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Emergency system prospective performance evaluation for cardiac arrest in Lombardia, an Italian region
Resuscitation 55 (2002) 247 /254 www.elsevier.com/locate/resuscitation
Emergency system prospective performance evaluation for cardiac arrest in Lombardia, an Italian region G. Citerio a,, D. Galli a, G.C. Cesana b, M. Bosio c, M. Landriscina d, M. Raimondi e, G.P. Rossi a,f, A. Pesenti a,g a
Dipartimento di Anestesia e Rianimazione, Azienda Ospedale San Gerardo di monza, Nuovo Ospedale San Gerardo, Via Donizetti, 106, 20052 Monza (MI), Italy b Unita` di Medicina del Lavoro, Azienda Ospedale San Gerardo di Monza, 20052 Monza, Italy c Direzione Generale Sanita`, Regione Lombardia, Milan, Italy d S.S.U.Em. 118 Como, Azienda Ospedaliera Sant’Anna Como, Como, Italy e S.S.U.Em. 118 Pavia, IRCCS Policlinico San Matteo Pavia, Pavia, Italy f S.S.U.Em. 118 Brianza, Brianza, Italy g Universita` Milano Bicocca, Milan, Italy Received 26 February 2002; received in revised form 8 April 2002; accepted 17 July 2002
Abstract Background: The aim of this research is to evaluate quality of out-of-hospital medical services in our country, using performance indicators and a new computerised database. Methods: (a) Experimental design: Data were collected prospectively in three emergency dispatch centres for 90 days. Follow-up was evaluated at 1 day and 1 month after the event. This paper presents data on the cardiac arrest cohort only. (b) Setting: Three emergency dispatch centres in Lombardia. (c) Patients: One hundred and seventyeight patients in non-traumatic cardiac arrest were enrolled. (d) Interventions: None. The study was observational only. Results: Mean interval between phone call and arrival on scene was 8.59/3.5 min. BLS manoeuvres were carried out from bystanders only in 15% of the cohort; this was associated with significant mortality reduction (85.7 versus 95.8%, x2 P B/0.05). One hundred and thirtythree patients (75%) received assistance from BLS crews while only 45 patients (25%) were assisted by ALS medical personel, with a significant mortality reduction (ALS deaths 86.7%, BLS deaths 97%). Total 24 h survival was 9% and survival at 1 month declined to 6.17%. Conclusions: Quality monitoring produces objective information on interventions and outcomes. Only with this information, is it possible to implement improvement programmes that are planned according to the data presented. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Cardiac arrest; Emergency medical services; Resuscitation; Outcome
Resumo Contexto: Poucos dados esta˜o disponı´veis, no nosso paı´s, relativos a´ qualidade dos sistemas de emergeˆncia. O objectivo deste estudo e´ avaliar a qualidade dos servic¸os me´dicos extra-hospitalares utilizando indicadores de desempenho e uma nova base de dados computadorizada. Me´todos: (a) Desenho experimental: Os dados foram coligidos prospectivamente em treˆs centros de orientac¸a˜o de emergeˆncia durante 90 dias. A evoluc¸a˜o foi avaliada um dia e 1 meˆs apo´s o evento. Este artigo apresenta apenas os dados do coorte com paragem cardı´aca. (b) Local: Treˆs centros de orientac¸a˜o de emergeˆncia na Lombardia. (c) Doentes: Foram envolvidos 178 doentes com paragem cardı´aca na˜o associada a trauma. (d) Intervenc¸o˜es: Nenhuma. O estudo foi apenas observacional. Resultados: O intervalo me´dio entre a chamada telefo´nica e a chegada ao local foi de 8.59/3.5 min. Estavam a ser prestadas manobras de SBV pelas testemunhas em apenas 15 % do coorte; este dado associou-se a uma reduc¸a˜o significativa da mortalidade (85.7 versus 95.8%, x2 P B/0.05). Cento e trinta e treˆs doentes (75%) receberam assisteˆncia por equipes de SBV enquanto 45 doentes (25%) foram assistidos por pessoal me´dico com qualificac¸a˜o em SAV, com uma reduc¸a˜o significativa da
Corresponding author. Tel.: /39-039-2333293; fax: /39-039-2332297 E-mail address: [email protected] (G. Citerio). 0300-9572/02/$ - see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 0 0 - 9 5 7 2 ( 0 2 ) 0 0 2 6 7 - 8
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mortalidade (mortes com SAV 86.7%, mortes com SBV 97%). A sobreviveˆncia total a`s 24h foi de 9% e diminuiu para 6.17% ao fim de 30 dias. Concluso˜es: a monitorizac¸a˜o da qualidade produz informac¸a˜o objectiva sobre as intervenc¸o˜es e resultados. Apenas com esta informac¸a˜o e´ possı´vel implementar programas de melhoria que sa˜o planeados de acordo com os dados apresentados. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Palavras chave: Paragem cardı´aca; Servic¸os de Emergeˆncia Me´dica; Ressuscitac¸a˜o
Resumen Antecedentes : En nuestro paı´s existen pocos datos disponibles acerca de la calidad de los sistemas de emergencia. El objetivo de esta investigacio´n es evaluar la calidad de los servicios me´dicos prehospitalarios, usando indicadores de desempen˜o y una nueva base de datos computarizada. Me´todos : (a) Disen˜o experimental: Se recolectaron prospectivamente los datos en tres centros de despacho durante 90 dı´as. Se realizo´ una evaluacio´n de seguimiento al dı´a y al mes despue´s del evento. Este artı´culo presenta datos en cohorte de paro cardı´aco solamente. (b) escenario : Tres centros de despacho de emergencias en Lombardı´a. (c) Pacientes : Se enrolaron 178 pacientes en paro cardı´aco no trauma´tico. (d) Intervenciones :Ninguna. El estudio fue solamente observacional. Resultados : El intervalo promedio entre llamada telefo´nica y llegada a la escena fue 8.59/3.5 min. Se realizaron maniobras de soporte vital ba´sico por testigos solamente en un 15% de la cohorte; esto se asocio´ con reduccio´n significativa de la mortalidad (85.7 versus 95.8%, x2 P B/0.05). Ciento treinta y tres pacientes (75%) recibieron asistencia de equipos de soporte vital ba´sico(BLS), mientras que solo 45 pacientes (25%) fueron asistidos por personal de salud de soporte vital avanzado (ALS), con una reduccio´n significativa de la mortalidad (ALS 86.7% muertes, BLS 97% muertes). La sobrevida total a las 24 horas fue de 9% y declino hasta 6.17 al mes. Conclusiones : El monitoreo de la calidad produce informacio´n objetiva acerca de las intervenciones y los resultados. Solo con esta informacio´n, es posible implementar programas de mejorı´a planificados de acuerdo a los datos presentados. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Palabras clave: Paro cardı´aco; Servicios de Emergencias me´dicas; Resucitacio´n; Resultados
1. Introduction Out of hospital cardiac arrest, despite the relatively widespread use of cardiopulmonary resuscitation (CPR), still carries a very high mortality [1 /37]. Outcome is strongly related to the quality of pre-hospital treatment [38 /43]. This is emphasised in the chain-ofsurvival concept (early access, early CPR, early defibrillation and early advanced care) [44 /58]. First, the bystander should call for help (in Italy by dialling 118, which alerts the emergency system). Second, CPR should be started and maintained until advanced help arrives. Third, defibrillation should be available on scene as soon as possible and shocks performed if indicated. Defibrillation [59 /69] is the definitive therapy for ventricular fibrillation and pulseless ventricular tachycardia. The sooner defibrillation occurs, the higher the likelihood of survival. Fourth, medications and advanced care (definitive airway control, usually by tracheal intubation, and ventilation) should be provided. If all four links of the chain come together quickly, the chances of successful resuscitation are maximised [70]. Communities in which the chain of survival is best organised show the best survival rates, ranging from 4 to 33%. Other factors [70] influencing survival include whether or not the collapse was witnessed, the underlying health status of the patient, and the associated rhythm. For Lombardia, an Italian Region, no information is available about the quality and outcome of pre-hospital emergency care of cardiac arrest victims. In the last 10
years, the regional public health administration has directed considerable economic and professional investment to provide an improved emergency medical system to an increasing number of patients. Between 1992 and 1998, 12 dispatch centres (so called ‘Centrali 118’) have been activated to cover the entire Lombardia region, which extends over an area of 23,859 km2, mainly plain, but bounded by the Alps mountains in the northern area. The population amounts to 9.065.440 inhabitants, with an average density of 380 people per square kilometre (ranging from a maximum of 1.895 people per square kilometre in the urban area to 55 people per square kilometre in the mountain area). All the dispatch centres are hospital based and coordinated by trained physicians from the Anaesthesia and Intensive Care Department. After the early phase, in which the effort was to tune-up the system, ALS and BLS crews have been allocated to cover the territory. Attention has been recently focused on the quality of the emergency system performance; IRER (Istituto Regionale di Ricerca, a regional research institute) has commissioned a study to assess the quality of out-ofhospital interventions that focused on three acute medical conditions (non-traumatic cardiac arrest, severe head injury, chest pain). At the time this study was carried out, there were 83 BLS vehicles staffed by lay-volunteers crews, 14 ALS vehicles with at least a professional nurse, 36 ALS vehicles with a physician on crew and 4 ALS helicopters with a physician on board, in the regional area.
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This paper presents only data related to non-traumatic cardiac arrest and analyses the performance of the Lombardia emergency system; quality indicators derived from international literature were used.
2. Materials and method 2.1. System configuration For feasibility reasons, the study was conducted in three Lombardia 118-dispatch-centres based on Pavia, Como and Monza hospitals. These sites were selected from the 12 118-dispatch-centres for their different geographical and demographic characteristics; 994.612 inhabitants in the 118-Monza, 528.496 in 118-Como and 490.666 in 118-Pavia. Pavia is located in an agricultural area; Como is in a territory with lakes and mountains; while Monza is mainly an urban-industrialised district on the northern boundary of Milan metropolitan area. The population covered represented more than 20% of the whole Region. When 118-dispatch-centres are activated for suspected cardiac arrest, different kinds of ambulance-crews may be dispatched. Volunteers, that are trained to perform BLS manoeuvres but not allowed to defibrillate or to apply ALS protocols, compose the BLS crews. Advanced care is performed only by ALS crews composed of nurses and/or emergency physicians.
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development phases, discussing all details from the concept to completion of the data collection and analysis. 2.2.2. Software interface The software was developed by two of the authors (GC and DG) using File Maker Pro, version 4 (Claris Corporation, Santa Clara, CA, USA). The latest version was a run-time version produced using File Maker Pro SDK (Claris Solution Alliance, Claris Corporation, Santa Clara, CA, USA) running on Macintosh or Window-based computers. The database captured 41 items of information. Each group of information was presented on a single screen. Buttons were used to allow simple ‘navigation’ through the different parts of the database. A manual was written, containing definitions and clinical examples for every field. The manual has been incorporated in the software and printed as a booklet. Data were sent by e-mail as electronic sheets. 2.3. Inclusion and exclusion criteria All confirmed cases of out-of-hospital cardiac arrest in the area covered by the three dispatch-centres were eligible for inclusion in the data collection. Cases of cardiac arrest younger than 18 years, with signs of irreversible death or due to non-cardiac origin (terminal illness, trauma, primary respiratory arrest, overdose, upper airway obstruction and drowning) were excluded.
2.2. Data collection 2.4. Outcome tracking Data collection was carried out February 1st to April 30th 2000 database, which included quality from international literature. The applied.
prospectively from using a dedicated indicators derived Utstein style was
The primary end point was death at different time intervals (on the scene, at emergency department, at hospital discharge and at 1 month). 2.5. Statistical analysis
2.2.1. Design of the database The data collection form was designed for use with a computer interface and was composed of four different computer screen layouts covering: 1) General data (demographic data and times of interventions), 2) Pre-hospital data and treatment, 3) Hospital data and treatment, 4) Data on outcome. Assistance was offered by a help-section included in the database, which provided a complete on-line codebook. Every layout had a specific help-page describing the design, the purpose of the page and definitions of every field. Practical examples were included, describing the most common situations and errors. A committee, composed of the database authors, supervised all the
The methods used are largely descriptive. All summary data are expressed as mean9/standard deviation (SD). Means were compared by analysis of variance. Differences in proportions were analysed by the x2-test. A level of P B/0.05 was considered significant.
3. Results 3.1. Epidemiology One hundred and seventy-eight cardiac arrests of cardiac aetiology were included in the data-collection. The three dispatch centres enrolled differently: Como 86 (48.6%); Monza 54 (30.5%); and Pavia 37 patients (20.9%).
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Mean age was 70.29/15 years (median 72, minimum 18, maximum 96). No age difference was noted between the 1-month-non-survivors (mean 70.49/15 years, median 72 years) and 1-month-survivors (mean 66.19/18 years, median 70 years, NS). A greater proportion of males was observed (male/ female ratio /2:1). The mean age of the female cohort was higher (75.29/14 years versus male 67.79/15 years; P 5/0.05). Nevertheless, the female mortality at 1 month was lower (89.3 versus 96.6%; x2-test P 5/0.05). This difference seems not to be related to presentation rhythms, which were uniformly distributed between male and female (Table 1). As indicated in Table 2, cardiac arrest occurred mainly at home (75.2% of the patients, survival rate at 1 month 4.47%), indoor public places (6.74% of the patients, survival rate at 1 month 16.66%), outdoor public places (6.74% of the patients, survival rate at 1 month 14.28%). The event was witnessed in the 72% of the cases; there was no statistical difference in 1-month survival between witnessed (mortality 92.8%) and non-witnessed cardiac arrests (mortality 97.9%), even if the presence of a witness was associated with a trend towards the better outcome. Lay people witnesses started CPR in only 15% of the witnessed cardiac arrests. Analysing only witnessed arrest patients, CPR by lay people significantly reduced mortality at 1 month (no CPR 95.1% versus CPR 84.6%, x2-test P 5/0.05).
Table 2 Distribution of places of occurrence of cardiac arrest with survival rate at 1 month
Home Indoor public places Working places Outdoor public places Other places
Total
Dead
Alive
134 12 4 14 14
128 10 4 12 13
6 2 0 2 1
(4.47%) (16.66%) (0%) (14.28%) (7.14%)
x2-test P NS.
3.3. Time-intervals Time intervals from the 178 calls were recorded: . Mean interval between call and activation of the ambulance was 2.09/1.6 min. . Mean interval between call and departure of the ambulance was 3.69/2.0 min. . Mean interval between call and arrival on scene of the ambulance was 8.59/3.5 min (median, 8 min; minimum, 3 min; maximum 22 min). In 75% of the cases, an ambulance was on scene within 10 min from the call to the 118-dispatch centre. . Median interval between call and arrival at the hospital (Emergency Department) was 329/15 min. 3.4. Presenting rhythm
One hundred and thirty-three patients (75%) were treated by a BLS crew while 45 patients (25%) received ALS treatment. No differences in the time of interval between the call and arrival at the scene were recorded between BLS and ALS crews (mean 89/3 min in both groups, NS). A significant difference was noticed (x2test P 5/0.05), in terms of survival rates, between patients treated by BLS (mortality at 1 month 97%) and those treated by ALS teams (mortality at 1 month 86.7%).
Table 3 shows the different presenting rhythms with the associated mortality rate. Very frequently (69%), no cardiac rhythm was documented or asystole was described. As shown, ventricular fibrillation, an indicator for fast activation of the emergency system, though not frequent (21%) and correlates with a significantly better survival at 1 month (ventricular fibrillation survival rate 15.8%, asystole survival rate 1.61%). Survival at 1 month decreases gradually in relation with the time required to achieve a return of spontaneous circulation (ROSC), if ever achieved. In fact, if ROSC is achieved on the scene or during the transport to the hospital, the mortality rate is 70%, while it is 95% if the patient arrives at hospital still in cardiac arrest.
Table 1 Distributions of presenting rhythms between sexes
Table 3 Presenting rhythm on the scene and outcome at 1 month
3.2. Emergency medical system
Asystole Ventricular fibrillation Not revealed PEA and bradiasystole Ventricular tachycardia Total x2-test NS.
Male
Female
Total
39 (32.8%) 26 (21.8%) 43 (36.1%) 9 (7.56%) 2 (1.68%) 119 (100%)
23 (39%) 12 (20.3%) 19 (32.2%) 5 (8.47%) 0 (0%) 59 (100%)
62 38 62 14 2 178 (100%)
Asystole Ventricular fibrillation Not revealed PEA and bradyasystole Ventricular tachycardia Total x2-test P 5 0.05.
Dead (%)
Alive (%)
Total
61 (98.4) 32 (84.2) 59 (95.2) 14 (100) 2 (100) 168 (94.4)
1 (1.61) 6 (15.8) 3 (4.84) 0 0 10 (5.62)
62 38 62 14 2 178
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3.5. Procedures at the scene
4.1. Early access
Procedures performed at the scene were evaluated. Tracheal intubation was performed in the 35% of the total cohort (85% of the patients treated by an ALS crew). Inspired air oxygen enrichment was frequently used (91% of the patients) by BLS as well as ALS crews. The ALS team delivered electric shocks in 92.1% (35/ 38) patients found in VF and in 100% (2/2) of the patients found in pulseless-TV.
In our Region an ambulance is activated in 2.09/1.6 min after the call and is on scene in 8.59/3.5 min after the call. These intervals can be considered, in relation to traffic and geographic conditions, adequate. Nevertheless, specific interventions should be implemented in order to improve community awareness of the importance of early activation of the emergency system. Until now, no educational intervention have been planned for this first link in the chain of survival. 4.2. Early CPR
3.6. Outcome Seventy-four patients (41.5%) died at the scene, 77 patients (43.2%) were transported to the hospital still in cardiac arrest, 24 patients (13.4%) had a ROSC on scene and three patients (1.6%) had ROSC during the transfer to the hospital. In 24 h, 160 patients (90.9%) were dead. The total survival rate in 24 h was 9%, while the 1-month survival rate was 6.17%. We also analysed survival rate in relation to the specific dispatch-centre. As shown by Table 4, one of the three dispatch-centres (named as ‘c’) achieved a better survival rate even if did not reach a statistical significance due to the small sample size. Epidemiological data, presenting rhythms and timing of interventions were similar between the three dispatch-centres. The only difference noticed was the higher employment of ALS crews (a, 24%; b, 13%; c, 42%; x2-test P 5/0.05).
4. Discussion These data come from a prospective database prepared in Lombardia with the aim of evaluating the quality of the pre-hospital emergency system. It was set up after the definition of quality indicators derived from the emergency literature [38 /43]. Data should be analysed in the light of the concept of the ‘ chain of survival’ [44 /58].
4.3. Early defibrillation Early defibrillation has been clearly proved to be effective in a number of studies [59 /69]. Literature showed that for people found in VF, the time to defibrillation is the best predictor of good outcome. During our data collection, law restrictions allowed only physicians to use defibrillators. None of the patients recorded was defibrillated before the arrival of an emergency crew. The application of new law, recently approved, that allow the use of AED by non-physicianfirst-responders, should augment the number of patients treated by defibrillation, when this specific treatment is required, it must be in an acceptable time from the collapse. 4.4. Early advanced care
Table 4 Outcome at 1 month related to the dispatch-centre Dispatch-centre
Dead (%)
Alive (%)
a b c
96.5 95.9 86.5
3.53 4.08 13.5
x2-test NS.
Even though the arrest was witnessed in 72% of cases, only a minority (15%) of them received some sort of CPR performed by bystanders. Even if the cohort is very small, the patients who received ‘some CPR’ from bystanders presented a reduced mortality. Eighty-five percent of the witnessed arrests received first CPR at the arrival of the emergency crew (8.59/3.5 min after the collapse). The mean time to beginning CPR-manoeuvres is, certainly late in the light of the information from the literature: survival rate declines rapidly during each minute passing without CPR. This is confirmed by the low survival rate of these patients (4.9%). New strategies should be planned to disseminate CPR knowledge to lay people though as CPR training programmes especially targeting relatives of high-risk patients.
Treatment by an ALS crew, involving the use of drugs and airways adjuncts, was performed only in a quarter of the patients. No information is available on the criteria of ALS activation or on the availability around the clock of ALS crews. However, the use of ALS was associated with a better clinical outcome and a better
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survival rate was noticed by the dispatch-centre with a higher number of patients treated by an ALS crew. Few rhythms were documented on the scene; between these, a low proportion was composed by ventricular fibrillations (indicator of a fast intervention) and so few could be defibrillated. Unfortunately, a high proportion of patients were transported still in cardiac arrest. This mirrors the high proportion of patients treated by BLS crews that in the absence of a medical person, transport the patient to the hospital performing CPR. We showed an unfavourable outcome associated with this policy. The low (6.17%) 1-month survival rate is the unequivocal sign of a quality that has to be improved. This aim could be reached by analysing all the links in the chain of survival, as we did, and planning interventions aimed to optimise each step.
Acknowledgements We gratefully acknowledge the medical and nurse personnel of the three dispatch-centres that collaborated in this data collection (118 Como, 118 Monza Brianza, 118 Pavia). This research received a grant from IRER, Regional Research Institute, of Lombardia Region, Italy.
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[43] Cummins RO, Eisenberg MS. Prehospital cardiopulmonary resuscitation. Is it effective? J Am Med Assoc 1985;253(16):2408 /12April 26 (No abstract available). [44] Ewy GA. Cardiopulmonary resuscitation: strengthening the links in the chain of survival. Md Med. 2001 Spring; Suppl:8 /11. [45] Jacobs I, Callanan V, Nichol G, Valenzuela T, Mason P, Jaffe AS, Landau W, Vetter N. The chain of survival. Ann Emerg Med 2001;37(4):S5 /S16 (April). [46] Several authors: Part 12: from science to survival. Strengthening the chain of survival in every community. European Resuscitation Council. Resuscitation. 2000 August 23;46(1 /3): 417 /430. [47] Gullo A, Sallusti R, Trillo G. The chain of survival. A review in year 2000. Minerva Anestesiol 2000;66(7 /8):503 /16 (July /August). [48] Ewy GA. Cardiopulmonary resuscitation */strengthening the links in the chain of survival. N Engl J Med 2000;342(21):1599 / 601 (May 25). [49] Kuisma M. Lengthening the chain of survival. Ann Emerg Med 1998;32(5):636 /7 (November). [50] Stratton S, Niemann JT. Effects of adding links to ‘the chain of survival’ for prehospital cardiac arrest: a contrast in outcomes in 1975 and 1995 at a single institution. Ann Emerg Med 1998;31(4):471 /7 (April). [51] Wilson EM. The weakest link in the chain of survival? J Emerg Nurs 1998;24(1):69 /70 (February). [52] Newman M. The chain of survival revisited. The emergence of early recognition as the unsung vital link, J Emerg Med Serv JEMS. 1998 May; 23(5):46 /50, 52, 54 /56. [53] Hay DR. Strengthening the chain of survival. N Z Med J 1993;106(965):425 /6 (October 13). [54] Stiell IG. Cardiac arrest in your community: are there weak links in the chain of survival? CMAJ 1993;149(5):563 /5 (September 1). [55] Cummins RO. Emergency medical services and sudden cardiac arrest: the ‘chain of survival’ concept. Annu Rev Public Health 1993;14:313 /33. [56] Montgomery WH. Prehospital cardiac arrest: the chain of survival concept. Ann Acad Med Singapore 1992;21(1):69 /72 (January). [57] Cummins RO. The ‘chain of survival’ concept: how it can save lives. Heart Dis Stroke 1992;1(1):43 /5 (January /February). [58] Cummins RO, Ornato JP, Thies WH, Pepe PE. Improving survival from sudden cardiac arrest: the ‘chain of survival’ concept. A statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Association. Circulation 1991;83(5):1832 /47May (Review). [59] Gratton M, Lindholm DJ, Campbell JP. Public-access defibrillation: where do we place the AEDs? Prehosp Emerg Care 1999;3(4):303 /35 (October /December). [60] Stiell IG, Wells GA, Field BJ, Spaite DW, De Maio VJ, Ward R, Munkley DP, Lyver MB, Luinstra LG, Campeau T, Maloney J, Dagnone E. Improved out-of-hospital cardiac arrest survival through the inexpensive optimization of an existing defibrillation program: OPALS study phase II. Ontario prehospital advanced life support. J Am Med Assoc 1999;281(13):1175 /81 (April 7). [61] Stiell IG, Wells GA, DeMaio VJ, Spaite DW, Field BJ, Munkley DP, Lyver MB, Luinstra LG, Ward R. Modifiable factors associated with improved cardiac arrest survival in a multicenter basic life support/defibrillation system: OPALS Study Phase I results. Ontario prehospital advanced life support. Ann Emerg Med 1999;33(1):44 /50 (January). [62] Ho J, Held T, Heegaard W, Crimmins T. Automatic external defibrillation and its effects on neurologic outcome in cardiac arrest patients in an urban, two-tiered EMS system. Prehosp Disaster Med 1997;12(4):284 /7 (October /December). [63] Kaye W, Mancini ME, Giuliano KK, Richards N, Nagid DM, Marler CA, Sawyer-Silva S. Strengthening the in-hospital chain of
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survival with rapid defibrillation by first responders using automated external defibrillators: training and retention issues. Ann Emerg Med 1995;25(2):163 /8 (February). [64] Sanders AB, Berg RA, Burress M, Genova RT, Kern KB, Ewy GA. The efficacy of an ACLS training program for resuscitation from cardiac arrest in a rural community. Ann Emerg Med 1994;23(1):56 /9 (January). [65] Schrading WA, Stein S, Eitel DR, Grove L, Horner L, Steckert G, Sabulsky NK, Ogden CS, Hess DR. An evaluation of automated defibrillation and manual defibrillation by emergency medical technicians in a rural setting. Am J Emerg Med 1993;11(2):125 / 30 (March). [66] Hargarten KM, Stueven HA, Waite EM, Olson DW, Mateer JR, Aufderheide TP, Darin JC. Prehospital experience with defibrillation of coarse ventricular fibrillation: a 10-year review. Ann Emerg Med 1990;19(2):157 /62 (February).
[67] Olson DW, LaRochelle J, Fark D, Aprahamian C, Aufderheide TP, Mateer JR, Hargarten KM, Stueven HA. MT-defibrillation: the Wisconsin experience. Ann Emerg Med 1989;18(8):806 /11 (August). [68] Hunt RC, McCabe JB, Hamilton GC, Krohmer JR. Influence of emergency medical services systems and prehospital defibrillation on survival of sudden cardiac death victims. Am J Emerg Med 1989;7(1):68 /82 (January). [69] Gentile D, Auerbach P, Gaffron J, Foon G, Phillips J, Jr.. Prehospital defibrillation by emergency medical technicians. Results of a pilot study in Tennessee. J Tenn Med Assoc 1988;81(3):144 /8 (March). [70] Schuttler J, Bartsch AC, Bremer F, Ebeling BJ, Fodisch M, Kulka P, Pflitsch D. The efficiency of prehospital cardiopulmonary resuscitation. Which factors determine the outcome? Anasth Intensivther Notfallmed 1990;25(5):340 /7 (October).
Emergency system prospective performance evaluation for cardiac arrest in Lombardia, an Italian region G. Citerio a,, D. Galli a, G.C. Cesana b, M. Bosio c, M. Landriscina d, M. Raimondi e, G.P. Rossi a,f, A. Pesenti a,g a
Dipartimento di Anestesia e Rianimazione, Azienda Ospedale San Gerardo di monza, Nuovo Ospedale San Gerardo, Via Donizetti, 106, 20052 Monza (MI), Italy b Unita` di Medicina del Lavoro, Azienda Ospedale San Gerardo di Monza, 20052 Monza, Italy c Direzione Generale Sanita`, Regione Lombardia, Milan, Italy d S.S.U.Em. 118 Como, Azienda Ospedaliera Sant’Anna Como, Como, Italy e S.S.U.Em. 118 Pavia, IRCCS Policlinico San Matteo Pavia, Pavia, Italy f S.S.U.Em. 118 Brianza, Brianza, Italy g Universita` Milano Bicocca, Milan, Italy Received 26 February 2002; received in revised form 8 April 2002; accepted 17 July 2002
Abstract Background: The aim of this research is to evaluate quality of out-of-hospital medical services in our country, using performance indicators and a new computerised database. Methods: (a) Experimental design: Data were collected prospectively in three emergency dispatch centres for 90 days. Follow-up was evaluated at 1 day and 1 month after the event. This paper presents data on the cardiac arrest cohort only. (b) Setting: Three emergency dispatch centres in Lombardia. (c) Patients: One hundred and seventyeight patients in non-traumatic cardiac arrest were enrolled. (d) Interventions: None. The study was observational only. Results: Mean interval between phone call and arrival on scene was 8.59/3.5 min. BLS manoeuvres were carried out from bystanders only in 15% of the cohort; this was associated with significant mortality reduction (85.7 versus 95.8%, x2 P B/0.05). One hundred and thirtythree patients (75%) received assistance from BLS crews while only 45 patients (25%) were assisted by ALS medical personel, with a significant mortality reduction (ALS deaths 86.7%, BLS deaths 97%). Total 24 h survival was 9% and survival at 1 month declined to 6.17%. Conclusions: Quality monitoring produces objective information on interventions and outcomes. Only with this information, is it possible to implement improvement programmes that are planned according to the data presented. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Cardiac arrest; Emergency medical services; Resuscitation; Outcome
Resumo Contexto: Poucos dados esta˜o disponı´veis, no nosso paı´s, relativos a´ qualidade dos sistemas de emergeˆncia. O objectivo deste estudo e´ avaliar a qualidade dos servic¸os me´dicos extra-hospitalares utilizando indicadores de desempenho e uma nova base de dados computadorizada. Me´todos: (a) Desenho experimental: Os dados foram coligidos prospectivamente em treˆs centros de orientac¸a˜o de emergeˆncia durante 90 dias. A evoluc¸a˜o foi avaliada um dia e 1 meˆs apo´s o evento. Este artigo apresenta apenas os dados do coorte com paragem cardı´aca. (b) Local: Treˆs centros de orientac¸a˜o de emergeˆncia na Lombardia. (c) Doentes: Foram envolvidos 178 doentes com paragem cardı´aca na˜o associada a trauma. (d) Intervenc¸o˜es: Nenhuma. O estudo foi apenas observacional. Resultados: O intervalo me´dio entre a chamada telefo´nica e a chegada ao local foi de 8.59/3.5 min. Estavam a ser prestadas manobras de SBV pelas testemunhas em apenas 15 % do coorte; este dado associou-se a uma reduc¸a˜o significativa da mortalidade (85.7 versus 95.8%, x2 P B/0.05). Cento e trinta e treˆs doentes (75%) receberam assisteˆncia por equipes de SBV enquanto 45 doentes (25%) foram assistidos por pessoal me´dico com qualificac¸a˜o em SAV, com uma reduc¸a˜o significativa da
Corresponding author. Tel.: /39-039-2333293; fax: /39-039-2332297 E-mail address: [email protected] (G. Citerio). 0300-9572/02/$ - see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 0 0 - 9 5 7 2 ( 0 2 ) 0 0 2 6 7 - 8
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mortalidade (mortes com SAV 86.7%, mortes com SBV 97%). A sobreviveˆncia total a`s 24h foi de 9% e diminuiu para 6.17% ao fim de 30 dias. Concluso˜es: a monitorizac¸a˜o da qualidade produz informac¸a˜o objectiva sobre as intervenc¸o˜es e resultados. Apenas com esta informac¸a˜o e´ possı´vel implementar programas de melhoria que sa˜o planeados de acordo com os dados apresentados. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Palavras chave: Paragem cardı´aca; Servic¸os de Emergeˆncia Me´dica; Ressuscitac¸a˜o
Resumen Antecedentes : En nuestro paı´s existen pocos datos disponibles acerca de la calidad de los sistemas de emergencia. El objetivo de esta investigacio´n es evaluar la calidad de los servicios me´dicos prehospitalarios, usando indicadores de desempen˜o y una nueva base de datos computarizada. Me´todos : (a) Disen˜o experimental: Se recolectaron prospectivamente los datos en tres centros de despacho durante 90 dı´as. Se realizo´ una evaluacio´n de seguimiento al dı´a y al mes despue´s del evento. Este artı´culo presenta datos en cohorte de paro cardı´aco solamente. (b) escenario : Tres centros de despacho de emergencias en Lombardı´a. (c) Pacientes : Se enrolaron 178 pacientes en paro cardı´aco no trauma´tico. (d) Intervenciones :Ninguna. El estudio fue solamente observacional. Resultados : El intervalo promedio entre llamada telefo´nica y llegada a la escena fue 8.59/3.5 min. Se realizaron maniobras de soporte vital ba´sico por testigos solamente en un 15% de la cohorte; esto se asocio´ con reduccio´n significativa de la mortalidad (85.7 versus 95.8%, x2 P B/0.05). Ciento treinta y tres pacientes (75%) recibieron asistencia de equipos de soporte vital ba´sico(BLS), mientras que solo 45 pacientes (25%) fueron asistidos por personal de salud de soporte vital avanzado (ALS), con una reduccio´n significativa de la mortalidad (ALS 86.7% muertes, BLS 97% muertes). La sobrevida total a las 24 horas fue de 9% y declino hasta 6.17 al mes. Conclusiones : El monitoreo de la calidad produce informacio´n objetiva acerca de las intervenciones y los resultados. Solo con esta informacio´n, es posible implementar programas de mejorı´a planificados de acuerdo a los datos presentados. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Palabras clave: Paro cardı´aco; Servicios de Emergencias me´dicas; Resucitacio´n; Resultados
1. Introduction Out of hospital cardiac arrest, despite the relatively widespread use of cardiopulmonary resuscitation (CPR), still carries a very high mortality [1 /37]. Outcome is strongly related to the quality of pre-hospital treatment [38 /43]. This is emphasised in the chain-ofsurvival concept (early access, early CPR, early defibrillation and early advanced care) [44 /58]. First, the bystander should call for help (in Italy by dialling 118, which alerts the emergency system). Second, CPR should be started and maintained until advanced help arrives. Third, defibrillation should be available on scene as soon as possible and shocks performed if indicated. Defibrillation [59 /69] is the definitive therapy for ventricular fibrillation and pulseless ventricular tachycardia. The sooner defibrillation occurs, the higher the likelihood of survival. Fourth, medications and advanced care (definitive airway control, usually by tracheal intubation, and ventilation) should be provided. If all four links of the chain come together quickly, the chances of successful resuscitation are maximised [70]. Communities in which the chain of survival is best organised show the best survival rates, ranging from 4 to 33%. Other factors [70] influencing survival include whether or not the collapse was witnessed, the underlying health status of the patient, and the associated rhythm. For Lombardia, an Italian Region, no information is available about the quality and outcome of pre-hospital emergency care of cardiac arrest victims. In the last 10
years, the regional public health administration has directed considerable economic and professional investment to provide an improved emergency medical system to an increasing number of patients. Between 1992 and 1998, 12 dispatch centres (so called ‘Centrali 118’) have been activated to cover the entire Lombardia region, which extends over an area of 23,859 km2, mainly plain, but bounded by the Alps mountains in the northern area. The population amounts to 9.065.440 inhabitants, with an average density of 380 people per square kilometre (ranging from a maximum of 1.895 people per square kilometre in the urban area to 55 people per square kilometre in the mountain area). All the dispatch centres are hospital based and coordinated by trained physicians from the Anaesthesia and Intensive Care Department. After the early phase, in which the effort was to tune-up the system, ALS and BLS crews have been allocated to cover the territory. Attention has been recently focused on the quality of the emergency system performance; IRER (Istituto Regionale di Ricerca, a regional research institute) has commissioned a study to assess the quality of out-ofhospital interventions that focused on three acute medical conditions (non-traumatic cardiac arrest, severe head injury, chest pain). At the time this study was carried out, there were 83 BLS vehicles staffed by lay-volunteers crews, 14 ALS vehicles with at least a professional nurse, 36 ALS vehicles with a physician on crew and 4 ALS helicopters with a physician on board, in the regional area.
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This paper presents only data related to non-traumatic cardiac arrest and analyses the performance of the Lombardia emergency system; quality indicators derived from international literature were used.
2. Materials and method 2.1. System configuration For feasibility reasons, the study was conducted in three Lombardia 118-dispatch-centres based on Pavia, Como and Monza hospitals. These sites were selected from the 12 118-dispatch-centres for their different geographical and demographic characteristics; 994.612 inhabitants in the 118-Monza, 528.496 in 118-Como and 490.666 in 118-Pavia. Pavia is located in an agricultural area; Como is in a territory with lakes and mountains; while Monza is mainly an urban-industrialised district on the northern boundary of Milan metropolitan area. The population covered represented more than 20% of the whole Region. When 118-dispatch-centres are activated for suspected cardiac arrest, different kinds of ambulance-crews may be dispatched. Volunteers, that are trained to perform BLS manoeuvres but not allowed to defibrillate or to apply ALS protocols, compose the BLS crews. Advanced care is performed only by ALS crews composed of nurses and/or emergency physicians.
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development phases, discussing all details from the concept to completion of the data collection and analysis. 2.2.2. Software interface The software was developed by two of the authors (GC and DG) using File Maker Pro, version 4 (Claris Corporation, Santa Clara, CA, USA). The latest version was a run-time version produced using File Maker Pro SDK (Claris Solution Alliance, Claris Corporation, Santa Clara, CA, USA) running on Macintosh or Window-based computers. The database captured 41 items of information. Each group of information was presented on a single screen. Buttons were used to allow simple ‘navigation’ through the different parts of the database. A manual was written, containing definitions and clinical examples for every field. The manual has been incorporated in the software and printed as a booklet. Data were sent by e-mail as electronic sheets. 2.3. Inclusion and exclusion criteria All confirmed cases of out-of-hospital cardiac arrest in the area covered by the three dispatch-centres were eligible for inclusion in the data collection. Cases of cardiac arrest younger than 18 years, with signs of irreversible death or due to non-cardiac origin (terminal illness, trauma, primary respiratory arrest, overdose, upper airway obstruction and drowning) were excluded.
2.2. Data collection 2.4. Outcome tracking Data collection was carried out February 1st to April 30th 2000 database, which included quality from international literature. The applied.
prospectively from using a dedicated indicators derived Utstein style was
The primary end point was death at different time intervals (on the scene, at emergency department, at hospital discharge and at 1 month). 2.5. Statistical analysis
2.2.1. Design of the database The data collection form was designed for use with a computer interface and was composed of four different computer screen layouts covering: 1) General data (demographic data and times of interventions), 2) Pre-hospital data and treatment, 3) Hospital data and treatment, 4) Data on outcome. Assistance was offered by a help-section included in the database, which provided a complete on-line codebook. Every layout had a specific help-page describing the design, the purpose of the page and definitions of every field. Practical examples were included, describing the most common situations and errors. A committee, composed of the database authors, supervised all the
The methods used are largely descriptive. All summary data are expressed as mean9/standard deviation (SD). Means were compared by analysis of variance. Differences in proportions were analysed by the x2-test. A level of P B/0.05 was considered significant.
3. Results 3.1. Epidemiology One hundred and seventy-eight cardiac arrests of cardiac aetiology were included in the data-collection. The three dispatch centres enrolled differently: Como 86 (48.6%); Monza 54 (30.5%); and Pavia 37 patients (20.9%).
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Mean age was 70.29/15 years (median 72, minimum 18, maximum 96). No age difference was noted between the 1-month-non-survivors (mean 70.49/15 years, median 72 years) and 1-month-survivors (mean 66.19/18 years, median 70 years, NS). A greater proportion of males was observed (male/ female ratio /2:1). The mean age of the female cohort was higher (75.29/14 years versus male 67.79/15 years; P 5/0.05). Nevertheless, the female mortality at 1 month was lower (89.3 versus 96.6%; x2-test P 5/0.05). This difference seems not to be related to presentation rhythms, which were uniformly distributed between male and female (Table 1). As indicated in Table 2, cardiac arrest occurred mainly at home (75.2% of the patients, survival rate at 1 month 4.47%), indoor public places (6.74% of the patients, survival rate at 1 month 16.66%), outdoor public places (6.74% of the patients, survival rate at 1 month 14.28%). The event was witnessed in the 72% of the cases; there was no statistical difference in 1-month survival between witnessed (mortality 92.8%) and non-witnessed cardiac arrests (mortality 97.9%), even if the presence of a witness was associated with a trend towards the better outcome. Lay people witnesses started CPR in only 15% of the witnessed cardiac arrests. Analysing only witnessed arrest patients, CPR by lay people significantly reduced mortality at 1 month (no CPR 95.1% versus CPR 84.6%, x2-test P 5/0.05).
Table 2 Distribution of places of occurrence of cardiac arrest with survival rate at 1 month
Home Indoor public places Working places Outdoor public places Other places
Total
Dead
Alive
134 12 4 14 14
128 10 4 12 13
6 2 0 2 1
(4.47%) (16.66%) (0%) (14.28%) (7.14%)
x2-test P NS.
3.3. Time-intervals Time intervals from the 178 calls were recorded: . Mean interval between call and activation of the ambulance was 2.09/1.6 min. . Mean interval between call and departure of the ambulance was 3.69/2.0 min. . Mean interval between call and arrival on scene of the ambulance was 8.59/3.5 min (median, 8 min; minimum, 3 min; maximum 22 min). In 75% of the cases, an ambulance was on scene within 10 min from the call to the 118-dispatch centre. . Median interval between call and arrival at the hospital (Emergency Department) was 329/15 min. 3.4. Presenting rhythm
One hundred and thirty-three patients (75%) were treated by a BLS crew while 45 patients (25%) received ALS treatment. No differences in the time of interval between the call and arrival at the scene were recorded between BLS and ALS crews (mean 89/3 min in both groups, NS). A significant difference was noticed (x2test P 5/0.05), in terms of survival rates, between patients treated by BLS (mortality at 1 month 97%) and those treated by ALS teams (mortality at 1 month 86.7%).
Table 3 shows the different presenting rhythms with the associated mortality rate. Very frequently (69%), no cardiac rhythm was documented or asystole was described. As shown, ventricular fibrillation, an indicator for fast activation of the emergency system, though not frequent (21%) and correlates with a significantly better survival at 1 month (ventricular fibrillation survival rate 15.8%, asystole survival rate 1.61%). Survival at 1 month decreases gradually in relation with the time required to achieve a return of spontaneous circulation (ROSC), if ever achieved. In fact, if ROSC is achieved on the scene or during the transport to the hospital, the mortality rate is 70%, while it is 95% if the patient arrives at hospital still in cardiac arrest.
Table 1 Distributions of presenting rhythms between sexes
Table 3 Presenting rhythm on the scene and outcome at 1 month
3.2. Emergency medical system
Asystole Ventricular fibrillation Not revealed PEA and bradiasystole Ventricular tachycardia Total x2-test NS.
Male
Female
Total
39 (32.8%) 26 (21.8%) 43 (36.1%) 9 (7.56%) 2 (1.68%) 119 (100%)
23 (39%) 12 (20.3%) 19 (32.2%) 5 (8.47%) 0 (0%) 59 (100%)
62 38 62 14 2 178 (100%)
Asystole Ventricular fibrillation Not revealed PEA and bradyasystole Ventricular tachycardia Total x2-test P 5 0.05.
Dead (%)
Alive (%)
Total
61 (98.4) 32 (84.2) 59 (95.2) 14 (100) 2 (100) 168 (94.4)
1 (1.61) 6 (15.8) 3 (4.84) 0 0 10 (5.62)
62 38 62 14 2 178
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3.5. Procedures at the scene
4.1. Early access
Procedures performed at the scene were evaluated. Tracheal intubation was performed in the 35% of the total cohort (85% of the patients treated by an ALS crew). Inspired air oxygen enrichment was frequently used (91% of the patients) by BLS as well as ALS crews. The ALS team delivered electric shocks in 92.1% (35/ 38) patients found in VF and in 100% (2/2) of the patients found in pulseless-TV.
In our Region an ambulance is activated in 2.09/1.6 min after the call and is on scene in 8.59/3.5 min after the call. These intervals can be considered, in relation to traffic and geographic conditions, adequate. Nevertheless, specific interventions should be implemented in order to improve community awareness of the importance of early activation of the emergency system. Until now, no educational intervention have been planned for this first link in the chain of survival. 4.2. Early CPR
3.6. Outcome Seventy-four patients (41.5%) died at the scene, 77 patients (43.2%) were transported to the hospital still in cardiac arrest, 24 patients (13.4%) had a ROSC on scene and three patients (1.6%) had ROSC during the transfer to the hospital. In 24 h, 160 patients (90.9%) were dead. The total survival rate in 24 h was 9%, while the 1-month survival rate was 6.17%. We also analysed survival rate in relation to the specific dispatch-centre. As shown by Table 4, one of the three dispatch-centres (named as ‘c’) achieved a better survival rate even if did not reach a statistical significance due to the small sample size. Epidemiological data, presenting rhythms and timing of interventions were similar between the three dispatch-centres. The only difference noticed was the higher employment of ALS crews (a, 24%; b, 13%; c, 42%; x2-test P 5/0.05).
4. Discussion These data come from a prospective database prepared in Lombardia with the aim of evaluating the quality of the pre-hospital emergency system. It was set up after the definition of quality indicators derived from the emergency literature [38 /43]. Data should be analysed in the light of the concept of the ‘ chain of survival’ [44 /58].
4.3. Early defibrillation Early defibrillation has been clearly proved to be effective in a number of studies [59 /69]. Literature showed that for people found in VF, the time to defibrillation is the best predictor of good outcome. During our data collection, law restrictions allowed only physicians to use defibrillators. None of the patients recorded was defibrillated before the arrival of an emergency crew. The application of new law, recently approved, that allow the use of AED by non-physicianfirst-responders, should augment the number of patients treated by defibrillation, when this specific treatment is required, it must be in an acceptable time from the collapse. 4.4. Early advanced care
Table 4 Outcome at 1 month related to the dispatch-centre Dispatch-centre
Dead (%)
Alive (%)
a b c
96.5 95.9 86.5
3.53 4.08 13.5
x2-test NS.
Even though the arrest was witnessed in 72% of cases, only a minority (15%) of them received some sort of CPR performed by bystanders. Even if the cohort is very small, the patients who received ‘some CPR’ from bystanders presented a reduced mortality. Eighty-five percent of the witnessed arrests received first CPR at the arrival of the emergency crew (8.59/3.5 min after the collapse). The mean time to beginning CPR-manoeuvres is, certainly late in the light of the information from the literature: survival rate declines rapidly during each minute passing without CPR. This is confirmed by the low survival rate of these patients (4.9%). New strategies should be planned to disseminate CPR knowledge to lay people though as CPR training programmes especially targeting relatives of high-risk patients.
Treatment by an ALS crew, involving the use of drugs and airways adjuncts, was performed only in a quarter of the patients. No information is available on the criteria of ALS activation or on the availability around the clock of ALS crews. However, the use of ALS was associated with a better clinical outcome and a better
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survival rate was noticed by the dispatch-centre with a higher number of patients treated by an ALS crew. Few rhythms were documented on the scene; between these, a low proportion was composed by ventricular fibrillations (indicator of a fast intervention) and so few could be defibrillated. Unfortunately, a high proportion of patients were transported still in cardiac arrest. This mirrors the high proportion of patients treated by BLS crews that in the absence of a medical person, transport the patient to the hospital performing CPR. We showed an unfavourable outcome associated with this policy. The low (6.17%) 1-month survival rate is the unequivocal sign of a quality that has to be improved. This aim could be reached by analysing all the links in the chain of survival, as we did, and planning interventions aimed to optimise each step.
Acknowledgements We gratefully acknowledge the medical and nurse personnel of the three dispatch-centres that collaborated in this data collection (118 Como, 118 Monza Brianza, 118 Pavia). This research received a grant from IRER, Regional Research Institute, of Lombardia Region, Italy.
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