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Factors associated with return to work among survivors of out-of-hospital cardiac arrest
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Available online at www.sciencedirect.com
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Clinical paper
Factors associated with return to work among survivors of out-of-hospital cardiac arrest Jason Kearney a, * , Kylie Dyson a,b , Emily Andrew a,b , Stephen Bernard a,b,c , Karen Smith a,b,d a
Centre for Research and Evaluation, Ambulance Victoria, Blackburn North, Victoria, Australia Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Victoria, Australia c The Alfred Hospital, Melbourne, Victoria, Australia d Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Victoria, Australia b
Abstract Background: Although out-of-hospital cardiac arrest (OHCA) is a major cause of global mortality, survival rates have increased over the last decade. As such, there is an increasing need to explore long-term functional outcomes of survivors, such as return to work (RTW). Methodology: We analysed baseline and 12-month follow-up data from the Victorian Ambulance Cardiac Arrest Registry for patients that arrested between 2010 and 2016 who were working prior to their arrest. We also conducted more detailed RTW interviews in a subset of OHCA survivors who arrested between July and September 2017. Factors associated with RTW were assessed using multivariable logistic regression analysis. Results: A total of 884 previously working survivors were included in the analysis, 650 (73%) of whom RTW. Male sex (AOR 1.80; 95%CI: 1.10 2.94), arrests witnessed by emergency medical services (AOR 2.72; 95%CI: 1.50 9.25), discharge directly home from hospital (AOR 4.13; 95%CI: 2.38 7.18) and favourable 12-month health-related quality of life according to the EQ-5D were associated with RTW. Increasing age (AOR 0.97; 95%CI: 0.95 0.98), traumatic arrest aetiology (AOR 0.18; 95%CI: 0.04 0.77), and labour-intensive occupations (AOR 0.44; 95%CI: 0.29 0.66) were associated with decreased odds of RTW. Of the 23 OHCA survivors that participated in the more detailed RTW telephoneinterview, 87% RTW. Flexible work hours or modified duties were offered to 74% of participants. Fatigue was the most frequently reported barrier to RTW. Conclusion: This is the largest study to collectively examine factors associated with RTW among survivors of OHCA. Although larger qualitative studies are needed, our findings highlight which patients are at risk of not RTW and who may benefit from targeted rehabilitation strategies. Keywords: Out-of-hospital, Heart arrest, Return to work, Employment
Introduction Out-of-hospital cardiac arrest (OHCA) is a leading cause of global mortality which impacts a reported 55 per 100,000 people each year and has an average survival rate of 7%.1,2 Although survival to hospital discharge remains low, rates of survival have been improving over the last decade.3 This can be
attributed to new advancements in global resuscitation techniques, increased community access to Public Access Defibrillators (PADs) and cardiopulmonary resuscitation (CPR) training programs.3 Due to improving survival rates, there is a greater need to explore patient outcomes beyond the point of hospital discharge. One area that is seldom explored is return to work (RTW) among OHCA survivors.
* Corresponding author. E-mail address: [email protected] (J. Kearney). https://doi.org/10.1016/j.resuscitation.2019.09.006 Available online xxx 0300-9572/© 2019 Elsevier B.V. All rights reserved.
Please cite this article in press as: J. Kearney, et al., Factors associated with return to work among survivors of out-of-hospital cardiac arrest, Resuscitation (2019), https://doi.org/10.1016/j.resuscitation.2019.09.006
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Work is a key determinant of health and wellbeing and RTW following illness is associated with improved health status and recovery.4,5 Work has an important role in positive physical and mental health as well as a role in the development of individual identity, purpose and societal position. Each of these contribute to overall wellbeing.4,5 RTW following an OHCA may be reflective of an individual’s capability to continue to maintain their pre-arrest societal function. This may be indicative of positive physical and mental health and an overall positive outcome post-OHCA.5 7 Existing literature examining RTW among survivors of OHCA8 12 suggests that the majority of survivors do RTW. However, many of these studies are limited by small sample size and few have concurrently examined the demographic, pre-hospital and workplace factors associated with successful RTW. As such, this study aims to identify the factors associated with RTW among adult survivors of OHCA across the state of Victoria, Australia.
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including after hours. Participants (or proxies) respond to a series of introductory questions related to residential and employment status (pre and post-OHCA), and also complete the 12 Item Short Form Health Survey (SF12), EuroQol-5D-3L (EQ-5D) and the Glasgow Outcome Scale-Extended (GOSE). The follow-up process and instruments have been described in detail previously.18 In addition to these standard follow-up interviews at 12 months postarrest, for this study, individuals arresting between July 1, 2017 and September 30, 2017 were invited to participate in a more detailed RTW interview at the completion of the standard interview. Participants were asked a series of additional questions specifically related to their RTW, whether successful or unsuccessful. The additional questions covered areas such as employer support, flexible work hours, alternative duties and barriers to RTW.
Definitions
Methods Study design We performed a retrospective analysis of patients within the Victorian Ambulance Cardiac Arrest Registry (VACAR). We included adults (aged 18 years) who sustained an OHCA of any aetiology between 1 January 2010 and 31 December 2016, survived to be discharged from hospital and who were working prior to their arrest. Patients not working prior to arrest and those for whom RTW status was unknown were excluded. In addition, we conducted more detailed cross-sectional RTW telephone-interviews with OHCA survivors that experienced their arrest between 1 July 2017 and 30 September 2017 at 12 months post-arrest.
Setting The state of Victoria, Australia is the most densely populated state in Australia with an approximate area of 227,000 km2. Victoria has a population of 6.2 million people, of which 76% live within the state capital of Melbourne.13 Prehospital emergency medical services (EMS) in Victoria are solely provided by Ambulance Victoria. All EMS calls are assigned a level of priority based on the case nature and severity.14 In the event of cardiac arrest, two intensive care paramedics and two advanced life support paramedics are dispatched concurrently if resourcing permits.15 In select regions of the state, basic life support (BLS) first responders are also dispatched. All OHCA treatment is based on the Australian Resuscitation Council Guidelines.16
Data sources The VACAR is a state-wide registry that collects data on every OHCA case attended by EMS in Victoria.15 The methodology of data collection, case identification and quality control employed by the registry has previously been described.3 The registry data is comprised of more than 150 data elements primarily based on the Utstein recommendations17 and includes patient demographics, event characteristics and pre-hospital management.15 Hospital follow-up data and discharge direction are obtained from the medical records of transported patients. Data obtained from the Victorian Registry of Births, Deaths and Marriages is used to validate survivor status. Since 2010, the VACAR has routinely collected health-related quality of life (HR-QOL), long-term functional recovery and RTW outcomes 12 months after OHCA.15,18 Adult patients identified as being alive 12 months post-arrest are invited to participate in a telephone interview. Patient contact is attempted on at least 5 separate occasions, each at varying time points,
Work was defined as paid or volunteer employment or education of any type (i.e. full-time, part-time or casual). Patients on leave from work or those employed on a sporadic or seasonal manner were classified as working. Patient pre-OHCA occupation classification was based on the occupational groupings outlined in the Australian Standard Classification of Occupation 2nd edition.19
Statistical analysis The primary outcome measure was successful RTW at 12 months postOHCA. Baseline characteristics, as well as data from the RTW interviews, were summarised descriptively using frequencies and percentages for categorical variables, and medians and interquartile ranges for continuous variables. Univariate Chi-squared and Mann Whitney U tests were performed to compare the responses between participants who returned to work and those that did not. We calculated the standardised mean difference (SMD) of SF-12 physical component (PCS) and mental component (MCS) summary scores using the Australian standard population SF-12 scores.20 The magnitude of the SMD represents the variation between the SF-12 scores of the Australian population and the OHCA cohort used in this study.20 Scores 0.8 suggest clinically significant variation from population norms. To examine the factors independently associated with RTW, we conducted multivariable logistic regression analyses. Three models were constructed. Model 1 included factors known to be associated with OHCA outcomes using the Utstein definitions21 as well as other pre and post-arrest factors. The independent variables included in this model were: age in years, sex, presumed cardiac aetiology, arrest location, witness status, bystander CPR, EMS response time, initial shockable rhythm, transport to a percutaneous coronary intervention (PCI) capable hospital, discharge direction from hospital, highest level of education, pre-arrest occupation type, and workload prior to arrest. For patients who were witnessed to arrest by EMS, bystander CPR was set to ‘No’, and EMS response time was set to 0 min. Due to HR-QOL having a likely influence on RTW, as well as being influenced by RTW, HR-QOL measures were excluded from Model 1. As such, we performed a sensitivity analysis to assess for the effect of HR-QOL on RTW (Model 2). This model included a binary EQ-5D index score term (1 vs <1) in addition to all variables included in Model 1. The EQ-5D was selected as the HR-QOL measure due to its ability to be completed by both patient and proxy responders. Finally, in Model 3 we included all variables in Model 2, however replaced the EQ-5D index score term with all five EQ-5D domains
Please cite this article in press as: J. Kearney, et al., Factors associated with return to work among survivors of out-of-hospital cardiac arrest, Resuscitation (2019), https://doi.org/10.1016/j.resuscitation.2019.09.006
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(pain; anxiety; self-care; mobility; and activity) to understand the association between individual domains and RTW. In addition, given that the majority of patients in our population arrested into a shockable cardiac arrest rhythm, we repeated Models 1 and 2 in only those patients with an initial shockable arrest rhythm. In these models, we included all of the independent variables listed above, as well as a term describing who provided the first defibrillation (public access defibrillator/ first responder/ ambulance paramedics). The Hosmer Lemeshow test was used to assess goodness of fit for each model. The effect size of independent variables was presented using odds ratios (OR) and 95% confidence intervals (CI). Statistical analyses were conducted using Stata Statistical Software 14 (StataCorp LP, Version 14). A p-value of <0.05 was considered statistically significant.
increased odds of RTW (AOR 3.80; 95%CI: 2.59 5.58; p < 0.001). No variation in the factors associated with RTW were seen between Model 1 and Model 2. When this model was restricted to patients who arrested into an initial shockable arrest rhythm, patients initially defibrillated by first responders were more likely to RTW than those initially defibrillated by paramedics (AOR 2.60; 95%CI: 1.07 6.34; p = 0.035). In the final sensitivity analysis that included the five EQ-5D domains (Model 3, Supplemental Table 2), no problems with mobility, self-care, anxiety or activity were associated with increased odds of RTW compared to patients that reported some or extreme problems. Problems with pain was not associated with RTW.
Ethics
Over the three-month study period of the more detailed RTW interviews, 77 OHCA patients survived to hospital discharge and were working prior to their arrest (Fig. 1b). A total of 23 patients completed the RTW interview and formed the population for this component of the study. Of the 23 patients interviewed, 20 (87%) returned to work, with 80% returning to the same role with the same employer (Table 3). Patients took a median of 7 weeks (IQR 4 22) to RTW following discharge from hospital.
The VACAR maintains ethical approval from the Victorian Government Department of Health Human Research Ethics Committee as a quality assurance project. Approval from individual hospital ethics committees is also obtained for hospital data collection. Ethical approval for the more detailed RTW interviews was obtained from the Ambulance Victoria Research Governance Committee.
Return to work experiences reported in the detailed RTW interviews
Workplace accommodation: flexible work hours and alternative or modified duties
Results Over the 6-year study period, 17,638 individuals who sustained an OHCA received a resuscitation attempt, of which 2328 (13%) survived to hospital discharge (Fig. 1a). A total of 1765 participants completed the 12-month follow-up interview, with an overall response rate of 82%. Of these, 884 participants reported working prior to their OHCA and had a known RTW status.
The majority of interview patients (85%) were offered flexibility with work hours by their employers (Table 3). RTW patients reported re-integrating back into the workforce with fewer shifts, shifts of shorter duration or a combination of both. Role sharing with another employee, adopting a smaller workload and less physical duties were the modified and alternative duties offered to patients by their employers.
Barriers to return to work Unadjusted baseline and post-arrest characteristics The median age was 54 (IQR 46 61) years and most were male (85%) (Table 1). The majority of participants (73%) successfully returned to work at 12-month follow-up, with most remaining in the same role (88%) at the same organisation (89%). Patients that did not RTW were more often of older age, had lower levels of formal education, were working in a labour-intensive occupation, working part-time prior to arrest and had an arrest of non-cardiac aetiology. Additionally, patients that did not RTW were more likely to report lower levels of HR-QOL and to have been discharged directly to a rehabilitation centre rather than home.
Overall, 85% (n = 17) of all patients reported barriers to their RTW. Professionals were more likely to report no difficulties in RTW (75%). Those employed as tradespersons (100%), in the production and transport industry (86%) or in the sales and service industry (100%) experienced the greatest number of RTW barriers (Fig. 2a). Fatigue was the most frequently reported factor to restrict RTW, with 30% of all patients reporting post-OHCA fatigue followed by mild cognitive impairment manifesting as impaired memory and cognitive processing (26%) (Fig. 2b). Medical restrictions on the use of commercial driver’s licenses following OHCA were reported to have been a barrier impeding RTW by four patients, all of which were employed in the transport industry.
Multivariable analyses Factors independently associated with RTW on multivariable analysis are presented in Table 2. Male sex, being witnessed to arrest by EMS and discharge directly home from hospital were all positively associated with RTW. Arrests of traumatic aetiology, increasing participant age and prearrest employment in the trade or labour industries were all negatively associated with RTW. Neither workload prior to arrest nor education level were associated with RTW. When we restricted this model to patients who arrested into a shockable cardiac arrest rhythm, patients initially defibrillated by first responders were more likely to RTW than those initially defibrillated by paramedics (AOR 2.79; 95%CI: 1.17 6.65; p = 0.020). In the sensitivity analysis including the EQ-5D index score (Model 2, Supplemental Table 1), an EQ-5D index score of 1 was associated with
Discussion To our knowledge, this is the largest study to collectively examine baseline and post-arrest characteristics associated with RTW among survivors of OHCA. The majority of participants successfully returned to work at 12month follow-up. We identified multiple factors to be associated with RTW following OHCA survival, including early initiation of resuscitative measures, employment in non-labour-intensive occupations, and discharge directly home from hospital. While we did not find RTW to be associated with education level, our findings suggest that RTW was associated with favourable HR-QOL at 12 months post-arrest.
Please cite this article in press as: J. Kearney, et al., Factors associated with return to work among survivors of out-of-hospital cardiac arrest, Resuscitation (2019), https://doi.org/10.1016/j.resuscitation.2019.09.006
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Fig. 1 – a. Selection process of the study population included in the epidemiological component of this study. Participant selection obtained from the Victorian Ambulance Cardiac Arrest Registry, 2010 2016. Lost to follow-up is inclusive of participants unable to be contacted or living overseas. Other includes participants unable to be contacted due to a language barrier, terminal illness, psychiatric illness or residence outside of Victoria. b. Selection process of the study population for the return to work qualitative interview in this study. Participant selection obtained from the Victorian Ambulance Cardiac Arrest Registry, July 1, 2017 September 30, 2017. Lost to follow-up is inclusive of participants unable to be contacted or living overseas. Abbreviations: OHCA, out-of-hospital cardiac arrest; EMS, emergency medical service; RTW, return to work.
Patients with labour-intensive occupations such as labourers, tradespersons, and production and transport workers were less likely to RTW compared to professionals. These findings are consistent with previous reports for OHCA patients and other conditions such as stroke, trauma and muscular disorders.5,8,22,23 It is likely that the physiological effects of illness or injury have a greater impact on individuals employed in predominantly
physical occupations. Limitations with mobility, activity or self-care following an OHCA are more likely to affect those with physical occupations when attempting or considering RTW.8,24 Indeed, our results suggest that patients with problems in each of these EQ-5D domains were less likely to RTW. However, the negative association between employment in the transport industry and RTW may be a reflection of Australia’s national
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Table 1 – Baseline and post-arrest characteristics.
Pre-arrest characteristics Age in years, median (IQR) Male sex, n (%) Highest level of education completed, n (%) Primary school Secondary school Year 11 equivalent or below Secondary school Year 12 or equivalent Certificate/diploma/advanced diploma Bachelor’s degree Postgraduate study Unknown Pre-arrest occupation, n (%) Professionals Managers and administrators Associate professionals Tradespersons and related Clerical, sales and service Intermediate production and transport Labourers and related Other Unknown Workload prior to arrest, n (%) Full-time Part-time Other Unknown Arrest characteristics Aetiology, n (%) Presumed cardiac Trauma Respiratory Neurological Other EMS response time (mins), median (IQR)b Witness of arrest, n (%) Unwitnessed Bystander witnessed EMS witnessed Unknown Bystander CPR, n (%)b Initial arrest rhythm, n (%) Ventricular fibrillation/ventricular tachycardia Pulseless electrical activity Asystole Unknown Initial defibrillation, n (%)a Paramedics First responders Public access defibrillator Arrest Location, n (%) Private residence Public location Ambulance Medical clinic Other Arrest region, n (%) Metropolitan Rural Post-arrest characteristics Transported to PCI capable hospital, n (%)
All (n = 884)
RTW (n = 650)
No RTW (n = 234)
p-Value
54 753
(46 61) (85.2)
53 565
(44 60) (86.9)
58 188
(49 64) (80.3)
<0.001 <0.015 <0.001
7 181 123 296 136 99 42
(0.8) (21.5) (14.6) (35.2) (16.2) (11.7)
4 113 93 219 116 76 29
(0.6) (18.2) (15.0) (35.3) (18.7) (12.2)
3 68 30 77 20 23 13
(1.3) (30.8) (13.6) (34.8) (9.1) (10.4)
214 106 97 147 104 101 76 20 19
(24.7) (12.3) (11.2) (17.0) (12.0) (11.7) (8.8) (2.3)
171 87 79 104 75 59 49 16 10
(26.7) (13.6) (12.3) (16.3) (11.7) (9.2) (7.7) (2.5)
43 19 18 43 29 42 27 4 9
(19.1) (8.4) (8.0) (19.1) (12.9) (18.7) (12.0) (1.8)
721 134 20 9
(82.4) (15.3) (2.3)
546 86 14 4
(84.5) (13.3) (2.2)
175 48 6 5
(76.4) (21.0) (2.6)
821 15 23 15 10 8.1
(92.9) (1.7) (2.6) (1.7) (1.1) (6.2 10.9)
615 5 16 8 6 8.1
(94.6) (0.8) (2.5) (1.2) (0.9) (6.3 11.0)
206 10 7 7 4 8.1
(88.0) (4.3) (3.0) (3.0) (1.7) (6.2 10.7)
82 558 243 1 570
(9.3) (63.2) (27.5)
51 410 188 1 417
(7.9) (63.2) (28.9)
31 148 55
(13.3) (63.2) (23.5)
(90.3)
153
(85.5)
788 52 36 8
(90.0) (5.9) (4.1)
587 34 24 5
(91.0) (5.3) (3.7)
201 18 12 3
(87.0) (7.8) (5.2)
649 64 84
(81.4) (8.0) (10.6)
470 54 70
(79.1) (9.1) (11.8)
179 10 14
(88.2) (4.9) (6.9)
366 409 80 24 5
(41.4) (46.3) (9.1) (2.7) (0.5)
251 314 63 19 3
(38.6) (48.3) (9.7) (2.9) (0.5)
115 95 17 5 2
(49.1) (40.6) (7.3) (2.1) (0.9)
684 200
(77.4) (22.6)
503 147
(77.4) (22.6)
181 53
(77.4) (22.6)
772
(87.3)
575
(88.5)
197
(84.2)
<0.001
<0.019
<0.002
(88.9)
<0.738 <0.027
<0.736 <0.221
<0.016
<0.066
<0.991
<0.092
(continued on next page)
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Table 1 (continued)
Discharge direction, n (%) Home Rehabilitation Nursing facility Unknown Return to work same role, n (%) Yes No Unknown Return to work same organisation, n (%) Yes No Unknown GOSE, n (%) Upper good recovery Lower good recovery Upper moderate disability Lower moderate disability Upper severe disability Lower severe disability Vegetative state Unknown EQ-5D index score, median (IQR) EQ-5D VAS, median (IQR) Prior to arrest Current No problems in all EQ-5D domains, n (%) SF-12, mean (SD) PCS MCS SF-12, SMD (SD) PCS MCS
All (n = 884)
RTW (n = 650)
No RTW (n = 234)
p-Value
794 80 4 6
614 34
180 46 4 4
(78.3) (20.0) (1.7)
(16.3) (15.9) (9.4) (37.8) (6.4) (13.3) (0.9) (0.66 0.88)
<0.001
<0.001 (90.4) (9.1) (0.5)
(94.8) (5.2)
2 575 72 3
(88) (11) (1)
582 65 3
(89) (10) (1)
275 196 155 19 3
(42.4) (30.3) (23.9) (2.9) (0.5)
<0.001 313 233 177 107 18 31 2 3 1
(35.5) (26.5) (20.1) (12.1) (2.1) (3.5) (0.2) (0.80 1)
2 1
(0.85 1)
38 37 22 88 15 31 2 1 0.81
85 80 437
(75 95) (70 90) (49.3)
85 80 382
(75 95) (72 90) (59)
90 70 55
(80 99.5) (50 85) (24)
<0.001 <0.001
49.4 53.7
(9.21) (8.38)
51.2 54.5
(7.84) (7.23)
43.8 51.2
(10.75) (10.86)
<0.001 <0.004
0.06 0.07
(1.00) (1.03)
0.23 0.18
(0.87) (0.88)
(1.18) (1.35)
<0.001 <0.002
0.48 0.26
Abbreviations: IQR, interquartile range; CPR, cardiopulmonary resuscitation; EMS, emergency medical service; RTW, return to work; PCI, percutaneous coronary intervention; GOSE, glasgow outcome scale extended; EQ-5D, EuroQol-5D; VAS, visual analogue scale; SMD, standardised mean difference; SD; standard deviation; SF-12, short form 12 item health survey; PCS, physical component summary; MCS, mental component summary. a Initial defibrillation only relevant to participants presenting in ventricular tachycardia or ventricular fibrillation. b Excludes EMS witnessed arrests.
mandatory restrictions and suspensions imposed on holders of commercial driver’s licenses following cardiac arrest.25 Patients with OHCA of traumatic aetiology had lower odds of RTW compared to those of presumed cardiac cause. It is plausible that the injuries sustained as a result of the mechanisms involved in a traumatic OHCA, as well as the direct effects of the OHCA itself, collectively diminish the likelihood of recovering with the physical or cognitive level of functionality required to RTW. Traumatic OHCA represented a small cohort in our study (n = 15), therefore a large study of traumatic OHCA survivors is needed to specifically explore RTW outcomes in this population. Such a study might better identify the barriers to RTW that this unique population encounter, enabling them to be better supported with targeted strategies and rehabilitation programs. In contrast, we observed a positive association between RTW and first responder defibrillation and EMS witnessed arrests. These findings are likely to be a reflection of the benefits of early resuscitative measures and further emphasise the importance of the Chain of Survival in OHCA.21,26 Ours is not the first study to report these findings, Kragholm et al also reported an association between early OHCA intervention and RTW in Denmark.10
Despite shockable rhythms being one of the biggest drivers of survival following OHCA,27,28 we did not find an association between shockable rhythms and RTW. It is possible that RTW in survivors only may be better explained by post-arrest factors which were not adjusted for in our analyses, such as hospital interventions and post-discharge rehabilitation.12,29 Overall, HR-QOL and functional recovery outcomes were more favourable among patients who RTW than those who did not. Further, patients who were discharged directly home from hospital, which may be a surrogate for functional outcome at hospital discharge, were also more likely to RTW. It is possible that the barriers encountered by individuals that experience problems with mobility, activity, self-care and anxiety postarrest, restrict the execution of their usual workplace duties or limit the prospect of RTW. Poorer HR-QOL may in part be associated with an inability to RTW, considering the strong positive influence work can have on physical and mental health and overall wellbeing.4,5,7 However, we are unable to examine the direction of the association between HR-QOL and RTW, given that our HR-QOL telephone follow-up is conducted at 12 months post-arrest only. In contrast to other conditions such as trauma and stroke, evidencebased rehabilitation pathways for OHCA survivors are limited.30 Future
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Table 2 – Independent factors associated with return to work.
Age (per year) Male sex Aetiology Presumed cardiac Trauma Othera Arrest location Private residence/other Public location Witness of arrest Unwitnessed EMS witnessed Public witnessed Bystander CPR Transport to a PCI capable hospital Discharge direction Rehabilitation/nursing home Home Initial rhythm Non-shockable Shockable EMS response time (per minute) Highest level of education completed Schoolb Bachelor degree/diplomac Postgraduate Pre-arrest occupation Professionals/managersd Trades/labourerse Clerical/otherf Workload prior to arrest Full time Part time Other
OR
95% CI
p-Value
0.97 1.80
0.95 0.98 1.10 2.94
<0.001 <0.020
Reference 0.18 0.49
0.04 0.77 0.20 1.18
<0.021 <0.110
Reference 1.46
0.99 2.16
<0.056
Reference 2.72 1.39 1.46 1.37
1.50 0.78 0.77 0.83
9.25 2.47 2.74 2.24
<0.005 >0.266 <0.243 <0.215
Reference 4.13
2.38 7.18
<0.001
Reference 0.62 1.03
0.30 1.29 0.98 1.09
<0.200 <0.269
Reference 1.23 1.18
0.84 1.80 0.62 2.25
<0.288 <0.609
Reference 0.44 0.75
0.29 0.66 0.42 1.34
<0.001 <0.332
Reference 0.84 1.07
0.52 1.34 0.38 3.01
<0.464 <0.898
Abbreviations: OR, odds ratio; CI, confidence interval; EMS, emergency medical service; PCI, percutaneous coronary intervention; CPR, cardiopulmonary resuscitation. a Neurological, respiratory and other. b Primary school, secondary school year 11 or below and secondary school year 12 or equivalent. c Certificate, diploma, advanced diploma and bachelor degree. d Professionals, managers and administrators and associate professionals. e Tradespersons and related, labourers, intermediate production and transport. f Clerical, sales and service and other occupations. 802 patients included in the model. Goodness of fit using the Hosmer Lemeshow test, p = 0.157.
Table 3 – Return to work experiences outlined in the detailed RTW interview. All (n = 23) Return to work same role, n (%) Yes No Return to work same organisation, n (%) Yes No Duration of most recent employment in years, median (IQR)
RTW (n = 20)
6
16 4
(80) (20)
16 4 6
(80) (20) (2 13)
7
(4 22)
No RTW (n = 3)
7
(1 10)
(1 13) Duration to RTW in weeks, median (IQR) Flexible work hours offered by employer, n (%) Yes No Alternative workplace duties offered by employer, n (%) Yes No
17 6
(74) (26)
17 3
(85) (15)
0 3
(0) (100)
17 6
(74) (26)
17 3
(85) (15)
0 3
(0) (100)
Abbreviations: IQR, interquartile range; RTW, return to work.
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Fig. 2 – a. Proportion of participants reporting barriers to return to work based on occupation type. Barriers refer to factors that impeded participant return to work when recovering from the out-of-hospital cardiac arrest. Potential barriers included: medical restrictions, lack of workplace flexibility, chronic pain, anxiety or depression, fatigue, physical impairment, cognitive impairment and no reported difficulties. Number of participants within each occupational category: intermediate production and transport, n = 7; clerical, sales and service, n = 2; tradespersons, n = 4; associate professionals, n = 3; managers and administrators, n = 3; professionals, n = 4. b. Participant responses relating to barriers or difficulties impeding return to work. Participants had the opportunity to select more than one answer if applicable. Medical restrictions refer to restrictions ordered by medical practitioners regarding workplace duties and is inclusive of the suspension of commercial driver’s license; cognitive impairment refers to mild impairment in memory and cognitive processing. Study population, n = 23; return to work, n = 20; no return to work, n = 3. Abbreviations: RTW, return to work.
studies are required to examine post-OHCA rehabilitation with hope that this will lead to improved HR-QOL and RTW outcomes among survivors. Our RTW interviews identified a number of barriers that OHCA survivors face when attempting to RTW. Fatigue and mild cognitive impairment were the most prevalent. Chronic fatigue is a commonly reported
symptom among survivors of cardiac arrest.31 Fatigue diminishes the ability to focus on workplace tasks, maintain productivity and maintain motivation, all of which lead to increased rates of absenteeism and withdrawal from the workforce.32,33 Similarly, mild cognitive impairment, the second most commonly reported barrier to RTW, has the potential to greatly impact
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workplace functionality due to impaired recall and a diminished ability to process large amounts of new information quickly.11,23,34,35 Despite fatigue and mild cognitive impairment being reported by the majority of RTW interview participants, a large proportion were still able to RTW. This is possibly due to modified workplace duties and flexible work hours facilitating the transition back into the workforce.
Limitations This study has a number of limitations. First, due to the retrospective design there may be other unknown or unmeasured factors that we could not account for. Such factors may include the influence of specific hospital treatments, recommendations of medical personnel and participation in specific rehabilitation programs following hospital discharge. Second, as the research was solely conducted in the state of Victoria with one EMS agency, the findings may not be generalisable to other EMS agencies and regions. Third, this study was also limited by loss to follow-up which reduced the effective sample size of both components of this study. Finally, the follow-up interviews were only conducted at a single time point. It is therefore unclear whether employment was sustained by those that reported successful RTW or whether participants that reported no RTW were able to return to the workforce following the interview.
Conclusion In our study, early resuscitative intervention, non-traumatic aetiology and non-labour-intensive occupations were associated with RTW following OHCA, as were discharge directly home from hospital and favourable 12month HR-QOL. Fatigue and mild cognitive impairment were the most frequently reported barriers to survivors returning to the workforce. Although larger qualitative studies are needed, our findings highlight patient groups which may be at risk of not returning to work and who may benefit from targeted rehabilitation strategies.
Conflicts of interest None.
Acknowledgements We would like to acknowledge Ambulance Victoria and the Victorian Ambulance Cardiac Arrest Registry team for the management and maintenance of the registry.
Appendix A. Supplementary data Supplementary material related to this article can be found, in the online version, at doi:https://doi.org/10.1016/j.resuscitation.2019.09.006.
REFERENCES
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22. Moshe S, Izhaki R, Chodick G, et al. Predictors of return to work with upper limb disorders. Occup Med (Lond) 2015;65(7): 564 9. 23. Edwards JD, Kapoor A, Linkewich E, Swartz RH. Return to work after young stroke: a systematic review. Int J Stroke 2017;1747493017743059. 24. Smedegaard L, Nume AK, Charlot M, Kragholm K, Gislason G, Hansen PR. Return to work and risk of subsequent detachment from employment after myocardial infarction: insights from Danish nationwide registries. J Am Heart Assoc. 20176:. 25. Austroads. Assessing fitness to drive for commercial and private vehicle drivers: 2016 medical standards for licensing and clinical management guidelines. . p. 1 188. 26. O’Keeffe C, Nicholl J, Turner J, Goodacre S. Role of ambulance response times in the survival of patients with out-of-hospital cardiac arrest. Emerg Med J 2011;28:703 6. 27. Sasson C, Rogers MA, Dahl J, Kellermann AL. Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes 2010;3(1):63 81.
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28. Eisenberg MS. Resuscitate!: how your community can improve survival from sudden cardiac arrest. second edition Seattle, United States: University of Washington Press; 2013. 29. Hofgren C, Lundgren-Nilsson A, Esbjornsson E, Sunnerhagen KS. Two years after cardiac arrest; cognitive status, ADL function and living situation. Brain Inj 2008;22:972 8. 30. Boyce LW, Goossens PH. Rehabilitation after cardiac arrest: integration of neurologic and cardiac rehabilitation. Semin Neurol 2017;37:094 102. 31. Wachelder EM, Moulaert VR, van Heugten C, Verbunt JA, Bekkers SC, Wade DT. Life after survival: long-term daily functioning and quality of life after an out-of-hospital cardiac arrest. Resuscitation 2009;80(5):517 22. 32. Sudden Cardiac Arrest UK. Fatigue. Available from:. . https://www. suddencardiacarrestuk.org/fatigue/. 33. Piegza M, Jaszke M, Scislo P, et al. Symptoms of depression and anxiety after cardiac arrest. Psychiatrica Polska 2015;49(3):465 76. 34. Moulaert VR, Verbunt JA, van Heugten CM, Wade DT. Cognitive impairments in survivors of out-of-hospital cardiac arrest: a systematic review. Resuscitation 2009;80(3):297 305. 35. Sabedra AR, Kristan J, Raina K, et al. Neurocognitive outcomes following successful resuscitation from cardiac arrest. Resuscitation 2015;90:67 72.
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Available online at www.sciencedirect.com
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Clinical paper
Factors associated with return to work among survivors of out-of-hospital cardiac arrest Jason Kearney a, * , Kylie Dyson a,b , Emily Andrew a,b , Stephen Bernard a,b,c , Karen Smith a,b,d a
Centre for Research and Evaluation, Ambulance Victoria, Blackburn North, Victoria, Australia Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Victoria, Australia c The Alfred Hospital, Melbourne, Victoria, Australia d Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Victoria, Australia b
Abstract Background: Although out-of-hospital cardiac arrest (OHCA) is a major cause of global mortality, survival rates have increased over the last decade. As such, there is an increasing need to explore long-term functional outcomes of survivors, such as return to work (RTW). Methodology: We analysed baseline and 12-month follow-up data from the Victorian Ambulance Cardiac Arrest Registry for patients that arrested between 2010 and 2016 who were working prior to their arrest. We also conducted more detailed RTW interviews in a subset of OHCA survivors who arrested between July and September 2017. Factors associated with RTW were assessed using multivariable logistic regression analysis. Results: A total of 884 previously working survivors were included in the analysis, 650 (73%) of whom RTW. Male sex (AOR 1.80; 95%CI: 1.10 2.94), arrests witnessed by emergency medical services (AOR 2.72; 95%CI: 1.50 9.25), discharge directly home from hospital (AOR 4.13; 95%CI: 2.38 7.18) and favourable 12-month health-related quality of life according to the EQ-5D were associated with RTW. Increasing age (AOR 0.97; 95%CI: 0.95 0.98), traumatic arrest aetiology (AOR 0.18; 95%CI: 0.04 0.77), and labour-intensive occupations (AOR 0.44; 95%CI: 0.29 0.66) were associated with decreased odds of RTW. Of the 23 OHCA survivors that participated in the more detailed RTW telephoneinterview, 87% RTW. Flexible work hours or modified duties were offered to 74% of participants. Fatigue was the most frequently reported barrier to RTW. Conclusion: This is the largest study to collectively examine factors associated with RTW among survivors of OHCA. Although larger qualitative studies are needed, our findings highlight which patients are at risk of not RTW and who may benefit from targeted rehabilitation strategies. Keywords: Out-of-hospital, Heart arrest, Return to work, Employment
Introduction Out-of-hospital cardiac arrest (OHCA) is a leading cause of global mortality which impacts a reported 55 per 100,000 people each year and has an average survival rate of 7%.1,2 Although survival to hospital discharge remains low, rates of survival have been improving over the last decade.3 This can be
attributed to new advancements in global resuscitation techniques, increased community access to Public Access Defibrillators (PADs) and cardiopulmonary resuscitation (CPR) training programs.3 Due to improving survival rates, there is a greater need to explore patient outcomes beyond the point of hospital discharge. One area that is seldom explored is return to work (RTW) among OHCA survivors.
* Corresponding author. E-mail address: [email protected] (J. Kearney). https://doi.org/10.1016/j.resuscitation.2019.09.006 Available online xxx 0300-9572/© 2019 Elsevier B.V. All rights reserved.
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Work is a key determinant of health and wellbeing and RTW following illness is associated with improved health status and recovery.4,5 Work has an important role in positive physical and mental health as well as a role in the development of individual identity, purpose and societal position. Each of these contribute to overall wellbeing.4,5 RTW following an OHCA may be reflective of an individual’s capability to continue to maintain their pre-arrest societal function. This may be indicative of positive physical and mental health and an overall positive outcome post-OHCA.5 7 Existing literature examining RTW among survivors of OHCA8 12 suggests that the majority of survivors do RTW. However, many of these studies are limited by small sample size and few have concurrently examined the demographic, pre-hospital and workplace factors associated with successful RTW. As such, this study aims to identify the factors associated with RTW among adult survivors of OHCA across the state of Victoria, Australia.
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including after hours. Participants (or proxies) respond to a series of introductory questions related to residential and employment status (pre and post-OHCA), and also complete the 12 Item Short Form Health Survey (SF12), EuroQol-5D-3L (EQ-5D) and the Glasgow Outcome Scale-Extended (GOSE). The follow-up process and instruments have been described in detail previously.18 In addition to these standard follow-up interviews at 12 months postarrest, for this study, individuals arresting between July 1, 2017 and September 30, 2017 were invited to participate in a more detailed RTW interview at the completion of the standard interview. Participants were asked a series of additional questions specifically related to their RTW, whether successful or unsuccessful. The additional questions covered areas such as employer support, flexible work hours, alternative duties and barriers to RTW.
Definitions
Methods Study design We performed a retrospective analysis of patients within the Victorian Ambulance Cardiac Arrest Registry (VACAR). We included adults (aged 18 years) who sustained an OHCA of any aetiology between 1 January 2010 and 31 December 2016, survived to be discharged from hospital and who were working prior to their arrest. Patients not working prior to arrest and those for whom RTW status was unknown were excluded. In addition, we conducted more detailed cross-sectional RTW telephone-interviews with OHCA survivors that experienced their arrest between 1 July 2017 and 30 September 2017 at 12 months post-arrest.
Setting The state of Victoria, Australia is the most densely populated state in Australia with an approximate area of 227,000 km2. Victoria has a population of 6.2 million people, of which 76% live within the state capital of Melbourne.13 Prehospital emergency medical services (EMS) in Victoria are solely provided by Ambulance Victoria. All EMS calls are assigned a level of priority based on the case nature and severity.14 In the event of cardiac arrest, two intensive care paramedics and two advanced life support paramedics are dispatched concurrently if resourcing permits.15 In select regions of the state, basic life support (BLS) first responders are also dispatched. All OHCA treatment is based on the Australian Resuscitation Council Guidelines.16
Data sources The VACAR is a state-wide registry that collects data on every OHCA case attended by EMS in Victoria.15 The methodology of data collection, case identification and quality control employed by the registry has previously been described.3 The registry data is comprised of more than 150 data elements primarily based on the Utstein recommendations17 and includes patient demographics, event characteristics and pre-hospital management.15 Hospital follow-up data and discharge direction are obtained from the medical records of transported patients. Data obtained from the Victorian Registry of Births, Deaths and Marriages is used to validate survivor status. Since 2010, the VACAR has routinely collected health-related quality of life (HR-QOL), long-term functional recovery and RTW outcomes 12 months after OHCA.15,18 Adult patients identified as being alive 12 months post-arrest are invited to participate in a telephone interview. Patient contact is attempted on at least 5 separate occasions, each at varying time points,
Work was defined as paid or volunteer employment or education of any type (i.e. full-time, part-time or casual). Patients on leave from work or those employed on a sporadic or seasonal manner were classified as working. Patient pre-OHCA occupation classification was based on the occupational groupings outlined in the Australian Standard Classification of Occupation 2nd edition.19
Statistical analysis The primary outcome measure was successful RTW at 12 months postOHCA. Baseline characteristics, as well as data from the RTW interviews, were summarised descriptively using frequencies and percentages for categorical variables, and medians and interquartile ranges for continuous variables. Univariate Chi-squared and Mann Whitney U tests were performed to compare the responses between participants who returned to work and those that did not. We calculated the standardised mean difference (SMD) of SF-12 physical component (PCS) and mental component (MCS) summary scores using the Australian standard population SF-12 scores.20 The magnitude of the SMD represents the variation between the SF-12 scores of the Australian population and the OHCA cohort used in this study.20 Scores 0.8 suggest clinically significant variation from population norms. To examine the factors independently associated with RTW, we conducted multivariable logistic regression analyses. Three models were constructed. Model 1 included factors known to be associated with OHCA outcomes using the Utstein definitions21 as well as other pre and post-arrest factors. The independent variables included in this model were: age in years, sex, presumed cardiac aetiology, arrest location, witness status, bystander CPR, EMS response time, initial shockable rhythm, transport to a percutaneous coronary intervention (PCI) capable hospital, discharge direction from hospital, highest level of education, pre-arrest occupation type, and workload prior to arrest. For patients who were witnessed to arrest by EMS, bystander CPR was set to ‘No’, and EMS response time was set to 0 min. Due to HR-QOL having a likely influence on RTW, as well as being influenced by RTW, HR-QOL measures were excluded from Model 1. As such, we performed a sensitivity analysis to assess for the effect of HR-QOL on RTW (Model 2). This model included a binary EQ-5D index score term (1 vs <1) in addition to all variables included in Model 1. The EQ-5D was selected as the HR-QOL measure due to its ability to be completed by both patient and proxy responders. Finally, in Model 3 we included all variables in Model 2, however replaced the EQ-5D index score term with all five EQ-5D domains
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(pain; anxiety; self-care; mobility; and activity) to understand the association between individual domains and RTW. In addition, given that the majority of patients in our population arrested into a shockable cardiac arrest rhythm, we repeated Models 1 and 2 in only those patients with an initial shockable arrest rhythm. In these models, we included all of the independent variables listed above, as well as a term describing who provided the first defibrillation (public access defibrillator/ first responder/ ambulance paramedics). The Hosmer Lemeshow test was used to assess goodness of fit for each model. The effect size of independent variables was presented using odds ratios (OR) and 95% confidence intervals (CI). Statistical analyses were conducted using Stata Statistical Software 14 (StataCorp LP, Version 14). A p-value of <0.05 was considered statistically significant.
increased odds of RTW (AOR 3.80; 95%CI: 2.59 5.58; p < 0.001). No variation in the factors associated with RTW were seen between Model 1 and Model 2. When this model was restricted to patients who arrested into an initial shockable arrest rhythm, patients initially defibrillated by first responders were more likely to RTW than those initially defibrillated by paramedics (AOR 2.60; 95%CI: 1.07 6.34; p = 0.035). In the final sensitivity analysis that included the five EQ-5D domains (Model 3, Supplemental Table 2), no problems with mobility, self-care, anxiety or activity were associated with increased odds of RTW compared to patients that reported some or extreme problems. Problems with pain was not associated with RTW.
Ethics
Over the three-month study period of the more detailed RTW interviews, 77 OHCA patients survived to hospital discharge and were working prior to their arrest (Fig. 1b). A total of 23 patients completed the RTW interview and formed the population for this component of the study. Of the 23 patients interviewed, 20 (87%) returned to work, with 80% returning to the same role with the same employer (Table 3). Patients took a median of 7 weeks (IQR 4 22) to RTW following discharge from hospital.
The VACAR maintains ethical approval from the Victorian Government Department of Health Human Research Ethics Committee as a quality assurance project. Approval from individual hospital ethics committees is also obtained for hospital data collection. Ethical approval for the more detailed RTW interviews was obtained from the Ambulance Victoria Research Governance Committee.
Return to work experiences reported in the detailed RTW interviews
Workplace accommodation: flexible work hours and alternative or modified duties
Results Over the 6-year study period, 17,638 individuals who sustained an OHCA received a resuscitation attempt, of which 2328 (13%) survived to hospital discharge (Fig. 1a). A total of 1765 participants completed the 12-month follow-up interview, with an overall response rate of 82%. Of these, 884 participants reported working prior to their OHCA and had a known RTW status.
The majority of interview patients (85%) were offered flexibility with work hours by their employers (Table 3). RTW patients reported re-integrating back into the workforce with fewer shifts, shifts of shorter duration or a combination of both. Role sharing with another employee, adopting a smaller workload and less physical duties were the modified and alternative duties offered to patients by their employers.
Barriers to return to work Unadjusted baseline and post-arrest characteristics The median age was 54 (IQR 46 61) years and most were male (85%) (Table 1). The majority of participants (73%) successfully returned to work at 12-month follow-up, with most remaining in the same role (88%) at the same organisation (89%). Patients that did not RTW were more often of older age, had lower levels of formal education, were working in a labour-intensive occupation, working part-time prior to arrest and had an arrest of non-cardiac aetiology. Additionally, patients that did not RTW were more likely to report lower levels of HR-QOL and to have been discharged directly to a rehabilitation centre rather than home.
Overall, 85% (n = 17) of all patients reported barriers to their RTW. Professionals were more likely to report no difficulties in RTW (75%). Those employed as tradespersons (100%), in the production and transport industry (86%) or in the sales and service industry (100%) experienced the greatest number of RTW barriers (Fig. 2a). Fatigue was the most frequently reported factor to restrict RTW, with 30% of all patients reporting post-OHCA fatigue followed by mild cognitive impairment manifesting as impaired memory and cognitive processing (26%) (Fig. 2b). Medical restrictions on the use of commercial driver’s licenses following OHCA were reported to have been a barrier impeding RTW by four patients, all of which were employed in the transport industry.
Multivariable analyses Factors independently associated with RTW on multivariable analysis are presented in Table 2. Male sex, being witnessed to arrest by EMS and discharge directly home from hospital were all positively associated with RTW. Arrests of traumatic aetiology, increasing participant age and prearrest employment in the trade or labour industries were all negatively associated with RTW. Neither workload prior to arrest nor education level were associated with RTW. When we restricted this model to patients who arrested into a shockable cardiac arrest rhythm, patients initially defibrillated by first responders were more likely to RTW than those initially defibrillated by paramedics (AOR 2.79; 95%CI: 1.17 6.65; p = 0.020). In the sensitivity analysis including the EQ-5D index score (Model 2, Supplemental Table 1), an EQ-5D index score of 1 was associated with
Discussion To our knowledge, this is the largest study to collectively examine baseline and post-arrest characteristics associated with RTW among survivors of OHCA. The majority of participants successfully returned to work at 12month follow-up. We identified multiple factors to be associated with RTW following OHCA survival, including early initiation of resuscitative measures, employment in non-labour-intensive occupations, and discharge directly home from hospital. While we did not find RTW to be associated with education level, our findings suggest that RTW was associated with favourable HR-QOL at 12 months post-arrest.
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Fig. 1 – a. Selection process of the study population included in the epidemiological component of this study. Participant selection obtained from the Victorian Ambulance Cardiac Arrest Registry, 2010 2016. Lost to follow-up is inclusive of participants unable to be contacted or living overseas. Other includes participants unable to be contacted due to a language barrier, terminal illness, psychiatric illness or residence outside of Victoria. b. Selection process of the study population for the return to work qualitative interview in this study. Participant selection obtained from the Victorian Ambulance Cardiac Arrest Registry, July 1, 2017 September 30, 2017. Lost to follow-up is inclusive of participants unable to be contacted or living overseas. Abbreviations: OHCA, out-of-hospital cardiac arrest; EMS, emergency medical service; RTW, return to work.
Patients with labour-intensive occupations such as labourers, tradespersons, and production and transport workers were less likely to RTW compared to professionals. These findings are consistent with previous reports for OHCA patients and other conditions such as stroke, trauma and muscular disorders.5,8,22,23 It is likely that the physiological effects of illness or injury have a greater impact on individuals employed in predominantly
physical occupations. Limitations with mobility, activity or self-care following an OHCA are more likely to affect those with physical occupations when attempting or considering RTW.8,24 Indeed, our results suggest that patients with problems in each of these EQ-5D domains were less likely to RTW. However, the negative association between employment in the transport industry and RTW may be a reflection of Australia’s national
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Table 1 – Baseline and post-arrest characteristics.
Pre-arrest characteristics Age in years, median (IQR) Male sex, n (%) Highest level of education completed, n (%) Primary school Secondary school Year 11 equivalent or below Secondary school Year 12 or equivalent Certificate/diploma/advanced diploma Bachelor’s degree Postgraduate study Unknown Pre-arrest occupation, n (%) Professionals Managers and administrators Associate professionals Tradespersons and related Clerical, sales and service Intermediate production and transport Labourers and related Other Unknown Workload prior to arrest, n (%) Full-time Part-time Other Unknown Arrest characteristics Aetiology, n (%) Presumed cardiac Trauma Respiratory Neurological Other EMS response time (mins), median (IQR)b Witness of arrest, n (%) Unwitnessed Bystander witnessed EMS witnessed Unknown Bystander CPR, n (%)b Initial arrest rhythm, n (%) Ventricular fibrillation/ventricular tachycardia Pulseless electrical activity Asystole Unknown Initial defibrillation, n (%)a Paramedics First responders Public access defibrillator Arrest Location, n (%) Private residence Public location Ambulance Medical clinic Other Arrest region, n (%) Metropolitan Rural Post-arrest characteristics Transported to PCI capable hospital, n (%)
All (n = 884)
RTW (n = 650)
No RTW (n = 234)
p-Value
54 753
(46 61) (85.2)
53 565
(44 60) (86.9)
58 188
(49 64) (80.3)
<0.001 <0.015 <0.001
7 181 123 296 136 99 42
(0.8) (21.5) (14.6) (35.2) (16.2) (11.7)
4 113 93 219 116 76 29
(0.6) (18.2) (15.0) (35.3) (18.7) (12.2)
3 68 30 77 20 23 13
(1.3) (30.8) (13.6) (34.8) (9.1) (10.4)
214 106 97 147 104 101 76 20 19
(24.7) (12.3) (11.2) (17.0) (12.0) (11.7) (8.8) (2.3)
171 87 79 104 75 59 49 16 10
(26.7) (13.6) (12.3) (16.3) (11.7) (9.2) (7.7) (2.5)
43 19 18 43 29 42 27 4 9
(19.1) (8.4) (8.0) (19.1) (12.9) (18.7) (12.0) (1.8)
721 134 20 9
(82.4) (15.3) (2.3)
546 86 14 4
(84.5) (13.3) (2.2)
175 48 6 5
(76.4) (21.0) (2.6)
821 15 23 15 10 8.1
(92.9) (1.7) (2.6) (1.7) (1.1) (6.2 10.9)
615 5 16 8 6 8.1
(94.6) (0.8) (2.5) (1.2) (0.9) (6.3 11.0)
206 10 7 7 4 8.1
(88.0) (4.3) (3.0) (3.0) (1.7) (6.2 10.7)
82 558 243 1 570
(9.3) (63.2) (27.5)
51 410 188 1 417
(7.9) (63.2) (28.9)
31 148 55
(13.3) (63.2) (23.5)
(90.3)
153
(85.5)
788 52 36 8
(90.0) (5.9) (4.1)
587 34 24 5
(91.0) (5.3) (3.7)
201 18 12 3
(87.0) (7.8) (5.2)
649 64 84
(81.4) (8.0) (10.6)
470 54 70
(79.1) (9.1) (11.8)
179 10 14
(88.2) (4.9) (6.9)
366 409 80 24 5
(41.4) (46.3) (9.1) (2.7) (0.5)
251 314 63 19 3
(38.6) (48.3) (9.7) (2.9) (0.5)
115 95 17 5 2
(49.1) (40.6) (7.3) (2.1) (0.9)
684 200
(77.4) (22.6)
503 147
(77.4) (22.6)
181 53
(77.4) (22.6)
772
(87.3)
575
(88.5)
197
(84.2)
<0.001
<0.019
<0.002
(88.9)
<0.738 <0.027
<0.736 <0.221
<0.016
<0.066
<0.991
<0.092
(continued on next page)
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Table 1 (continued)
Discharge direction, n (%) Home Rehabilitation Nursing facility Unknown Return to work same role, n (%) Yes No Unknown Return to work same organisation, n (%) Yes No Unknown GOSE, n (%) Upper good recovery Lower good recovery Upper moderate disability Lower moderate disability Upper severe disability Lower severe disability Vegetative state Unknown EQ-5D index score, median (IQR) EQ-5D VAS, median (IQR) Prior to arrest Current No problems in all EQ-5D domains, n (%) SF-12, mean (SD) PCS MCS SF-12, SMD (SD) PCS MCS
All (n = 884)
RTW (n = 650)
No RTW (n = 234)
p-Value
794 80 4 6
614 34
180 46 4 4
(78.3) (20.0) (1.7)
(16.3) (15.9) (9.4) (37.8) (6.4) (13.3) (0.9) (0.66 0.88)
<0.001
<0.001 (90.4) (9.1) (0.5)
(94.8) (5.2)
2 575 72 3
(88) (11) (1)
582 65 3
(89) (10) (1)
275 196 155 19 3
(42.4) (30.3) (23.9) (2.9) (0.5)
<0.001 313 233 177 107 18 31 2 3 1
(35.5) (26.5) (20.1) (12.1) (2.1) (3.5) (0.2) (0.80 1)
2 1
(0.85 1)
38 37 22 88 15 31 2 1 0.81
85 80 437
(75 95) (70 90) (49.3)
85 80 382
(75 95) (72 90) (59)
90 70 55
(80 99.5) (50 85) (24)
<0.001 <0.001
49.4 53.7
(9.21) (8.38)
51.2 54.5
(7.84) (7.23)
43.8 51.2
(10.75) (10.86)
<0.001 <0.004
0.06 0.07
(1.00) (1.03)
0.23 0.18
(0.87) (0.88)
(1.18) (1.35)
<0.001 <0.002
0.48 0.26
Abbreviations: IQR, interquartile range; CPR, cardiopulmonary resuscitation; EMS, emergency medical service; RTW, return to work; PCI, percutaneous coronary intervention; GOSE, glasgow outcome scale extended; EQ-5D, EuroQol-5D; VAS, visual analogue scale; SMD, standardised mean difference; SD; standard deviation; SF-12, short form 12 item health survey; PCS, physical component summary; MCS, mental component summary. a Initial defibrillation only relevant to participants presenting in ventricular tachycardia or ventricular fibrillation. b Excludes EMS witnessed arrests.
mandatory restrictions and suspensions imposed on holders of commercial driver’s licenses following cardiac arrest.25 Patients with OHCA of traumatic aetiology had lower odds of RTW compared to those of presumed cardiac cause. It is plausible that the injuries sustained as a result of the mechanisms involved in a traumatic OHCA, as well as the direct effects of the OHCA itself, collectively diminish the likelihood of recovering with the physical or cognitive level of functionality required to RTW. Traumatic OHCA represented a small cohort in our study (n = 15), therefore a large study of traumatic OHCA survivors is needed to specifically explore RTW outcomes in this population. Such a study might better identify the barriers to RTW that this unique population encounter, enabling them to be better supported with targeted strategies and rehabilitation programs. In contrast, we observed a positive association between RTW and first responder defibrillation and EMS witnessed arrests. These findings are likely to be a reflection of the benefits of early resuscitative measures and further emphasise the importance of the Chain of Survival in OHCA.21,26 Ours is not the first study to report these findings, Kragholm et al also reported an association between early OHCA intervention and RTW in Denmark.10
Despite shockable rhythms being one of the biggest drivers of survival following OHCA,27,28 we did not find an association between shockable rhythms and RTW. It is possible that RTW in survivors only may be better explained by post-arrest factors which were not adjusted for in our analyses, such as hospital interventions and post-discharge rehabilitation.12,29 Overall, HR-QOL and functional recovery outcomes were more favourable among patients who RTW than those who did not. Further, patients who were discharged directly home from hospital, which may be a surrogate for functional outcome at hospital discharge, were also more likely to RTW. It is possible that the barriers encountered by individuals that experience problems with mobility, activity, self-care and anxiety postarrest, restrict the execution of their usual workplace duties or limit the prospect of RTW. Poorer HR-QOL may in part be associated with an inability to RTW, considering the strong positive influence work can have on physical and mental health and overall wellbeing.4,5,7 However, we are unable to examine the direction of the association between HR-QOL and RTW, given that our HR-QOL telephone follow-up is conducted at 12 months post-arrest only. In contrast to other conditions such as trauma and stroke, evidencebased rehabilitation pathways for OHCA survivors are limited.30 Future
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Table 2 – Independent factors associated with return to work.
Age (per year) Male sex Aetiology Presumed cardiac Trauma Othera Arrest location Private residence/other Public location Witness of arrest Unwitnessed EMS witnessed Public witnessed Bystander CPR Transport to a PCI capable hospital Discharge direction Rehabilitation/nursing home Home Initial rhythm Non-shockable Shockable EMS response time (per minute) Highest level of education completed Schoolb Bachelor degree/diplomac Postgraduate Pre-arrest occupation Professionals/managersd Trades/labourerse Clerical/otherf Workload prior to arrest Full time Part time Other
OR
95% CI
p-Value
0.97 1.80
0.95 0.98 1.10 2.94
<0.001 <0.020
Reference 0.18 0.49
0.04 0.77 0.20 1.18
<0.021 <0.110
Reference 1.46
0.99 2.16
<0.056
Reference 2.72 1.39 1.46 1.37
1.50 0.78 0.77 0.83
9.25 2.47 2.74 2.24
<0.005 >0.266 <0.243 <0.215
Reference 4.13
2.38 7.18
<0.001
Reference 0.62 1.03
0.30 1.29 0.98 1.09
<0.200 <0.269
Reference 1.23 1.18
0.84 1.80 0.62 2.25
<0.288 <0.609
Reference 0.44 0.75
0.29 0.66 0.42 1.34
<0.001 <0.332
Reference 0.84 1.07
0.52 1.34 0.38 3.01
<0.464 <0.898
Abbreviations: OR, odds ratio; CI, confidence interval; EMS, emergency medical service; PCI, percutaneous coronary intervention; CPR, cardiopulmonary resuscitation. a Neurological, respiratory and other. b Primary school, secondary school year 11 or below and secondary school year 12 or equivalent. c Certificate, diploma, advanced diploma and bachelor degree. d Professionals, managers and administrators and associate professionals. e Tradespersons and related, labourers, intermediate production and transport. f Clerical, sales and service and other occupations. 802 patients included in the model. Goodness of fit using the Hosmer Lemeshow test, p = 0.157.
Table 3 – Return to work experiences outlined in the detailed RTW interview. All (n = 23) Return to work same role, n (%) Yes No Return to work same organisation, n (%) Yes No Duration of most recent employment in years, median (IQR)
RTW (n = 20)
6
16 4
(80) (20)
16 4 6
(80) (20) (2 13)
7
(4 22)
No RTW (n = 3)
7
(1 10)
(1 13) Duration to RTW in weeks, median (IQR) Flexible work hours offered by employer, n (%) Yes No Alternative workplace duties offered by employer, n (%) Yes No
17 6
(74) (26)
17 3
(85) (15)
0 3
(0) (100)
17 6
(74) (26)
17 3
(85) (15)
0 3
(0) (100)
Abbreviations: IQR, interquartile range; RTW, return to work.
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Fig. 2 – a. Proportion of participants reporting barriers to return to work based on occupation type. Barriers refer to factors that impeded participant return to work when recovering from the out-of-hospital cardiac arrest. Potential barriers included: medical restrictions, lack of workplace flexibility, chronic pain, anxiety or depression, fatigue, physical impairment, cognitive impairment and no reported difficulties. Number of participants within each occupational category: intermediate production and transport, n = 7; clerical, sales and service, n = 2; tradespersons, n = 4; associate professionals, n = 3; managers and administrators, n = 3; professionals, n = 4. b. Participant responses relating to barriers or difficulties impeding return to work. Participants had the opportunity to select more than one answer if applicable. Medical restrictions refer to restrictions ordered by medical practitioners regarding workplace duties and is inclusive of the suspension of commercial driver’s license; cognitive impairment refers to mild impairment in memory and cognitive processing. Study population, n = 23; return to work, n = 20; no return to work, n = 3. Abbreviations: RTW, return to work.
studies are required to examine post-OHCA rehabilitation with hope that this will lead to improved HR-QOL and RTW outcomes among survivors. Our RTW interviews identified a number of barriers that OHCA survivors face when attempting to RTW. Fatigue and mild cognitive impairment were the most prevalent. Chronic fatigue is a commonly reported
symptom among survivors of cardiac arrest.31 Fatigue diminishes the ability to focus on workplace tasks, maintain productivity and maintain motivation, all of which lead to increased rates of absenteeism and withdrawal from the workforce.32,33 Similarly, mild cognitive impairment, the second most commonly reported barrier to RTW, has the potential to greatly impact
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workplace functionality due to impaired recall and a diminished ability to process large amounts of new information quickly.11,23,34,35 Despite fatigue and mild cognitive impairment being reported by the majority of RTW interview participants, a large proportion were still able to RTW. This is possibly due to modified workplace duties and flexible work hours facilitating the transition back into the workforce.
Limitations This study has a number of limitations. First, due to the retrospective design there may be other unknown or unmeasured factors that we could not account for. Such factors may include the influence of specific hospital treatments, recommendations of medical personnel and participation in specific rehabilitation programs following hospital discharge. Second, as the research was solely conducted in the state of Victoria with one EMS agency, the findings may not be generalisable to other EMS agencies and regions. Third, this study was also limited by loss to follow-up which reduced the effective sample size of both components of this study. Finally, the follow-up interviews were only conducted at a single time point. It is therefore unclear whether employment was sustained by those that reported successful RTW or whether participants that reported no RTW were able to return to the workforce following the interview.
Conclusion In our study, early resuscitative intervention, non-traumatic aetiology and non-labour-intensive occupations were associated with RTW following OHCA, as were discharge directly home from hospital and favourable 12month HR-QOL. Fatigue and mild cognitive impairment were the most frequently reported barriers to survivors returning to the workforce. Although larger qualitative studies are needed, our findings highlight patient groups which may be at risk of not returning to work and who may benefit from targeted rehabilitation strategies.
Conflicts of interest None.
Acknowledgements We would like to acknowledge Ambulance Victoria and the Victorian Ambulance Cardiac Arrest Registry team for the management and maintenance of the registry.
Appendix A. Supplementary data Supplementary material related to this article can be found, in the online version, at doi:https://doi.org/10.1016/j.resuscitation.2019.09.006.
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