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The utstein abbey and survival from cardiac arrest: What is the connection?
EDITORIAL
EDITORIAL The Utstein Abbey and Survival From Cardiac Arrest: What is the Connection? This issue of Annals contains an article entitled "Recommended Guidelines for Uniform Reporting of Data from O u t - o f - H o s p i t a l Cardiac Arrest: The Utstein Style." This article establishes a new first for Ammls, for it is being published simultaneously in Circulatio,, the official journal of the American Heart Association (AHA). Moreover, the a r t i c l e will be published in ResuscitatiolL the official journal of the European Resuscitation Council. An abridged version of the "Utstein Style" will appear in Lancet, and editorials that describe the "Utstein Style" are also being p u b l i s h e d this m o n t h in the
Journal of the Cmmdian Medical Associati~m and the Medical Journal of Australia. The manuscript has also been translated into German for the journals Notfallmedizin and h~tesiv-
medizin und Notfallmedizin. A quick glance at this w)luminous article will reveal that it is largely a listing of terms and definitions associated with o u t - o f - h o s p i t a l cardiac arrest. W h y are so m a n y i n t e r n a t i o n a l j o u r n a l s and o r g a n i z a t i o n s willing to present and publicize such a prosaic topic? After all, the taxonomy and nomenclature of cardiac arrest are hardly topics that capture the immediate attention and interest of most journal readers. See related article, p 861. These recommended guidelines for reporting data from o u t - o f - h o s p i t a l cardiac arrest represent a landmark publication. The article is unique because it presents in several journals of different countries recommendations that are international, multid i s c i p l i n a r y , and c r o s s - o r g a n i z a tional. The Utstein style recognizes that unexpected, out-of-hospital cardiac arrest does not belong exclusively to emergency medicine, or cardiology, or anesthesiology, or critical care medicine. Rather, this topic belongs to all of these disciplines. A 20:8 August 1991
single organization, such as the AHA or the A m e r i c a n College of Emergency Physicians, cannot serve as the major arbiter of standards and guidelines. This is true no m a t t e r how w i d e l y c i r c u l a t e d these s t a n d a r d s might be. In 1991, cardiac arrest must be a p p r o a c h e d by t e c h n i q u e s t h a t cross m a n y disciplines, specialties, and national boundaries. The Emergency Cardiac Care (ECC) C o m m i t t e e of the AHA has demonstrated clearly its acceptance of this idea by forming international liaisons with the European Resuscitation Council and the Heart and Stroke Foundation of Canada. These coincide with an already established relationship with the American College of Emergency Physicians. Several perceptive leaders in Europe also recognized that cardiologists and ane s t h e s i o l o g i s t s could improve survival from unexpected cardiac arrest through e x p l i c i t l y c o l l a b o r a t i v e efforts. Their efforts led to the formation of the mu]tidisciplinary European Resuscitation Council. W h a t e x a c t l y is t h e " U t s t e i n Style"? In the s u m m e r of 1990, a symposium was held at Utstein Abbey, a h i s t o r i c s i t e l o c a t e d on M o s t e r o y , a s m a l l i s l a n d off the southwestern Norwegian coast. The participants in this symposium concluded that lack of agreed on terminology for reporting outcomes from cardiac arrest presented a major problem for resuscitation research. Previous p u b l i c a t i o n s have d i s c u s s e d the problems associated with a lack of standardized nomenclature.~ ; At its simplest level the symposium reco g n i z e d t h a t t h e r e is no w i d e l y accepted best outcomes measure for r e p o r t i n g success. W h i l e m o s t researchers agreed that the best numerator to report was people discharged alive from the hospital, there was no consensus on what denominator was most appropriate. P a r t i c i p a n t s in this s y m p o s i u m were aware of the precedent established by the International CommitAnnals of Emergency Medicine
tee of Medical Journal Editors, which recommended uniform requirements for articles submitted to biomedical journals.S, 7 Researchers have come to know these recommendations as the "Vancouver style" after the site for their first conference. The AHA and the European Resuscitation Council approved a proposal to conduct a second two-day consensus conference. Conference planners also invited representatives from the Canadian Heart and Stroke Foundation and the Australian Resuscitation Council. A second Utstein Conference was held in England in December 1990 with the purpose of developing guidelines and uniform definitions for reporting outcome data from cardiac arrest. A grant from the A s m u n d S Laerdal Foundation for Acute Medicine generously supported the conference. The second U t s t e i n C o n f e r e n c e broadened its focus beyond the simple question of a standard definition of survival from out-of-hospital cardiac arrest. It focused on six areas: how to describe the community and population served by an emergency medical services (EMS) system; how to describe and classify different EMS response systems; uniform definitions for event time points and intervals; the provision of more descriptive information on the epidemiology of cardiac arrest; individual clinical data that should be recorded in the field; and c l i n i c a l o u t c o m e s t h a t should be reported. In the two days the participants discovered multiple problems with semantics, with the same term possessing different meanings for different people. Therefore, the conference prepared a "glossary of terms" for the uniform recommendations. We think the most valuable contribution of the Utstein style is a strong recommendation to use a template approach to gathering data about cardiac arrest as well as reporting system outcomes. Personnel can fill out the template with specific data from their system. The template approach 918/139
EDITORIAL
permits researchers to calculate multiple survival rates and yet m a i n t a i n i m p o r t a n t a d m i n i s t r a t i v e a n d descriptive data for their system. W h e n all e m e r g e n c y m e d i c a l s y s t e m s report their data this way, no single o u t c o m e criterion has to be adopted. Instead, each s y s t e m can present its results at all levels of the template. T h i s p r o v i d e s for i n t e r s y s t e m outcome c o m p a r i s o n s as w e l l as intrasystem quality i m p r o v e m e n t . T h e U t s t e i n s t y l e a i m s for s i m plicity, conciseness, and practicality. There are r e c o m m e n d a t i o n s for both core data to report as well as supplem e n t a l data. T h e c o r e d a t a a l l o w n o n r e s e a r c h - o r i e n t e d EMS s y s t e m s to collect r o u t i n e d a t a and y e t still compare their results w i t h other systems. The use of s u p p l e m e n t a l data p e r m i t s m u l t i c e n t e r trials of different interventions because every part i c i p a n t c o l l e c t s d a t a in t h e s a m e m a n n e r and w i t h t h e s a m e definitions. While we cannot overemphasize the i m p o r t a n c e of t i m e in cardiac resuscitation, published studies s e l d o m have used consistent definitions. Becker appears to be the first person to e m p h a s i z e t h e i m p o r t a n t difference b e t w e e n time events and time intervals, t e r m s t h a t are q u i t e distinct. -~ Confusion follows the failure of a u t h o r s to d i s c r i m i n a t e b e t w e e n events that occur at a single point in t i m e , and intervals t h a t m a r k t h e p a s s a g e of t i m e b e t w e e n t h o s e events. The U t s t e i n style does n o t provide specific d e f i n i t i o n s for confusing t e r m s as " d o w n t i m e " (when the patient w e n t down? w h e n the patient was no longer down? the interval b e t w e e n collapse and CPR? the interval between collapse or CPR and the restoration of a perfusing heartbeat?) Instead, the U t s t e i n style reco m m e n d s a p r e c i s e s t a t e m e n t of w h a t e v e n t s have occurred, and to follow a f o r m a t of " e v e n t - t o - e v e n t interval" for the passage of time.
140/919
The U t s t e i n style contains strong r e c o m m e n d a t i o n s for moving beyond t h e p r e s e n t a p p r o a c h of s i m p l e reports on w h e t h e r cardiac arrest patients live or die. Clearly, researchers m u s t describe survival not only in a "yes-no" fashion but also in the dim e n s i o n s of duration and quality of survival. Editors should consider future reports on cardiac arrest survival inadequate if they fail to provide data on the l e n g t h of s u r v i v a l and s o m e m e a s u r e m e n t of neurologic function. This recommendation will present n e w c h a l l e n g e s to v i r t u a l l y e v e r y EMS s y s t e m because few if any EMS s y s t e m s routinely collect such data. T h e U t s t e i n style c o n t a i n s specific r e c o m m e n d a t i o n s in these areas. The U t s t e i n r e c o m m e n d a t i o n s will s u p p o r t several m a j o r objectives: to obtain a better epidemiologic understanding of u n e x p e c t e d out-of-hospital cardiac arrest; to improve the lite r a t u r e of r e s u s c i t a t i o n research; to p e r m i t intersystem c o m p a r i s o n s ; to p e r m i t intrasystem c o m p a r i s o n s ; to establish the relative benefits of different s y s t e m approaches; to support local program evaluation and quality i m p r o v e m e n t ; to support basic clinical research; and to help d e t e r m i n e w h i c h o u t c o m e s are due to intervention differences and w h i c h results are due to EMS s y s t e m differences. Finally, the u n i f o r m r e c o m m e n d a t i o n s w i l l help s u p p o r t large-scale m u l t i center studies and data bases. R e a d e r s s h o u l d v i e w the r e c o m m e n d a t i o n s for t h e U t s t e i n guidelines as an initial public offering. The g u i d e l i n e s are a s t a r t i n g p o i n t for m a n y systems that have not yet begun s y s t e m a t i c e x a m i n a t i o n of their p e r f o r m a n c e , as w e l l as a s t a r t i n g point for future m u l t i c e n t e r studies. There will be future modifications of the u n i f o r m r e c o m m e n d a t i o n s , just as t h e r e h a v e b e e n a d d i t i o n s a n d changes to the u n i f o r m r e c o m m e n d a tions of the Vancouver style.S, 9 The editors of Annals, Circulation,
Annals of Emergency Medicine
and Resuscitation w i s e l y recognize the educational and research value of these consensus recommendations. T h e y share the vision of m a n y people active in e m e r g e n c y cardiac care our road to future i m p r o v e m e n t s is p a v e d w i t h b r i c k s of i n t e r n a t i o n a l and interdisciplinary cooperation. The U t s t e i n style is a first step down this path.
Richard 0 Cummins, MD, MPH, MSc Chairman, National ACLS Subcommittee of the American Heart Association Co-Chairman, Utstein Consensus Conference Seattle, Washington Douglas A Chamberlain, MD Board of Directors, European Resuscitatior~ Council Co-Chairman, Utstein Consensus Conference Brighton, England
I Eisenberg MS, Bergner L, Hearne T: Out at hnspital cardiac arrest: A review of major studies and a proposed uniform reporting system. A m I Public Health 1980; 70:236-239. 2. Eisenberg MS, Cummins RO, Damon S, et al: Survival rates trnm out obhospital cardiac arrest: Recommendations for uniform definitions and date tel report. Arm Emerg Med 1990;19:1249-1259 3. Eisenberg M, Horwood B, Cummins R, et al: Cardiac arrest and resuscitation: A tale of 29 cities Ann Emerx Med 1990;19:2~8 243. 4. Newman M Comparing apples with apples: Time for a standard definition of survival from out of hospital cardiac arrest. Czirrcnt; Nev,'~letter 199//;l:2 3. 5 Beckcr LB, Ostrander MP, Barrett ], et al: Survival from cardiopulmonary resuscitation in a large metropolitan area: Where are the survivors? /~t)17 Emer.¢ Melt 199l;20:355-361 6 International Committee of Medical hmmal Editors: Uniform requirements for manuscripts submitted to biomedical journals A i m hi,era Med 1979;96:766-771. 7 International Committee ~f Medical Iournal Editors: Uniform requirements for manuscripts submitted to biomedical itlurnals. Br Med ] 1978;1:137,4 13,t6 8 International Committee of Medical loumal Editors: Uni{ornl requirements for manuscripts submitted to biomedical journals. Am~ l n t e m Med 1988;1{18:258-265 9. Internatmnal Committee at Medical Journal Editors: Uniform requirements for manuscripts submitted to biomedical iournals, ltr M e d / 19821284:1766 1770.
20:8 August 1991
EDITORIAL The Utstein Abbey and Survival From Cardiac Arrest: What is the Connection? This issue of Annals contains an article entitled "Recommended Guidelines for Uniform Reporting of Data from O u t - o f - H o s p i t a l Cardiac Arrest: The Utstein Style." This article establishes a new first for Ammls, for it is being published simultaneously in Circulatio,, the official journal of the American Heart Association (AHA). Moreover, the a r t i c l e will be published in ResuscitatiolL the official journal of the European Resuscitation Council. An abridged version of the "Utstein Style" will appear in Lancet, and editorials that describe the "Utstein Style" are also being p u b l i s h e d this m o n t h in the
Journal of the Cmmdian Medical Associati~m and the Medical Journal of Australia. The manuscript has also been translated into German for the journals Notfallmedizin and h~tesiv-
medizin und Notfallmedizin. A quick glance at this w)luminous article will reveal that it is largely a listing of terms and definitions associated with o u t - o f - h o s p i t a l cardiac arrest. W h y are so m a n y i n t e r n a t i o n a l j o u r n a l s and o r g a n i z a t i o n s willing to present and publicize such a prosaic topic? After all, the taxonomy and nomenclature of cardiac arrest are hardly topics that capture the immediate attention and interest of most journal readers. See related article, p 861. These recommended guidelines for reporting data from o u t - o f - h o s p i t a l cardiac arrest represent a landmark publication. The article is unique because it presents in several journals of different countries recommendations that are international, multid i s c i p l i n a r y , and c r o s s - o r g a n i z a tional. The Utstein style recognizes that unexpected, out-of-hospital cardiac arrest does not belong exclusively to emergency medicine, or cardiology, or anesthesiology, or critical care medicine. Rather, this topic belongs to all of these disciplines. A 20:8 August 1991
single organization, such as the AHA or the A m e r i c a n College of Emergency Physicians, cannot serve as the major arbiter of standards and guidelines. This is true no m a t t e r how w i d e l y c i r c u l a t e d these s t a n d a r d s might be. In 1991, cardiac arrest must be a p p r o a c h e d by t e c h n i q u e s t h a t cross m a n y disciplines, specialties, and national boundaries. The Emergency Cardiac Care (ECC) C o m m i t t e e of the AHA has demonstrated clearly its acceptance of this idea by forming international liaisons with the European Resuscitation Council and the Heart and Stroke Foundation of Canada. These coincide with an already established relationship with the American College of Emergency Physicians. Several perceptive leaders in Europe also recognized that cardiologists and ane s t h e s i o l o g i s t s could improve survival from unexpected cardiac arrest through e x p l i c i t l y c o l l a b o r a t i v e efforts. Their efforts led to the formation of the mu]tidisciplinary European Resuscitation Council. W h a t e x a c t l y is t h e " U t s t e i n Style"? In the s u m m e r of 1990, a symposium was held at Utstein Abbey, a h i s t o r i c s i t e l o c a t e d on M o s t e r o y , a s m a l l i s l a n d off the southwestern Norwegian coast. The participants in this symposium concluded that lack of agreed on terminology for reporting outcomes from cardiac arrest presented a major problem for resuscitation research. Previous p u b l i c a t i o n s have d i s c u s s e d the problems associated with a lack of standardized nomenclature.~ ; At its simplest level the symposium reco g n i z e d t h a t t h e r e is no w i d e l y accepted best outcomes measure for r e p o r t i n g success. W h i l e m o s t researchers agreed that the best numerator to report was people discharged alive from the hospital, there was no consensus on what denominator was most appropriate. P a r t i c i p a n t s in this s y m p o s i u m were aware of the precedent established by the International CommitAnnals of Emergency Medicine
tee of Medical Journal Editors, which recommended uniform requirements for articles submitted to biomedical journals.S, 7 Researchers have come to know these recommendations as the "Vancouver style" after the site for their first conference. The AHA and the European Resuscitation Council approved a proposal to conduct a second two-day consensus conference. Conference planners also invited representatives from the Canadian Heart and Stroke Foundation and the Australian Resuscitation Council. A second Utstein Conference was held in England in December 1990 with the purpose of developing guidelines and uniform definitions for reporting outcome data from cardiac arrest. A grant from the A s m u n d S Laerdal Foundation for Acute Medicine generously supported the conference. The second U t s t e i n C o n f e r e n c e broadened its focus beyond the simple question of a standard definition of survival from out-of-hospital cardiac arrest. It focused on six areas: how to describe the community and population served by an emergency medical services (EMS) system; how to describe and classify different EMS response systems; uniform definitions for event time points and intervals; the provision of more descriptive information on the epidemiology of cardiac arrest; individual clinical data that should be recorded in the field; and c l i n i c a l o u t c o m e s t h a t should be reported. In the two days the participants discovered multiple problems with semantics, with the same term possessing different meanings for different people. Therefore, the conference prepared a "glossary of terms" for the uniform recommendations. We think the most valuable contribution of the Utstein style is a strong recommendation to use a template approach to gathering data about cardiac arrest as well as reporting system outcomes. Personnel can fill out the template with specific data from their system. The template approach 918/139
EDITORIAL
permits researchers to calculate multiple survival rates and yet m a i n t a i n i m p o r t a n t a d m i n i s t r a t i v e a n d descriptive data for their system. W h e n all e m e r g e n c y m e d i c a l s y s t e m s report their data this way, no single o u t c o m e criterion has to be adopted. Instead, each s y s t e m can present its results at all levels of the template. T h i s p r o v i d e s for i n t e r s y s t e m outcome c o m p a r i s o n s as w e l l as intrasystem quality i m p r o v e m e n t . T h e U t s t e i n s t y l e a i m s for s i m plicity, conciseness, and practicality. There are r e c o m m e n d a t i o n s for both core data to report as well as supplem e n t a l data. T h e c o r e d a t a a l l o w n o n r e s e a r c h - o r i e n t e d EMS s y s t e m s to collect r o u t i n e d a t a and y e t still compare their results w i t h other systems. The use of s u p p l e m e n t a l data p e r m i t s m u l t i c e n t e r trials of different interventions because every part i c i p a n t c o l l e c t s d a t a in t h e s a m e m a n n e r and w i t h t h e s a m e definitions. While we cannot overemphasize the i m p o r t a n c e of t i m e in cardiac resuscitation, published studies s e l d o m have used consistent definitions. Becker appears to be the first person to e m p h a s i z e t h e i m p o r t a n t difference b e t w e e n time events and time intervals, t e r m s t h a t are q u i t e distinct. -~ Confusion follows the failure of a u t h o r s to d i s c r i m i n a t e b e t w e e n events that occur at a single point in t i m e , and intervals t h a t m a r k t h e p a s s a g e of t i m e b e t w e e n t h o s e events. The U t s t e i n style does n o t provide specific d e f i n i t i o n s for confusing t e r m s as " d o w n t i m e " (when the patient w e n t down? w h e n the patient was no longer down? the interval b e t w e e n collapse and CPR? the interval between collapse or CPR and the restoration of a perfusing heartbeat?) Instead, the U t s t e i n style reco m m e n d s a p r e c i s e s t a t e m e n t of w h a t e v e n t s have occurred, and to follow a f o r m a t of " e v e n t - t o - e v e n t interval" for the passage of time.
140/919
The U t s t e i n style contains strong r e c o m m e n d a t i o n s for moving beyond t h e p r e s e n t a p p r o a c h of s i m p l e reports on w h e t h e r cardiac arrest patients live or die. Clearly, researchers m u s t describe survival not only in a "yes-no" fashion but also in the dim e n s i o n s of duration and quality of survival. Editors should consider future reports on cardiac arrest survival inadequate if they fail to provide data on the l e n g t h of s u r v i v a l and s o m e m e a s u r e m e n t of neurologic function. This recommendation will present n e w c h a l l e n g e s to v i r t u a l l y e v e r y EMS s y s t e m because few if any EMS s y s t e m s routinely collect such data. T h e U t s t e i n style c o n t a i n s specific r e c o m m e n d a t i o n s in these areas. The U t s t e i n r e c o m m e n d a t i o n s will s u p p o r t several m a j o r objectives: to obtain a better epidemiologic understanding of u n e x p e c t e d out-of-hospital cardiac arrest; to improve the lite r a t u r e of r e s u s c i t a t i o n research; to p e r m i t intersystem c o m p a r i s o n s ; to p e r m i t intrasystem c o m p a r i s o n s ; to establish the relative benefits of different s y s t e m approaches; to support local program evaluation and quality i m p r o v e m e n t ; to support basic clinical research; and to help d e t e r m i n e w h i c h o u t c o m e s are due to intervention differences and w h i c h results are due to EMS s y s t e m differences. Finally, the u n i f o r m r e c o m m e n d a t i o n s w i l l help s u p p o r t large-scale m u l t i center studies and data bases. R e a d e r s s h o u l d v i e w the r e c o m m e n d a t i o n s for t h e U t s t e i n guidelines as an initial public offering. The g u i d e l i n e s are a s t a r t i n g p o i n t for m a n y systems that have not yet begun s y s t e m a t i c e x a m i n a t i o n of their p e r f o r m a n c e , as w e l l as a s t a r t i n g point for future m u l t i c e n t e r studies. There will be future modifications of the u n i f o r m r e c o m m e n d a t i o n s , just as t h e r e h a v e b e e n a d d i t i o n s a n d changes to the u n i f o r m r e c o m m e n d a tions of the Vancouver style.S, 9 The editors of Annals, Circulation,
Annals of Emergency Medicine
and Resuscitation w i s e l y recognize the educational and research value of these consensus recommendations. T h e y share the vision of m a n y people active in e m e r g e n c y cardiac care our road to future i m p r o v e m e n t s is p a v e d w i t h b r i c k s of i n t e r n a t i o n a l and interdisciplinary cooperation. The U t s t e i n style is a first step down this path.
Richard 0 Cummins, MD, MPH, MSc Chairman, National ACLS Subcommittee of the American Heart Association Co-Chairman, Utstein Consensus Conference Seattle, Washington Douglas A Chamberlain, MD Board of Directors, European Resuscitatior~ Council Co-Chairman, Utstein Consensus Conference Brighton, England
I Eisenberg MS, Bergner L, Hearne T: Out at hnspital cardiac arrest: A review of major studies and a proposed uniform reporting system. A m I Public Health 1980; 70:236-239. 2. Eisenberg MS, Cummins RO, Damon S, et al: Survival rates trnm out obhospital cardiac arrest: Recommendations for uniform definitions and date tel report. Arm Emerg Med 1990;19:1249-1259 3. Eisenberg M, Horwood B, Cummins R, et al: Cardiac arrest and resuscitation: A tale of 29 cities Ann Emerx Med 1990;19:2~8 243. 4. Newman M Comparing apples with apples: Time for a standard definition of survival from out of hospital cardiac arrest. Czirrcnt; Nev,'~letter 199//;l:2 3. 5 Beckcr LB, Ostrander MP, Barrett ], et al: Survival from cardiopulmonary resuscitation in a large metropolitan area: Where are the survivors? /~t)17 Emer.¢ Melt 199l;20:355-361 6 International Committee of Medical hmmal Editors: Uniform requirements for manuscripts submitted to biomedical journals A i m hi,era Med 1979;96:766-771. 7 International Committee ~f Medical Iournal Editors: Uniform requirements for manuscripts submitted to biomedical itlurnals. Br Med ] 1978;1:137,4 13,t6 8 International Committee of Medical loumal Editors: Uni{ornl requirements for manuscripts submitted to biomedical journals. Am~ l n t e m Med 1988;1{18:258-265 9. Internatmnal Committee at Medical Journal Editors: Uniform requirements for manuscripts submitted to biomedical iournals, ltr M e d / 19821284:1766 1770.
20:8 August 1991