EMS World

JAN 2018

EMS World Magazine is the most authoritative source in the world for clinical and educational material designed to improve the delivery of prehospital emergency medical care.

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20 JANUARY 2018 | EMSWORLD.com T his month we discuss an interest- ing study recently published in the Journal of the American Heart Association. This is a fantastic manuscript—before now we really didn't have many studies that evaluated data on very large patient populations. Most use data from studies of regions, communities, or research networks (which are essentially collaborative agreements between hos- pitals, EMS agencies, and/or universities across regions, states, and sometimes coun- tries to work together on specific research initiatives). While these studies contribute to our over- all knowledge on their topics, their results often aren't generalizable. In other words, the results represent just that studied popula- tion, and we can't assume they would be the same if the study were performed in another location or with a different population. This is likely one of the reasons why the Institute of Medicine called for the development of a nationally representative cardiac arrest registry. This study examined data from the Car- diac Arrest Registry to Enhance Survival (CARES). Some of you reading this likely have entered data into CARES. CARES col- lects data from dispatch, EMS, and hospitals about out-of-hospital cardiac arrest (OHCA) patients. One of the most impressive aspects of CARES is that data is linked, so we can understand what happens to OHCA patients throughout the continuum of care. This study used data from Arizona, Min- nesota, North Carolina, Pennsylvania, and Washington, the first five states to collect CARES data. The study period was from January 1, 2011 to December 31, 2015. Patients eligible for inclusion were adults in a pulse- less state from a presumed cardiac etiology. Arrests could not be due to trauma, and the patient had to have received CPR by EMS and/or defibrillation or a shock from an AED. All OHCA rhythms were assessed. The authors also separately assessed a subgroup of patients that had bystander-witnessed OHCAs with initially shockable rhythms. This was called the Utstein subgroup. Outcomes There were a few outcomes of interest. First the authors wanted to understand the percentage of total OHCA cases they were capturing with CARES data. They did this by first estimating how many OHCAs they believed occurred in each state based on population; then they divided the number of OHCA cases in the CARES registry by this estimate to calculate the percentage. The authors also wanted to evaluate whether bystander CPR was provided, whether a bystander applied the AED, if targeted tem- perature management was performed, if the patient survived to hospital discharge, and if the patient had good functional status at hospital discharge. To address their outcomes of interest, the authors used a variety of statistical methods. They calculated descriptive statistics, used linear and logistic regression, and performed a Mantel-Haenszel test of trend. We lack space in this column to explain each of these tests, but based on the types of data avail- able and the study objectives, they appear to be the appropriate statistical tests. During the study period there were 66,306 patients treated for OHCA. There were 1,318 patients who were excluded from the study either because they were less than 18 years old (1,165) or didn't have survival data avail- able (153). Those with missing outcome data were younger, had bystander- or EMS- witnessed OHCAs in public locations, and had initial shockable rhythms. Remember this; it will help put these results into context. In total 64,988 patients were included in the all-rhythm OHCA population, and 10,046 patients in the Utstein subgroup. The overall population was mostly male (62.9%), with a median age of 65.7 years. Overall 41.2% of the OHCAs were witnessed by a bystander. Some of the results were pretty encourag- ing: From 2011 to 2015 there was more than a twofold increase in the percentage of OHCA cases captured in the CARES registry (39.0% to 89.2%). So, all of you who have been dili- gently entering data into CARES, well done! Keep up the good work. Over the entire study period, the rate of Look for PCRF research podcasts based on the topics featured in this column at www.pcrfpodcast.org. OHCA Survival: Is It Improving Or Not? REVIEWED THIS MONTH Multistate 5-Year Initiative to Improve Care for Out- of-Hospital Cardiac Arrest: Primary Results From the HeartRescue Project Authors: van Diepen S, Girotra S, Abella BS, et al. Published in: J Am Heart Assoc, 2017 Sep 22; 6(9). Missing data may hold the key to deciphering a discouraging finding By Antonio R. Fernandez, PhD, NRP, FAHA THE TRIP REPORT: TURNING RESEARCH INTO PRACTICE

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