Emergency Medical Services Response Time Research Articles

Do Modifications of the American Heart Association Guidelines Improve Survival of Patients with Out-of-Hospital Cardiac Arrest?

Major predictors of survival of patients with out-of-hospital primary cardiac arrest are witnessed collapse and a shockable rhythm. Since early bystander initiated resuscitation efforts prolong the electrical or shockable phase of untreated ventricular fibrillation, areas with higher rates of early-onset bystander resuscitation efforts and shorter emergency medical services (EMS) response times have higher survival rates.1,2 These areas enjoyed and enjoy acceptable survival rates by following the American Heart Association Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC),3,4 hereafter referred to as “guidelines.” However, because these 2 survival criteria (early bystander CPR and rapid EMS response times) are not present in most areas, the survival of individuals with out-of-hospital cardiac arrest (OHCA) overall remains suboptimal.5,6 Article see p 2597 In an effort to improve survival, chest compressions only for bystanders was advocated in the 1990s, and modifications of the 2000 guidelines for EMS providers were instituted by the Sarver Heart Center Resuscitation Research Group in 2003.7–11 The major elements of the EMS modifications were (1) eliminating the decades-long emphasis on early intubation and positive pressure ventilations, (2) eliminating the recommendation for immediate defibrillation and the use of stacked shocks, (3) eliminating all unnecessary interruptions of chest compressions, and (4) advocating chest compressions before and immediately after a single defibrillation shock, and the early administration of epinephrine. This approach for patients with OHCA was called cardiocerebral resuscitation. 8 to differentiate it from cardiopulmonary resuscitation , which we think should be reserved for cardiac arrest secondary to respiratory arrest or failure. Our first 2 outcomes reports using cardiocerebral resuscitation were published by Kellum and associates.12,13 In the first report from Rock and Walworth counties in Wisconsin, survival of patients with OHCA and an initially shockable rhythm was 18/92 (20%) …

Overall Asessment of the Response to Terrorist Bombings in Trains, Madrid, 11 March 2004.

To provide an overall assessment of the response to the terrorist bombings in Madrid, 11 March 2004, which were considered the deadliest terrorist attack on European soil in modern times. Overall data on the number of victims treated at the scenes and at primary care facilities and hospitals, as well as the logistics involved, were reported by the EMS and the Health Authority of the Comunidad de Madrid local government. Data were mainly obtained by retrospective chart review, and did not include casualties who had only emotional shock, superficial bruises or transient hearing loss from barotraumas without eardrum perforation. We defined as critical any casualty with an Injury Severity Score (ISS) >15. Over 70,000 personnel were mobilized in the care of the victims. EMS response and total evacuation times at the four blast scenes averaged 7 and 99 min, respectively. There were around 2,000 casualties, and a typical bimodal distribution of deaths, with 177 immediate fatalities and 14 subsequent in-hospital deaths. Almost 60% of casualties were taken to the two closest hospitals. Problems related to security, identification of casualties and record-keeping were encountered at the closest hospital. Closed doors increased the immediate fatality rate in the trains. Most survivors had noncritical injuries, but 14% of the 512 casualties assessed had an ISS >15. The critical mortality rate was 19.5%. The most frequently injured body regions were the head/neck and face. In all, 124 major surgical interventions were performed on 82 victims in the first 24 h, and orthopedic trauma procedures accounted for 50% of the case load. Most patients with lung injuries from the blasts required intubation and mechanical ventilation, and their survival rate was 88.3%. Also, 35% of laparotomies were either negative or nontherapeutic. There was a rapid EMS response and evacuation, but also overtriage, uneven distribution of casualties and difficulties in communication. The sizes and resources of the closest hospitals, as well as the early hour, were probably decisive in the adequacy of the overall response.

Direct Paramedic Transport of Acute Myocardial Infarction Patients to Percutaneous Coronary Intervention Centers: A Decision Analysis

One potential strategy in the emergency medical services (EMS) care of acute ST-segment elevation myocardial infarction (STEMI) is to bypass the nearest community hospital in favor of a more distant specialty center able to perform primary percutaneous coronary intervention. We seek to determine whether EMS transport of out-of-hospital STEMI patients directly to more distant specialty percutaneous coronary intervention centers will alter 30-day survival compared with transport to the nearest community hospital fibrinolytic therapy. This decision analysis used parameter values and ranges from meta-analyses and North American clinical studies of STEMI and chest pain care published after 2001. The primary hypothetical interventions were primary percutaneous coronary intervention versus community hospital-delivered fibrinolytic therapy. We defined total STEMI treatment time as the sum of symptom duration, EMS response time, EMS scene time, EMS transport time to the nearest community hospital, additional EMS transport time to a more distant percutaneous coronary intervention center, and door-to-drug or door-to-balloon time. We related total STEMI treatment time to the primary outcome 30-day post-STEMI survival. We assumed that the closest specialty percutaneous coronary intervention centers were located farther than the nearest community hospital and that patients would receive primary percutaneous coronary intervention at specialty centers and fibrinolytic therapy at community hospitals. We assumed the use of ground transportation only and excluded situations with fibrinolytic therapy contraindications. We examined standard risk and best-case scenarios for each intervention, as well as changes in predicted risk with parameter value variations. Baseline total treatment times (chest pain onset to intervention) were percutaneous coronary intervention 188 minutes (range 41 to 447 minutes) and community hospital fibrinolytic therapy 118 minutes (range 51 to 267 minutes). Thirty-day survival was higher for standard percutaneous coronary intervention than standard community hospital fibrinolytic therapy (95.8% versus 93.8%; relative risk [RR] 1.021; number needed to treat 50) but lower when compared to best-case community hospital fibrinolytic therapy (95.8% versus 97.8%; RR 0.980; number needed to harm 50). Best-case percutaneous coronary intervention was equivalent to best-case community hospital fibrinolytic therapy (RR 1.000). In 1-way sensitivity analyses, best-case community hospital fibrinolytic therapy versus standard percutaneous coronary intervention was sensitive to treatment time parameter variations. Probabilistic sensitivity analysis favored standard percutaneous coronary intervention over standard community hospital fibrinolytic therapy (RR=1.020; 95% probability range 1.002 to 1.045) but did not indicate a favored strategy for the other scenarios. In select out-of-hospital STEMI care scenarios, EMS transport of acute STEMI patients directly to percutaneous coronary intervention centers may offer small but uncertain survival benefits over nearest community hospital fibrinolytic therapy.

The impact of prehospital transport interval on survival in out-of-hospital cardiac arrest: Implications for regionalization of post-resuscitation care

There is growing evidence that therapeutic hypothermia and other post-resuscitation care improves outcomes in out-of-hospital cardiac arrest (OHCA). Thus, transporting patients with return of spontaneous circulation (ROSC) to specialized facilities may increase survival rates. However, it is unknown whether prolonging transport to reach a designated facility would be detrimental. Data from OHCA patients treated in EMS systems that cover approximately 70% of Arizona's population were evaluated (October 2004-December 2006). We analyzed the association between transport interval (depart scene to ED arrival) and survival to hospital discharge in adult, non-traumatic OHCA patients and in the subgroup who achieved ROSC and remained comatose. 1846 OHCA occurred prior to EMS arrival. Complete transport interval data were available for 1177 (63.8%) patients (study group). 253 patients (21.5%) achieved ROSC and remained comatose making them theoretically eligible for transport to specialized care. Overall, 70 patients (5.9%) survived and 43 (17.0%) comatose ROSC patients survived. Mean transport interval for the study group was 6.9 min (95% CI: 6.7, 7.1). Logistic regression revealed factors that were independently associated with survival: witnessed arrest, bystander CPR, method of CPR, initial rhythm of ventricular fibrillation, and shorter EMS response time interval. There was no significant association between transport interval and outcome in either the overall study group (OR=1.2; 0.77, 1.8) or in the comatose, ROSC subgroup (OR 0.94; 0.51, 1.8). Survival was not significantly impacted by transport interval. This suggests that a modest increase in transport interval from bypassing the closest hospital en route to specialized care is safe and warrants further investigation.

Does increased emergency medical services prehospital time affect patient mortality in rural motor vehicle crashes? A statewide analysis

Background Fatality rates from rural vehicular trauma are almost double those found in urban settings. It has been suggested that increased prehospital time is a factor that adversely affects fatality rates in rural vehicular trauma. By linking and analyzing Alabama's statewide prehospital data, emergency medical services (EMS) prehospital time was assessed for rural and urban vehicular crashes. Methods An imputational methodology permitted linkage of data from police motor vehicle crash (MVC) and EMS records. MVCs were defined as rural or urban by crash location using the United States Census Bureau criteria. Areas within Alabama that fell outside the Census Bureau definition of urban were defined as rural. Prehospital data were analyzed to determine EMS response time, scene time, and transport time in rural and urban settings. Results Over a 2-year period from January 2001 through December 2002, data were collected from EMS Patient Care Reports and police crash reports for the entire state of Alabama. By using an imputational methodology and join specifications, 45,763 police crash reports were linked to EMS Patient Care Reports. Of these, 34,341 (75%) were injured in rural settings and 11,422 (25%) were injured in urban settings. A total of 714 mortalities were identified, of which 611 (1.78%) occurred in rural settings and 103 (.90%) occurred in urban settings ( P < .0001). When mortalities occurred, the mean EMS response time in rural settings was 10.67 minutes and 6.50 minutes in urban settings ( P < .0001). When mortalities occurred, the mean EMS scene time in rural settings was 18.87 minutes and 10.83 minutes in urban settings (patients who were dead on scene and extrication patients were excluded from both settings) ( P < .0001). When mortalities occurred, the mean EMS transport time in rural settings was 12.45 minutes and 7.43 minutes in urban settings ( P < .0001). When mortalities occurred, the overall mean prehospital time in rural settings was 42.0 minutes and 24.8 minutes in urban settings ( P < .0001). The mean EMS response time for rural MVCs with survivors was 8.54 minutes versus a mean of 10.67 minutes with mortalities ( P < .0001). The mean EMS scene time for rural MVCs with survivors was 14.81 minutes versus 18.87 minutes with mortalities (patients who were dead on scene and extrication patients were excluded) ( P = .0014). Conclusions Based on this statewide analysis of MVCs, increased EMS prehospital time appears to be associated with higher mortality rates in rural settings.

New and Fringe Residential Development and Emergency Medical Services Response Times in the United States

Much has been written over the years about longer emergency medical services (EMS) response times in rural areas as opposed to urban areas. Yet within urban areas, outside of case studies of certain cities, not much has been written about longer EMS response times in newer, fringe suburban or ex-urban areas. Examining first the largest county within each metro area and next the municipalities and unincorporated areas of all of the counties of metropolitan areas, the findings of this exploratory research note show that the density and age of different residential areas or jurisdictions explain some of the variation in average EMS response times between urban and suburban or ex-urban locations. Holding other things constant, those who live in more sparsely settled and newer developments tend to have longer waiting times for EMS. The implications for regional growth management are discussed.

Outcomes of pediatric trauma patients transported from rural and urban scenes

Objectives Mortality differences exist between victims of urban and rural trauma. It is unknown if these differences persist in those patients who survive to HEMS transport. This study examined the in-hospital mortality, hospital LOS, and discharge status of pediatric blunt trauma victims transported by HEMS from rural and urban scenes. Methods Retrospective review of pediatric (< 17) transports between 1997 and 2001. 130 rural and 419 urban pediatric patients transported to area trauma centers were identified from HEMS and registry records. Results Total mileage, flight times, and scene times were significantly longer for rural flights ( P < 0.05). There were no significant differences between the groups with regard to age, gender, vitals, hospital/ICU days, and mortality. After controlling for ISS and mechanism of injury, urban patients were 9 times more likely to die compared to rural patients. Conclusions Pediatric patients injured in urban areas had shorter total flight and scene times than pediatric patients flown from rural scenes. Higher adjusted in-hospital mortality rates in the urban group were likely a result of faster EMS response and transport times, which minimized out-of-hospital deaths. Factors prior to HEMS arrival may have more impact on the increased mortality rates of rural blunt trauma victims documented nationally.

An observational study describing the geographic-time distribution of cardiac arrests in Singapore: What is the utility of geographic information systems for planning public access defibrillation? (PADS Phase I)

Public access defibrillation (PAD) has shown potential to increase cardiac arrest survival rates. To describe the geographic epidemiology of prehospital cardiac arrest in Singapore using geographic information systems (GIS) technology and assess the potential for deployment of a PAD program. We conducted an observational prospective study looking at the geographic location of pre-hospital cardiac arrests in Singapore. Included were all patients with out-of-hospital cardiac arrest (OHCA) presented to emergency departments. Patient characteristics, cardiac arrest circumstances, emergency medical service (EMS) response and outcomes were recorded according to the Utstein style. Location of cardiac arrests was spot-mapped using GIS. From 1 October 2001 to 14 October 2004, 2428 patients were enrolled into the study. Mean age for arrests was 60.6 years with 68.0% male. 67.8% of arrests occurred in residences, with 54.5% bystander witnessed and another 10.5% EMS witnessed. Mean EMS response time was 9.6 min with 21.7% receiving prehospital defibrillation. Cardiac arrest occurrence was highest in the suburban town centers in the Eastern and Southern part of the country. We also identified communities with the highest arrest rates. About twice as many arrests occurred during the day (07:00-18:59 h) compared to night (19:00-06:59 h). The categories with the highest frequencies of occurrence included residential areas, in vehicles, healthcare facilities, along roads, shopping areas and offices/industrial areas. We found a definite geographical distribution pattern of cardiac arrest. This study demonstrates the utility of GIS with a national cardiac arrest database and has implications for implementing a PAD program, targeted CPR training, AED placement and ambulance deployment.

Update on Sideline and Event Preparation for Management of Sudden Cardiac Arrest in Athletes

Sudden death in athletes occurs approximately once every 3 days in the United States. Each school or venue should have an emergency action plan that is coordinated with local emergency medical services (EMS). Access to early defibrillation to treat sudden cardiac arrest (SCA) is critical. If EMS response times are greater than 3 to 5 minutes from collapse to first shock, an on-site automated external defibrillator (AED) should be available. Delays in recognition of SCA in athletes occur commonly. Any collapsed and unresponsive athlete should be considered to be in cardiac arrest and an AED should be applied for rhythm analysis as soon as possible. Cardiopulmonary resuscitation should be provided while waiting for an AED and interruptions in chest compressions should be minimized. Rehearsal of the emergency action plan with potential first responders is essential to ensuring an efficient response to SCA in athletics.

Update on sideline and event preparation for management of sudden cardiac arrest in athletes

Sudden death in athletes occurs approximately once every 3 days in the United States. Each school or venue should have an emergency action plan that is coordinated with local emergency medical services (EMS). Access to early defibrillation to treat sudden cardiac arrest (SCA) is critical. If EMS response times are greater than 3 to 5 minutes from collapse to first shock, an on-site automated external defibrillator (AED) should be available. Delays in recognition of SCA in athletes occur commonly. Any collapsed and unresponsive athlete should be considered to be in cardiac arrest and an AED should be applied for rhythm analysis as soon as possible. Cardiopulmonary resuscitation should be provided while waiting for an AED and interruptions in chest compressions should be minimized. Rehearsal of the emergency action plan with potential first responders is essential to ensuring an efficient response to SCA in athletics.

Suburban sprawl: Where does emergency medicine fit on the map?

The built environments of the American suburbs stretch out from cities resembling “the end of a Scrabble game,” but these spacious suburban dreamscapes create havoc for emergency care. In some sense, the scattered environs and the high-speed arteries that connect them created the specialty of emergency medicine and laid the groundwork for emergency medical services. The landmark 1966 National Academy of Science’s report Accidental Death and Disability: The Neglected Disease of Modern Society was largely in response to automobile accidents and the then-nonexistent emergency care system. The notion was reinforced in 2006’s Institute of Medicine report titled The Future of Emergency Care in the United States Health Care System, which criticized the stillfragmented nature of trauma care.

Ex-Urban Sprawl as a Factor in Traffic Fatalities and EMS Response Times in the Southeastern United States

Many writers have covered the negative consequences of sprawl on community life and urban development in the US over the years. This paper looks at how sprawl impacts traffic fatalities and EMS response times in the Southeastern United States.

Are There Racial Disparities in Emergency Medical Services? Evidence from Mississippi

This paper analyzes the existence and scope of possible racial disparities in Emergency Medical Services using cardiac related incidence-level data for the state of Mississippi during 1995-2004. We use incidence-level EMS data through the Mississippi Emergency Medical Services Information System (MEMSIS) collected by the Mississippi Department of Health. Demographic data from the U.S. Census Bureau, the Bureau of Labor Statistics, and the U.S. Department of Commerce. Heart disease rates from the Center for Disease Control and Prevention. We estimate the relationships between race and two key measures of the quality of EMS - response time and respondent training - controlling for a variety of demographic and EMS organizational features that plausibly affect these performance measures. We also estimate models of the probability that the victim has already died when EMS arrives. Our study focuses on EMS incidents from 1995 to 2004 for which the initial call was related to cardiac problems for individuals aged 90 or below, including all calls made from a residence or public place. We select all cardiac-related EMS incidences between 1995 and 2004 from the Mississippi Emergency Medical Services Information System (MEMSIS). We exclude Inter-facility transfers (e.g. between extended care facilities and doctors' offices and clinics). We merge the MEMSIS data with county level demographics based on the caller's county. Our analysis provides little or no evidence of race-related disparities in EMS response time or quality of the responders. The only exception is for the population over 80 years old, where the evidence is relatively weak and plausibly related to imperfect controls for population density. In the case of response time, the evidence indicates faster response times for African Americans when we control for population density at the county level (population per square mile) only. However, when we include a county-level measure of population density that incorporates differences in African-American and white population density by census tract, the negative disparity in response times disappears. We find no economically or statistically significant difference in mean response time or the frequency of responses of eight minutes or below for African-Americans versus whites. Our analysis of possible differences in the likelihood of death-on-arrival at the scene provides some evidence that African-Americans on average are more likely to have died than whites. This paper provides little evidence of race-related disparities in EMS and highlights the importance of properly controlling for own-race density measures. Evidence of race-related disparities in EMS response time for population over 80 years old is weak and plausibly related to imperfect controls for population density and disparities in living arrangements. Evidence that African-Americans on average are more likely to have died when EMS arrives at the scene may reflect differences in episode severity or possibly longer durations between the onset of symptoms and initiation of calls.

Rescuer Fatigue: Standard versus Continuous Chest‐Compression Cardiopulmonary Resuscitation

Continuous chest-compression cardiopulmonary resuscitation (CCC-CPR) has been advocated as an alternative to standard CPR (STD-CPR). Studies have shown that CCC-CPR delivers substantially more chest compressions per minute and is easier to remember and perform than STD-CPR. One concern regarding CCC-CPR is that the rescuer may fatigue and be unable to maintain adequate compression rate or depth throughout an average emergency medical services response time. The specific aim of this study was to compare the effects of fatigue on the performance of CCC-CPR and STD-CPR on a manikin model. This was a prospective, randomized crossover study involving 53 medical students performing CCC-CPR and STD-CPR on a manikin model. Students were randomized to their initial CPR group and then performed the other type of CPR after a period of at least two days. Students were evaluated on their performance of 9 minutes of CPR for each method. The primary endpoint was the number of adequate chest compressions (at least 38 mm of compression depth) delivered per minute during each of the 9 minutes. The secondary endpoints were total compressions, compression rate, and the number of breaks taken for rest. The students' performance was evaluated on the basis of Skillreporter Resusci Anne (Laerdal, Wappingers Falls, NY) recordings. Primary and secondary endpoints were analyzed by using the generalized linear mixed model for counting data. In the first 2 minutes, participants delivered significantly more adequate compressions per minute with CCC-CPR than STD-CPR, (47 vs. 32, p = 0.004 in the 1st minute and 39 vs. 29, p = 0.04 in the 2nd minute). For minutes 3 through 9, the differences in number of adequate compressions between groups were not significant. Evaluating the 9 minutes of CPR as a whole, there were significantly more adequate compressions in CCC-CPR vs. STD-CPR (p = 0.0003). Although the number of adequate compressions per minute declined over time in both groups, the rate of decline was significantly greater in CCC-CPR compared with STD-CPR (p = 0.0003). The mean number of total compressions delivered in the first minute was significantly greater with CCC-CPR than STD-CPR (105 per minute vs. 58 per minute, p < 0.001) and did not change over 9 minutes in either group. There were no differences in compression rates or number of breaks between groups. CCC-CPR resulted in more adequate compressions per minute than STD-CPR for the first 2 minutes of CPR. However, the difference diminished after 3 minutes, presumably as a result of greater rescuer fatigue with CCC-CPR. Overall, CCC-CPR resulted in more total compressions per minute than STD-CPR during the entire 9 minutes of resuscitation.

Increased Mortality in Rural Vehicular Trauma: Identifying Contributing Factors Through Data Linkage

Fatality rates from rural vehicular trauma are almost double those found in urban settings. Causes of this difference in rural and urban trauma fatality rates have yet to be fully explored. The purpose of this study is to identify prehospital causes of the higher rural fatality rates by linking, analyzing, and comparing prehospital data for rural and urban vehicular crashes. A probabilistic algorithm was developed that permitted linkage of data from police motor vehicle crash reports, and from Emergency Medical Service (EMS), and hospital records. Motor vehicle crashes (MVCs) were defined as rural or urban by location of the crash using the United States Bureau of Census criteria. Areas that fell outside that urban definition were defined as rural. Linked data were analyzed to identify factors that were thought to be associated with the higher mortality rates observed in rural settings. During the 20-month period from November 2001 through May 2003, data were collected from police crash reports and EMS Patient Care Reports (PCRs) within seven counties in southwest Alabama. Using high probability match criteria and join specifications, 4,694 police crash reports were linked to EMS PCRs. Of these, 3,068 patients (65.4%) were injured in rural settings, and 1,626 (34.6%) were injured in urban settings. A total of 164 (3.5%) mortalities were identified. A total of 129 (4.2%) mortalities occurred in a rural setting and 35 (2.1%) were urban (p = 0.0001). Of the 129 rural deaths, 91 (70.5%) were dead on scene (DOS) and of 35 urban deaths, 20 (57.1%) were DOS (p < 0.0001). Mean EMS response time for rural MVCs with survivors was 11.2 minutes versus a mean of 13.9 minutes for rural MVC with survivors (p < 0.0002). When survivors were involved, mean EMS response time for an urban setting was 6.8 minutes versus 13.9 minutes for a rural setting (p < 0.0001). In a rural setting, mean EMS distance to the scene when patients were alive was 7.7 miles versus 10.5 miles when patients were DOS (p < 0.001). For patients who died after transfer from the scene, mean rural EMS time on scene was 16.1 minute versus 11.6 minutes in an urban setting (p < 0.04). In a setting of rural MVC, increased EMS response time, time on scene and distance to the scene are associated with higher rural trauma mortality rates.

Differences in Emergency Medical Services Response Time Based upon Dispatch Procedure

Differences in Emergency Medical Services Response Time Based upon Dispatch Procedure

The Prehospital Emergency Care System in Mexico City: A System's Performance Evaluation

Mexico City has one of the highest mortality rates in Mexico, with non-intentional injuries as a leading cause of death among persons 1-44 years of age. Emergency medical services (EMS) in Mexico can achieve high levels of efficiency by offering high quality medical care at a low cost through adequate system design. The objective of this study was to determine whether the prehospital EMS system in Mexico City meets the criteria standards established by the American Ambulance Association Guide for Contracting Emergency Medical Services (AAA Guide) for highly efficient EMS systems. This retrospective, descriptive study, evaluated the structure of Mexico City's EMS system and analyzed EMS response times, clinical capacity, economic efficiency, and customer satisfaction. These results were compared with the AAA guide, according to the soc ial, economic, and political context in Mexico. This paper describes the healthcare system structure in Mexico, followed by a description of the basic structure of EMS in Mexico City, and of each tenet described in the AAA guide. The p aper includesdata obtained from official documents and databases of government agencies, and operative and administrative data from public and private EMS providers. The quality of the data for response times (RT) were insufficient and widely varied among providers, with a minimum RT of 6.79 minutes (min) and a maximum RT of 61 min. Providers did not define RT clearly, and measured it with averages, which can hide potentially poor performance practices. Training institutions are not required to follow a standardized curriculum. Certifications are the responsibility of the individual training centers and have no government regulation. There was no evidence of active medical control involvement in direct patient care, and providers did not report that quality assurance programs were in place. There also are limited career advancement opportunities for EMS personnel. Small economies of scale may not allow providers to be economically efficient, unit hours are difficult to calculate, and few economic data are available. There is no evidence of customer satisfaction data. Emergency medical services in Mexico City did not meet the AAA requirements for high-quality, prehospital, emergency care. Coordination among EMS providers is difficult to achieve, due, in part, to the lack of: (1) an authoritative structure; (2) sound system design; and (3) appropriate legislation. The government, EMS providers, stakeholders, and community members should work together to build a high quality EMS system at the lowest possible cost.

Delaying shock for cardiopulmonary resuscitation: does it save lives?

Out-of-hospital cardiac arrest claims more than 450,000 lives annually in North America. Many communities have dedicated significant resources to provide rapid defibrillator response for patients in ventricular fibrillation. In spite of these efforts, mortality from out-of-hospital cardiac arrest has not improved significantly. Emerging evidence suggests some patients in ventricular fibrillation arrest may be harmed by immediate defibrillation. Recent laboratory studies have shown benefit in performing a period of chest compressions (cardiopulmonary resuscitation) prior to defibrillation in models with more than 4 minutes of induced ventricular fibrillation. During the initial 4 minutes the heart is more amenable to electrical defibrillation. Between 4-10 minutes, chest compressions create some coronary perfusion and fill the left ventricle to prepare the heart for electric shock. These findings, in conjunction with most emergency medical service response times reported to be 5-8 minutes, have prompted human investigation into a strategy of chest compression first. A recent randomized controlled trial reported a fivefold increase in survival for patients with more than 5 minutes of VF who received 3 minutes of chest compressions prior to defibrillation compared with those who had not. Current guidelines call for rapid defibrillation as the most important 'link' in the 'chain of survival'. For most ventricular fibrillation patients who have professional rescuers arrive after 5-8 minutes of ventricular fibrillation, however, immediate defibrillation is likely to be ineffective. Counterintuitively, these patients may benefit from a period of chest compressions prior to being shocked.

Sudden Cardiac Death in Division I Collegiate Athletics

To determine current outcomes of automated external defibrillator (AED) interventions in sports medicine programs in National Collegiate Athletic Association (NCAA) division I athletics. Qualitative scripted telephone interview with all positive responders to prior NCAA division I-wide study on AED utilization and implementation. NCAA division I sports medicine programs. Head athletic trainers were the main data source. All positive responders to a previously published study on AED implementation in the NCAA division I sports medicine community. Positive responders were those that indicated that they had used their departmental AEDs in a sudden cardiac death (SCD) scenario. Survival to hospital discharge was the main outcome sought. When available, additional outcomes were time to defibrillation, time to notification of athletic training staff, EMS response time, location of event, and sudden cardiac victim type (i.e., student, coach, fan). Sixteen departments that previously reported having had an SCD event at their institution responded to this follow-up telephone survey. Twenty percent of AED uses were attributed to student athletes, with 33% of utilizations for athletic department staff and 47% for fans. Defibrillation was actually administered in 53% of AED unit applications. Time to shock was an average of 3.4 minutes, with average EMS response time of 8.2 minutes for those events without EMS on site. Reported survival to hospital discharge in this university athletic department setting for SCD was 0% for students, 75% for staff, 57% for fans, and 61% overall. The results of this study demonstrate the need for NCAA division 1 athletic sports medicine programs to examine, and possibly expand, the traditional scope of practice of caring primarily for student athletes to include the larger community of sports participants comprised of athletes, departmental staff, and spectators. Athletic department AED programs were extremely successfully at increasing survival of SCD far above national prehospital standards, mainly in the nonathletic population. Further study is also necessary in the realm of AED placement, maintenance, and training of staff.

Termination of Resuscitative Efforts for Out-of-hospital Cardiac Arrests

To determine the rate of termination of resuscitative efforts for out-of-hospital cardiac arrest patients and whether variability exists among different base hospitals providing online medical control (OLMC). This was an observational one-year study that included all adult patients in the city of Los Angeles with nontraumatic, out-of-hospital cardiac arrests with attempted resuscitative efforts by paramedics. OLMC was provided by 13 base hospitals. The main outcome measure was the incidence of termination of resuscitative efforts on scene as directed by OLMC. Of 1,700 patients, 151 (9%) had resuscitative efforts terminated on scene via direction by OLMC. Patients pronounced on scene were statistically more likely to be older, be found in an extended care facility, have an unwitnessed arrest, and present in asystole. Two base hospitals were more likely to terminate resuscitative efforts via OLMC than all others. Incidence at base hospital A was 37% (odds ratio, 18.6; 95% confidence interval = 11.7 to 30.0; p < 0.0001); incidence at base hospital B was 14% (odds ratio, 3.3; 95% confidence interval = 1.9 to 5.5; p < 0.0001), and incidence at all other base hospitals was 5%. Cardiac arrest patients handled by base hospital A were more likely to be found in ventricular fibrillation; those patients handled by base hospital B had shorter emergency medical services response times and were more likely to be found in an extended care facility. All other characteristics of cardiac arrest patients were not significantly different among the base hospitals. There is significant variability in Los Angeles, depending on the particular base hospital that provides OLMC, in pronouncement of death and termination of resuscitative efforts for medical cardiac arrest in the field. Given potential ethical, logistical, and economic concerns, efforts to assure consistency in the practice of discontinuing resuscitative efforts in the field is warranted.