Improving Quality in Cardiac Arrest via Resuscitation Academy Training (IQ-CART): Study Protocol for a Mixed-Methods Study With a Focus on Low-Performing EMS Agencies.

Black and Hispanic patients are less likely to survive an out-of-hospital cardiac arrest (OHCA) than White patients. Given the central importance of emergency medical service (EMS) agencies in prehospital care, a better understanding of OHCA survival at EMS agencies that work in Black and Hispanic communities and White communities is needed to address OHCA disparities. To examine whether EMS agencies serving catchment areas with primarily Black and Hispanic populations (Black and Hispanic catchment areas) have different rates of OHCA survival than agencies serving catchment areas with primarily White populations (White catchment areas). A cohort study including adults with nontraumatic OHCA from January 1, 2015, to December 31, 2019, in the Cardiac Arrest Registry to Enhance Survival was conducted. Data analysis was conducted from August 17, 2022, to July 7, 2023. Emergency medical service agencies, categorized as working in catchment areas where the combination of Black and Hispanic residents made up more than 50% of the population or where White residents made up more than 50% of the population. The unit of analysis was the EMS agency. The primary outcome was agency-level risk-standardized survival rates (RSSRs) to hospital admission for OHCA at each EMS agency, which were calculated using hierarchical logistic regression and compared between agencies serving Black and Hispanic and White catchment areas. Whether differences in OHCA survival were explained by EMS and first responder measures was evaluated with additional adjustment for these factors. Among 764 EMS agencies representing 258 342 OHCAs, 82 EMS agencies (10.7%) had a Black and Hispanic catchment area. Overall median age of the patients was 63.0 (IQR, 52.0-75.0) years, 36.1% were women, and 63.9% were men. Overall, the mean (SD) RSSR was 27.5% (3.6%), with lower survival at EMS agencies with Black and Hispanic catchment areas (25.8% [3.6%]) compared with agencies with White catchment areas (27.7% [3.5%]; P < .001). Among the 82 EMS agencies with Black and Hispanic catchment areas, a disproportionately higher number (32 [39.0%]) was in the lowest survival quartile, whereas a lower number (12 [14.6%]) was in the highest survival quartile. Additional adjustment for EMS response times, EMS termination of resuscitation rates, and first responder rates of initiating cardiopulmonary resuscitation or applying an automated external defibrillator before EMS arrival did not meaningfully attenuate differences in RSSRs between agencies with Black and Hispanic compared with White catchment areas (mean [SD] RSSRs after adjustment, 25.9% [3.3%] vs 27.7% [3.1%]; P < .001). Risk-standardized survival rates for OHCA were 1.9% lower at EMS agencies working in Black and Hispanic catchment areas than in White catchment areas. This difference was not explained by EMS response times, rates of EMS termination of resuscitation, or first responder rates of initiating cardiopulmonary resuscitation or applying an automated external defibrillator. These findings suggest there is a need for further assessment of these discrepancies.

Background: Black and Hispanic individuals have lower survival rates for out-of-hospital cardiac arrest (OHCA). Whether there are Emergency Medical Service (EMS) agencies in Black and Hispanic communities with high survival rates for OHCA is unknown but critical to identifying strategies to reduce racial and ethnic disparities in OHCA survival. Methods: Within the Cardiac Arrest Registry to Enhance Survival, we identified adults with non-traumatic OHCA during 2015-2019. EMS agencies were categorized as working in Black/Hispanic communities if &gt;50% of residents in their catchment area were Black or Hispanic. Using hierarchical logistic regression, we calculated risk-standardized survival rates (RSSR) to hospital admission for OHCA in each EMS agency, adjusted for patients’ age, sex, witnessed arrest status, presumed arrest etiology, initial cardiac arrest rhythm, and arrest location. We then examined the distribution of EMS agencies that work in Black/Hispanic communities across quartiles of OHCA survival. Results: Among 764 EMS agencies (258,342 OHCAs), the median RSSR was 27.4% with an absolute difference of &gt;10% across quartiles (median 22.4% in the lowest vs. 32.9% in the highest quartile; 191 EMS agencies in each quartile). There were 82 EMS agencies working in Black/Hispanic communities overall, with 26 (31.7%) in the lowest RSSR quartile and 15 (18.3%) in the highest. After further adjustment for agency-level rates of bystander CPR, EMS response time and termination of resuscitation practices, there remained 29 (35.4%) EMS agencies in the lowest RSSR quartile and 16 (19.5%) in the highest. Conclusion: EMS agencies working in Black and Hispanic communities have lower prehospital survival for OHCA, although high-performing agencies exist. Identifying best practices at EMS agencies with the highest prehospital survival rates, particularly among agencies serving Black and Hispanic communities, has the potential to improve overall OHCA survival and reduce existing survival disparities.

Survival for out-of-hospital cardiac arrest (OHCA) varies widely across emergency medical service (EMS) agencies in the US. However, little is known about which EMS practices are associated with higher agency-level survival. To identify resuscitation practices associated with favorable neurological survival for OHCA at EMS agencies. This cohort study surveyed EMS agencies participating in the Cardiac Arrest Registry to Enhance Survival (CARES) with 10 or more OHCAs annually during January 2015 to December 2019; data analyses were performed from April to October 2023. Survey of resuscitation practices at EMS agencies. Risk-standardized rates of favorable neurological survival for OHCA at each EMS agency were estimated using hierarchical logistic regression. Multivariable linear regression then examined the association of EMS practices with rates of risk-standardized favorable neurological survival. Of 577 eligible EMS agencies, 470 agencies (81.5%) completed the survey. The mean (SD) rate of risk-standardized favorable neurological survival was 8.1% (1.8%). A total of 7 EMS practices across 3 domains (training, cardiopulmonary resuscitation [CPR], and transport) were associated with higher rates of risk-standardized favorable neurological survival. EMS agencies with higher favorable neurological survival rates were more likely to use simulation to assess CPR competency (β = 0.54; P = .05), perform frequent reassessment (at least once every 6 months) of CPR competency in new staff (β = 0.51; P = .04), use full multiperson scenario simulation for ongoing skills training (β = 0.48; P = .01), perform simulation training at least every 6 months (β = 0.63; P < .001), and conduct training in the use of mechanical CPR devices at least once annually (β = 0.43; P = .04). EMS agencies with higher risk-standardized favorable neurological survival were also more likely to use CPR feedback devices (β = 0.58; P = .007) and to transport patients to a designated cardiac arrest or ST-segment elevation myocardial infarction receiving center (β = 0.57; P = .003). Adoption of more than half (≥4) of the 7 practices was more common at EMS agencies in the highest quartile of favorable neurological survival rates (70 of 118 agencies [59.3%]) vs the lowest quartile (42 of 118 agencies [35.6%]) (P < .001). In a national registry for OHCA, 7 practices associated with higher rates of favorable neurological survival were identified at EMS agencies. Given wide variability in neurological survival across EMS agencies, these findings provide initial insights into EMS practices associated with top-performing EMS agencies in OHCA survival. Future studies are needed to validate these findings and identify best practices for EMS agencies.

Although survival for out-of-hospital cardiac arrest (OHCA) is lower at emergency medical service (EMS) agencies serving Black/Hispanic communities, it is unknown whether this is due to practice differences. Within the Cardiac Arrest Registry to Enhance Survival (CARES) registry in the United States, we conducted a survey from 2022 to 2023 of resuscitation practices at EMS agencies with ≥10 OHCAs annually between 2015 and 2019. We examined differences in dispatch, first responder, and EMS practices between agencies with majority Black/Hispanic catchment areas (>50% residents Black or Hispanic) and majority White catchment areas using χ2 tests. We estimated each agency's risk-standardized rate of survival to hospital admission for OHCA using multivariable hierarchical logistic regression and evaluated whether survival differences between the 2 agency groups were attenuated after adjusting for resuscitation practice differences. Among 470 EMS agencies (181 707 OHCAs), 47 (10.0%) served a majority Black/Hispanic catchment area. At EMS agencies with Black/Hispanic catchment areas, dispatchers and police first responders were less likely to always recognize a cardiac arrest (29.8% versus 43.0%); police first responders were less likely to respond to OHCA (46.8% versus 68.9%), initiate CPR (59.6% versus 83.2%), or apply an automated external defibrillator (29.8% versus 60.0%); and EMS staff were less likely to assess CPR competency annually (46.5% versus 65.0%) and use waveform capnography (91.5% versus 99.5%), as compared with agencies with White catchment areas. EMS agencies serving majority Black/Hispanic catchment areas had 2% (95% CI, 0.9-3.1%; P<0.001) lower risk-standardized rates of survival, as compared with agencies serving majority White catchment areas, and survival differences were partly attenuated after adjusting for practice differences between EMS groups. In the United States, we identified differences in dispatcher, first responder, and EMS practices for OHCA between agencies with majority Black/Hispanic and White catchment areas. These practice differences may partly account for disparities in OHCA survival between the 2 EMS agency groups.

Although studies have reported variation in out-of-hospital cardiac arrest (OHCA) survival by geographic location, little is known about variation in OHCA survival at the level of emergency medical service (EMS) agencies-which may have modifiable practices, unlike counties and regions. We quantified the variation in OHCA survival across EMS agencies and explored whether variation in 2 specific EMS resuscitation practices were associated with survival to hospital admission. Within the Cardiac Arrest Registry to Enhance Survival, a prospective registry representing ≈51% of the US population, we identified 258 342 OHCAs from 764 EMS agencies with >10 OHCA cases annually during 2015 to 2019. Using hierarchical logistic regression, risk-standardized rates of survival to hospital admission were computed for each EMS agency. We quantified inter-agency variation in survival with median odds ratios and assessed the association of 2 resuscitation practices (EMS response time and the proportion of OHCAs with termination of resuscitation without meeting futility criteria) with EMS agency survival rates to hospital admission. Across 764 EMS agencies comprising 258 342 OHCAs, the median risk-standardized rate of survival to hospital admission was 27.3% (interquartile range, 24.5%-30.1%; range: 16.0%-45.6%). The adjusted median odds ratio was 1.35 (95% CI, 1.32-1.39), denoting that the odds of survival of 2 patients with identical covariates varied by 35% at 2 randomly selected EMS agencies. EMS agencies in the lowest quartile of risk-standardized survival had longer EMS response times when compared with the highest quartile (12.0±3.4 versus 9.0±2.6 minutes; P<0.001), and a higher proportion of OHCAs with termination of resuscitation without meeting futility criteria (27.9±16.1% versus 18.9±11.4%; P<0.001). Survival after OHCA varies widely across EMS agencies. EMS response times and termination of resuscitation practices were associated with agency-level rates of survival to hospital admission, suggesting potentially modifiable practices which can improve OHCA survival.

Background: Out-of-hospital cardiac arrest (OHCA) is a common cause of premature death and the rate of survival is low. Early defibrillation and high quality chest compressions are known to influence OHCA survival and it is likely that paramedics who are frequently exposed to OHCA cases will perform more competently these vital components of resuscitation. Given that resuscitation skills decline over time and paramedic treatment of OHCA often falls short of the recommended standard, the number of OHCAs that paramedics are exposed to may be contributing to low and varied OHCA survival rates. Therefore, the broad aim of this thesis was to examine the association between paramedic exposure to OHCA and patient survival. Methods: Firstly, I performed a systematic review of the literature which identified that the association between paramedic exposure to OHCA and patient survival was a clear knowledge gap. To address this knowledge gap, I undertook a survey of emergency medical services (EMS) and conducted three epidemiological studies. The survey investigated the methods that EMS in Australia and New Zealand use to develop and maintain paramedic competency in resuscitation. The epidemiological studies were conducted in the setting of a large, statewide, two-tiered EMS agency, Ambulance Victoria (AV), and high quality data were sourced from the Victorian Ambulance Cardiac Arrest Registry as well as routinely collected data from AV. I measured typical paramedic exposure to OHCA. Then, using multivariable regression analysis, adjusting for internationally accepted covariates, I analysed the association between paramedic exposure to OHCA and patient survival. To determine whether increasing paramedic exposure is associated with better performance – the potential intermediary factor between exposure and outcomes, the association between paramedic exposure to endotracheal intubation (ETI) and performance (as measured by successful endotracheal tube [ETT] placement) was examined. I chose to investigate performance in ETI because it is one of the most technical individual skills carried out by paramedics during OHCA resuscitation. Results: The survey found that EMS agencies provided paramedics with minimal refresher training and rarely used other evidence-based methods of maintaining resuscitation competency. Paramedics were typically exposed to 1.4 (interquartile range [IQR]: 0.0-3.0) OHCAs per year and OHCA exposure declined over time. It would take paramedics an average of 163 days to be exposed to an OHCA and up to a decade for paediatric and traumatic OHCAs, which occur relatively rarely. OHCA exposure was lower in paramedics who were employed part-time, in rural areas, and with lower qualifications. Compared to patients treated by paramedics with a median of ≤6 exposures during the previous three years (7% survival), the odds of survival were higher for patients treated by paramedics with >6-11 (12%, adjusted odds ratio [AOR] :1.26, 95% confidence interval [CI] :1.04-1.54), >11-17 (14%, AOR:1.29, 95% CI:1.04-1.59) and >17 exposures (17%, AOR:1.50, 95% CI:1.22-1.86). I found that paramedic exposure to an individual component of OHCA resuscitation, namely ETI, was associated with better performance (AOR for successful ETT placement: 1.04, 95%CI: 1.03-1.05) but not OHCA patient survival. Intensive care paramedics typically performed 3 (IQR: 1-6) ETIs per year, the majority of which were performed on OHCAs (66%). Conclusions: Individual paramedics are rarely exposed to OHCA and increasing exposure is associated with improved patient survival. In addition, paramedic exposure to a single complex component of resuscitation, ETI, was associated with improved performance but not OHCA survival. The poor performance and patient outcomes commonly reported for OHCA may in part be the consequence of inadequate opportunities for paramedics to practise their resuscitation skills. These findings suggest that paramedic exposure to OHCA and resuscitation procedures need to be monitored and strategies to supplement low exposure, such as simulation training, should be explored.

Although advanced airway (AA) practice patterns have varied over time, their association with out-of-hospital cardiac arrest (OHCA) outcomes is unknown. To determine the association between AA temporal practice patterns of emergency medical service (EMS) agencies and OHCA outcomes. This cross-sectional study used data from multicenter EMS agencies participating in the Cardiac Arrest Registry to Enhance Survival database. The study included adults (aged ≥18 years) with OHCA treated by EMS agencies that had 25 or more OHCA episodes annually from January 1, 2016, through December 31, 2022. AA interventions included supraglottic airway (SGA) device use or endotracheal intubation (ETI). Patients were categorized into groups using the following EMS agency-level patterns defined by predominant AA use before and after 2019: (1) ongoing ETI, (2) ongoing SGA use (ongoing SGA), (3) transitioning from ETI to SGA use (ETI to SGA), or (4) transitioning from SGA use to ETI (SGA to ETI). Mixed-effects logistic regression models accounting for EMS agency clustering and adjusting for Utstein variables were used to evaluate the association between EMS agency AA practice patterns and OHCA outcomes including return of spontaneous circulation (ROSC) and survival. Subanalyses were also conducted for agencies in the lowest survival quartile. Odds ratios (ORs) are reported with 95% CIs. This study included 350 216 patients with OHCA treated by 254 eligible EMS agencies. The 214 EMS agencies (n = 305 341 patients) with a predominant AA pattern were grouped as follows for temporal pattern analysis: ongoing ETI (n = 72 [33.6%]), ongoing SGA (n = 66 [30.8%]), ETI to SGA (n = 67 [31.3%]), or SGA to ETI (n = 9 [4.2%]). Patients were predominantly male (62.2%), with a median age of 64 (IQR, 52-76) years, and most (81.7%) presented with nonshockable rhythms. ROSC occurred in 30.8% of patients, and 10.4% of patients survived to hospital discharge. Predominant SGA use among EMS agencies increased from 65 agencies in 2016 to 113 in 2022. ROSC decreased in all 4 groups from before to after 2019 as follows: from 36.5% to 30.7% (OR, 0.80 [95% CI, 0.77-0.82]) for ongoing ETI, from 32.4% to 26.4% (OR, 0.75 [95% CI, 0.73-0.78]) for ongoing SGA, from 32.1% to 28.5% (OR, 0.88 [95% CI, 0.85-0.91]) for ETI to SGA, and from 36.7% to 33.3% (OR, 0.92 [95% CI, 0.83-1.03]) for SGA to ETI. For the 15 lower-performing agencies (n = 20 860 patients) that transitioned from ETI to SGA after vs before 2019, an association with higher ROSC (from 25.7% to 29.1%; OR, 1.16 [95% CI, 1.09-1.24]) and survival (from 5.6% to 6.3%; OR, 1.17 [95% CI, 1.04-1.32]) was observed. In this cohort study, SGA use among EMS agencies increased over time. Although ROSC declined for all AA temporal practice patterns, the transition from ETI to SGA use at EMS agencies with lower baseline survival was associated with improved outcomes. Future studies are warranted to confirm these findings and to evaluate whether the observed associations are consistent across diverse populations.

IntroductionUnderstanding characteristics of top-performing emergency medical service (EMS) agencies and hospitals can be an important tool for improving community out-of-hospital cardiac arrest (OHCA) care. We compared deidentified EMS and hospital-level variations in OHCA performance and outcomes in Ohio.MethodsWe analyzed adult OHCA data from the 2019 Ohio Cardiac Arrest Registry to Enhance Survival (Ohio CARES). We limited the analysis to EMS agencies and receiving hospitals with ≥10 OHCA episodes. The primary outcomes were return of spontaneous circulation (ROSC) and survival to hospital discharge. We compared OHCA outcomes between EMS agencies using linear mixed models, with EMS agency as a random effect and adjusting for Utstein variables. We repeated the analysis by receiving hospital. We compared EMS agency population demographics, response times, and resuscitation characteristics of the top 10% of agencies against remaining agencies using chi-squared tests.ResultsWe included 2,841 OHCA among 44 EMS agencies in our analysis. The ROSC varied three-fold; mean 27.9%, range 15.8%‒51.0%. Among 40 hospitals, survival varied two-fold; mean 12.9%, range 8.1%‒19.0%. Top-performing EMS agencies included both medium- and large-sized agencies that tended to treat younger patients (59 vs 62 years, P<0.01) in public areas (15.7% vs 12.3%, P<0.01). There were no differences in bystander-witnessed arrest, bystander cardio-pulmonary resuscitation (CPR), or EMS response time. However, top-performing EMS agencies used less mechanical CPR (61.7% vs 76.0%, P<0.01) and were more successful in advanced airway placement (89.6% vs 74.8% P<0.01).ConclusionsThe ROSC and survival after out-of-hospital cardiac arrest varied across EMS agencies and hospitals in Ohio. Top-performing EMS agencies exhibited unique demographic characteristics, used less mechanical CPR, and were more successful in airway placement. These variations in OHCA care and outcomes can indicate opportunities for system improvement in Ohio.

Survey of resuscitation practices at emergency medical service agencies in the U.S

Emergency medical services (EMS) providers deliver the initial care for millions of people in the United States each year. The Institute of Medicine noted a deficit in research necessary to improve prehospital care, created by the existence of data silos, absence of long-term outcomes, and limited stakeholder engagement in research. This article describes a regional effort to create a high-performing infrastructure in southwestern Pennsylvania addressing these fundamental barriers. Regional EMS records from 33 agencies in January 2011 were linked to hospital-based electronic health records (EHRs) in a single nine-hospital system, with manual review of matches for accuracy. The use of community stakeholder engagement was included to guide scientific inquiry, as well as 2-year follow up for patient-centered outcomes. Local EMS medicine stakeholders emphasized the limits of single-agency EMS research and suggested that studies focus on improving cross-cutting, long-term outcomes. Guided by this input, more than 95% of EMS records (2,675 of 2,800) were linked to hospital-based EHRs. More than 80% of records were linked to 2-year mortality, with more deaths among EMS patients with prehospital hypotension (30.5%) or respiratory distress (19.5%) than chest pain (5.4%) or nonspecific complaints (9.4%). A prehospital comparative effectiveness research infrastructure composed of patient-level EMS data, EHRs at multiple hospitals, long-term outcomes, and community stakeholder perspectives is feasible and may be scalable to larger regions and networks. The lessons learned and barriers identified offer a roadmap to answering community and policy-relevant research questions in prehospital care.

Changes in Field Termination of Resuscitation and Survival Rates After an Educational Intervention to Promote on Scene Resuscitation for Out-of-Hospital Cardiac Arrest.

Community lessons to understand resuscitation excellence (culture): Association between emergency medical services (EMS) culture and outcome after out-of-hospital cardiac arrest

Variation in pre-hospital outcomes after out-of-hospital cardiac arrest in Michigan

Introduction: Survival after out-of-hospital cardiac arrest (OHCA) varies across emergency medical services (EMS) systems, but the EMS practices that contribute to the outcome variation are unclear. We evaluated the association between EMS agency variation in adherence to the termination recommendations in the Universal Termination of Resuscitation (TOR) rule and survival after OHCA. Methods: We conducted a secondary analysis of the Resuscitation Outcomes Consortium Epistry, a prospective multicenter OHCA registry in North America. We included adults (≥ 18 years) with OHCA for whom EMS providers attempted resuscitation from 2011 through 2015. The main exposure was proportion of patients meeting the Universal TOR rule (not EMS-witnessed arrest, no return of spontaneous circulation prior to transport, and no shock delivery prior to transport) among those who had prehospital TOR at the level of EMS agency. We categorized EMS agencies into quartiles based on the adherence to the Universal TOR rule. Our primary outcome was survival to hospital discharge. We used multilevel modified Poisson regression model, including patient-level and EMS-level covariates with patients nested within EMS agencies. Results: We included 43,656 EMS-treated OHCAs from 112 EMS agencies. The median adherence to the Universal TOR rule was 75.6% (interquartile range [IQR] 67.5-83.7) across EMS agencies. Compared with patients resuscitated at EMS agencies in the quartile of the lowest adherence (median adherence 62.5% [IQR 58.9-65.7]), survival to hospital discharge was inversely associated with treatment at EMS agencies in the second quartile (median adherence 72.6% [IQR 70.2-74.7]) (adjusted risk ratio [aRR] 0.83, 95% confidence interval [CI] 0.71-0.96), the third quartile (median adherence 80.6% [IQR 78.5-81.9]) (aRR 0.71, 95% CI 0.60-0.85), and the fourth quartile (median adherence 90.6% [IQR 86.2-93.7]) (aRR 0.68, 95% CI 0.58-0.80). Conclusions: In this large cohort study of adult patients with OHCA, we observed variation in the adherence to the Universal TOR rule’s termination recommendations across EMS agencies, and an association between higher EMS-level adherence and worse survival to hospital discharge after OHCA.

Introduction: Survival after out-of-hospital cardiac arrest (OHCA) varies across emergency medical services (EMS) systems. The contribution of EMS practices variation on the outcome disparities is unclear. We evaluated the association between EMS agency variation in adherence to the transport recommendations in the Universal Termination of Resuscitation (TOR) Rule and survival after OHCA. Methods: We conducted a secondary analysis of the Resuscitation Outcomes Consortium Epistry. We included adults (≥ 18 years) with OHCA for whom EMS providers attempted resuscitation from 2011 through 2015. The main exposure was the proportion of patients for whom the Universal TOR Rule recommended transport (i.e., meeting any one of the following criteria, EMS-witnessed arrest; return of spontaneous circulation prior to transport; or shock delivery prior to transport) among those transported to hospitals, at the level of EMS agency. We then categorized EMS agencies into quartiles. Our primary outcome was survival to hospital discharge. We used multilevel modified Poisson regression model, including patient-level and EMS-level covariates with patients nested within EMS agencies. Results: We included 42,584 EMS-treated OHCAs from 112 EMS agencies. The median proportion of patients for whom the TOR rule recommended transport among those transported was 88.2% (interquartile range [IQR] 76.1-96.7) across EMS agencies. Compared with the patients treated at EMS agencies in the quartile of the lowest proportion (the median proportion 66.7%[ IQR 50.9-71.7]), survival to hospital discharge was associated with treatment at EMS agencies in the second quartile (the median proportion 83.0% [IQR 79.8-85.3]) (adjusted risk ratio [aRR] 1.12, 95% confidence interval [CI] 0.96-1.31), the third quartile (the median proportion 93.0% [IQR 89.7-95.6]) (aRR 1.58, 95% CI 1.32-1.87), and the fourth quartile (the median proportion 100% [IQR 98.5-100]) (aRR 1.86, 95% CI 1.59-2.19). Conclusions: In this large cohort study of adult patients with OHCA, treatment at EMS agencies with higher proportion of patients who met transport criteria of the Universal TOR rule among transported patients was associated with survival to hospital discharge.