Quality of on-site performance in prehospital advanced cardiac life support (ACLS)

doi:10.1016/0300-9572(94)90034-5

Resuscitation

Volume 27, Issue 3, May 1994, Pages 207-213

https://doi.org/10.1016/0300-9572(94)90034-5 Get rights and content

Abstract

The aim of our prospective study was to assess the structural and procedural quality of an urban emergency medical services (EMS) system providing prehospital basic and advanced cardiac life support (BLS/ACLS), to compare the onsite performance of physicians and non-physicians in ECG diagnosis and defibrillation, and to identify incidence and causes of avoidable delays in the initial treatment sequences. Methods: Between 1 February 1991 and 1 July 1992, 162 on-line tape recordings of prehospital cardiopulmonary resuscitation (CPR) efforts performed by the staff of the EMS system of the city of Mainz were evaluated. After arrival at the patient's side, time intervals to initial ACLS steps (first ECG-diagnosis, first defibrillation, endotracheal intubation, first epinephrine administration) were measured. Times to rhythm identification and countershock by EMT-Ds vs. physicians were compared (Mann-Whitney U-test). Time intervals are presented as median values. One-hundred sixty-two adult patients with out-of-hospital cardiac arrests (ventricular fibrillation [VF] or ventricular tachycardia [VT], 72; asystole or electromechanical dissociation [EMD], 90) receiving CPR by EMTs, EMT-Ds, and physicians of the Mainz EMS were included. Patients with arrests due to non-cardiac aetiologies were excluded. Results: After arrival at the patient's side, for patients with VF/VT, the EMT-Ds took 1:36 min and the physicians took 1:00 min to obtain the first ECG diagnosis (P = 0.004). The first countershock was delivered within 1:42 min by both EMT-Ds and physicians of the mobile intensive care unit (MICU). After diagnosis was established, the EMT-Ds took 0:08 min to defibrillate, whereas the physicians took 0:36 min (P = 0.0001). Endotracheal intubation was performed within 3:30 min, and epinephrine was administered within 3:56 min. In patients with asystole or EMD, the first ECG-diagnosis was obtained within 0:48 min by both EMT-Ds and physicians. Patients were intubated within 2:44 min, and received epinephrine within 3:24 min. Conclusions: Since there is no consensus yet about the methods of EMS evaluation and comparison of ACLS time intervals, reliable reference data are lacking. Yet we found that in cases of VF/VT, physicians equipped with manual defibrillators obtain the diagnosis earlier than EMT-Ds equipped with semi-automatic devices, but deliver the first shock later. Another delay manifested itself in cases of asystole or EMD, between ECG-diagnosis and intubation or epinephrine administration. Possible causes for such delays in ACLS sequences are problems in communication between physicians and EMTs. As a result of this study, our EMS system has implemented rehearsals of taped real codes in our megacode training.

References (20)

O. Braun
EMS system performance: the use of cardiac arrest timelines
Ann Emerg Med
(1993)
M.S. Eisenberg et al.
Survival rates from out-of-hospital cardiac arrest: recommendations for uniform definitions and data to report
Ann Emerg Med
(1990)
L.F. Vukov et al.
New perspectives on rural EMT defibrillation
Ann Emerg Med
(1988)
L.B. Becker et al.
Outcome of CPR in a large metropolitan area — where are the survivors?
Ann Emerg Med
(1991)
K. Bradley
Use of a cassette recorder for data collection in prehospital cardiac arrest research
Ann Emerg Med
(1993)
D.A. Chamberlain et al.
Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the “Utstein style”
Resuscitation
(1991)
A. Donabedian
The quality of care. How can it be assessed?
J Am Med Assoc
(1988)
American Heart Association
Standards and guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC)
J Am Med Assoc
(1986)
A. Mullie et al.
Influence of time intervals on outcome of CPR
Resuscitation
(1989)
R.O. Cummins et al.
Improving survival from sudden cardiac arrest: the “chain of survival” concept
Circulation
(1991)

There are more references available in the full text version of this article.

Cited by (30)

European Resuscitation Council Guidelines for Resuscitation 2010 Section 4. Adult advanced life support
2010, Resuscitation
Citation Excerpt :
Some countries have adopted almost exclusively paramedic/emergency medical technician (EMT)-based systems while other incorporate prehospital physicians to a greater or lesser extent. In adult cardiac arrest, physician presence during resuscitation, compared with paramedics alone, has been reported to increase compliance with guidelines183,184 and physicians in some systems can perform advanced resuscitation procedures more successfully.183,185–188 When compared within individual systems, there are contradictory findings with some studies suggesting improved survival to hospital discharge when physicians are part of the resuscitation team189–192 and other studies suggesting no difference in short- or long-term survival.183,189,191,193–199
Part 12: Education, implementation, and teams: 2010 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations
2010, Resuscitation
Citation Excerpt :
In adult cardiac arrest (prehospital), does the performance of advanced life support procedures by experienced physicians, as opposed to standard care (without physicians), improve outcomes (e.g., ROSC, survival)? In adult cardiac arrest, physician presence during resuscitation, compared with paramedics alone, has been reported to increase compliance with guidelines (LOE 2307; LOE 4308) and physicians in some systems can perform advanced resuscitation procedures more successfully (LOE 2307,309; LOE 4310–312). When compared within individual systems, four studies suggested improved survival to hospital discharge when physicians were part of the resuscitation team (LOE 2313,314; LOE 3315,316) and 10 studies suggested no difference in survival of the event (LOE 2)307,313 or survival to hospital discharge (LOE 2)307,315,317–323.
Out-of hospital advanced life support with or without a physician: Effects on quality of CPR and outcome
2009, Resuscitation
Citation Excerpt :
A retrospective registry study found both intubation and intravenous drug treatment to be independent predictors of poor outcome in out-of-hospital cardiac arrest,3 and there is concern that current ALS protocols might be too complicated in the typical chaotic and stressful out-of-hospital setting. Previous studies have reported that physicians are more efficient in managing procedures such as ECG analysis and endotracheal intubation,20,21 and are more likely to comply with treatment guidelines than other ambulance personnel.22 We found that CPR quality measures such as hands-off ratio and pre-shock pauses were improved when treated by the physician-manned ambulance, and the frequency of endotracheal intubation was higher.
The presence of physicians is believed to facilitate optimal management of out-of-hospital cardiac arrest, but has not been sufficiently documented.
Adult non-traumatic cardiac arrests treated by Oslo EMS between May 2003 and April 2008 were prospectively registered. Patients were categorized according to being treated by the physician-manned ambulance (PMA) or by regular paramedic-manned ambulances (non-PMA). Patient records and continuous electrocardiograms (ECGs) with impedance signals were reviewed. Quality of cardiopulmonary resuscitation (CPR) and clinical outcomes were compared.
Resuscitation was attempted in 1128 cardiac arrests, of which 151 treated by non-PMA and PMA together were excluded from comparative analysis. Of the remaining 977 patients, 232 (24%) and 741 (76%) were treated by PMA and non-PMA, respectively. The PMA group was more likely to have bystander witnessed arrests and initial VF/VT, and received better CPR quality with shorter hands-off intervals and pre-shock pauses, and having a greater proportion of patients being intubated. Despite uneven distribution of positive prognostic factors and better CPR quality, short-term and long-term survival were not different for patients treated by the PMA vs. non-PMA, with 34% vs. 33% (p = 0.74) achieving return of spontaneous circulation (ROSC), 28% vs. 25% (p = 0.50) being admitted to ICU and 13% vs. 11% (p = 0.28) being discharged from hospital, respectively.
Survival after out-of-hospital cardiac arrest was not different for patients treated by the PMA and non-PMA in our EMS system.
Time to give the first medication during resuscitation in out-of-hospital cardiac arrest
2006, Resuscitation
There is no evidence showing an impact from any advanced cardiac life support (ACLS) medications on patient survival following cardiac arrest. One potential reason for a lack of such benefit may be medication timing. We formed the hypothesis that medications are given late after rescuer arrival, limiting any benefit. We performed a meta-analysis to determine the time from emergency medical services (EMS) dispatch to first medication administration, regardless of route, during out-of-hospital cardiac arrest (OOHCA). Then, the mean time and ranges of reported study medication delivery in clinical trials where medication was the experimental intervention was determined.
We conducted a comprehensive literature review between January 1990 and August 2005 in MEDLINE using the following MeSH headings: cardiopulmonary resuscitation, cardiac arrest, heart arrest, EMS, EMT, ambulance, and the names of all ACLS medications. We reviewed the abstracts of 632 studies and full manuscripts of 248 published papers. We eliminated the following articles from further analysis: non-peer reviewed; all without human primary data (includes review articles, guidelines or consensus manuscripts, editorials, or simulation studies); animal data; case reports. We used no language restriction. From this search, our independent reviewers found 17 papers that contained information on time to medication administration.
We analyzed reporting of drug delivery time to 7617 patients in 32 different emergency medical services systems. Time to first medication delivery by any route was a mean of 17.7 min (range 10.0–25.0; 95% CI around mean 10.6, 24.8). Time to intravenous experimental medication administration was a mean of 19.4 min (range 13.3–25.0; 95% CI around mean 12.8, 25.9).
Medications are given late during out-of-hospital cardiac arrest, even in cohorts where drug delivery is a key study intervention.
Incidence of EMS-treated out-of-hospital cardiac arrest in Europe
2005, Resuscitation
The potential impact of efforts in Europe to improve survival from out-of-hospital cardiac arrest is unclear, in part, because estimates of incidence and survival are uncertain. The aim of the investigation was to determine a representative European incidence and survival from cardiac arrest in all-rhythms and in ventricular fibrillation treated by the emergency medical services (EMS).
We used Medline to identify peer-reviewed articles published between 1 January 1980 and 30 June 2004 that reported a European community's EMS cardiac arrest experience. Inclusion criteria required the study to include at least 25 cases, report of the total number of all-rhythm and/or ventricular fibrillation arrests, and information about population size and study duration. The incidence was computed by dividing the total number of events by the product of the community's population and the study duration.
Reports from 37 communities met the inclusion criteria. A total of 18,105 all-rhythm EMS-treated cardiac arrests occurred during 48 million person-years of observation, resulting in an overall incidence for all-rhythm arrests of 37.72 per 100,000 person-years. Incidence of ventricular fibrillation arrest was 16.84 per 100,000 person-years. Survival was 10.7% for all-rhythm and 21.2% for ventricular fibrillation cardiac arrest. Applying these results to the European population, approximately, 275,000 persons would experience, all-rhythm cardiac arrest treated by the EMS with 29,000 persons surviving to hospital discharge.
The results provide a framework to assess opportunities and limitations of EMS care with regard to the public health burden of cardiac arrest in Europe.
Estimating the effect of bystander-initiated cardiopulmonary resuscitation in Japan
2001, Resuscitation
Low incidence of bystander-initiated cardiopulmonary resuscitation (CPR) is allegedly responsible for poor survival from out-of-hospital cardiac arrest (OHCA) in Japan. This study was conducted to determine significant predictors for survival after collapse-witnessed OHCA of presumed cardiac etiology to investigate the impact of bystander-initiated CPR. Logistic regression analysis of OHCA of presumed cardiac etiology was performed on retrospective data sets from three Japanese suburban communities. All arrest incidents were witnessed and occurred prior to the arrival of EMS personnel. Outcome measure was survival to discharge. Initial electrocardiogram (ECG) rhythm (ventricular fibrillation (VF) or not), interval from collapse to CPR (within 5 min or not), and initial ECG rhythm/collapse-to-CPR interval interaction were significantly associated with survival. Patient age (70 years or less/over 70 years), interval from collapse to EMS response, and bystander-initiated CPR were significantly associated with VF in an initial ECG. The effectiveness of bystander-initiated CPR for OHCA can be successfully predicted based on the interval from collapse to CPR and initial ECG rhythm. The increase in the proportion of bystander-initiated CPR from the present level of 20–50% would be expected to rescue another 1800 victims of OHCA per year in Japan.
A baixa incidência de reanimação cardio pulmonar (RCP) praticada por testemunhas presenciais, é alegadamente responsável pela baixa taxa de recuperação da paragens cardı́acas extra hospitalares (PCEH) no Japão. Este estudo foi desenhado para identificar factores de prognóstico relativos ás PCEH testemunhadas e o impacto que nelas tem a RCP iniciada pelas testemunha. Fez-se uma análise por regressão logı́stica das PCEH de etiologia presumivelmente cardı́aca a partir dos registos retrospectivos de três comunidades suburbanas japonesas. Todas as paragens tinham sido testemunhadas e ocorreram antes da chegada do pessoal dos serviços de emergência médica (SEM). Avaliou-se a sobrevida à data da alta. Verificou-se que o prognóstico foi fortemente influenciado pelo ritmo inicial (fibrilhação ventricular ou não), pelo intervalo de tempo do colapso ao inı́cio de SBV (maior ou menor do que cinco minutos) e pela relação entre o ritmo inicial/inı́cio da interacção colapso/SBV. A idade das vı́timas (70 anos ou menos/mais de 70 anos), o intervalo decorrido do colapso à chegada dos SEM e o inı́cio da reanimação pela testemunha relacionaram-se significativamente com a presença de VF como ritmo inicial. A eficácia da reanimação feita pela testemunha nas PCEH pode ser predita com base na avaliação do intervalo decorrido do colapso ao inı́cio de SBV e a existência de FV como ritmo inicial. Prevê-se que o aumento da actual percentagem de reanimações iniciadas pelas testemunhas das PCEH 20–50% poderia contribuir para salvar 1800 vı́timas de PCEH por ano no Japão.

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Quality of on-site performance in prehospital advanced cardiac life support (ACLS)

Abstract

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Resuscitation

The quality of care. How can it be assessed?

J Am Med Assoc

Standards and guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC)

J Am Med Assoc

Influence of time intervals on outcome of CPR

Resuscitation

Improving survival from sudden cardiac arrest: the “chain of survival” concept

Circulation