Commentary and conceptsThe formula for survival in resuscitation☆
Introduction
Many factors determine outcome after cardiac arrest and there is a large variation in reported survival rates.1 Following a consensus meeting at Utstein Abbey, Norway in 1990, the first of a series of Utstein guidelines was published in 1991.2 This established a set of common definitions for reporting out-of-hospital cardiac arrest (OHCA), enabling comparisons across communities and nations. A revised Utstein reporting format, published in 2004, attempted to clarify and simplify the required data elements for both OHCA and in-hospital cardiac arrest (IHCA).3 By defining and using an ‘Utstein comparator’ (witnessed cardiac arrest of presumed cardiac cause with first monitored rhythm of ventricular fibrillation (VF)), large differences between communities in the reported survival after OHCA became apparent.1, 4 Although many key factors associated with survival have been identified,5 a full explanation for the variability in survival rates has not been found. Differences in the quality of the local ‘chain of survival’6 may be the major factor contributing to the large worldwide survival differences.
In 2003 the International Liaison Committee on Resuscitation (ILCOR) published an Advisory Statement on Education and Resuscitation.7 This paper described the discussions that took place during a resuscitation education symposium held at the Utstein Abbey in 2001. It included the statement that “survival rates for unexpected cardiac arrest depend not only on the quality of the education given to potential caregivers but also on the validity of treatment guidelines and a well-functioning chain of survival”. The authors described a hypothetical formula – ‘the formula for survival’ – where three interactive factors, guideline quality (science), efficient education of patient caregivers (education) and a well-functioning chain of survival at a local level (local implementation), form multiplicands in determining survival from resuscitation (Table 1).
Section snippets
Utstein 2006 formula for survival meeting
In May 2006, a further symposium was held to discuss the validity of the formula for survival hypothesis and to investigate the influence of each of the multiplicands on survival. The symposium was again held at the Utstein Abbey. Thirty-five invited international experts participated in the symposium and a well-described Utstein rotating group format was used.7 This enabled small group discussion to develop key pathways that were then refined by moving the groups through a series of panel
Survival
Survival after cardiac arrest can be defined in several ways. The demonstration that an intervention improves disease-specific short-term outcomes such as return of spontaneous circulation (ROSC) provides insight into the physiology of cardiac arrest and successful resuscitation and may have implications for the further evaluation of the interventions. However, most resuscitation experts place higher value on evidence of sustained improvements, and neurological outcome at 90 days has most
Medical science
Although science is one of the three multiplicands in the FfS, it is recognised as an integral part of the other two factors: education and implementation. For many years, ILCOR has coordinated the review of science and the development of evidence-based resuscitation practice.13 Given the nature of resuscitation, high-quality scientific evidence from randomised controlled trials (RCTs) is often difficult to obtain and in many cases generation of clinical guidelines requires extrapolation from
Educational science and efficiency
Chamberlain and Hazinski identified several critical areas for improvement in resuscitation education.7 Just as there is a hierarchy of outcomes in resuscitation research and practice, there is a similar set of outcomes in resuscitation education (Table 2).
The expert panel recognised the difficulty in applying the same standards of evidence to educational recommendations as to treatment recommendations. However, resuscitation education designers can draw appropriate extrapolations from the vast
Local implementation
Implementation is the third multiplicand in the FfS. It was clear from the outset of the discussions that implementation based on scientific evidence was the strategy for success. The panel based the discussion on the innovation principles by Rogers.14 In 2003, Don M. Berwick published an excellent review of Rogers classical work and described how it may help to disseminate innovations in health care.15 The panel set out to define components that would optimise local implementation.
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Local
Further development of the Utstein formula for survival 2006-2012
The 2006 Utstein FfS consensus meeting did not generate a publication immediately, but it started a process that influenced other publications that have aimed to improve resuscitation outcomes,19 as well as the 2010 and 2015 ILCOR resuscitation consensus on science with treatment recommendation process.20
For the three chosen examples, RRS, TH and bystander CPR, the discussion around the impact of the three multiplicands on survival (Table 1 and Fig. 1) was complicated by several conflicting
Medical science
The RRS concept has now been introduced in the majority of Australasian and North American hospitals as well as in many European hospitals. While most before-after studies have found a significant effect of implementing RRS,21 the inconclusive results of a large cluster-randomised controlled trial9 triggered debate about the scientific merit of widespread implementation of such RRS.
The RRS concept involves the identification of a seriously ill or deteriorating patient followed by a rapid
Educational efficiency
In 2006, the discussion around bystander CPR and educational efficiency was focused on how to achieve better CPR quality and how to secure higher bystander CPR rates. Recently, teaching chest compression-only CPR (without rescue breaths) has been proposed as the way of improving educational efficiency. It is easier to learn and does not involve mouth-to-mouth contact with the victim, which increases the likelihood that a bystander will attempt CPR and reduces the risk of regurgitation.35 A
Implementation
Implementation is the crucial part of changing attitudes and behaviour to ensure local processes of care changes that are maintained with high quality. Publishing clinical practice guidelines is insufficient. Changing clinical practice and maintaining high quality resuscitation practice is often as demanding as the work required to generate the medical science behind the suggested change.47 Therefore, ensuring that the guidelines are translated into high quality clinical practice is essential
Survival
Most resuscitation research scientists consider that long-term neurological outcome is the best way to describe outcome after resuscitation.12 In many cardiac arrest survivors neurological status improves in the period between one and six months after the event.55 Unfortunately, collecting long-term data, such as neurological outcome at 90 days, is expensive and subject to selection bias, thus a balance must be struck between that deemed ideal and that considered feasible. A recent study has
Conclusion
The FfS concept is an attempt to account for variability in cardiac arrest survival worldwide and provides a conceptual framework for improvement. According to this concept, improvements in one or all three multiplicands, (1) medical science (guidelines), (2) educational efficiency, and (3) local implementation (Fig. 1 and Table 3), will improve cardiac arrest survival. The FfS has been discussed as a template to improve outcomes since 2003, and we have demonstrated its strengths and weaknesses
Conflicts of interest statement
ES has received unrestricted research grant funding from the Laerdal Foundation for Acute Medicine. LJM receives salary support from the National Institute of Health to conduct clinical trials in out-of-hospital cardiac arrest. Dr Morrison has operating grants from the Canadian government (Canadian Institute of Health Research) and charitable foundations (American Heart Association, Heart and Stroke Foundation of Canada and the Laerdal Foundation) to conduct implementation research in both
Acknowledgments
The 2006 Utstein meeting on FfS was generously supported by an unrestricted grant from the Laerdal Foundation for Acute Medicine, Stavanger, Norway
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A Spanish translated version of the summary of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2013.07.020.
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On behalf of the Utstein Formula for Survival Collaborators. The members of Utstein Formula for Survival Collaborators are listed in Appendix A.