sheets) are easily adapted to this style of data collection, although certain data for the template (eg, resuscitations not attempted and alive at 1-year) are more difficult to ascertain. Additionally, the authors report their own experience during a 2-year period, including data that suggest that the majority of patients with cardiac arrest who survive to hospital discharge are still alive at 1 year.

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Cited by (39)

Long-term outcomes after out-of-hospital cardiac arrest: A systematic review and meta-analysis
2022, Resuscitation
Long term outcomes after out-of-hospital cardiac arrest (OHCA) are not well understood. This study aimed to evaluate the long-term (1-year and beyond) survival outcomes, including overall survival and survival with favorable neurological status and the quality-of-life (QOL) outcomes, among patients who survived the initial OHCA event (30 days or till hospital discharge).
Embase, Medline and PubMed were searched for primary studies (randomized controlled trials, cohort and cross-sectional studies) which reported the long-term survival outcomes of OHCA patients. Data abstraction and quality assessment was conducted, and survival at predetermined timepoints were assessed via single-arm meta-analyses of proportions, using generalized linear mixed models. Comparative meta-analyses were conducted using the Mantel-Haenszel Risk Ratio (RR) estimates, using the DerSimonian and Laird model.
67 studies were included, and among patients that survived to hospital discharge or 30-days, 77.3% (CI = 71.2–82.4), 69.6% (CI = 54.5–70.3), 62.7% (CI = 54.5–70.3), 46.5% (CI = 32.0–61.6), and 20.8% (CI = 7.8–44.9) survived to 1-, 3-, 5-, 10- and 15-years respectively. Compared to Asia, the probability of 1-year survival was greater in Europe (RR = 2.1, CI = 1.8–2.3), North America (RR = 2.0, CI = 1.7–2.2) and Oceania (RR = 1.9, CI = 1.6–2.1). Males had a higher 1-year survival (RR:1.41, CI = 1.25–1.59), and patients with initial shockable rhythm had improved 1-year (RR = 3.07, CI = 1.78–5.30) and 3-year survival (RR = 1.45, CI = 1.19–1.77). OHCA occurring in residential locations had worse 1-year survival (RR = 0.42, CI = 0.25–0.73).
Our study found that up to 20.8% of OHCA patients survived to 15-years, and survival was lower in Asia compared to the other regions. Further analysis on the differences in survival between the regions are needed to direct future long-term treatment of OHCA patients.
Variation in out-of-hospital cardiac arrest resuscitation and transport practices in the Resuscitation Outcomes Consortium: ROC Epistry-Cardiac Arrest
2011, Resuscitation
Citation Excerpt :
Out-of-hospital cardiac arrest (OOHCA) is a major cause of death in North America.1–4 Witnessed events, bystander initiated cardiopulmonary resuscitation (CPR), presenting rhythm of ventricular fibrillation, arrest location and the prehospital return of spontaneous circulation (ROSC) have all been associated with increased survival.1,5–18 Assessments of incidence and outcome also indicate community-level variation as a significant factor in EMS treatment and survival from OOHCA.1,6,19
To identify variation in patient, event, and scene characteristics of out-of-hospital cardiac arrest (OOHCA) patients assessed by emergency medical services (EMS), and to investigate variation in transport practices in relation to documented prehospital return of spontaneous circulation (ROSC) within eight regional clinical centers participating in the Resuscitation Outcomes Consortium (ROC) Epistry–Cardiac Arrest.
OOHCA patient, event, and scene characteristics were compared to identify variation in treatment and transport practices across sites. Findings were adjusted for site and standard Utstein covariates. Using logistic regression, these covariates were modeled to identify factors related to the initiation of transport without documented prehospital ROSC as well as survival in these patients. Setting: Eight US and Canadian sites participating in the ROC Epistry–Cardiac Arrest. Population: Persons ≥20 years with OOHCA who (a) received compressions or shock by EMS providers and/or received bystander AED shock or (b) were pulseless but received no EMS compressions or shock between December 2005 and May 2007.
23,233 OOHCA cases were assessed by EMS in the defined period. Resuscitation (treatment) was initiated by EMS in 13,518 cases (58%, site range: 36–69%, p < 0.0001). Of treated cases, 59% were transported (site range: 49–88%, p < 0.0001). Transport was initiated in the absence of documented ROSC for 58% of transported cases (site range: 14–95%, p < 0.0001). Of these transported cases, 8% achieved ROSC before hospital arrival (site range: 5–21%, p < 0.0001) and 4% survived to hospital discharge (site range: 1–21%, p < 0.0001). In cases with transport from the scene initiated after documented ROSC, 28% survived to hospital discharge (site range: 18–44%, p < 0.0001).
Initiation of resuscitation and transport of OOHCA and the reporting of ROSC prior to transport markedly varies among ROC sites. This variation may help clarify reported differences in survival rates among sites and provide a target for identifying EMS practices most likely to enhance survival from OOHCA.
A comprehensive investigation of cardiac arrest before and after arrival of emergency medical services
2010, Resuscitation
Citation Excerpt :
A few studies have reported demographic trends and survival in patients who arrested after arrival as their primary objective.7–14 Additionally, other studies have reported data on patients who arrested after arrival secondary to other purposes.15–27 Like our study, most of these papers reported around 10% of all cardiac arrests occurred after arrival of EMS, though proportions varied from less than 5% in Ketchikan, Alaska20 and Alachua County, Florida,25 to over 30% on San Juan Island, Washington.15
Many of the factors that affect survival from out-of-hospital cardiac arrest are not relevant in patients who arrest after arrival of emergency medical services (EMS). Because all arrests that occur after arrival of EMS are witnessed and care is immediate, one might expect survival to be very high. Several studies have described communities’ experiences of arrest after arrival but few have compared survival rates stratified by rhythm and witness status. The purpose of this paper was to describe the characteristics of patients who arrested after arrival of EMS and to compare survival in this population to those who had witnessed and unwitnessed arrests before EMS arrival.
We conducted a retrospective cohort study in King County, WA, USA. Descriptive statistics were calculated in patients whose arrests were not witnessed, in patients whose arrests were witnessed by citizens, and in those whose arrests were witnessed by EMS personnel.
The majority of bystander- and EMS-witnessed arrests were initially in ventricular fibrillation (VF), but EMS-witnessed arrests were more likely to initially have been in pulseless electrical activity (PEA) than bystander-witnessed events. Patients whose arrests were witnessed by EMS had the greatest likelihood of survival compared to patients whose arrests were not witnessed or were witnessed by bystanders. Patients whose arrests were witnessed by EMS and were initially in VF had the highest rates of survival (59%).
Patients whose arrests were witnessed by EMS were more likely to have survived their cardiac arrests than those who arrested before EMS arrived. We suggest that survival rates from VF arrests that occur after EMS arrival should be widely reported in order to measure overall EMS performance since many factors such as response times, bystander actions, and witness status are equalized in this subset of patients.
Epidemiology of Sudden Cardiac Death: Clinical and Research Implications
2008, Progress in Cardiovascular Diseases
The current annual incidence of sudden cardiac death in the United States is likely to be in the range of 180 000 to 250 000 per year. Coinciding with the decreased mortality from coronary artery disease, there is evidence pointing toward a significant decrease in rates of sudden cardiac death in the United States during the second half of the 20th century. However, the alarming rise in prevalence of obesity and diabetes in the first decade of the new millennium both in the United States and worldwide, would indicate that this favorable trend is unlikely to persist. We are likely to witness a resurgence of coronary artery disease and heart failure, as a result of which sudden cardiac death will have to be confronted as a shared and indiscriminate, worldwide public health problem. There is also increasing recognition of the fact that discovery of meaningful and relevant risk stratification and prevention methodologies will require careful prospective community-wide analyses, with access to large archives of DNA, serum, and tissue that link with well-phenotyped databases. The purpose of this review is to summarize current knowledge of sudden cardiac death epidemiology. We will discuss the significance and strengths of community-wide evaluations of sudden cardiac death, summarize recent observations from such studies, and finally highlight specific potential predictors that warrant further evaluation as determinants of sudden cardiac death in the general population.
The Changing Epidemiology of Ventricular Arrhythmias
2008, Cardiology Clinics
Investigations of the impact of ventricular arrhythmias in populations have focused primarily on two aspects, ventricular ectopic activity and sudden cardiac death (SCD). The observation that coronary heart disease (CHD) is an important background of death due to ventricular tachyarrhythmia (VTA) remains the dominant belief today. The evidence supports the principle that reduction of deaths due to VTA is multifactorial and results from improved primary prevention, treatment of CHD complications, and secondary prevention. Recent evidence for unfavorable trends for SCD and CHD mortality raises the specter of a reversal in the gains made against fatal VTA in recent decades.
Public health impact of full implementation of therapeutic hypothermia after cardiac arrest
2008, Resuscitation
Citation Excerpt :
However, some studies define ROSC as a spontaneous pulse upon hospital arrival.14,18 The percent of patients with OHCA reported to have ROSC varies from 13 to 33%.12,18–21 We used 20% as our base case estimate and varied ROSC from 10 to 30% in the sensitivity analysis.
Induced hypothermia improves outcomes in patients resuscitated successfully after cardiac arrest due to ventricular fibrillation. However, a minority of US physicians currently use the therapy. The aim of this study was to project the public health impact of implementing hypothermia in all eligible US out-of-hospital cardiac arrest (OHCA) survivors.
The number of OHCA patients expected to have a good outcome after hypothermia was calculated using a linear model. Literature-derived input variables included OHCA incidence rates and US 2000 census data, percent with return to spontaneous circulation (ROSC), percent eligible for hypothermia, and the expected benefit from hypothermia. Sensitivity analyses were performed to calculate a plausible range around the reference case.
An additional 2298 US patients per year are expected to have a good neurological outcome if US physicians implement hypothermia fully in comatose survivors of OHCA. The two-way sensitivity analyses found that this number ranged from 766 to 5171 patients. This model is similarly sensitive to varying the incidence of OHCA, percent with ROSC, percent of patients eligible for hypothermia, and the number needed to treat.
If US physicians adopt therapeutic hypothermia fully in eligible patients with OHCA, 2298 additional patients per year would be expected to achieve a good neurological outcome, a substantial public health impact. Barriers to adoption should be researched and addressed to increase acceptance and use by US physicians.

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^☆: Presented in poster format at the Society for Academic Emergency Medicine Annual Meeting, Toronto, May, 1992 and the Pennsylvania Chapter, American College of Emergency Physicians Scientific Assembly, Philadelphia, April, 1992.

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Original contributionOne-year survival after prehospital cardiac arrest: The Utstein style applied to a rural-suburban system☆

Abstract

Ann Emerg Med

Ann Emerg Med

Soc Sci Med

Ann Emerg Med

Am J Emerg Med

Ann Emerg Med

JACEP

Am J Med

Am Heart J

Ann Emerg Med

Lancet

Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: The Utstein Style

Ann Emerg Med

Original contribution
One-year survival after prehospital cardiac arrest: The Utstein style applied to a rural-suburban system☆