-
Laurie J Morrison,
Robert W Neumar,
Janice L Zimmerman,
Mark S Link,
L Kristin Newby,
Paul W McMullan,
Terry Vanden Hoek,
Colleen C Halverson,
Lynn Doering,
Mary Ann Peberdy,
Dana P Edelson
Circulation 03/2013; · 14.74 Impact Factor
-
Jan L Jensen,
Blair L Bigham,
Ian E Blanchard,
Katie N Dainty,
Doug Socha,
Alix Carter,
Lawrence H Brown,
Andrew H Travers,
Alan M Craig,
Ryan Brown, Laurie J Morrison
[show abstract]
[hide abstract]
ABSTRACT: Introduction:Research is essential for the development of evidence-based emergency medical services (EMS) systems of care. When resources are scarce and gaps in evidence are large, a national agenda may inform the growth of EMS research in Canada. This mixed methods consensus study explores current barriers and existing strengths within Canadian EMS research, provides recommendations, and suggests EMS topics for future study.Methods:Purposeful sampling was employed to invite EMS research stakeholders from various roles across the country. Study phases consisted of 1) baseline interviews of a subsample, 2) roundtable discussion, and 3) an online Delphi survey, in which participants scored each statement for importance. Consensus was defined a priori and met if 80% scored a statement as "important" or "very important."Results:Fifty-three stakeholders participated, representing researchers (37.7%), EMS administrators (24.6%), clinicians/providers (20.7%), and educators (17.0%). Participation rates were as follows: interviews, 13 of 13 (100%); roundtable, 47 of 53 (89%); survey round 1, 50 of 53 (94%); survey round 2, 47 of 53 (89%); and survey round 3, 40 of 53 (75%). A total of 141 statements were identified as important: 20 barriers, 54 strengths/opportunities, 31 recommendations, and 36 suggested topics for future research. Like statements were synthesized, resulting in barriers (n = 10), strengths/opportunities (n = 24), and recommendations (n = 19), which were categorized as time, opportunities, and funding; education and mentorship; culture of research and collaboration; structure, process, and outcome of research; EMS and paramedic practice; and the future of the EMS Research Agenda.Conclusion:Consensus-based key messages from this agenda should be considered when designing, funding, and publishing EMS research and will advance EMS research locally, regionally, and nationally.
CJEM: Canadian journal of emergency medical care = JCMU: journal canadien de soins medicaux d'urgence 03/2013; 15(2):73-82. · 1.18 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Purpose:This study forms the first phase in the development of the Canadian National EMS Research Agenda. The purpose was to understand the current state of emergency medical services (EMS) research through the barriers and opportunities perceived by key stakeholders in the Canadian system and to identify the recommendations this group had for moving forward.Methods:This qualitative study was conducted in the spring of 2011 using one-on-one semistructured telephone interviews. Purposeful sampling was used to recruit a cross section of EMS research stakeholders, representing a breadth of geographic regions and roles. Data were collected until thematic saturation was reached. A constant comparative approach was used to develop a basic coding framework and identify emerging themes.Results:Twenty stakeholders were invited to participate, and saturation was reached after 13 interviews. Thematic saturation was used to ensure that the findings were grounded in the data. Four major themes were identified: 1) the need for additional research education within EMS; 2) the importance of creating an infrastructure to support pan-Canadian research collaboration; 3) addressing the complexities of involving EMS providers in research; and 4) considerations for a national research agenda.Conclusion:This hypothesis-generating study reveals key areas regarding EMS research in Canada and through the guidance it provides is a first step in the development of a comprehensive national research agenda. Our intention is to collate the identified themes with the results of a larger roundtable discussion and Delphi survey and, in doing so, guide development of a Canadian national EMS research agenda.
CJEM: Canadian journal of emergency medical care = JCMU: journal canadien de soins medicaux d'urgence 03/2013; 15(2):83-9. · 1.18 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Objectives:Bystander resuscitation efforts, such as cardiopulmonary resuscitation (CPR) and use of an automatic external defibrillator (AED), save lives in cardiac arrest cases. School training in CPR and AED use may increase the currently low community rates of bystander resuscitation. The study objective was to determine the rates of CPR and AED training in Toronto secondary schools and to identify barriers to training and training techniques.Methods:This prospective study consisted of telephone interviews conducted with key school staff knowledgeable about CPR and AED teaching. An encrypted Web-based tool with prespecified variables and built-in logic was employed to standardize data collection.Results:Of 268 schools contacted, 93% were available for interview and 83% consented to participate. Students and staff were trained in CPR in 51% and 80% of schools, respectively. Private schools had the lowest training rate (39%). Six percent of schools provided AED training to students and 47% provided AED training to staff. Forty-eight percent of schools had at least one AED installed, but 25% were unaware if their AED was registered with emergency services dispatch. Cost (17%), perceived need (11%), and school population size (10%) were common barriers to student training. Frequently employed training techniques were interactive (32%), didactic instruction (30%) and printed material (16%).Conclusions:CPR training rates for staff and students were moderate overall and lowest in private schools, whereas training rates in AED use were poor in all schools. Identified barriers to training include cost and student population size (perceived to be too small to be cost-effective or too large to be implemented). Future studies should assess the application of convenient and cost-effective teaching alternatives not presently in use.
CJEM: Canadian journal of emergency medical care = JCMU: journal canadien de soins medicaux d'urgence 01/2013; 15:1-9. · 1.18 Impact Factor
-
Vineet Bhan,
Warren J Cantor,
Raymond T Yan,
Shamir R Mehta, Laurie J Morrison,
Michael Heffernan,
David Fitchett,
Vladimir Džavík,
John Ducas,
Bjug Borgundvaag,
Eric A Cohen,
Shaun G Goodman,
Andrew T Yan
[show abstract]
[hide abstract]
ABSTRACT: The TRANSFER-AMI study demonstrated that early routine percutaneous coronary intervention post-fibrinolysis (pharmacoinvasive strategy) is superior to conservative management for ST-elevation myocardial infarction. However, it is not clear whether treatment efficacy differs between men and women.
In this pre-specified subgroup analysis, we compared the efficacy of a pharmacoinvasive strategy in men versus women with acute ST-elevation myocardial infarction who were randomized to a pharmacoinvasive versus standard management following fibrinolysis. The primary end point was a composite of death, recurrent myocardial infarction, recurrent ischemia, heart failure and shock at 30 days. We tested for treatment heterogeneity between men and women using the Breslow-Day test. We also performed multivariable analysis adjusting for GRACE risk score and its interaction with treatment assignment, and evaluated for death/recurrent myocardial reinfarction as a secondary outcome.
Of the 1059 patients, 843 were men and 216 were women. Compared to men, women were older, had worse Killip class, higher GRACE risk score, and higher rates of death and death/myocardial reinfarction at 30 days. The primary end point did not differ significantly between men and women (13.4% vs 16.7%, P = .22). Compared to standard treatment, a pharmacoinvasive strategy was associated with a lower rate of the primary end point in men (17.5% vs 9.4%, respectively, P < .001), but not in women (16.2% vs 17.1%, P = .86). There was a trend toward an interaction between treatment assignment and sex for the composite primary end point (P = .06). After adjustment for the significant interaction between GRACE risk score and treatment (P < .001), there was no significant interaction between sex and treatment for all the end points (all P > .40).
The borderline heterogeneity in treatment efficacy of a pharmacoinvasive strategy in men versus women was no longer evident after adjustment for the difference in baseline risk. This suggests that sex per se was not an important determinant of the efficacy of a pharmacoinvasive strategy. Owing to the small number of women in this trial, further study in this area is needed.
American heart journal 09/2012; 164(3):343-50. · 4.65 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: BACKGROUND: While prior studies highlight regional variations in out-of-hospital cardiac arrest (OHCA) survival, the underlying reasons remain unknown. We sought to characterize regional variations early and later survival to hospital discharge after OHCA. METHODS: We studied adult, non-traumatic OHCA treated by 10 regional sites of the Resuscitation Outcomes Consortium (ROC) during 12/01/2005-6/30/2007. We compared (1) early survival (up to one calendar day after arrest) and (2) later conditional survival to hospital discharge (early survivors progressing to eventual hospital discharge) between ROC regional sites. RESULTS: Among 3763 VF/VT with complete covariates, site unadjusted early survival varied from 11.3 to 54.3%, and site unadjusted later survival varied from 33.3 to 70.5%. Compared with the largest site, adjusted VF/VT survival varied across sites: early survival OR 0.33 (95% CI: 0.17, 0.65) to 2.87 (2.20, 3.73), overall site variation p<0.001; later survival OR 0.29 (0.14, 0.59) to 1.21 (0.73, 2.00), p<0.001. Among 10,879 non-VF/VT with complete covariates, site unadjusted early survival varied from 6.6 to 14.3%, and site unadjusted later survival varied from 4.5 to 39.6%. Compared with the largest site, adjusted non-VF/VT survival varied across sites: early survival OR 1.02 (0.63, 1.64) to 2.43 (1.91, 3.12), p<0.001; later survival OR 0.11 (0.01, 0.82) to 1.56 (0.90, 2.70), p=0.02. CONCLUSIONS: In this prospective multicenter North American series, there were regional disparities in early and later survival after OHCA, suggesting that there are underlying regional differences in out-of-hospital and post-arrest care beyond traditional Utstein predictors. Community efforts to improve OHCA survival must address both out-of-hospital and in-hospital care.
Resuscitation 07/2012; 83(11):1343-1348. · 3.60 Impact Factor
-
Ahamed H Idris,
Danielle Guffey,
Tom P Aufderheide,
Siobhan Brown, Laurie J Morrison,
Patrick Nichols,
Judy Powell,
Mohamud Daya,
Blair L Bigham,
Dianne L Atkins,
Robert Berg,
Dan Davis,
Ian Stiell,
George Sopko,
Graham Nichol
[show abstract]
[hide abstract]
ABSTRACT: Guidelines for cardiopulmonary resuscitation recommend a chest compression rate of at least 100 compressions per minute. Animal and human studies have reported that blood flow is greatest with chest compression rates near 120/min, but few have reported rates used during out-of-hospital (OOH) cardiopulmonary resuscitation or the relationship between rate and outcome. The purpose of this study was to describe chest compression rates used by emergency medical services providers to resuscitate patients with OOH cardiac arrest and to determine the relationship between chest compression rate and outcome.
Included were patients aged ≥ 20 years with OOH cardiac arrest treated by emergency medical services providers participating in the Resuscitation Outcomes Consortium. Data were abstracted from monitor-defibrillator recordings during cardiopulmonary resuscitation. Multiple logistic regression analysis assessed the association between chest compression rate and outcome. From December 2005 to May 2007, 3098 patients with OOH cardiac arrest were included in this study. Mean age was 67 ± 16 years, and 8.6% survived to hospital discharge. Mean compression rate was 112 ± 19/min. A curvilinear association between chest compression rate and return of spontaneous circulation was found in cubic spline models after multivariable adjustment (P=0.012). Return of spontaneous circulation rates peaked at a compression rate of ≈ 125/min and then declined. Chest compression rate was not significantly associated with survival to hospital discharge in multivariable categorical or cubic spline models.
Chest compression rate was associated with return of spontaneous circulation but not with survival to hospital discharge in OOH cardiac arrest.
Circulation 05/2012; 125(24):3004-12. · 14.74 Impact Factor
-
Robert H Schmicker,
Brian G Leroux,
Gena K Sears,
Ian Stiell, Laurie J Morrison,
Tom P Aufderheide,
Ray Fowler,
Rusty Lowe,
Stanley Morrow,
Ed Plumlee,
Sheldon Cheskes
[show abstract]
[hide abstract]
ABSTRACT: Low compliance to randomized nondrug interventions can affect treatment estimates of clinical trials. Cluster-randomized crossover may be appropriate for increasing compliance in the out-of-hospital cardiac arrest setting.
The purpose was to determine whether the elapsed time from start of a nonblinded treatment period to episode enrollment date in a cluster-randomized crossover trial is associated with compliance to either a period of brief cardiopulmonary resuscitation (CPR) with electrocardiogram (ECG) rhythm analysis or a period of longer CPR with a delayed ECG rhythm analysis in patients with out-of-hospital cardiac arrest.
The Resuscitation Outcomes Consortium PRIMED Analyze Late (AL) versus Analyze Early (AE) trial was a cluster-randomized crossover trial at 10 North American regional sites. Clusters were created based on local service preference with treatment periods varying from 3 to 12 months depending on the expected enrollment rate of each randomizing unit. Episodes on the AL arm had a target of 180 s from CPR start to shock assessment and were deemed compliant if total time was between 150 and 210 s. Episodes on the AE arm had a target of <30 s from CPR start to shock assessment and were deemed compliant if total time was <60 s. We used logistic regression to examine the association between compliance (yes/no) and the elapsed number of days from the start of the treatment period to the episode in the framework of generalized estimating equations, controlling for randomized treatment (Late, reference = Early) and treatment period length (reference = 3, 4-5, 6, 7-11, and 12 months).
We had 8769 episodes in our analysis population. Overall compliance to the randomized arm was 63.5%. After adjusting for treatment arm and treatment period length, the odds of compliance for episodes occurring >300 days from treatment period start were 33% lower (odds ratio (OR): 0.67; 95% confidence interval (CI): 0.52, 0.86) than for those <60 days from treatment period start. There was no significant difference in compliance between episodes before and immediately after a cluster crossed over to the opposite arm (OR: 0.81; 95% CI: 0.57, 1.16).
A major challenge was the lack of synchronicity between training cycles and agency crossover dates.
We found a significant decrease in compliance to the AL versus AE cardiac arrest intervention as the elapsed time from start of treatment period increased. We did not find a difference in compliance immediately before and after a crossover. While these results suggest that future cluster with crossover trials in the out-of-hospital setting be designed with short treatment periods and frequent crossovers, provider logistical concerns must also be considered.
Clinical Trials 03/2012; 9(3):314-21. · 1.92 Impact Factor
-
Eileen M Bulger,
Danielle Guffey,
Francis X Guyette,
Russell D Macdonald,
Karen Brasel,
Jeffery D Kerby,
Joseph P Minei,
Craig Warden,
Sandro Rizoli, Laurie J Morrison,
Graham Nichol
The journal of trauma and acute care surgery. 03/2012; 72(3):803.
-
Eileen M Bulger,
Danielle Guffey,
Francis X Guyette,
Russell D MacDonald,
Karen Brasel,
Jeffery D Kerby,
Joseph P Minei,
Craig Warden,
Sandro Rizoli, Laurie J Morrison,
Graham Nichol
[show abstract]
[hide abstract]
ABSTRACT: There is ongoing controversy about the relative effectiveness of air medical versus ground transportation for severely injured patients. In some systems, air medical crews may provide a higher level of care but may require longer transport times. We sought to evaluate the impact of mode of transport on outcome based on analysis of data from two randomized trials of prehospital hypertonic resuscitation.
Injured patients were enrolled based on prehospital evidence of hypovolemic shock (systolic blood pressure ≤70 mm Hg or systolic blood pressure = 71-90 mm Hg with heart rate ≥108 bpm) or severe traumatic brain injury (TBI; Glasgow Coma Scale score ≤8). Patient demographics, injury severity, and physiology were compared based on mode of transport. Multivariate logistic regression was used to determine the impact of mode of transport on 24-hour and 28-day survival for all patients and 6-month extended Glasgow Outcome Scale for patients with TBI, adjusting for differences in injury severity.
Included were 2,049 patients, of which 703 (34%) were transported by air. Patients transported by air were more severely injured (mean Injury Severity Score, 30.3 vs. 22.8; p < 0.001), more likely to be in the TBI cohort (70% vs. 55.4%; p < 0.001), and more likely blunt mechanism (94.0% vs. 78.1%; p < 0.001). Patients transported by air had higher rates of prehospital intubation (81% vs. 36%; p < 0.001), received more intravenous fluids (mean 1.3 L vs. 0.8 L; p < 0.001), and had longer prehospital times (mean 76.1 minutes vs. 43.5 minutes; p < 0.001). Adjusted analysis revealed no significant impact of mode of transport on survival or 6-month neurologic outcome (air transport-28-day survival: odds ratio, 1.11; 95% confidence interval, 0.82-1.51; 6-month extended Glasgow Outcome Scale score ≤4: odds ratio, 0.94; 95% confidence interval, 0.68-1.31).
There was no difference in the adjusted clinical outcome according to mode of transport. However, air medical transported more severely injured patients with more advanced life support procedures and longer prehospital time.
III.
The journal of trauma and acute care surgery. 03/2012; 72(3):567-73; discussion 573-5; quiz 803.
-
[show abstract]
[hide abstract]
ABSTRACT: Preventable harm from medical care has been extensively documented in the inpatient setting. Emergency medical services (EMS) providers care for patients in dynamic and challenging environments; prehospital emergency care is a field that represents an area of high risk for errors and harm, but has received relatively little attention in the patient safety literature.
To identify the threats to patient safety unique to the EMS environment and interventions that mitigate those threats, we completed a systematic review of the literature.
We searched MEDLINE, EMBASE, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) for combinations of key EMS and patient safety terms composed by a pan-canadian expert panel using a year limit of 1999 to 2011. We excluded commentaries, opinions, letters, abstracts, and non-english publications. Two investigators performed an independent hierarchical screening of titles, abstracts, and full-text articles blinded to source. We used the kappa statistic to examine interrater agreement. Any differences were resolved by consensus.
We retrieved 5,959 titles, and 88 publications met the inclusion criteria and were categorized into seven themes: adverse events and medication errors (22 articles), clinical judgment (13), communication (6), ground vehicle safety (9), aircraft safety (6), interfacility transport (16), and intubation (16). Two articles were randomized controlled trials; the remainder were systematic reviews, prospective observational studies, retrospective database/chart reviews, qualitative interviews, or surveys. The kappa statistics for titles, abstracts, and full-text articles were 0.65, 0.79, and 0.87, respectively, for the first search and 0.60, 0.74, and 0.85 for the second.
We found a paucity of scientific literature exploring patient safety in EMS. Research is needed to improve our understanding of problem magnitude and threats to patient safety and to guide interventions.
Prehospital Emergency Care 01/2012; 16(1):20-35. · 1.78 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Abstract The out-of-hospital setting is unique to health care and presents many challenges to providing safe, high-quality medical care in emergency situations. The challenges of the prehospital environment require thoughtful design of systems and processes of care. The unique challenges of ambulance safety may be met by analyzing systems and incorporating process improvements. The purposes of this paper are to 1) outline the nature of this problem, 2) introduce a framework for this discussion, 3) provide expert opinion from a two-day ambulance safety conference, and 4) propose a plan of action to address the safety issues identified in the literature and expert opinion at the conference. Utilizing the Haddon Matrix as a framework, we present the safety issues and proposed solutions for factors contributing to an injury event in the emergency medical services (EMS) transport environment: host, agent, physical environment, and social environment. Host refers to the person or persons at risk, in this case, the EMS personnel or the patient. The agent of injury refers to the energy exerted during the course of an injury, and may be modified to include unrestrained equipment that contributes to the injury. The physical environment refers to the characteristics of the setting in which the injury takes place, such as the roadway or the physical design of the ambulance. Finally, the social environment refers to the social, legal, and cultural norms and practices in the society, such as peer pressure and a culture that discourages the use of safety equipment.
Prehospital Emergency Care 01/2012; 16(1):3-19. · 1.78 Impact Factor
-
Ian G Stiell,
Siobhan P Brown,
James Christenson,
Sheldon Cheskes,
Graham Nichol,
Judy Powell,
Blair Bigham, Laurie J Morrison,
Jonathan Larsen,
Erik Hess,
Christian Vaillancourt,
Daniel P Davis,
Clifton W Callaway
[show abstract]
[hide abstract]
ABSTRACT: The 2010 international guidelines for cardiopulmonary resuscitation recently recommended an increase in the minimum compression depth from 38 to 50 mm, although there are limited human data to support this. We sought to study patterns of cardiopulmonary resuscitation compression depth and their associations with patient outcomes in out-of-hospital cardiac arrest cases treated by the 2005 guideline standards.
Prospective cohort.
Seven U.S. and Canadian urban regions.
We studied emergency medical services treated out-of-hospital cardiac arrest patients from the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest for whom electronic cardiopulmonary resuscitation compression depth data were available, from May 2006 to June 2009.
We calculated anterior chest wall depression in millimeters and the period of active cardiopulmonary resuscitation (chest compression fraction) for each minute of cardiopulmonary resuscitation. We controlled for covariates including compression rate and calculated adjusted odds ratios for any return of spontaneous circulation, 1-day survival, and hospital discharge.
We included 1029 adult patients from seven U.S. and Canadian cities with the following characteristics: Mean age 68 yrs; male 62%; bystander witnessed 40%; bystander cardiopulmonary resuscitation 37%; initial rhythms: Ventricular fibrillation/ventricular tachycardia 24%, pulseless electrical activity 16%, asystole 48%, other nonshockable 12%; outcomes: Return of spontaneous circulation 26%, 1-day survival 18%, discharge 5%. For all patients, median compression rate was 106 per minute, median compression fraction 0.65, and median compression depth 37.3 mm with 52.8% of cases having depth <38 mm and 91.6% having depth <50 mm. We found an inverse association between depth and compression rate ( p < .001). Adjusted odds ratios for all depth measures (mean values, categories, and range) showed strong trends toward better outcomes with increased depth for all three survival measures.
We found suboptimal compression depth in half of patients by 2005 guideline standards and almost all by 2010 standards as well as an inverse association between compression depth and rate. We found a strong association between survival outcomes and increased compression depth but no clear evidence to support or refute the 2010 recommendations of >50 mm. Although compression depth is an important component of cardiopulmonary resuscitation and should be measured routinely, the most effective depth is currently unknown.
Critical care medicine 12/2011; 40(4):1192-8. · 6.37 Impact Factor
-
Jan L Jensen,
Ian E Blanchard,
Blair L Bigham,
Katie N Dainty,
Doug Socha,
Alix Carter,
Lawrence H Brown,
Alan M Craig,
Andrew H Travers,
Ryan Brown,
Ed Cain, Laurie J Morrison
[show abstract]
[hide abstract]
ABSTRACT: Many health care disciplines use evidence-based decision making to improve patient care and system performance. While the amount and quality of emergency medical services (EMS) research in Canada has increased over the past two decades, there has not been a unified national plan to enable research, ensure efficient use of research resources, guide funding decisions and build capacity in EMS research. Other countries have used research agendas to identify barriers and opportunities in EMS research and define national research priorities. The objective of this project is to develop a national EMS research agenda for Canada that will: 1) explore what barriers to EMS research currently exist, 2) identify current strengths and opportunities that may be of benefit to advancing EMS research, 3) make recommendations to overcome barriers and capitalize on opportunities, and 4) identify national EMS research priorities.
Paramedics, educators, EMS managers, medical directors, researchers and other key stakeholders from across Canada will be purposefully recruited to participate in this mixed methods study, which consists of three phases: 1) qualitative interviews with a selection of the study participants, who will be asked about their experience and opinions about the four study objectives, 2) a facilitated roundtable discussion, in which all participants will explore and discuss the study objectives, and 3) an online Delphi consensus survey, in which all participants will be asked to score the importance of each topic discovered during the interviews and roundtable as they relate to the study objectives. Results will be analyzed to determine the level of consensus achieved for each topic.
A mixed methods approach will be used to address the four study objectives. We anticipate that the keys to success will be: 1) ensuring a representative sample of EMS stakeholders, 2) fostering an open and collaborative roundtable discussion, and 3) adhering to a predefined approach to measure consensus on each topic. Steps have been taken in the methodology to address each of these a priori concerns.
BMC Emergency Medicine 09/2011; 11:15.
-
Ian G Stiell,
Graham Nichol,
Brian G Leroux,
Thomas D Rea,
Joseph P Ornato,
Judy Powell,
James Christenson,
Clifton W Callaway,
Peter J Kudenchuk,
Tom P Aufderheide, [......],
Sheldon Cheskes,
Robert H Schmicker,
Ray Fowler,
Christian Vaillancourt,
David Hostler,
Dana Zive,
Ronald G Pirrallo,
Gary M Vilke,
George Sopko,
Myron Weisfeldt
[show abstract]
[hide abstract]
ABSTRACT: In a departure from the previous strategy of immediate defibrillation, the 2005 resuscitation guidelines from the American Heart Association-International Liaison Committee on Resuscitation suggested that emergency medical service (EMS) personnel could provide 2 minutes of cardiopulmonary resuscitation (CPR) before the first analysis of cardiac rhythm. We compared the strategy of a brief period of CPR with early analysis of rhythm with the strategy of a longer period of CPR with delayed analysis of rhythm.
We conducted a cluster-randomized trial involving adults with out-of-hospital cardiac arrest at 10 Resuscitation Outcomes Consortium sites in the United States and Canada. Patients in the early-analysis group were assigned to receive 30 to 60 seconds of EMS-administered CPR and those in the later-analysis group were assigned to receive 180 seconds of CPR, before the initial electrocardiographic analysis. The primary outcome was survival to hospital discharge with satisfactory functional status (a modified Rankin scale score of ≤3, on a scale of 0 to 6, with higher scores indicating greater disability).
We included 9933 patients, of whom 5290 were assigned to early analysis of cardiac rhythm and 4643 to later analysis. A total of 273 patients (5.9%) in the later-analysis group and 310 patients (5.9%) in the early-analysis group met the criteria for the primary outcome, with a cluster-adjusted difference of -0.2 percentage points (95% confidence interval, -1.1 to 0.7; P=0.59). Analyses of the data with adjustment for confounding factors, as well as subgroup analyses, also showed no survival benefit for either study group.
Among patients who had an out-of-hospital cardiac arrest, we found no difference in the outcomes with a brief period, as compared with a longer period, of EMS-administered CPR before the first analysis of cardiac rhythm. (Funded by the National Heart, Lung, and Blood Institute and others; ROC PRIMED ClinicalTrials.gov number, NCT00394706.).
New England Journal of Medicine 09/2011; 365(9):787-97. · 53.30 Impact Factor
-
Dini Hui, Laurie J Morrison,
Rory Windrim,
Andrea Y Lausman,
Laura Hawryluck,
Paul Dorian,
Stephen E Lapinsky,
Stephen H Halpern,
Douglas M Campbell,
Paul Hawkins,
Randy S Wax,
Jose C A Carvalho,
Katie N Dainty,
Cynthia Maxwell,
Farida M Jeejeebhoy
Journal of obstetrics and gynaecology Canada: JOGC = Journal d'obstetrique et gynecologie du Canada: JOGC 08/2011; 33(8):858-63.
-
[show abstract]
[hide abstract]
ABSTRACT: To describe the consensus on science pertaining to resuscitation of the pregnant patient.
Systematic review.
EMBASE, Ovid MEDLINE, Evidence Based Reviews, American Heart Association library and bibliographies of selected articles.
The following inclusion criteria were used: pregnancy and cardiac arrest out of hospital, pregnancy and cardiac arrest in hospital, cardiovascular, respiratory, fetal survival, and pharmacology as they relate to cardiac arrest and resuscitation. Non-English papers, case reports and reviews were excluded. Studies were selected through an independent review of titles, abstracts and full article. Two reviewers independently graded the methodological quality of selected articles.
1305 articles were identified and 5 were selected for further review. There were no randomized trials and overall the quality of the selected studies was good. Two studies examined chest compressions on a manikin in left lateral tilt from the horizontal and concluded that although feasible with increasing degrees of tilt forcefulness of the chest compressions decreases. The third study observed the transthoracic impedance was not altered during pregnancy. One case series and one retrospective cohort study reviewed perimortem cesarean section. Both reports concluded that perimortem cesarean section is rarely done within the recommended time frame of 5 min after the onset of maternal cardiac arrest.
Usual defibrillation dosages are likely appropriate in pregnancy. Perimortem cesarean section is an intervention which is rarely done within 5 min to optimize maternal salvage from cardiac arrest. Chest compressions in left lateral tilt are less forceful compared to the supine position.
Resuscitation 07/2011; 82(7):801-9. · 3.60 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: We examined the effect of the 2005 American Heart Association guidelines on survival in the Resuscitation Outcomes Consortium (ROC) Cardiac Arrest Epistry.
We surveyed 174 EMS agencies from 8 of 10 ROC sites to determine 2005 AHA guideline implementation, or crossover, date. Two sites with 2005 compatible treatment algorithms prior to guideline release, and agencies that did not adopt the new guidelines during the study period were excluded. Non-traumatic adult cardiac arrests that were not witnessed by EMS, and did not have do not resuscitate orders were included. A linear mixed effects model was applied for survival controlling for time and agency. The "crossover" date was added to the model to determine the effect of the 2005 guidelines.
Of 174 agencies, 85 contributed cases to both cohorts during the 18 month period between 2005/12/01 and 2007/05/31. Of 7779 cases, 5054 occurred during the 13 month (median) interval before crossover and 2725 occurred in the five month (median) interval after crossover. The overall survival rate was 6.1%; 5.8% in the old cohort vs. 6.5%, p=0.23. For VF/VT patients, survival was 14.6% vs. 18.0%, p=0.063. Our model estimated no increase in survival over time (monthly OR 1.014, 95% CI 0.988, 1.041, p=0.28).
This study found no significant change in survival rate over time in the early months after implementation. Further longitudinal study is needed to determine the full impact of the guidelines on survival and methods to translate knowledge quickly and effectively in EMS.
Resuscitation 03/2011; 82(8):979-83. · 3.60 Impact Factor
-
Laurie J Morrison,
Valeria E Rac,
James M Bowen,
Brian Schwartz,
Tyrone Perreira,
Welson Ryan,
Cathy Zahn,
Rishab Chadha,
Alan Craig,
Daria O'Reilly,
Ron Goeree
[show abstract]
[hide abstract]
ABSTRACT: A standard of prehospital care for patients presenting with ST-segment elevation myocardial infarction (STEMI) includes prehospital 12-lead and advance Emergency Department notification or prehospital bypass to percutaneous coronary intervention centres. Implementation of either care strategies is variable across communities and neither may exist in some communities. The main objective is to compare prehospital care strategies for time to treatment and survival outcomes as well as cost effectiveness.
PREDICT is a multicentre, prospective population-based cohort study of all chest pain patients 18 years or older presenting within 30 mins to 6 hours of symptom onset and treated with nitroglycerin, transported by paramedics in a number of different urban and rural regions in Ontario. The primary objective of this study is to compare the proportion of study subjects who receive reperfusion within the target door-to-reperfusion times in subjects obtained after four prehospital strategies: 12-lead ECG and advance emergency department (ED) notification or 3-lead ECG monitoring and alert to dispatch prior to hospital arrival; either with or without the opportunity to bypass to a PCI centre.
We anticipate four challenges to successful study implementation and have developed strategies for each: 1) diversity in the interpretation of the ethical and privacy issues across 47 research ethics boards/committees covering 71 hospitals, 2) remote oversight of data guardian abstraction, 3) timeliness of implementation, and 4) potential interference in the study by concurrent technological advances. Research ethics approvals from academic centres were obtained initially and submitted to non academic centre applications. Data guardians were trained by a single investigator and data entry is informed by a detailed data dictionary including variable definitions and abstraction instructions and subjected to error and logic checks. Quality oversight provided by a single investigator. The window of the trial in each community has been confirmed with the base-hospital medical director to correspond to the planned technological advances of the system of care. We hope this comparative analysis across treatment strategies for clinical outcomes and cost will provide sufficient evidence to implement the superior strategy across all communities and improve outcomes for all STEMI patients.
BMC Emergency Medicine 03/2011; 11:4.
-
Emergency Medicine Journal 02/2011; 28(2):171-2. · 1.44 Impact Factor
