Clinical paperEpidemiology and outcomes from out-of-hospital cardiac arrests in England☆
Introduction
Each year 60,000 people sustain an out-of-hospital cardiac arrest (OHCA) in England,1, 2 for whom resuscitation is attempted in less than half.3 Internationally, cardiac arrest survival rates vary widely from 0.6% to 25%,4, 5 and in the United Kingdom (UK) rates are much worse than in the best performing Emergency Medical Services (EMS) systems. Doubling the reported UK survival rates to a level comparable with the best performing systems could save 1000 lives a year.6
Improving links in the cardiac arrest chain of survival can improve outcomes,7 particularly the early links in this chain. Interventions known to improve survival include, improving early recognition and calling for help from EMS (link 1), bystander cardiopulmonary resuscitation (CPR) (link 2) and the use of public access defibrillation (PAD) (link 3).8 By definition, these interventions mean increasing the proportion of the population with skills to provide them. The impact of such interventions with regional, or even national populations occurs incrementally over time and can occur in different locations at different times, depending on who is organising and delivering improvement strategies e.g. voluntary sector or public sector organisations, and the level of national or local policy support. Demonstrating the scale and rate of improvement warrants baseline measurement as well as measurement over time of both the proportions of OHCA patients experiencing process outcomes (such as bystander CPR) and clinical outcomes (such as survival). Comprehensive measurement nationally, using clearly defined outcome measures enables evaluation of the impact of both national and local initiatives. Comparison with systems outside the UK is also possible.
Other regional and national OHCA registries have successfully provided such measurement data.9 They have been used to evaluate national initiatives (e.g. Denmark,10 Sweden11 and USA12) demonstrating the value of regional and national interventions to improve outcome from cardiac arrest (e.g. mandating CPR training in schools and for people taking a driving test).
Beyond OHCA survival outcomes in England,13 little is known about patient demographics, event characteristics, process variables and treatments administered. The Out-of-Hospital Cardiac Arrest Outcomes (OHCAO) project aimed to establish a national registry including detailed process and clinical outcomes relevant to all links in the chain of survival, to facilitate research and quality improvement in OHCA.14
This study reports the 2014 data from England as a baseline for future reference, summarising patient characteristics, processes and outcomes for OHCA.
Section snippets
Setting and population
This analysis is based on OHCA events that occurred between 1st January 2014 and 31st December 2014 in 10 English ambulance service (EMS) regions, which together serve a population of approximately 54 million in England. One small service providing emergency care for an island (Isle of Wight, population 139,105 inhabitants) did not submit data. The registry covered 99.74% of the 2014 population of England and 83.87% of the UK population.15 OHCA patients of all ages with resuscitation commenced
Results
Following removal of duplicates and ineligible cases, 28,729 OHCA cases with resuscitation commenced or continued by EMS were included in the 2014 analysis (Fig. 1).
For all eligible cases (mean age 68.6 (SD = 19.6) years; 58.7% male), in cases with a known event location, one in four occurred outside of a place of residence. Over half (52.7%, n = 15,153) the cases were witnessed by either the EMS or a bystander. In non-EMS witnessed cases, 55.2%, n = 11,145 received bystander CPR. Bystanders witnessed
Discussion
We have established an OHCA registry in England, with 28,729 cases analysed for 2014.
This figure is comparable to data reported by the ambulance services to NHS England of just under 30,000 cases in the year 2013/14, but indicates our data completeness could be improved.13
Our initial interrogation of the data shows an incidence of OHCA of 53.2 per 100,000. ROSC at hospital transfer was 25.8% and a survival to hospital discharge rate of 7.9% (comparable to NHS England figures of 26.1% and 8.7%
Conclusions
Cardiac arrest is an important cause of death in England. With less than one in ten patients surviving, there is scope to improve outcomes. Survival rates were highest amongst those who received bystander CPR and PAD.
Conflict of interest statement
Claire Hawkes, Scott Booth, Chen Ji, Samantha Brace-McDonnell, Terry Brown and Gavin Perkins are employed by the University of Warwick, which receives grants from the British Heart Foundation and the Resuscitation Council (UK) for the conduct of the OHCAO project.
Andrew Whittington reports grants from the British Heart Foundation, personal fees from West Midlands Ambulance Service Foundation Trust, outside the submitted work.
Matthew Cooke, Charles Deakin, Chris Gale, Rachael Fothergill, Jerry
Funding
The study is supported by research grants from the British Heart Foundation and Resuscitation Council (UK). Gavin Perkins is supported as NIHR Senior Investigator and Director of Research for the Intensive Care Foundation. Samantha Brace-McDonnell is supported by a NIHR Clinical Doctoral Fellowship.
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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2016.10.030.
- 1
OHCAO Collaborators: Theresa Foster, East of England Ambulance Service NHS Trust; Frank Mersom, East of England Ambulance Service NHS Trust; Robert Spaight, East Midlands Ambulance Service NHS Trust; Gurkamal Virdi, London Ambulance Service NHS Trust; Dawn Evison, North East Ambulance Service NHS Trust; Clare Bradley, North West Ambulance Service NHS Trust; Philip King, South Central Ambulance Service NHS Trust; Ed England, South Central Ambulance Service NHS Trust; Patricia Bucher, South East Coast Ambulance Service NHS Trust; Nancy Loughlin, South Western Ambulance Service NHS Trust; Jessica Lynde, South Western Ambulance Service NHS Trust; Jenny Lumley-Holmes, West Midlands Ambulance Service NHS Trust; Dr Julian Mark, Yorkshire Ambulance Service NHS Trust.