Prof Gavin Perkins Co-Chair ILCOR
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1 Epidemiology of out of hospital cardiac arrest how to improve survival Prof Gavin Perkins Co-Chair ILCOR Chair, Community Resuscitation Committee, Resuscitation Council (UK)
2 Conflict of interest Commercial nil Academic National Institute for Health Research funding to conduct clinical trials in cardiac arrest BHF / RCUK support for OHCAO registry Co-Chair ILCOR BLS/AED roles (ILCOR, ERC, RCUK) Editor Resuscitation
3 Outline National Out of Hospital Cardiac Arrest Registry Epidemiology of cardiac arrest Chain of survival System approaches to improving survival from cardiac arrest Research, audit and quality improvement
4 National Out of Hospital Cardiac Arrest Outcomes Project
5
6 Perkins GD, Jacobs J, Nadkarni V et al 2015
7
8 Case-mix adjustment
9 Data linkage
10
11 Collaborations
12 28,000 cardiac arrests 25.8% ROSC 7.9% survival to discharge
13
14 Quality of survival 12 months follow-up 12.2% alive (n=851) Smith Circulation 2016
15 Quality of survival Smith Circulation 2016
16 Return to work Cumulative incidence (%) 796 survivors 75% returned to work at a median 4 of months Average length of employment 11 years Kragholm Circulation 2015
17
18 Perkins GD et al, Resuscitation 2015, 95:81-99
19 3 month survival Circulation 2009 Unrecognised P=0.038 Dispatcher
20 Resuscitation Dispatch Arrival Relative change 15 in survival (%) Activation interval Response interval n=2, Absolute difference in time (sec)
21 Seconds Resuscitation 2014 Time to CA recognition 03:39 s (range 00:33 09:40) Time to first chest compression 04:45 s (range 00:24 10:47)
22 Cardiac arrest recognition Unresponsive Not breathing normally Seizures Train bystanders and dispatchers to recognise agonal breathing Perkins Circulation 2015
23 Heart 2017 Unconscious, fitting, choking Normal breathing CPR instructions
24 Heart 2017 Sensitivity (95% CI 0.74 to 0.77) Specificity (95% CI 0.99 to 0.99)
25
26 Before after study Dispatcher bundle Dispatcher training Simplified cardiac arrest recognition Emphasis on time to T-CPR Quality improvement (system and individual)
27 Quality improvement metrics (1) % recognised need for T-CPR (2) % T-CPR instructions (3) % bystander started CPR (4) Time to recognition of CA (5) Time from call to T-CPR instructions (6) Time from call to first compression
28 Adj OR % CI Survival Before Favourable neurological outcome After Adj OR %CI, % Increase T-CPR; Shorter time to T-CPR (42s)
29
30 < % > < % > <4%>
31 Increases chances resuscitation attempted by EMS OR 27.8 (95% CI ) Rajagopal Resuscitation 2016 Increases survival where CPR is attempted by EMS OR 2.44 (95% CI, 1.69 to 3.19) Sasson Circ Cardiovasc Qual Outcomes 2010
32 Bystander CPR 80 % Norway (2008) Seattle 2014 * Norway, cardiac cause arrests
33 All school children are taught CPR and how to use an AED Mrs Sheryll Murray (MP South East Cornwall) (Con): If somebody has a pulse that cannot be detected, or if somebody is breathing very shallowly, someone who comes along and starts to administer CPR could do damage to their health.
34 Everyone who is able to should learn CPR
35 2016: 150,000 children trained
36 JAMA 2015 Community intervention CPR in schools Mass CPR training Dispatcher First responders Legislation AED, CPR in schools Post resuscitation care
37 Survival to discharge 8.4% to 10.5% Favourable neurological outcome 9% to 9.5%
38
39 Bystander CPR rate (%) Adj Diff 14% (95% CI 6 to 21; P< SMS Control NEJM 2015
40 Favourable neurological outcome % >12 Time to shock (min) Blom Circulation 2014
41 < % > < % > <4%>
42 Resuscitation 2015, 303-9
43
44 2% received PAD NEJM 2015
45 Reduced time to first shock by 2 min 39 s compared to EMS Zijlstra et al Resuscitation 2014
46
47 AED locator Contact:
48
49 12 10 Odds ratio = 1.35 (95% CI: 1.05, 1.73) 8 Survival to discharge (%) Zero 1 to 2 3 to 4 5 to 6 7 to 8 > 8 Number EMS providers
50 Skilled teams Cardiac arrests attended in previous 3 years Paramedic exposure to cardiac arrest influences survival Dyson Circ Cardiovasc Qual Outcomes Time since attended last cardiac arrest (months)
51 High quality CPR
52 Avoid interruptions in compressions 319 OHCAs VF/VT Lower odds ratio (OR) for survival per 5 second increase in: Longest overall pause OR 0.85 ( ) Longest peri-shock OR 0.85 ( ) Longest non-shock OR 0.83 ( ) Message: Any pause is bad Brouwer TF Circulation 2015
53 Drilled teams Bobrow et al Ann Emerg Med 62(1), 2013, e1
54 Improved survival 15 Adj OR 2.7 ( ) Adj OR 2.69 ( ) 10 5 Pre Post 0 Survival to discharge Neurologically intact
55 % survival to discharge * * * All Byst witnessed EMS witnessed Unwitnessed Amiodarone Lidocaine Placebo NEJM 2016
56
57 Percentage of patients Percentage of patients Percentage of patients (a) All patients (b) STEMI patients (c) Not a STEMI patients PCI or Thrombolysis Thrombolysis PCI PCI or Thrombolysis Thrombolysis PCI PCI or Thrombolysis Thrombolysis PCI Year Year Year
58 Caterpillar plot for odds ratio of in-hospital mortality (adjusted analysis) Variable (Baseline category) Age (NA) Gender (Female) Geo IMD score (NA) Ethnicity (White) Diabetes (Not diabetic) Smoking status (Never smoked) Hypercholesterolaemia (No) Heart failure (No) Cerebrovascular disease (No) Previous AMI (No) Asthma or COPD (No) Chronic renal failure (No) Peripheral vascular disease (No) Previous angina (No) Previous PCI (No) Previous CABG (No) Hypertension (No) OHCA after ambulance (No) Presenting rhythm (Asystole) Glucose (NA) Haemoglobin level (NA) Cholesterol (NA) Admission diagnosis (Definite MI - anterior infarct) ECG determining treatment (Other acute abnormality or no acute changes) Heart rate (NA) Time of the day (8am to <8pm) Year (NA) EMS response in mins (NA) Place ECG performed (Pre hospital) Distance (NA) Hospital volume (25 82 cases) Hospital PCI capability (PCI incapable) Reperfusion treatment w ith time (None) Admission w ard (Cardiac care unit) Admitting consultant (Other consultant) Category NA Male NA Asian Black Other Diabetic Ever smoked Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes PEA VF/pulseness VT NA NA NA Other diagnosis Definite MI other infarct site ST segment elevation or Left bundle branch block ST segment depression T w ave changes only NA 8pm to <8am Slope (2003 to 2008) Slope (2009 to 2015) NA In hospital NA 0 10 cases cases PCI capable Thrombolysis (performed early) Thrombolysis (performed late) Thrombolysis (time missing) PCI (performed early) PCI (performed late) PCI (time missing) Intensive therapy unit General ward or other Cardiac w ard non CCU Cardiologist EMS witnessed Shockable rhythms PCI capable centre Time to PCI (Predominantly STEMI) Odds ratio
59 61
60
61 UK-ROC Epidemiology and outcome Clinical Quality Improvement Observational studies Randomised controlled trials developing knowledge and capacity to save lives 63
62 UK-ROC developing knowledge and capacity to save lives
63 Summary 28k cardiac arrests less than 1 in 10 survive System wide approaches early in Chain of Survival likely to have greatest impact Dispatcher, CPR, Defibrillation Drive for excellence Research, audit, quality improvement
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