Resuscitation 85 (2014) 1640–1641
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Editorial
Increasing bystander participation in resuscitation
Timely bystander cardiopulmonary resuscitation (CPR) and defibrillation after an out-of-hospital cardiac arrest (OHCA) are essential steps for improving OHCA outcomes.1 The strategy of first responders being dispatched with automated external defibrillators (AEDs) has enabled treatment to commence prior to the arrival of emergency medical services (EMS).2 Additionally, placement of AEDs in public places for use by laypersons/bystanders as part of public access defibrillation (PAD) programs has further led to decreased time to defibrillation and improved survival for patients who arrest in a public place.3–5 For example, within PAD programs in Denmark and Los Angeles, it has been possible to achieve a survival rate of 69% amongst defibrillated cases in both locations.6,7 Rates of PAD by lay persons have steadily increased over time, as has the number of public AEDs.8,9 In Victoria, Australia we have seen a 10-fold increase in the use of PAD AEDs over the last decade.10 However, PAD programs are aimed primarily at providing AEDs at sites with high population throughput, likely high OHCA incidence and are typically public locations.3–5 Considering that the majority of OHCA occur in residential locations, the concept of lay rescuers reaching OHCA patients in the home is attractive.9,11 This would naturally translate to lay rescuers being able to reach a higher proportion of OHCA patients than normally possible with traditional PAD programs. In this issue of Resuscitation, Zijlstra et al. describe an alert system for lay rescuers to attend OHCA occurring in both public and private settings. Their study examines the use of a text message (TM) alert system in two regions of the Netherlands covering 127 million inhabitants. Dispatchers are able to send a TM to volunteer lay rescuers trained in the use of CPR and AED if they are within 1000 m of a suspected cardiac arrest. Just over 11,000 TM-responders and 1200 AEDs were registered per million-population. This level of coverage meant that TM-responders were available to respond in over 95% of OHCAs where the system was activated. During the period February 2010–July 2013, the TM alert system was activated by dispatchers in 58% of 1536 arrests; in 12% of cases an AED was connected to the patient by a TM responder prior to the arrival of EMS. As part of the TM alert system, up to 30 volunteers may be mobilised, with 10 being sent directly to the patient and 20 sent to retrieve an AED. This can pose a space and safety problem should all responders be available to attend a patient, as already alluded to by a preliminary study on the programme.12 This could have an impact on the time to treatment and may lead to a large number of people potentially entering private homes for any single event. Zijlstra et al. recognise that improvements to the global positioning
http://dx.doi.org/10.1016/j.resuscitation.2014.09.001 0300-9572/© 2014 Elsevier Ireland Ltd. All rights reserved.
system, so as to more accurately pinpoint the closest TM responders to the patient, could reduce the maximum number of responders being alerted. A legal issue for consideration is how the TM alert system could be translated to other countries, as it is a relatively new concept for lay persons acting in a rescue role to enter private residences. Whilst professional rescue personnel are guided by formal operational frameworks when entering premises as part of their role, including private homes, it is unknown if similar frameworks exist for volunteer lay persons.13 The success of a programme aimed at increasing layperson use of public AEDs is dependent on an accurate registry of AED location and availability and on dispatcher compliance. In the current study, dispatchers did not activate the TM-alert system in 41.8% of EMS treated OHCAs. Additionally, registration of AEDs for the programme was reliant on AED owner awareness of the programme and agreement to “opt in”. Rea et al. have previously found that less than half of AEDs (9 of 22) used by lay persons prior to the arrival of EMS in King County (excluding Seattle) were registered with the EMS dispatch service.14 The University of Washington in Seattle has since run an innovative campaign aimed at discovering the location of AEDs via a city-wide scavenger hunt. The competition resulted in over 2000 AEDs being reported by competing teams. A similar campaign has also been run in Philadelphia.15 One advantage of the TM-alert database used in the Netherlands is that it notes availability of AEDs according to time of day; a study in the city of Copenhagen highlighted that more than half of arrests in public locations would not have access to public AEDs out of normal business hours.16 A recent paper in Resuscitation outlined how mobile phones can play an integral part in numerous parts of the chain of survival, including being used to access EMS, receive guidance about the performance of CPR and locate AEDs using positioning systems.17 One prospective case–control study showed that laypersons trained in the use of CPR and AED who received text message prompts to watch a reminder video clip about CPR and AED use had significantly improved retention of resuscitation skills than controls, including more accurate hand positioning (p = 0.004) and AED electrode positioning (p < 0.001) and more prompt resumption of CPR after defibrillation (p < 0.001).18 Zijlstra et al. used local advertisements and campaigns to recruit TM-responders. This in itself is likely to increase public awareness regarding the importance of bystander CPR and early defibrillation for OHCA. Additionally 100% of patients where TM-responders arrived received bystander CPR. Bystander CPR improves survival,
Editorial / Resuscitation 85 (2014) 1640–1641
directly and through the mediation of VF/VT, and is an essential component of an integrated response to OHCA.19 We know that one life is saved for every 24–36 persons who receive bystander CPR.20 The TM alert system described by Zijlstra et al. and the above strategies using mobile phone technology are important additional steps towards further improving bystander CPR rates, public AED use and OHCA survival. Conflict of interest statement
13.
14.
15.
16.
There is no conflicts of interest to declare. References
17. 18.
1. Capucci A, Aschieri D. Public access defibrillation: new developments for mass implementation. Heart 2011;97:1528–32. 2. Berdowski J, Blom MT, Bardai A, Tan HL, Tijssen JG, Koster RW. Impact of onsite or dispatched automated external defibrillator use on survival after out-of-hospital cardiac arrest. Circulation 2011;124:2225–32. 3. The American Heart Association in Collaboration with the International Liaison Committee on Resuscitation. Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. Part 4: the automated external defibrillator: key link in the chain of survival. Circulation 2000;102(Suppl.):I60–76. 4. Handley AJ, Koster R, Monsieurs K, Perkins GD, Davies S, Bossaert L. European Resuscitation Council guidelines for resuscitation 2005 Section 2. Adult basic life support and use of automated external defibrillators. Resuscitation 2005;67(Suppl. (1)):S7–23. 5. Australian Resuscitation Council. Australian resuscitation council guidelines; 2010. 6. Nielsen AM, Folke F, Lippert FK, Rasmussen LS. Use and benefits of public access defibrillation in a nation-wide network. Resuscitation 2013;84:430–4. 7. Eckstein M. The Los Angeles public access defibrillator (PAD) program: ten years after. Resuscitation 2012;83:1411–2. 8. Kitamura T, Iwami T, Kawamura T, Nagao K, Tanaka H, Hiraide A. Nationwide public-access defibrillation in Japan. N Engl J Med 2010;362:994–1004. 9. Wissenberg M, Lippert FK, Folke F, et al. Association of national initiatives to improve cardiac arrest management with rates of bystander intervention and patient survival after out-of-hospital cardiac arrest. JAMA 2013;310:1377–84. 10. Ambulance Victoria.Victorian Ambulance Cardiac Arrest Registry (VACAR) Annual Report 2012/13. 2013. 11. Nehme Z, Andrew E, Cameron PA, et al. Population density predicts outcome from out-of-hospital cardiac arrest in Victoria, Australia. Med J Aust 2014;200:471–5. 12. Scholten AC, van Manen JG, van der Worp WE, Ijzerman MJ, Doggen CJ. Early cardiopulmonary resuscitation and use of Automated External Defibrillators by
19.
20.
1641
laypersons in out-of-hospital cardiac arrest using an SMS alert service. Resuscitation 2011;82:1273–8. UK Department for Communities and Local Government. Fire and rescue service operational guidance: operational risk information. London, UK: UK Department for Communities and Local Government; 2012. Rea T, Blackwood J, Damon S, Phelps R, Eisenberg M. A link between emergency dispatch and public access AEDs: potential implications for early defibrillation. Resuscitation 2011;82:995–8. Merchant RM, Asch DA, Hershey JC, et al. A crowdsourcing innovation challenge to locate and map automated external defibrillators. Circ Cardiovasc Qual Outcomes 2013;6:229–36. Hansen CM, Wissenberg M, Weeke P, et al. Automated external defibrillators inaccessible to more than half of nearby cardiac arrests in public locations during evening, nighttime, and weekends. Circulation 2013;128: 2224–31. Kovic I, Lulic I. Mobile phone in the chain of survival. Resuscitation 2011;82:776–9. Ahn JY, Cho GC, Shon YD, Park SM, Kang KH. Effect of a reminder video using a mobile phone on the retention of CPR and AED skills in lay responders. Resuscitation 2011;82:1543–7. Fridman M, Barnes V, Whyman A, et al. A model of survival following prehospital cardiac arrest based on the Victorian Ambulance Cardiac Arrest Register. Resuscitation 2007;75:311–22. Sasson C, Rogers MA, Dahl J, Kellermann AL. Predictors of survival from out-ofhospital cardiac arrest: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes 2010;3:63–81.
K. Smith ∗ Ambulance Victoria, Melbourne, Victoria, Australia Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia Department of Emergency Medicine, University of Western Australia, Perth, Western Australia, Australia M. Lijovic Ambulance Victoria, Melbourne, Victoria, Australia Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia ∗ Corresponding author. E-mail address: [email protected] (K. Smith)
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Editorial
Increasing bystander participation in resuscitation
Timely bystander cardiopulmonary resuscitation (CPR) and defibrillation after an out-of-hospital cardiac arrest (OHCA) are essential steps for improving OHCA outcomes.1 The strategy of first responders being dispatched with automated external defibrillators (AEDs) has enabled treatment to commence prior to the arrival of emergency medical services (EMS).2 Additionally, placement of AEDs in public places for use by laypersons/bystanders as part of public access defibrillation (PAD) programs has further led to decreased time to defibrillation and improved survival for patients who arrest in a public place.3–5 For example, within PAD programs in Denmark and Los Angeles, it has been possible to achieve a survival rate of 69% amongst defibrillated cases in both locations.6,7 Rates of PAD by lay persons have steadily increased over time, as has the number of public AEDs.8,9 In Victoria, Australia we have seen a 10-fold increase in the use of PAD AEDs over the last decade.10 However, PAD programs are aimed primarily at providing AEDs at sites with high population throughput, likely high OHCA incidence and are typically public locations.3–5 Considering that the majority of OHCA occur in residential locations, the concept of lay rescuers reaching OHCA patients in the home is attractive.9,11 This would naturally translate to lay rescuers being able to reach a higher proportion of OHCA patients than normally possible with traditional PAD programs. In this issue of Resuscitation, Zijlstra et al. describe an alert system for lay rescuers to attend OHCA occurring in both public and private settings. Their study examines the use of a text message (TM) alert system in two regions of the Netherlands covering 127 million inhabitants. Dispatchers are able to send a TM to volunteer lay rescuers trained in the use of CPR and AED if they are within 1000 m of a suspected cardiac arrest. Just over 11,000 TM-responders and 1200 AEDs were registered per million-population. This level of coverage meant that TM-responders were available to respond in over 95% of OHCAs where the system was activated. During the period February 2010–July 2013, the TM alert system was activated by dispatchers in 58% of 1536 arrests; in 12% of cases an AED was connected to the patient by a TM responder prior to the arrival of EMS. As part of the TM alert system, up to 30 volunteers may be mobilised, with 10 being sent directly to the patient and 20 sent to retrieve an AED. This can pose a space and safety problem should all responders be available to attend a patient, as already alluded to by a preliminary study on the programme.12 This could have an impact on the time to treatment and may lead to a large number of people potentially entering private homes for any single event. Zijlstra et al. recognise that improvements to the global positioning
http://dx.doi.org/10.1016/j.resuscitation.2014.09.001 0300-9572/© 2014 Elsevier Ireland Ltd. All rights reserved.
system, so as to more accurately pinpoint the closest TM responders to the patient, could reduce the maximum number of responders being alerted. A legal issue for consideration is how the TM alert system could be translated to other countries, as it is a relatively new concept for lay persons acting in a rescue role to enter private residences. Whilst professional rescue personnel are guided by formal operational frameworks when entering premises as part of their role, including private homes, it is unknown if similar frameworks exist for volunteer lay persons.13 The success of a programme aimed at increasing layperson use of public AEDs is dependent on an accurate registry of AED location and availability and on dispatcher compliance. In the current study, dispatchers did not activate the TM-alert system in 41.8% of EMS treated OHCAs. Additionally, registration of AEDs for the programme was reliant on AED owner awareness of the programme and agreement to “opt in”. Rea et al. have previously found that less than half of AEDs (9 of 22) used by lay persons prior to the arrival of EMS in King County (excluding Seattle) were registered with the EMS dispatch service.14 The University of Washington in Seattle has since run an innovative campaign aimed at discovering the location of AEDs via a city-wide scavenger hunt. The competition resulted in over 2000 AEDs being reported by competing teams. A similar campaign has also been run in Philadelphia.15 One advantage of the TM-alert database used in the Netherlands is that it notes availability of AEDs according to time of day; a study in the city of Copenhagen highlighted that more than half of arrests in public locations would not have access to public AEDs out of normal business hours.16 A recent paper in Resuscitation outlined how mobile phones can play an integral part in numerous parts of the chain of survival, including being used to access EMS, receive guidance about the performance of CPR and locate AEDs using positioning systems.17 One prospective case–control study showed that laypersons trained in the use of CPR and AED who received text message prompts to watch a reminder video clip about CPR and AED use had significantly improved retention of resuscitation skills than controls, including more accurate hand positioning (p = 0.004) and AED electrode positioning (p < 0.001) and more prompt resumption of CPR after defibrillation (p < 0.001).18 Zijlstra et al. used local advertisements and campaigns to recruit TM-responders. This in itself is likely to increase public awareness regarding the importance of bystander CPR and early defibrillation for OHCA. Additionally 100% of patients where TM-responders arrived received bystander CPR. Bystander CPR improves survival,
Editorial / Resuscitation 85 (2014) 1640–1641
directly and through the mediation of VF/VT, and is an essential component of an integrated response to OHCA.19 We know that one life is saved for every 24–36 persons who receive bystander CPR.20 The TM alert system described by Zijlstra et al. and the above strategies using mobile phone technology are important additional steps towards further improving bystander CPR rates, public AED use and OHCA survival. Conflict of interest statement
13.
14.
15.
16.
There is no conflicts of interest to declare. References
17. 18.
1. Capucci A, Aschieri D. Public access defibrillation: new developments for mass implementation. Heart 2011;97:1528–32. 2. Berdowski J, Blom MT, Bardai A, Tan HL, Tijssen JG, Koster RW. Impact of onsite or dispatched automated external defibrillator use on survival after out-of-hospital cardiac arrest. Circulation 2011;124:2225–32. 3. The American Heart Association in Collaboration with the International Liaison Committee on Resuscitation. Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. Part 4: the automated external defibrillator: key link in the chain of survival. Circulation 2000;102(Suppl.):I60–76. 4. Handley AJ, Koster R, Monsieurs K, Perkins GD, Davies S, Bossaert L. European Resuscitation Council guidelines for resuscitation 2005 Section 2. Adult basic life support and use of automated external defibrillators. Resuscitation 2005;67(Suppl. (1)):S7–23. 5. Australian Resuscitation Council. Australian resuscitation council guidelines; 2010. 6. Nielsen AM, Folke F, Lippert FK, Rasmussen LS. Use and benefits of public access defibrillation in a nation-wide network. Resuscitation 2013;84:430–4. 7. Eckstein M. The Los Angeles public access defibrillator (PAD) program: ten years after. Resuscitation 2012;83:1411–2. 8. Kitamura T, Iwami T, Kawamura T, Nagao K, Tanaka H, Hiraide A. Nationwide public-access defibrillation in Japan. N Engl J Med 2010;362:994–1004. 9. Wissenberg M, Lippert FK, Folke F, et al. Association of national initiatives to improve cardiac arrest management with rates of bystander intervention and patient survival after out-of-hospital cardiac arrest. JAMA 2013;310:1377–84. 10. Ambulance Victoria.Victorian Ambulance Cardiac Arrest Registry (VACAR) Annual Report 2012/13. 2013. 11. Nehme Z, Andrew E, Cameron PA, et al. Population density predicts outcome from out-of-hospital cardiac arrest in Victoria, Australia. Med J Aust 2014;200:471–5. 12. Scholten AC, van Manen JG, van der Worp WE, Ijzerman MJ, Doggen CJ. Early cardiopulmonary resuscitation and use of Automated External Defibrillators by
19.
20.
1641
laypersons in out-of-hospital cardiac arrest using an SMS alert service. Resuscitation 2011;82:1273–8. UK Department for Communities and Local Government. Fire and rescue service operational guidance: operational risk information. London, UK: UK Department for Communities and Local Government; 2012. Rea T, Blackwood J, Damon S, Phelps R, Eisenberg M. A link between emergency dispatch and public access AEDs: potential implications for early defibrillation. Resuscitation 2011;82:995–8. Merchant RM, Asch DA, Hershey JC, et al. A crowdsourcing innovation challenge to locate and map automated external defibrillators. Circ Cardiovasc Qual Outcomes 2013;6:229–36. Hansen CM, Wissenberg M, Weeke P, et al. Automated external defibrillators inaccessible to more than half of nearby cardiac arrests in public locations during evening, nighttime, and weekends. Circulation 2013;128: 2224–31. Kovic I, Lulic I. Mobile phone in the chain of survival. Resuscitation 2011;82:776–9. Ahn JY, Cho GC, Shon YD, Park SM, Kang KH. Effect of a reminder video using a mobile phone on the retention of CPR and AED skills in lay responders. Resuscitation 2011;82:1543–7. Fridman M, Barnes V, Whyman A, et al. A model of survival following prehospital cardiac arrest based on the Victorian Ambulance Cardiac Arrest Register. Resuscitation 2007;75:311–22. Sasson C, Rogers MA, Dahl J, Kellermann AL. Predictors of survival from out-ofhospital cardiac arrest: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes 2010;3:63–81.
K. Smith ∗ Ambulance Victoria, Melbourne, Victoria, Australia Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia Department of Emergency Medicine, University of Western Australia, Perth, Western Australia, Australia M. Lijovic Ambulance Victoria, Melbourne, Victoria, Australia Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia ∗ Corresponding author. E-mail address: [email protected] (K. Smith)
