Survival after cardiac arrest outside hospital in Sweden

doi:10.1016/S0300-9572(97)00089-0

Resuscitation

Volume 36, Issue 1, January 1998, Pages 29-36

https://doi.org/10.1016/S0300-9572(97)00089-0 Get rights and content

Abstract

The voluntary Swedish Cardiac Arrest Registry has collected and analyzed 14 065 standardised reports on cardiac arrests up until May 1995. The reports have been collected from approximately half of Sweden's ambulance districts, which cover 60% of the population. Resuscitation was attempted in 10 966 cases. The median age was 70 years. In 70.0% the arrest was witnessed, and in 43.3% the first recorded rhythm was VT/VF. Bystander-CPR was initiated in 32.3% of the cases. Most cardiac arrests took place at home (65.8%) and 67.1% were judged to be of cardiac origin. In 1692 cases (15.4%), the patient was admitted alive in hospital and 544 patients (5.0%) were alive after 1 month. Survival to 1 month in the subgroup which presented with VT/VF was 9.5%. We found no significant difference between survival in large cities and smaller communities. The survivors were analysed in relation to time to defibrillation and we found a strong correlation between a short time and increased survival.

Introduction

Sudden unexpected cardiac arrest accounts for a high proportion of the deaths in western societies. The majority of these cases occur outside hospital [1]. Until recently death was almost inevitable for these cardiac arrest victims. The introduction of techniques for basic cardiopulmonary resuscitation (CPR) and defibrillation has dramatically changed the chances of survival. There are numerous reports of effective resuscitation with a wide variation of survival rates [2].

Some of these reports have shown very positive results, but it has been claimed that survival rates on a national level probably are very low, perhaps as low as 2–5% 3, 4.

Most reports are based on data from a city or a limited region, and information on survival from larger regions or countries is rare 5, 6, 7.

Sweden, like most European countries, has been slow in introducing the techniques for resuscitation; both for basic and advanced cardiac life support (ACLS). In 1983, a basic CPR national training program was introduced in Sweden, which has been rapidly adopted both by the medical professionals and lay people and is now widely used all over the country. In 1987, a national ACLS training program was introduced and rapidly accepted.

In the late 1970s, there were a few ambulance systems equipped with defibrillators in different parts of Sweden. After the introduction of the semiautomatic defibrillators in 1986 there has been a rapid development/expansion and now approximately 90% of Swedish ambulances are equipped with semiautomatic defibrillators.

With an ongoing large scale CPR training programme in society and with effective ambulance systems it is interesting and important to evaluate the efficiency of the ambulance systems in their efforts to resuscitate patients with cardiac arrest.

The aim of this study was to investigate the survival rates for out-of-hospital cardiac arrests in Sweden.

Section snippets

Ambulance registry

This study is based on material collected by the Swedish ambulance cardiac arrest registry. The registry, which is voluntary, started in 1990 with a few ambulance services. It has successively been joined by more, and by now the registry is based on reports from 57 ambulance services. These services cover 5 million out of a total of 8.7 million inhabitants in Sweden.

Most of the ambulance organisations which were included serve smaller communities with less than 100 000 inhabitants, and only

Demographics

The distance for the ambulances to travel from ambulance station to the collapsed patient is shown in Fig. 1. The median driving distance was 4.9 km and 28% of the ambulances had more than 10 km to the place of arrest. The distance from the patient to the nearest hospital was often longer as there are more ambulance stations than there are hospitals. This is also illustrated in Fig. 1.

Patients

From January 1990 to May 1995, 14 065 forms were received. As the number of ambulance systems included in the

Representation and validity

This study is based on a voluntary registry from 57 out of approximately 100 ambulance organisations in Sweden. It can only be speculated as to whether the data from these organisations are representative for all of Sweden. One might expect that the organisations which choose to participate were especially active and interested. Furthermore, the areas of Sweden which were not included, have to a large extent a sparse population and long driving distances for ambulances and hence lower survival

Conclusion

The data presented are retrieved from an ongoing national registry for out-of-hospital cardiac arrest, where the basic concept is that data should be reported back to the individual ambulance districts, both national data and data specific for that ambulance district. This feed-back process is considered to be a very powerful mechanism for quality assurance and quality improvement. Through the feed-back of information, each ambulance district can discover their own weak points and try to

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Cited by (170)

European Resuscitation Council Guidelines 2021: Systems saving lives
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The European Resuscitation Council (ERC) has produced these Systems Saving Lives guidelines, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include chain of survival, measuring performance of resuscitation, social media and smartphones apps for engaging community, European Restart a Heart Day, World Restart a Heart, KIDS SAVE LIVES campaign, lower-resource setting, European Resuscitation Academy and Global Resuscitation Alliance, early warning scores, rapid response systems, and medical emergency team, cardiac arrest centres and role of dispatcher.
Effect of awareness time interval for out-of-hospital cardiac arrest on outcomes: A nationwide observational study
2020, Resuscitation
Awareness of out-of-hospital cardiac arrest (OHCA) is critically important for bystanders to receive early instruction of dispatch-assisted cardiopulmonary resuscitation (DA-CPR) as well as to call for ambulance services. This study aimed to determine the association between awareness time interval and outcomes.
EMS-treated, witnessed, adult (≥18 years old) OCHAs with presumed cardiac etiology between 2012 and 2017 were analyzed, excluding patients with unknown awareness time factors and outcomes. The main exposure was awareness time interval (ATI), defined as the time from the witnessed event to calling for ambulance. Patients were categorized into five groups according to ATI: Group 1 (0–1 min), Group 2 (2−3 min), Group 3 (4−5 min), Group 4 (6−30 min) and Group 5 (31−60 min). The primary outcome was good neurological recovery defined as cerebral performance category 1 or 2 (good CPC). Multivariable logistic regression analysis was performed to calculate adjusted odds ratios (AORs) and 95% confidence intervals (CIs) for outcomes by ATI group (reference = Group 1) and by one-minute delay. We compared the effect size of ATI on outcomes across three witness groups (Layperson, Family, and Unknown).
A total of 36,809 OHCAs were analyzed. The AOR (95% CI) by one-minute ATI delay was 0.91 (0.90–0.92) for good CPC. The AORs (95% CIs) for outcomes compared with Group 1 were 0.98 (0.88–1.09) for Group 2, 0.64 (0.56–0.74) for Group 3, 0.30 (0.26–0.35) for Group 4, and 0.10 (0.05–0.20) for Group 5. In the Family bystander group, AORs (95% CIs) compared with Group 1 were significantly decreased by delay of ATI; 1.04 (0.88–1.11) for Group 2, 0.63 (0.81–0.83) for Group 3, and 0.31 (0.31–0.40) for Group 4 and 5. In Layperson-witnessed OHCAs, however, the AORs were significantly higher in the delayed awareness groups (Group 2 and Group 3).
A longer ATI in witnessed adult OHCAs was associated with poor neurological recovery. A one-minute delay in ATI was associated with a 9% decrease of good neurological recovery, and the effect was significantly increased in Family-witnessed OHCAs.
Does lying in the recovery position increase the likelihood of not delivering cardiopulmonary resuscitation?
2017, Resuscitation
Resuscitation guidelines endorse unconscious and normally breathing out-of-hospital victims to be placed in the recovery position to secure airway patency, but recently a debate has been opened as to whether the recovery position threatens the cardiac arrest victim's safety assessment and delays the start of cardiopulmonary resuscitation.
To compare the assessment of the victim's breathing arrest while placed in the recovery position versus maintaining an open airway with the continuous head tilt and chin lift technique to know whether the recovery position delays the cardiac arrest victim's assessment and the start of cardiopulmonary resuscitation.
Basic life support-trained university students were randomly divided into two groups: one received a standardized cardiopulmonary resuscitation refresher course including the recovery position and the other received a modified cardiopulmonary resuscitation course using continuous head tilt and chin lift for unconscious and spontaneously breathing patients. A human simulation test to evaluate the victim's breathing assessment was performed a week later.
In total, 59 participants with an average age of 21.9 years were included. Only 14 of 27 (51.85%) students in the recovery position group versus 23 of 28 (82.14%) in the head tilt and chin lift group p = 0.006 (OR 6.571) detected breathing arrest within 2 min.
The recovery position hindered breathing assessment, delayed breathing arrest identification and the initiation of cardiac compressions, and significantly increased the likelihood of not starting cardiopulmonary resuscitation when compared to the results shown when the continuous head tilt and chin lift technique was used.
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The aim of this study was to compare on manikin chest compressions only CPR performance carried out by untrained volunteers following Dispatcher assisted Cardiopulmonary Resuscitation (DACPR), and then by the same trained volunteers immediately after chest compressions only CPR course and 4 months after the CPR course.
38 university student volunteers with no previous experience in CPR took part in three on manikin chest compressions only CPR skill evaluations: first in a DACPR, then after chest compressions only CPR course (ACPRC) and lastly, four months after a CPR course (4MACPRC). Only 22 completed the whole process.
In DACPR 7.89% of participants carried out cardiac compressions outside the thorax. The mean average time from collapse to first compression was reduced in 4MACPRC (40.77 s), as compared to DACPR (144.54 s); p < 0.001).
The following parameters were significantly better in 4MACPRC than in DACPR: Average compression depth (44.72 vs 25.22; p < 0.001), average compression rate (106.1 vs 87.90; p < 0.001), total number of compressions in 3 min (317 vs 245; p < 0.001), percentage of correct compressions (53.00% vs 4.72 %; p < 0.001) and percentage of correct hand positioning (95.40 vs 91.09; p < 0.001).
Even though chest compressions only DACPR allows lay bystanders to be able to carry out cardiac compressions in 92.1% of cases, these were delivered later and were less efficient than chest compressions only CPR given by trained bystanders after a CPR course and four months after the course.
European Resuscitation Council Guidelines for Resuscitation 2015. Section 2. Adult basic life support and automated external defibrillation.
2015, Resuscitation
Do early emergency calls before patient collapse improve survival after out-of-hospital cardiac arrests?
2015, Resuscitation
Some out-of-hospital cardiac arrests (OHCAs) are witnessed after emergency calls. This study aimed to confirm the benefit of early emergency calls before patient collapse on survival after OHCAs witnessed by bystanders and/or emergency medical technicians (EMTs).
We analysed 278,310 witnessed OHCAs [EMT-witnessed cases (n = 54,172), bystander-witnessed cases (n = 224,138)] without pre-hospital physician involvement from all Japanese OHCA data prospectively collected between 2006 and 2012. The data were analysed for the correlation between neurologically favourable 1-month survival and the time interval between the emergency call and patient collapse.
When emergency calls were placed earlier before patient collapse, the proportion of EMT-witnessed cases and survival rate after OHCAs witnessed by bystanders and EMTs were higher. When analysed only for bystander-witnessed cases, for earlier emergency calls placed before patient collapse, survival rate and incidences of bystander cardiopulmonary resuscitation (CPR) and dispatcher-assisted CPR decreased: 2.9%, 33.6% and 24.4%, respectively, for emergency calls placed >6 min before collapse and 5.5%, 48.8% and 48.5%, respectively, for those placed 1–2 min after collapse. Multivariable logistic regression showed that call-to-collapse interval (adjusted odds ratio; 95% confidence interval) (0.92; 0.90–0.94) and EMT response time after collapse (0.84; 0.82–0.86) were associated with survival after bystander-witnessed OHCAs with emergency calls before collapse.
Early emergency calls before patient collapse efficiently increases the proportion of EMT-witnessed cases and promotes survival after witnessed OHCAs. However, early emergency call before collapse may worsen the outcome when the patient's condition deteriorates to cardiac arrest before EMT arrival.

View all citing articles on Scopus

¹: See Appendix A

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Survival after cardiac arrest outside hospital in Sweden

Abstract

Introduction

Section snippets

Ambulance registry

Demographics

Patients

Representation and validity

Conclusion

Ann Emerg Med

Resuscitation

Resuscitation

Ann Emerg Med

Ann Emerg Med

Death outside hospital with special reference to heart disease

Eur Heart J

Improving survival from sudden cardiac arrest. The Chain of survival concept

Circulation

Outcome of out-of-hospital cardiac arrest in New York City. The pre-hospital arrest survival evaluation (PHASE) study

J Am Med Assoc

Defining the benefits of rural emergency medical technician defibrillation

Ann Emerg Med

Out-of-hospital cardiac arrest due to coronary heart disease: a comparison of survival before and after the introduction of defibrillators in ambulances

Br Heart J

Use of the automatic external defibrillator in the management of out-of-hospital cardiac arrest

N Engl J Med