Victorian Ambulance Cardiac Arrest Registry (VACAR)

Transcription

1 Victorian Ambulance Cardiac Arrest Registry (VACAR) Dr Karen Smith (PhD) VACAR Chair Manager Research and Evaluation Ambulance Victoria Smith K, Bray J, Barnes V, Lodder M, Cameron P, Bernard S and Currell A on behalf of the VACAR Steering Committee

2 Ambulance Victoria Provides EMS for state of Victoria (amalgamation of two services MAS and RAV in 2008) pop of 5.4 million Operates a two-tiered emergency medical service (EMS) response for all suspected cardiac arrests 2143 ALS paramedics who are authorised to provide defibrillation, laryngeal mask airway insertion and intravenous administration of epinephrine. 416 intensive care paramedics are authorised to perform endotracheal intubation and administer a range of additional cardiac drugs such as amiodarone and sodium biacarbonate. Response to suspected cardiac arrests also includes fire first responders for inner Melbourne and CERTS (29 teams) in rural areas Cardiac arrest protocols follow the recommendations of the Australian Resuscitation Council Patients with ROSC are transported to the nearest hospital with an emergency department.

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4 VACAR Funded by Victorian Dept Health Classified as Quality Assurance Employs 5 staff including a Senior Research Fellow Overseen by Steering Committee including AV, Medical Directors and Monash University Aims to collect data on all cardiac arrest patients attended by ambulance in Victoria Data collection dates back to 1999

5 Value of Registry Benchmark patient outcomes and ambulance response intervals Describe the epidemiology of out-of-hospital cardiac arrest in Victoria Identify modifiable predictors of outcome and model impact of changes Assist in the analysis of the sensitivity and specificity of the ambulance dispatch protocol Aid in the audit of ambulance patient care record compliance and quality assurance (provide feedback to teams) Monitor trends and impact of new treatment regimes and programs Base-line for clinical trials Aid in monitoring paramedic treatment experience.

6 Registry Cases identified via data filter, manual PCR sort, Team Managers and clinical audits Registry Based on Utstein template and definitions Extracts clinical and operational data from PCRs (AV and Fire) and operational databases Supplemented with hospital discharge data (date, direction, diagnosis) (Ethics approvals from > 100 participating hospitals) Data entry lags 2-3 weeks post event Some coroners data (aetiology) included for discrete projects

7 Quality of Life VACAR has commenced a QOL follow-up on adult patients arresting from Jan 2010 onwards Follow-up at 12-months post arrest Death registry checked prior to contact Built into ongoing DH funding Tools: Residential and work status question GOSE EQ5D SF-12 Discharged patients sent a letter explaining intended follow-up Phoned approx 30 minute interview Outsourced to Monash University- experience and align with VSTR For Jan- Mar 2010: QOL obtained for 84% of discharged adult patients who are alive at 12-months

8 Quality Control Mandatory fields Validation of field combinations Range validations Rhythm confirmation from ECG Monthly retrospective audit (10% cases-random) Targeted retrospective reviews Senior paramedics audit all cases for: Defibrillated patients Death in AV care

9 Data Reasonably Complete All cardiac arrests attended by AV (n=46,388) Key field Missing items (%) Age 1939 (4.2%) Gender 373 (0.8%) Arrest location type 4 Witnessed status 600 (1.3%) Bystander CPR 2719 (5.9%) Outcome at scene 49 (0.1%) Hospital discharge status 592 (1.3%) EMS response time 1352 (2.9%) Presenting rhythm 169 (0.4%)

10 Epidemiology All arrests attended by AV over 10 years ( ) Item Number (%) Total patients 46,399 (range 3,779 5,259 per year) Presumed cardiac aetiology (73.0%) Witnessed By public By paramedics 13,641 (29.4%) 3,065 (6.6%) Male Gender 30,353 (65.6%) Adult arrests (>15 years) 45,520 (98.1%) Median age (IQR) 70 years (28) Arrest at home 34, 125 (73.6%) Resuscitation initiated by EMS 19,911 (42.9%) EMS response time (call to scene): Median 90 th percentile Metropolitan location (74%) 8 16

11 Precipitating event

12 Proportion with resuscitation attempted by EMS (adult patients) Cardiac Trauma Respiratory Overdose Drowning Hanging Other

13 Age cohorts (all OHCA ) Series1, years, 38% Series1, >80 years, 26% Series1, years, 20% Series1, years, 11% Series1, 3-17 years, Series1, <2 years, 1.0% 1.0% Series1, Missing, 3%

14 Arrest Location (all OHCA ) Series1, Home, 73% Series1, Public place, 16% Series1, Nursing home /hostel, 7% Series1, Work, 2% Series1, Medical center, 2%

15 Survival influenced by usual predictors Adult, presumed cardiac, resuscitation attempted by EMS (n= 11,829) Odds ratio P value 95% CI VF/VT 5.76 < Witnessed 2.03 < Bystander CPR 1.34 < Female Year of arrest 1.12 < Age 0.98 < EMS response time 0.90 < Arrest at home 0.62 < Excludes EMS witnessed

16 Survival (adult all aetiologies)

17 Increased survival over the decade Adult, presumed cardiac, resuscitation attempted by EMS Metro survival increased from 7% in 2000 to 13% in 2009, p<0.001 Rural survival increased from 6% in 2000 to 7% in 2009

18 Survival increase predominantly in VF/VT patients Adult, presumed cardiac, VF/VT, resuscitation attempted by EMS Metro survival increased from 14% in 2000 to 34% in 2009, p<0.001

19 VACAR Research Epidemiology All patients 1 Traumatic 2 Urban/rural 3 Age cohorts (paediatric 4, young adult (inc coroners findings), elderly 5 ) Nursing homes, terminally ill EMS witnessed Paediatric hangings 6 Asystolic cardiac arrests 7 Clinical Trials Therapeutic hypothermia by paramedics following resuscitation from VF: RCT 8 Autopulse in rural areas The Rinse Trial. The Rapid Infusion of Normal cold SalinE by paramedics during CPR. NHMRC $678k AVOID- RCT on oxygen in STEMI Treatment / programs Dispatcher CPR 2005 guidelines Fire First Responders 9,10 Sensitivity of AMPDS 11 Impact of hospitals (ICS) Impact of post ROSC BP Environmental Impact of air pollution on OHCA incidence Fridman et al Resuscitation Ashour et al Emerg Med J Jennings et al MJA Deasy et al Resuscitation Deasy et al ResuscittaionJ Deasy et al Emerg Med J In press 7. Meyer et al Emerg Med Bernard et al Circulation Smith et al Resuscitation Smith et al MJA Flynn et al Prehosp Disaster Med Dennekamp et al Epidemiology 2010

20 Conclusion VACAR is one of the largest cardiac arrest registries in the world (currently n>53,000). Data is collected from a single state-wide ambulance service (two services prior to 2008) which reduces heterogeneity. Despite increasing response times, significant improvements in survival have been observed in the metropolitan area of Victoria. Used to benchmark AV and monitor quality of care Currently a significant body of research using VACAR data

21 Acknowledgements Acknowledge the VACAR team Janet Bray Marian Lodder Vanessa Barnes Resmi Nair Devina Vaughan