Strategies to Improve Cardiac Arrest Survival A Time to Act (2015) / Chapter Skim
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3 The Public Experience with Cardiac Arrest
3 The Public Experience with Cardiac Arrest
Pages 101-172
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From page 101... ...
For example, a definitive body of literature demonstrates statistically significant improvements to cardiac arrest survival rates when bystander CPR is performed (Akahane et al., 2013; Avalli et al., 2014; Campbell et al., 1997; Dowie et al., 2003; Ghose et al., 2010; Gilmore et al., 2006; Grmec et al., 2007; Herlitz et al., 2003, 2005; Kuisma et al., 2005; McNally et al., 2011; Nordberg et al., 2009; Rea et al., 2010a; Rudner et al., 2004; Vadeboncoeur et al., 2007; Vilke et al., 2005; Weiser et al., 2013; Yasunaga et al., 2010)
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From page 102... ...
, engagement in bystander CPR, and application of AEDs. In addition to reviewing existing literature about the effectiveness of the elements of basic life support, this chapter also explores barriers and opportunities for increasing public engagement in cardiac arrest response.
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From page 103... ...
In a study derived from the 1997 London Ambulance Service database that included 2,772 OHCAs, 48 percent of witnessed cardiac arrests with bystander CPR resulted in a ventricular tachycardia (VT) or VF rhythm; whereas, only 27 percent of witnessed arrests without bystander CPR were in VF/VT (Dowie et al., 2003)
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From page 104... ...
found a similar improvement in a sample of 10,681 OHCA patients, where survival rates were 22.1 percent in shockable cases where bystander CPR was performed compared to a 7.8 percent survival rate overall. A recent Swedish study also found that the positive correlation between early CPR and cardiac arrest survival rates remained stable over a 21-year period (Hasselqvist-Ax et al., 2015)
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From page 105... ...
Among 95,072 bystander-witnessed cardiac arrests that occurred between 2005 and 2007 in Japan, bystander CPR increased the likelihood of favorable neurologic outcome (Yasunaga et al., 2010)
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From page 106... ...
program noted increased survival rates (from 3.7 to 9.8 percent over 5 years) after implementation of a statewide effort focused on increasing bystander CPR rates by training lay persons on COCPR (Bobrow et al., 2010)
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From page 107... ...
In a meta-analysis, which included 79 studies involving 142,740 patients, the pooled odds ratio (OR) for survival among patients who received bystander CPR compared with those who did not ranged from 1.23 in the studies with the highest baseline survival rates to 5.01 in the studies with the lowest baseline rates (Sasson et al., 2010b)
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From page 108... ...
For example, bystander CPR rates are 19 percent less in high-income African American neighborhoods than rates in high-income non–African American neighborhoods (Sasson et al., 2012b)
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From page 109... ...
Spatial epidemiological clustering techniques can be used to identify high-risk neighborhoods for OHCA incidence and low provision of bystander CPR in order to target and allocate resources for training where it is most needed. Barriers to Bystander Response Despite evidence that bystander CPR can improve health outcomes from cardiac arrest, each year less than 5 percent of the American public receives formal CPR training (Anderson et al., 2014)
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From page 110... ...
For many undocumented immigrants with limited English proficiency, language discordance and fear of exposing immigration status are significant concerns that may lead to delays in 911 activation (Ong et al., 2012; Sasson et al., 2013b; Seo et al., 2014; Skolarus et al., 2013; Watts et al., 2011)
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From page 111... ...
These concerns are frequently cited by individuals who have never received CPR training and those who have had training but fear that they have forgotten how to perform it correctly. Studies indicate that previous training increases bystanders' confidence and willingness to perform bystander CPR (Cho et al., 2010; Coons and Guy, 2009; Donohoe et al., 2006; Johnston et al., 2003; Kuramoto et al., 2008)
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From page 112... ...
. Despite evidence that indicates the importance of bystander CPR in cardiac arrest outcomes (described previously in the report)
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From page 113... ...
. Moreover, home training by video selfinstruction with peer facilitation has been shown to provide similar competence at a lower cost compared to traditional classroom-based training for lay responders expanding the reach of bystander CPR instruction (Wik et al., 1995)
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From page 114... ...
. Similar policy statements calling for the protection of citizen rescuers who perform CPR along with financial support for public participation, education, funding, and coordination for successful implementation of such laws should be promoted by medical societies so as to eliminate this commonly cited barrier to performing bystander CPR.
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From page 115... ...
. Strategies to Increase Bystander CPR Training Although studies indicate that individuals who have previously participated in CPR training are more likely to initiate resuscitation than those who have not (Swor et al., 2006; Tanigawa et al., 2011)
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From page 116... ...
. The widespread adoption of school-based CPR and AED training would not be expected to substantially increase bystander CPR rates throughout the country.
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From page 117... ...
In the long term, CPR and AED education in schools represents an investment in training multiple generations of people, and it could greatly multiply the number of adults willing to perform bystander CPR and use an AED in one generation. Although there are no longitudinal studies that assess the impact of school-based CPR training on the probability that students will provide CPR as adults, evidence demonstrates that training -- undertaken at any point -- increases the likelihood that a bystander will provide appropriate care when faced with an OHCA (Swor et al., 2006; Tanigawa et al., 2011)
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From page 118... ...
House of Representatives in 2013.4 However, the bill was never enacted. Some states, such as Colorado and North Dakota, have established programs that reimburse the purchase of CPR and AED training equipment for schools.5 Although legislation in Massachusetts does not mandate, but rather encourages, CPR training in schools, the state offers funding for training programs when they are included as part of a health education program.6 A number of options aimed at overcoming financial obstacles and time constraints for training in schools have been introduced and supported in the academic literature.
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From page 119... ...
These factors have contributed to the increase in bystander CPR rates in countries such as Denmark and Sweden (Stromsoe et al., 2010)
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From page 120... ...
Emergency departments also provide an opportunity to refer high-risk patients and their families for appropriate CPR training. In a cross-sectional study of patients presenting to the emergency department with chest pain, only two in five households had prior CPR training.
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From page 121... ...
. To improve cardiac arrest survival rates, especially for cardiac arrests that occur in homes and other private settings, policy makers and health care systems need to consider the widespread implementation of training for family members of patients who have medical conditions that place them at higher risk for cardiac arrest.
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From page 122... ...
. Moreover, the quality of bystander CPR is associated with a higher probability of survival than having no CPR.
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From page 123... ...
. Early simulation studies proposed the use of dispatcher-assisted CPR as a strategy to increase the rate of bystander CPR in communities where few people have CPR training and to improve the quality of CPR performed by bystanders who had prior training (Kellermann et al., 1989)
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From page 124... ...
This initiative included widespread CPR and AED training in schools and businesses, deployment of AED in schools and public places, and updates to EMS and post–cardiac arrest care protocols. This initiative was correlated with an increase in bystander CPR rates between 2005 and 2009 from 20 to 29 percent.
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From page 125... ...
PUBLIC ACCESS DEFIBRILLATION (PAD) PROGRAMS Cardiac arrests caused by shockable arrhythmias (e.g., VF, VT)
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From page 126... ...
The survival rates for locations with PAD programs can vary between 28 and 56 percent (Berger, 2014)
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From page 127... ...
. In 2004, the PAD Trial, which involved trained laypersons in 24 North American regions, found a statistically significant twofold survival benefit with favorable neurologic outcome for adults who received bystander CPR plus AED compared with those who only received bystander CPR (Hallstrom et al., 2004)
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From page 128... ...
Other countries have demonstrated the potential for bolstering PAD programs by implementing nationwide initiatives that are focused on increasing bystander CPR and AED use overall (Wissenberg et al., 2013)
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From page 129... ...
As described here and throughout this chapter, the best strategy for improving survival and outcomes through bystander CPR and AED use is to develop and implement multipronged initiatives that not only teach the skills necessary to respond, but also instill a culture of action throughout communities and the public. Children and School-Based PAD Programs In recent years, particular attention has been focused on AED placement and education in school settings (Berger et al., 2004; Cave et al., 2011; Drezner et al., 2009; Hart et al., 2013)
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From page 130... ...
. Despite differences in training and compliance and variability in willingness to respond in school settings, when resuscitation efforts occur, high rates of bystander CPR (up to 94 percent)
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From page 131... ...
. Limitations in finances and personnel have also been cited as barriers to widespread implementation of AEDs and PAD programs in school settings.
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From page 132... ...
. The authors emphasized the importance of optimizing all links in the chain of survival for improved survival and that low rates of bystander CPR or delays in activating EMS may be barriers for achieving the full potential of early AED availability and use.
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From page 133... ...
PAD Program Challenges Despite abundant evidence that supports the potential benefit of PAD programs, there is substantial variability in how recommendations for CPR and AED training have been adopted across the United States (Haskell et al., 2009)
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From page 134... ...
. A number of challenges have prevented the successful implementation of PAD programs throughout the United States.
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From page 135... ...
Other countries have taken action to track and increase the use of publicly available AEDs; these successes could provide useful models for similar efforts in the United States. For example, in some communities in Denmark, AEDs are registered in an accessible database that allows dispatchers to alert callers reporting a cardiac arrest of nearby AEDs.
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From page 136... ...
Currently, there is an incomplete and disjointed dissemination of PAD programs nationally. Facilities that could participate in a PAD program have reported implementation barriers that include fear of litigation, difficulties associated with training personnel, developing facility-specific emergency response plans, and establishing around the clock response capability (Richardson et al., 2005)
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From page 137... ...
Therefore, CPR training should include instructions on the purpose and basic function of an AED. AED Adverse Events Ensuring that AEDs are safe for use as medical devices is one responsibility of the U.S.
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From page 138... ...
. These emerging approaches also provide opportunities to enhance self-tracking and monitoring of PAD program progress to improve cardiac arrest survival and outcomes.
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From page 139... ...
Framing AEDs and AED programs in a similar manner may be crucial to achieving their full potential to save lives. AEDs and the Potential of Social Media, Mobile Media, and Crowdsourcing Several efforts have been specifically designed in order to improve and track AED location awareness and public knowledge through mobile media, social media, and crowdsourcing (Ahn et al., 2011; Bosley et al., 2013; Chang et al., 2014; Merchant and Asch, 2012; Merchant et al., 2013; Ranney and Daya, 2013; Sakai et al., 2011; Scholten et al., 2011; You et al., 2008)
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From page 140... ...
. PulsePoint mobile apps share information about cardiac arrests in public locations with nearby bystanders.
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From page 141... ...
Additional studies and pilot projects are needed in order to understand the opportunities, limitations, and benefits of digital tools and how these tools might complement existing infrastructure for individual and community response to cardiac arrest. AED Registries Registries represent one approach to overcoming the challenges associated with tracking AED locations and increasing the likelihood that an OHCA patient will receive bystander CPR and early defibrillation.
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From page 142... ...
. As mentioned above, AEDs registry in combination with alerted lay rescuers have been shown to decrease time to defibrillation (Hansen et al., 2013b)
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From page 143... ...
. For example, the Home Automated External Defibrillator Trial evaluated the effectiveness of in-home AEDs for approximately 7,000 patients with a prior myocardial infarction who were not candidates for an implantable cardioverter defibrillator (Bardy et al., 2008)
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From page 144... ...
. Although there is a multitude of evidence that indicates that bystander CPR can markedly improve survival, neurologic outcomes, and resulting quality of life, rates of bystander CPR in the United States remain adversely low, and less than 5 percent of the general public has been trained in CPR.
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From page 145... ...
2008. Reducing barriers for implementation of bystander-initiated cardiopulmonary resuscitation: A scientific statement from the American Heart Association for healthcare providers, policymakers, and community leaders regarding the effectiveness of cardiopulmonary resuscitation.
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From page 146... ...
2013. Video self-instruction for police officers in cardiopulmonary resuscitation and automated external defibrillators.
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From page 147... ...
2010. Part 13: Pediatric basic life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.
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From page 148... ...
2010. Part 5: Adult basic life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.
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From page 149... ...
2011. Bystander CPR in out-of-hospital cardiac arrest: The role of limited English proficiency.
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From page 150... ...
2011. Importance and implementation of training in cardiopulmonary resuscitation and automated external defibrillation in schools: a science advisory from the American Heart Association.
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From page 151... ...
2009. Performing bystander CPR for sudden cardiac arrest: Behavioral intentions among the general adult population in Arizona.
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From page 152... ...
2003. "Event tree" analysis of out-of-hospital cardiac arrest data: Confirming the importance of bystander CPR.
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2009. Effectiveness of emergency response planning for sudden cardiac arrest in United States high schools with automated external defibrillators.
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From page 154... ...
2007. Utstein Style analysis of out-of-hospital cardiac arrest -- bystander CPR and end expired carbon dioxide.
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2013b. Automated external defibrillators inaccessible to more than half of nearby cardiac arrests in public locations during evening, nighttime, and weekends.
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From page 156... ...
2005. Efficacy of bystander CPR: Intervention by lay people and by health care professionals.
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2011. CPR knowledge and attitude to performing bystander CPR among secondary school students in norway.
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From page 158... ...
2008. Public perception of and willingness to perform bystander CPR in Japan.
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From page 159... ...
1995. Bystander cardiopulmonary resuscitation.
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1989. Disagreeable physical characteristics affecting bystander CPR.
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From page 161... ...
2014. Disparities in bystander CPR provision and survival from out-of-hospital cardiac arrest according to neighborhood ethnicity.
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From page 162... ...
2009. Aspects on the increase in bystander CPR in Sweden and its association with outcome.
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From page 163... ...
2013. Cardiac arrest at exercise facilities: Implications for placement of automated external defibrillators.
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From page 164... ...
2007. Automated external defibrillators in Washington state high schools.
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From page 165... ...
2003. Use of automated external defibrillators for children: An update: An advisory statement from the Pediatric Advanced Life Support Task Force, International Liaison Committee on Resuscitation.
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From page 166... ...
2011. Early cardiopulmonary resuscitation and use of automated external defibrillators by laypersons in out-of-hospital cardiac arrest using an SMS alert service.
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From page 167... ...
2011. The 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiac care: An overview of the changes to pediatric basic and advanced life support.
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From page 168... ...
2011. Are trained individuals more likely to perform bystander CPR?
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From page 169... ...
2008. Socioeconomic status influences bystander CPR and survival rates for out of-hospital cardiac arrest victims.
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From page 170... ...
2013. Automated external defibrillators and emergency planning for sudden cardiac arrest in Vermont high schools a rural state's perspective.
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From page 171... ...
2002. Refibrillation, resuscitation and survival in out-of-hospital sudden cardiac arrest victims treated with biphasic automated external defibrillators.
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From page 172... ...
2014. Local lay rescuers with AEDs, alerted by text messages, contribute to early defibrillation in a Dutch out-of-hospital cardiac arrest dispatch system.
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