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The MERIT 3 project: Alerting general practitioners to cardiac arrest in the community
Resuscitation 121 (2017) 141–146
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Clinical paper
The MERIT 3 project: Alerting general practitioners to cardiac arrest in the community T. Barry a,∗ , N. Conroy a , M. Headon a , M. Egan a , M. Quinn b , C. Deasy c,d , G. Bury a a
UCD Centre for Emergency Medical Science, School of Medicine, Health Sciences Centre, University College Dublin, Belfield, Dublin 4, Ireland Out of Hospital Cardiac Arrest Register, St. Eunans Hall, St. Conals Hospital, Letterkenny, Co. Donegal, Ireland Cork University Hospital, Cork, Ireland d National Ambulance Service, Ireland b c
a r t i c l e
i n f o
Article history: Received 22 May 2017 Received in revised form 13 October 2017 Accepted 28 October 2017 Keywords: Out-of-hospital cardiac arrest Resuscitation Emergency responder General practice
a b s t r a c t Background: The work context of the general practitioner (GP) potentially lends itself to the provision of early community based, cardiac arrest care. GPs have traditionally encountered out of hospital cardiac arrest (OHCA) as a component of routine patient care but have not been formally linked with the statutory ambulance service. Computer aided dispatch technology now allows real time GP text message alert to nearby cardiac arrest events. Aim: To examine the feasibility, uptake and outcome of a novel scheme to alert GPs to nearby OHCA events in their communities. Methods: GPs are recruited to voluntarily participate in a cardiac arrest text alert initiative called the ‘MERIT 3 project. GPs indicate the hours during which they wish to receive OHCA text alerts, and also specify a geo-location from which they will receive alerts to OHCA events occurring within a specified radius. Data on alerts, responses, OHCA incidents and outcomes are gathered prospectively, using ambulance control and GP data and with corroborative data from the national OHCA registry. Results: 423 general practices throughout Ireland were invited to participate. In the initial 12 months, 100 GPs from 85 individual practices have enrolled, 74 GPs have received alerts and 26 GPs have responded to incidents. Only 222/781 (28.4%) text alerts issued by ambulance control have proven to be recognised as cardiac arrests with resuscitation attempts. GPs have attended 51/776 (6.6%) OHCA incidents to which they have been alerted, with resuscitation undertaken in 34 cases with three survivors. Conclusion: Text alert activation of GPs to nearby OHCA events has proven feasible, with significant activity during the establishment period, but a low survival rate which is similar to the overall national OHCA survival rate. A high proportion of alerts do not involve resuscitation opportunities. © 2017 Elsevier B.V. All rights reserved.
Introduction Ireland is a northern European country with a population in excess of 4.75 million [1] for which out of hospital cardiac arrest (OHCA), primarily due to ischemic heart disease (IHD) is a key health issue; IHD causes approximately fifteen percent of all deaths [2]. In the region of 2000 OHCAs with attempted resuscitation are dealt with by the ambulance services in Ireland annually; unfortunately survival rates remain less than seven percent [3,4]. Early cardiopulmonary resuscitation (CPR) and defibrillation are vital but critically time sensitive treatments following OHCA [5]. Improved
∗ Corresponding author. E-mail address: [email protected] (T. Barry). https://doi.org/10.1016/j.resuscitation.2017.10.025 0300-9572/© 2017 Elsevier B.V. All rights reserved.
OHCA survival requires early availability of these treatments in the community where OHCA occurs. Ireland has in the region of 3000 general practitioners (GPs) [6]. This group of health professionals live and work in the communities for which they provide comprehensive primary care. GPs are potentially well placed to deliver early, community based cardiac arrest care. GP participation in OHCA resuscitation has been associated with increased patient survival [7–11]. In Ireland the MERIT 1/2 (Medical Emergency Responders Integration and Training) projects [7] recruited more than 500 Irish general practices to receive automatic external defibrillators (AEDs) and training in OHCA management. The project demonstrated that 18.7% of patients who suffered an OHCA and were treated by a participating GP, survived to hospital discharge [8]. In general however, the role of the GP in cardiac arrest resuscitation has traditionally received little attention [12]. Schemes to
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equip general practitioners for OHCA have existed since the 1970 s and 80 s [13,14] and although OHCA is not a frequent occurrence in general practice, over time many GPs are involved in OHCA resuscitation; research from Greece suggests an incidence of OHCA in primary healthcare of 15.3/100,000 per year [15], a nationwide survey from Denmark demonstrated that 29% of GPs had encountered an OHCA at their practice [16], while in Ireland a cohort study of GPs showed that 36% encountered OHCA where resuscitation was attempted within a five year period [8]. Irish Department of Health policy has long emphasised the importance of first responders in addressing OHCA and more recently has highlighted the role of GP responders [17,18]. To date in Ireland, GPs who participate in MERIT have reported incidents which they encounter during their day-to-day practice and have not been formally linked with the 999/112 system of emergency ambulance dispatch. New technology allows real-time ambulance control text message alerts to be sent to ‘GP responders’ when a nearby OHCA occurs. A novel project termed ‘MERIT 3 , examines the feasibility and outcome of recruiting GP volunteers to be alerted to nearby OHCA using text message technology. While a number of papers have recently reported on text alert systems involving lay responders to OHCA, we are not aware of any reports of systems involving volunteer medical networks [19,20] .This paper outlines the initial period of establishment, recruitment and experience of implementation of this project.
Methods 505 General Practices enrolled in the MERIT 1/2 projects continue to prospectively report data on their experience of OHCA in routine general practice. Approximately two thirds of the country’s population lives in urban areas [21], which are well served by full-time professional ambulance services and relatively nearby hospitals. MERIT has focused on populations and general practices in rural and other areas in which local GPs may often be the initial contact in a medical emergency. Of the 505 MERIT 1/2 practices, 423 (83.8%) in rural, suburban and mixed locations were therefore identified for potential recruitment to MERIT 3. In MERIT 3, GPs volunteer to be alerted to nearby incidents of OHCA via text message from the Health Services Executive, National Ambulance Service (NAS) control centre. The text alert includes the patient’s age, gender and the exact address where the OHCA has occurred. GPs are under no obligation to attend the OHCA, but can do so if circumstances permit; the ambulance service always responds in the standard fashion. GPs indicate the hours during which they wish to receive text alerts and specify a fixed geo-location around which they will receive OHCA text alerts; GPs can define a specified radius of response (usually 10 Km’s). If alerted and in a position to attend, GPs are asked to contact a dedicated ambulance dispatch phone line to update ambulance control on their intention to travel to the incident and to obtain additional information if available. Data on alerts, responses, OHCA clinical care and outcomes are gathered at a number of levels. The NAS notifies the MERIT 3 team of all OHCA text alerts sent to participating GPs on a monthly basis. GPs individually provide reports on text alerts received and clinical anonymised data on individual cases attended using a standardised incident report form. Data is also collected from the Out of Hospital Cardiac Arrest Register (OHCAR) on all cases where GPs have been alerted; OHCAR data provides standardised information on the timings and outcomes of all OHCAs reported to it by all statutory ambulance services in Ireland. It is thus possible to determine what proportion of text alerts are recognised by OHCAR as out of hospital cardiac arrest events where resuscitation is attempted and to record intervention and outcome data on those incidents. Structures to address professional indemnity, clinical governance and
data management have been developed and implemented in liaison with NAS and OHCAR. The MERIT 3 project is part-funded by charitable support from Irish Community Rapid Response (ICRR) who subsidise the cost of immediate care training for GPs who participate and also fund a response bag containing basic life support and personal protective equipment. GPs do not receive any additional payments for participating in the scheme or responding to alerts. Ethical approval for the study has been provided by the UCD Human Research Ethics Committee and both OHCAR and the NAS have provided permission for access to data. Data is reported in this initial study on the 12 month period 1st Oct 2015 to 30th Sept 2016. Results 423 MERIT 1/2 practices were contacted by letter and invited to participate in MERIT 3. As of September 2016, 100 GPs from 78 MERIT practices and seven new practices had enrolled. An initial 39 GPs went live on the text alert system in April 2015, with the remainder joining in increments over the following months. Fig. 1. Illustrates the geographic distribution of MERIT 3 GPs. Table 1 presents data on text alerts issued to GPs and the numbers/proportions recognised by OHCAR as cardiac arrests with resuscitation attempts (CARA). Over the twelve-month period GPs were alerted to a total of 781 events. The OHCAR database recognises 222/781 (28.4%) of these incidents to have been CARAs and has no information on the remaining 559/781 (71.6%). Fig. 2. presents data on GP participation and alert frequency, it demonstrates that almost three quarters (74/100) of participating GPs received at least one text alert (range 1–354, median 3) over the study period. Ultimately a quarter of GPs (26%) responded to at least one text alert (range 1–21, median 1) during the study period. Fig. 3. presents data on the distribution of alerts & responses by time of day and shows that the majority of alerts were received after 8am and before 11pm. Alerts and responses were distributed across the days of the week with 200/781 (26%) of alerts and 12/60 (20%) responses occurring at weekends. Fig. 4. summarises the experience of participants over the study time period. MERIT 3 GPs attended 51 cases, the majority of which (42/51, 82.4%) were at residential locations. In half of the incidents (25/51) GPs arrived in advance of the ambulance service. Of the incidents attended, 45/51 (88.2%) were OHCA and six were other clinical problems (not involving loss of cardiac output) including overdoses (2), alcohol related issues (2), sepsis (1) and a psychiatric presentation(1). Of the 45 OHCAs, eleven were recent deaths where no resuscitation was appropriate, while 34 represented cardiac arrests where resuscitation was attempted (CARA). Of the 34 CARAs, BLS efforts appear to have been ceased promptly after the GPs arrival in seven cases and after a period of resuscitation in 17 cases, while the patient was transferred to hospital in 10 cases. Three patients survived to hospital discharge, representing 8.8% of the 34 cases in which resuscitation was attempted. Of note, OHCAR did not have information on six of the CARA cases in which extended resuscitation occurred. Discussion The MERIT 3 project represents a novel, community based, general practice response to OHCA. Although the concept of a rapid-response cardiac arrest scheme for GPs has previously been proposed [22], we are not aware of any published description of a similar scheme in operation elsewhere. GPs in Britain and Ireland are said to be under significant financial, workload and morale pressures [23,24]. It is noteworthy that under such circumstances, a significant number of individuals (representing around a fifth of
T. Barry et al. / Resuscitation 121 (2017) 141–146
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Fig. 1. Merit 3 GP locations.
Table 1 Monthly Text Alerts to GPs and the number/proportion recognised by OHCAR where resuscitation was attempted (CARA cases). Month Cases Alerted CARA n (%)
Oct-15 64 13 (20.3)
Nov-15 45 19 (42.2)
Dec-15 66 21 (31.8)
Jan-16 67 14 (20.9)
Feb-16 57 13 (22.8)
Mar-16 75 21 (28.0)
Apr-16 65 21 (32.3)
May-16 79 23 (29.1)
Jun-16 66 23 (34.8)
Jul- 16 61 22 (36.1)
Aug- 16 63 10 (15.9)
Sep- 16 73 22 (30.1)
Total 781 222 (28.4)
*CARA − Cardiac Arrest with Resuscitation Attempt, recognised by OHCAR
the practices invited) are prepared to re-affirm their commitment to the communities they serve by volunteering for a project such as this. The recruitment and alerting processes utilised during the set-up phase of the MERIT 3 project have proved to be feasible and effective.
Previous research has suggested that GPs working in remote settings were more likely to have equipped themselves for OHCA management than their urban colleagues [25], whilst the experience of GPs participating in the MERIT 1/2 projects was that rural GPs encountered twice as many OHCA events as their urban/mixed
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Fig. 2. GP Participation and Alert Frequency.
Fig. 3. Alert & Response Distribution over 24 h.
practice counterparts [8]. The willingness of GPs to provide a local emergency response in a rural setting may represent a vital link in the chain of survival for a remote community. It is possible that rural GPs perceive a greater need for community OHCA response given that ambulance service response times to their communities are likely to be prolonged. In terms of building on this project, future qualitative research will explore the factors that influence GP participation in schemes such as MERIT 3. The preliminary data now available concerning circumstances where GPs have been alerted to and have responded to OHCA events in their communities must be interpreted with caution, given its initial small scale and the fact that this novel project is in evolution. Over the time period described, GPs offered to or actually attended 60/776 (7.7%) of the incidents of presumed OHCA to which they were alerted and were involved in significant decision making in 45 OHCAs. The ultimate survival rate (8.8%) is similar to the national norm and is significantly lower than the survival rate for OHCAs encountered during a normal GP working day (around 18%). These results are based on relatively small numbers of cases but may indicate that although all of these incidents occur in the com-
munity, differences exist between groups of patients encountered in different settings. The response/attendance rates encountered thus far may suggest a modest capacity to supplement the statutory ambulance service OHCA response. It is likely that this response rate is to some degree a function of logistic barriers such as geographical distance or other work responsibilities. These elements of GP OHCA response have not been explored during our initial research exercise and will need to be examined in detail as the project progresses. The current MERIT 3 text alert system is based on a fixed geographical response area, involving a radius of (mostly) 10kms from a set point address location. Modern smart-phone global positioning technology has been used to alert the geographically closest OHCA responders elsewhere [26,27] and could potentially facilitate a more dynamic GP OHCA alert model, where the GP responder’s position would be available in real time to ambulance control using GPS tracking systems. Less than 30% of alerts issued from ambulance control have ultimately been recognised as cases of OHCA in which resuscitation was attempted. This raises several issues. The standard ambulance
T. Barry et al. / Resuscitation 121 (2017) 141–146
Fig. 4. M3 Project; Alerts and Responses Flowsheet.
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*CARA: Cardiac arrest with resuscitation attempt **OHCA: Out of Hospital cardiac arrest
service response to each OHCA alert is to mobilise two ambulances, an Advanced Paramedic and any nearby volunteer responders. While a degree of over triage is necessary to insure call taking procedures are sufficiently sensitive to detect all instances of cardiac arrest where resuscitation should be attempted, if the alerting system is ‘wrong’ in 70% of cases, this represents a significant impact on resources and a significant opportunity cost in a vital area. In addition it may lead to ‘alert fatigue’ resulting in decreased or suboptimal responses over time.
As it is likely that the majority of the 70% not recognised as OHCA in which resuscitation was attempted are in fact patients who have died and in whom resuscitation is inappropriate; no resuscitation report would therefore be submitted to OHCAR. Our data suggest that further work to refine the activation system to better identify the group of patients in whom resuscitation is inappropriate could improve the efficient use of ambulance service and community resources. Our data also suggests that some of the cases which are not reported to OHCAR as resuscitation attempts, have in fact been just that. Significant work of data validation has been
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undertaken by OHCAR, as in many other national registry systems [4,28]; linkages to research such as this may further improve that process. Ultimately our findings will require further exploration in partnership with NAS and OHCAR and may well be a function of the complexity of community OHCA care and the challenges of maximising data capture during and after the difficult circumstance of cardiac arrest. It is notable that when GPs attended incidents, they frequently arrived on scene in advance of the statutory ambulance service. If this observation continues to be borne out as the project progresses, it is likely that in select cases, MERIT 3 GPs could make a significant contribution to individual patient survival by bringing essential skills and equipment to the scene of an OHCA earlier than would otherwise be possible. Although the exact response times of the ambulance service represent important data when considering the impact of early GP arrival to an OHCA scene, unfortunately this information is currently not available to the MERIT 3 team. In the majority of OHCA cases attended by MERIT 3 GPs to date, resuscitation efforts have been terminated at the scene. The potential benefit of GP OHCA care relating to clinical and ethical decision making in the termination of resuscitation has previously been considered [22]. Research has demonstrated that resuscitation is more likely to be ceased on scene when a GP is present suggesting the “compassionate management of death in unviable circumstances” [29]. This component of resuscitation practice has previously received little attention but has noteworthy individual and societal importance. In addition to the ethical concern of continued resuscitation in futile circumstances, significant resources may be engaged that would otherwise be available to treat other critically unwell or injured patients. Conclusion Text alert activation of GPs to nearby OHCA events has proven acceptable to GPs and feasible in the real world context. Preliminary data suggests that GPs can reach patients in advance of the ambulance service potentially bringing lifesaving therapies earlier to scene than would otherwise be available. A significant aspect of the care delivered thus far during the MERIT 3 project has related to decision making around end of life care. The MERIT 3 project describes a novel system of OHCA care in the community. Conflicts of interest The authors declare no conflicts of interest. Acknowledgements The authors wish to acknowledge the general practitioners who participate voluntarily in the MERIT project. The authors wish to acknowledge charitable project support from Irish Community Rapid Response. References [1]. CSO. Census of population 2016– preliminary results. Dublin: Central Statistics Office; 2016 [Accessed 21 August 2017, at http://www. cso.ie/en/releasesandpublications/ep/p-cpr/censusofpopulation2016preliminaryresults/]. [2]. CSO. In: Vital statistics yearly summary 2015. Dublin: Central Statistics Office; 2016 [Accessed 21 August 2017, at http://www.cso.ie/en/ releasesandpublications/ep/pvsys/vitalstatisticsyearlysummary2015].
[3]. OHCAR. Out of hospital cardiac arrest register Ireland: annual report 2014. Galway: Out of Hospital Cardiac Arrest Register; 2016 [Accessed 21 August 2017, at https://www.phecit.ie/Images/PHECC/Publications%20and%20Media/ Other%20Publications/5.1%20OHCAR%206th%20Annual%20Report.pdf]. [4]. OHCAR. Out of hospital cardiac arrest register Ireland: annual report 2015. Galway: Out of Hospital Cardiac Arrest Register; 2017 [Accessed 21 August 2017, at https://www.nuigalway.ie/media/collegeofmedicinenursinghealthsciences/ disciplines/generalpractice/OHCAR-2015-Annual-Report.pdf]. [5]. Monsieurs KG, Nolan JP, Bossaert LL, Greif R, Maconochie IK, Nikolaou NI, et al. European resuscitation council guidelines for resuscitation. section 1 executive summary. Resuscitation 2015;95:1–80. [6]. Teljeur C, Tyrrell E, Kelly A, O’Dowd T, Thomas S. Getting a handle on the general practice workforce in Ireland. Ir J Med Sci 2014;183:207–13. [7]. Bury G, Headon M, Dixon M, Egan M. Cardiac arrest in Irish general practice: an observational study from 426 general practices. Resuscitation 2009;80:1244–7. [8]. Bury G, Headon M, Egan M, Dowling J. Cardiac arrest management in general practice in Ireland: a 5-year cross-sectional study. BMJ Open 2013;3. [9]. Colquhoun MC. Defibrillation by general practitioners. Resuscitation 2002;52:143–8. [10]. Colquhoun M. Resuscitation by primary care doctors. Resuscitation 2006;70:229–37. [11]. Bury G, Egan M, Tobin H, Headon M. Immediate care training in Ireland, 2002–2013: a potential link between high uptake rates and effect. Ir Med J 2015;108:140. [12]. Colquhoun MC. Resuscitation in general practice – time for action: editorial on: the presence of resuscitation equipment and influencing factors at general practitioners’ offices in Denmark: a cross-sectional study by Niegsch ML, Krarup NT, Clausen NE. Resuscitation 2014;85:5–6. [13]. Clyde C, Kerr A, Varghese A, Wilson C. Practice research defibrillators In general practice. Br Med J (Clin Res Ed) 1984;289:1351–3. [14]. Pai GR, Haites NE, Rawles JM. Practice research one thousand heart attacks in grampian: the place of cardiopulmonary resuscitation in general practice. Br Med J (Clin Res Ed) 1987;294:352–4. [15]. Chalkias A, Koutsovasilis A, Mazarakis A, Lelovas P, Kakkavas S, Papadimitriou L, et al. Cardiac arrest in Greek primary health care and willingness of general practitioners to use automatic external defibrillator. Resuscitation 2011;82:1144–7. [16]. Niegsch ML, Krarup NT, Clausen NE. The presence of resuscitation equipment and influencing factors at general practitioners’ offices in Denmark: a crosssectional study. Resuscitation 2014;85:65–9. [17]. Department of Health and Children. Reducing the risk: a strategic approach: the report of the task force on sudden cardiac death. Dublin: Department of Health and Children; 2006. [18]. HIQA. In: Health technology assesment of public access defibrillation. Dublin: Health Information and Quality Authority; 2014 [Accessed 21 August 2017, https://www.hiqa.ie/sites/default/files/2017-01/HTA-of-Public-Accessat Defibrillation.pdf]. [19]. Caputo ML, Muschietti S, Burkart R, Benvenuti C, Conte G, Regoli F, et al. Lay persons alerted by mobile application system initiate earlier cardio-pulmonary resuscitation: a comparison with SMS-based system notification. Resuscitation 2017;114:73–8. [20]. Hansen CM, Kragholm K, Granger CB, Pearson DA, Tyson C, Monk L, et al. The role of bystanders, first responders, and emergency medical service providers in timely defibrillation and related outcomes after out-of-hospital cardiac arrest: results from a statewide registry. Resuscitation 2015;96:303–9. [21]. CSO. In: Chapter 2. Geographical distribution. Census 2016 summary results – part 1. Dublin: Central Statistics Office; 2016 [Accessed 21 August 2017, at http://www.cso.ie/en/media/csoie/newsevents/documents/ census2016summaryresultspart1/Census2016SummaryPart1.pdf]. [22]. Soo L, Smith N, Gray D. The place of general practitioners in the management of out-of-hospital cardiopulmonary resuscitation. Resuscitation 1999;43:57–63. [23]. Roland M, Everington S. Tackling the crisis in general practice. BMJ 2016;352:i942. [24]. Wilkinson E. UK general practice in crisis: time for a rethink. Lancet 2014;384:295–6. [25]. Barry T, Bury G. Advisory external defibrillator availability in general practice. Ir Med J 2015;108:212. [26]. Ringh M, Rosenqvist M, Hollenberg J, Jonsson M, Fredman D, Nordberg P, et al. Mobile-phone dispatch of laypersons for CPR in out-of-hospital cardiac arrest. N Engl J Med 2015;372:2316–25. [27]. Brooks SC, Simmons G, Worthington H, Bobrow BJ, Morrison LJ. The pulsepoint respond mobile device application to crowdsource basic life support for patients with out-of-hospital cardiac arrest: challenges for optimal implementation. Resuscitation 2016;98:20–6. [28]. Gräsner JT, Herlitz J, Koster RW, Rosell-Ortiz F, Stamatakis L, Bossaert L, et al. Quality management in resuscitation –towards a european cardiac arrest registry (EuReCa). Resuscitation 2011;82:989–94. [29]. Masterson S, Vellinga A, Wright P, Dowling J, Bury G, Murphy AW. General practitioner contribution to out-of-hospital cardiac arrest outcome: a national registry study. Eur J Gen Pract 2015;21:131–7.
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Clinical paper
The MERIT 3 project: Alerting general practitioners to cardiac arrest in the community T. Barry a,∗ , N. Conroy a , M. Headon a , M. Egan a , M. Quinn b , C. Deasy c,d , G. Bury a a
UCD Centre for Emergency Medical Science, School of Medicine, Health Sciences Centre, University College Dublin, Belfield, Dublin 4, Ireland Out of Hospital Cardiac Arrest Register, St. Eunans Hall, St. Conals Hospital, Letterkenny, Co. Donegal, Ireland Cork University Hospital, Cork, Ireland d National Ambulance Service, Ireland b c
a r t i c l e
i n f o
Article history: Received 22 May 2017 Received in revised form 13 October 2017 Accepted 28 October 2017 Keywords: Out-of-hospital cardiac arrest Resuscitation Emergency responder General practice
a b s t r a c t Background: The work context of the general practitioner (GP) potentially lends itself to the provision of early community based, cardiac arrest care. GPs have traditionally encountered out of hospital cardiac arrest (OHCA) as a component of routine patient care but have not been formally linked with the statutory ambulance service. Computer aided dispatch technology now allows real time GP text message alert to nearby cardiac arrest events. Aim: To examine the feasibility, uptake and outcome of a novel scheme to alert GPs to nearby OHCA events in their communities. Methods: GPs are recruited to voluntarily participate in a cardiac arrest text alert initiative called the ‘MERIT 3 project. GPs indicate the hours during which they wish to receive OHCA text alerts, and also specify a geo-location from which they will receive alerts to OHCA events occurring within a specified radius. Data on alerts, responses, OHCA incidents and outcomes are gathered prospectively, using ambulance control and GP data and with corroborative data from the national OHCA registry. Results: 423 general practices throughout Ireland were invited to participate. In the initial 12 months, 100 GPs from 85 individual practices have enrolled, 74 GPs have received alerts and 26 GPs have responded to incidents. Only 222/781 (28.4%) text alerts issued by ambulance control have proven to be recognised as cardiac arrests with resuscitation attempts. GPs have attended 51/776 (6.6%) OHCA incidents to which they have been alerted, with resuscitation undertaken in 34 cases with three survivors. Conclusion: Text alert activation of GPs to nearby OHCA events has proven feasible, with significant activity during the establishment period, but a low survival rate which is similar to the overall national OHCA survival rate. A high proportion of alerts do not involve resuscitation opportunities. © 2017 Elsevier B.V. All rights reserved.
Introduction Ireland is a northern European country with a population in excess of 4.75 million [1] for which out of hospital cardiac arrest (OHCA), primarily due to ischemic heart disease (IHD) is a key health issue; IHD causes approximately fifteen percent of all deaths [2]. In the region of 2000 OHCAs with attempted resuscitation are dealt with by the ambulance services in Ireland annually; unfortunately survival rates remain less than seven percent [3,4]. Early cardiopulmonary resuscitation (CPR) and defibrillation are vital but critically time sensitive treatments following OHCA [5]. Improved
∗ Corresponding author. E-mail address: [email protected] (T. Barry). https://doi.org/10.1016/j.resuscitation.2017.10.025 0300-9572/© 2017 Elsevier B.V. All rights reserved.
OHCA survival requires early availability of these treatments in the community where OHCA occurs. Ireland has in the region of 3000 general practitioners (GPs) [6]. This group of health professionals live and work in the communities for which they provide comprehensive primary care. GPs are potentially well placed to deliver early, community based cardiac arrest care. GP participation in OHCA resuscitation has been associated with increased patient survival [7–11]. In Ireland the MERIT 1/2 (Medical Emergency Responders Integration and Training) projects [7] recruited more than 500 Irish general practices to receive automatic external defibrillators (AEDs) and training in OHCA management. The project demonstrated that 18.7% of patients who suffered an OHCA and were treated by a participating GP, survived to hospital discharge [8]. In general however, the role of the GP in cardiac arrest resuscitation has traditionally received little attention [12]. Schemes to
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T. Barry et al. / Resuscitation 121 (2017) 141–146
equip general practitioners for OHCA have existed since the 1970 s and 80 s [13,14] and although OHCA is not a frequent occurrence in general practice, over time many GPs are involved in OHCA resuscitation; research from Greece suggests an incidence of OHCA in primary healthcare of 15.3/100,000 per year [15], a nationwide survey from Denmark demonstrated that 29% of GPs had encountered an OHCA at their practice [16], while in Ireland a cohort study of GPs showed that 36% encountered OHCA where resuscitation was attempted within a five year period [8]. Irish Department of Health policy has long emphasised the importance of first responders in addressing OHCA and more recently has highlighted the role of GP responders [17,18]. To date in Ireland, GPs who participate in MERIT have reported incidents which they encounter during their day-to-day practice and have not been formally linked with the 999/112 system of emergency ambulance dispatch. New technology allows real-time ambulance control text message alerts to be sent to ‘GP responders’ when a nearby OHCA occurs. A novel project termed ‘MERIT 3 , examines the feasibility and outcome of recruiting GP volunteers to be alerted to nearby OHCA using text message technology. While a number of papers have recently reported on text alert systems involving lay responders to OHCA, we are not aware of any reports of systems involving volunteer medical networks [19,20] .This paper outlines the initial period of establishment, recruitment and experience of implementation of this project.
Methods 505 General Practices enrolled in the MERIT 1/2 projects continue to prospectively report data on their experience of OHCA in routine general practice. Approximately two thirds of the country’s population lives in urban areas [21], which are well served by full-time professional ambulance services and relatively nearby hospitals. MERIT has focused on populations and general practices in rural and other areas in which local GPs may often be the initial contact in a medical emergency. Of the 505 MERIT 1/2 practices, 423 (83.8%) in rural, suburban and mixed locations were therefore identified for potential recruitment to MERIT 3. In MERIT 3, GPs volunteer to be alerted to nearby incidents of OHCA via text message from the Health Services Executive, National Ambulance Service (NAS) control centre. The text alert includes the patient’s age, gender and the exact address where the OHCA has occurred. GPs are under no obligation to attend the OHCA, but can do so if circumstances permit; the ambulance service always responds in the standard fashion. GPs indicate the hours during which they wish to receive text alerts and specify a fixed geo-location around which they will receive OHCA text alerts; GPs can define a specified radius of response (usually 10 Km’s). If alerted and in a position to attend, GPs are asked to contact a dedicated ambulance dispatch phone line to update ambulance control on their intention to travel to the incident and to obtain additional information if available. Data on alerts, responses, OHCA clinical care and outcomes are gathered at a number of levels. The NAS notifies the MERIT 3 team of all OHCA text alerts sent to participating GPs on a monthly basis. GPs individually provide reports on text alerts received and clinical anonymised data on individual cases attended using a standardised incident report form. Data is also collected from the Out of Hospital Cardiac Arrest Register (OHCAR) on all cases where GPs have been alerted; OHCAR data provides standardised information on the timings and outcomes of all OHCAs reported to it by all statutory ambulance services in Ireland. It is thus possible to determine what proportion of text alerts are recognised by OHCAR as out of hospital cardiac arrest events where resuscitation is attempted and to record intervention and outcome data on those incidents. Structures to address professional indemnity, clinical governance and
data management have been developed and implemented in liaison with NAS and OHCAR. The MERIT 3 project is part-funded by charitable support from Irish Community Rapid Response (ICRR) who subsidise the cost of immediate care training for GPs who participate and also fund a response bag containing basic life support and personal protective equipment. GPs do not receive any additional payments for participating in the scheme or responding to alerts. Ethical approval for the study has been provided by the UCD Human Research Ethics Committee and both OHCAR and the NAS have provided permission for access to data. Data is reported in this initial study on the 12 month period 1st Oct 2015 to 30th Sept 2016. Results 423 MERIT 1/2 practices were contacted by letter and invited to participate in MERIT 3. As of September 2016, 100 GPs from 78 MERIT practices and seven new practices had enrolled. An initial 39 GPs went live on the text alert system in April 2015, with the remainder joining in increments over the following months. Fig. 1. Illustrates the geographic distribution of MERIT 3 GPs. Table 1 presents data on text alerts issued to GPs and the numbers/proportions recognised by OHCAR as cardiac arrests with resuscitation attempts (CARA). Over the twelve-month period GPs were alerted to a total of 781 events. The OHCAR database recognises 222/781 (28.4%) of these incidents to have been CARAs and has no information on the remaining 559/781 (71.6%). Fig. 2. presents data on GP participation and alert frequency, it demonstrates that almost three quarters (74/100) of participating GPs received at least one text alert (range 1–354, median 3) over the study period. Ultimately a quarter of GPs (26%) responded to at least one text alert (range 1–21, median 1) during the study period. Fig. 3. presents data on the distribution of alerts & responses by time of day and shows that the majority of alerts were received after 8am and before 11pm. Alerts and responses were distributed across the days of the week with 200/781 (26%) of alerts and 12/60 (20%) responses occurring at weekends. Fig. 4. summarises the experience of participants over the study time period. MERIT 3 GPs attended 51 cases, the majority of which (42/51, 82.4%) were at residential locations. In half of the incidents (25/51) GPs arrived in advance of the ambulance service. Of the incidents attended, 45/51 (88.2%) were OHCA and six were other clinical problems (not involving loss of cardiac output) including overdoses (2), alcohol related issues (2), sepsis (1) and a psychiatric presentation(1). Of the 45 OHCAs, eleven were recent deaths where no resuscitation was appropriate, while 34 represented cardiac arrests where resuscitation was attempted (CARA). Of the 34 CARAs, BLS efforts appear to have been ceased promptly after the GPs arrival in seven cases and after a period of resuscitation in 17 cases, while the patient was transferred to hospital in 10 cases. Three patients survived to hospital discharge, representing 8.8% of the 34 cases in which resuscitation was attempted. Of note, OHCAR did not have information on six of the CARA cases in which extended resuscitation occurred. Discussion The MERIT 3 project represents a novel, community based, general practice response to OHCA. Although the concept of a rapid-response cardiac arrest scheme for GPs has previously been proposed [22], we are not aware of any published description of a similar scheme in operation elsewhere. GPs in Britain and Ireland are said to be under significant financial, workload and morale pressures [23,24]. It is noteworthy that under such circumstances, a significant number of individuals (representing around a fifth of
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Fig. 1. Merit 3 GP locations.
Table 1 Monthly Text Alerts to GPs and the number/proportion recognised by OHCAR where resuscitation was attempted (CARA cases). Month Cases Alerted CARA n (%)
Oct-15 64 13 (20.3)
Nov-15 45 19 (42.2)
Dec-15 66 21 (31.8)
Jan-16 67 14 (20.9)
Feb-16 57 13 (22.8)
Mar-16 75 21 (28.0)
Apr-16 65 21 (32.3)
May-16 79 23 (29.1)
Jun-16 66 23 (34.8)
Jul- 16 61 22 (36.1)
Aug- 16 63 10 (15.9)
Sep- 16 73 22 (30.1)
Total 781 222 (28.4)
*CARA − Cardiac Arrest with Resuscitation Attempt, recognised by OHCAR
the practices invited) are prepared to re-affirm their commitment to the communities they serve by volunteering for a project such as this. The recruitment and alerting processes utilised during the set-up phase of the MERIT 3 project have proved to be feasible and effective.
Previous research has suggested that GPs working in remote settings were more likely to have equipped themselves for OHCA management than their urban colleagues [25], whilst the experience of GPs participating in the MERIT 1/2 projects was that rural GPs encountered twice as many OHCA events as their urban/mixed
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Fig. 2. GP Participation and Alert Frequency.
Fig. 3. Alert & Response Distribution over 24 h.
practice counterparts [8]. The willingness of GPs to provide a local emergency response in a rural setting may represent a vital link in the chain of survival for a remote community. It is possible that rural GPs perceive a greater need for community OHCA response given that ambulance service response times to their communities are likely to be prolonged. In terms of building on this project, future qualitative research will explore the factors that influence GP participation in schemes such as MERIT 3. The preliminary data now available concerning circumstances where GPs have been alerted to and have responded to OHCA events in their communities must be interpreted with caution, given its initial small scale and the fact that this novel project is in evolution. Over the time period described, GPs offered to or actually attended 60/776 (7.7%) of the incidents of presumed OHCA to which they were alerted and were involved in significant decision making in 45 OHCAs. The ultimate survival rate (8.8%) is similar to the national norm and is significantly lower than the survival rate for OHCAs encountered during a normal GP working day (around 18%). These results are based on relatively small numbers of cases but may indicate that although all of these incidents occur in the com-
munity, differences exist between groups of patients encountered in different settings. The response/attendance rates encountered thus far may suggest a modest capacity to supplement the statutory ambulance service OHCA response. It is likely that this response rate is to some degree a function of logistic barriers such as geographical distance or other work responsibilities. These elements of GP OHCA response have not been explored during our initial research exercise and will need to be examined in detail as the project progresses. The current MERIT 3 text alert system is based on a fixed geographical response area, involving a radius of (mostly) 10kms from a set point address location. Modern smart-phone global positioning technology has been used to alert the geographically closest OHCA responders elsewhere [26,27] and could potentially facilitate a more dynamic GP OHCA alert model, where the GP responder’s position would be available in real time to ambulance control using GPS tracking systems. Less than 30% of alerts issued from ambulance control have ultimately been recognised as cases of OHCA in which resuscitation was attempted. This raises several issues. The standard ambulance
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Fig. 4. M3 Project; Alerts and Responses Flowsheet.
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*CARA: Cardiac arrest with resuscitation attempt **OHCA: Out of Hospital cardiac arrest
service response to each OHCA alert is to mobilise two ambulances, an Advanced Paramedic and any nearby volunteer responders. While a degree of over triage is necessary to insure call taking procedures are sufficiently sensitive to detect all instances of cardiac arrest where resuscitation should be attempted, if the alerting system is ‘wrong’ in 70% of cases, this represents a significant impact on resources and a significant opportunity cost in a vital area. In addition it may lead to ‘alert fatigue’ resulting in decreased or suboptimal responses over time.
As it is likely that the majority of the 70% not recognised as OHCA in which resuscitation was attempted are in fact patients who have died and in whom resuscitation is inappropriate; no resuscitation report would therefore be submitted to OHCAR. Our data suggest that further work to refine the activation system to better identify the group of patients in whom resuscitation is inappropriate could improve the efficient use of ambulance service and community resources. Our data also suggests that some of the cases which are not reported to OHCAR as resuscitation attempts, have in fact been just that. Significant work of data validation has been
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undertaken by OHCAR, as in many other national registry systems [4,28]; linkages to research such as this may further improve that process. Ultimately our findings will require further exploration in partnership with NAS and OHCAR and may well be a function of the complexity of community OHCA care and the challenges of maximising data capture during and after the difficult circumstance of cardiac arrest. It is notable that when GPs attended incidents, they frequently arrived on scene in advance of the statutory ambulance service. If this observation continues to be borne out as the project progresses, it is likely that in select cases, MERIT 3 GPs could make a significant contribution to individual patient survival by bringing essential skills and equipment to the scene of an OHCA earlier than would otherwise be possible. Although the exact response times of the ambulance service represent important data when considering the impact of early GP arrival to an OHCA scene, unfortunately this information is currently not available to the MERIT 3 team. In the majority of OHCA cases attended by MERIT 3 GPs to date, resuscitation efforts have been terminated at the scene. The potential benefit of GP OHCA care relating to clinical and ethical decision making in the termination of resuscitation has previously been considered [22]. Research has demonstrated that resuscitation is more likely to be ceased on scene when a GP is present suggesting the “compassionate management of death in unviable circumstances” [29]. This component of resuscitation practice has previously received little attention but has noteworthy individual and societal importance. In addition to the ethical concern of continued resuscitation in futile circumstances, significant resources may be engaged that would otherwise be available to treat other critically unwell or injured patients. Conclusion Text alert activation of GPs to nearby OHCA events has proven acceptable to GPs and feasible in the real world context. Preliminary data suggests that GPs can reach patients in advance of the ambulance service potentially bringing lifesaving therapies earlier to scene than would otherwise be available. A significant aspect of the care delivered thus far during the MERIT 3 project has related to decision making around end of life care. The MERIT 3 project describes a novel system of OHCA care in the community. Conflicts of interest The authors declare no conflicts of interest. Acknowledgements The authors wish to acknowledge the general practitioners who participate voluntarily in the MERIT project. The authors wish to acknowledge charitable project support from Irish Community Rapid Response. References [1]. CSO. Census of population 2016– preliminary results. Dublin: Central Statistics Office; 2016 [Accessed 21 August 2017, at http://www. cso.ie/en/releasesandpublications/ep/p-cpr/censusofpopulation2016preliminaryresults/]. [2]. CSO. In: Vital statistics yearly summary 2015. Dublin: Central Statistics Office; 2016 [Accessed 21 August 2017, at http://www.cso.ie/en/ releasesandpublications/ep/pvsys/vitalstatisticsyearlysummary2015].
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