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Observational Study
. 2017 Nov 1;2(11):1226-1235.
doi: 10.1001/jamacardio.2017.3471.

Association of Public Health Initiatives With Outcomes for Out-of-Hospital Cardiac Arrest at Home and in Public Locations

Christopher B Fordyce  1   2 , Carolina M Hansen  2 , Kristian Kragholm  2   3   4 , Matthew E Dupre  2   5 , James G Jollis  6 , Mayme L Roettig  2 , Lance B Becker  7 , Steen M Hansen  2 , Tomoya T Hinohara  2 , Claire C Corbett  8 , Lisa Monk  2 , R Darrell Nelson  9 , David A Pearson  10 , Clark Tyson  2 , Sean van Diepen  11   12 , Monique L Anderson  2 , Bryan McNally  13 , Christopher B Granger  2
Affiliations
Observational Study

Association of Public Health Initiatives With Outcomes for Out-of-Hospital Cardiac Arrest at Home and in Public Locations

Christopher B Fordyce et al. JAMA Cardiol. .

Abstract

Importance: Little is known about the influence of comprehensive public health initiatives according to out-of-hospital cardiac arrest (OHCA) location, particularly at home, where resuscitation efforts and outcomes have historically been poor.

Objective: To describe temporal trends in bystander cardiopulmonary resuscitation (CPR) and first-responder defibrillation for OHCAs stratified by home vs public location and their association with survival and neurological outcomes.

Design, setting, and participants: This observational study reviewed 8269 patients with OHCAs (5602 [67.7%] at home and 2667 [32.3%] in public) for whom resuscitation was attempted using data from the Cardiac Arrest Registry to Enhance Survival (CARES) from January 1, 2010, through December 31, 2014. The setting was 16 counties in North Carolina.

Exposures: Patients were stratified by home vs public OHCA. Public health initiatives to improve bystander and first-responder interventions included training members of the general population in CPR and in the use of automated external defibrillators, teaching first responders about team-based CPR (eg, automated external defibrillator use and high-performance CPR), and instructing dispatch centers on recognition of cardiac arrest.

Main outcomes and measures: Association of resuscitation efforts with survival and neurological outcomes from 2010 through 2014.

Results: Among home OHCA patients (n = 5602), the median age was 64 years, and 62.2% were male; among public OHCA patients (n = 2667), the median age was 68 years, and 61.5% were male. After comprehensive public health initiatives, the proportion of patients receiving bystander CPR increased at home (from 28.3% [275 of 973] to 41.3% [498 of 1206], P < .001) and in public (from 61.0% [275 of 451] to 70.5% [424 of 601], P = .01), while first-responder defibrillation increased at home (from 42.2% [132 of 313] to 50.8% [212 of 417], P = .02) but not significantly in public (from 33.1% [58 of 175] to 37.8% [93 of 246], P = .17). Survival to discharge improved for arrests at home (from 5.7% [60 of 1057] to 8.1% [100 of 1238], P = .047) and in public (from 10.8% [50 of 464] to 16.2% [98 of 604], P = .04). Compared with emergency medical services-initiated CPR and resuscitation, patients with home OHCA were significantly more likely to survive to hospital discharge if they received bystander-initiated CPR and first-responder defibrillation (odds ratio, 1.55; 95% CI, 1.01-2.38). Patients with arrests in public were most likely to survive if they received both bystander-initiated CPR and defibrillation (odds ratio, 4.33; 95% CI, 2.11-8.87).

Conclusions and relevance: After coordinated and comprehensive public health initiatives, more patients received bystander CPR and first-responder defibrillation at home and in public, which was associated with improved survival.

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Conflict of interest statement

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Fordyce reported serving on an advisory board for Bayer. Dr C. M. Hansen reported receiving research grants from the Laerdal Foundation, TrygFonden, and Helsefonden. Dr Kragholm reported receiving a research grant from the Laerdal Foundation and speaker’s honoraria from Novartis. Dr Jollis reported receiving grants from the Medtronic Foundation. Dr Becker reported receiving institutional grants or research support (funds go to Northwell Health) from Philips Medical Systems, National Institutes of Health (NIH), ZOLL Medical Corporation, and Nihon Kohden; reported serving as a scientific consultant or on advisory panels for the NIH Data Safety Monitoring Board and Protocol Review Committee, NIH Resuscitation Outcomes Consortium, and NIH New York Icahn School of Medicine at Mount Sinai K12 Training Grant; reported serving on a scientific advisory board for Nihon Kohden; reported holding patents for hypothermia induction and reperfusion therapies, including 7 issued patents and several pending patents involving the use of medical slurries as human coolant devices to create slurries, as well as reperfusion cocktails; reported owning equity and royalties in privately held companies, including inventor’s equity and royalties from Helar, a company started by the University of Pennsylvania to develop technologies for medical cooling using slurry technology; and reported long-standing volunteer membership in the American Heart Association (currently serving on several committees), which has a financial interest in the outcome of resuscitation studies being conducted. Dr S. M. Hansen reported receiving grants from the Laerdal Foundation. Dr Granger reported receiving grants from the Medtronic Foundation. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Selection of the Study Population With Out-of-Hospital Cardiac Arrest
CARES indicates Cardiac Arrest Registry to Enhance Survival; DNR, do not resuscitate; and NC, North Carolina.
Figure 2.
Figure 2.. Percentage Survival and Favorable Neurological Survival Calculated as the Proportion of All Patients With Out-of-Hospital Cardiac Arrest per Year by Location
Shown are trends in survival to discharge (A) and favorable neurological survival at discharge (B) stratified for both home and public locations for out-of-hospital cardiac arrest.
Figure 3.
Figure 3.. Adjusted Survival and Favorable Neurological Survival According to Who Initiated Cardiopulmonary Resuscitation and Defibrillation
A and B, Shown is the adjusted mortality among patients who received out-of-hospital cardiopulmonary resuscitation and defibrillation at home (A) and in public (B). C and D, Shown is the adjusted survival to discharge with good neurological function (cerebral performance category 1 or 2) among patients who received out-of-hospital cardiopulmonary resuscitation and defibrillation at home (C) and in public (D). The combination of bystander cardiopulmonary resuscitation and either first-responder defibrillation (at home) or bystander defibrillation (in public) was most strongly associated with both age and sex–adjusted survival and age and sex–adjusted favorable neurological survival (reference EMS/EMS). EMS indicates emergency medical services; NA, not applicable; and OR, odds ratio. aNote that we could not calculate the OR for bystander/bystander efforts in A and C.
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