Collaborative effects of bystander-initiated cardiopulmonary resuscitation and prehospital advanced cardiac life support by physicians on survival of out-of-hospital cardiac arrest: a nationwide population-based observational study

Successful rescue of patients with cardiac arrest outside the hospital setting is a long-term public health issue in most jurisdictions in the majority of countries [1, 2]. Reported out-of-hospital cardiac arrest (OHCA) survival rates vary widely [2‐8], and this variation can be attributed, in part, to differences among countries in the chain of survival, as described by the American Heart Association [9]. Ideally, communities and emergency medical service (EMS) providers should optimize the following four links: rapid access through an emergency telephone system; early bystander-initiated cardiopulmonary resuscitation (BCPR) [10]; early defibrillation with an automated external defibrillator [11]; and advanced cardiac life support (ACLS) [12, 13].

Numerous studies have elucidated the independent effects of BCPR coupled with use of an automated external defibrillator [11]. On the other hand, the extent to which prehospital ACLS can improve patient survival remains somewhat controversial [7, 10, 12, 13], even more than 40 years after Pantridge and Geddes introduced the concept of providing ACLS to OHCA patients through mobile intensive care vehicles [1]. The issue of who provides the prehospital ACLS is considered one of the factors affecting outcomes after OHCA. Several studies have assessed the effects of physician-manned ACLS [12, 13], but the studies were conducted in limited geographic areas. Furthermore, the relative importance of BCPR and ACLS and the effectiveness of their combination on the survival rate of patients and their subsequent well-being have not been clearly demonstrated.

The aims of the present study were to analyze the collaborative effects of BCPR and prehospital ACLS with or without physicians on the health outcomes of OHCA patients, in terms of their overall survival and cerebral performance at 1 month.

During the study period, we identified 95,072 bystander-witnessed OHCA patients (29,215 in 2005, 31,849 in 2006 and 34,008 in 2007) and 23,127 EMS provider-witnessed OHCA patients (7,554 in 2005, 7,717 in 2006 and 7,856 in 2007).

Table 1 presents demographic data of the bystander-witnessed OHCA patients. Overall, 39,993 patients (42.1%) received BCPR and 3,513 patients (3.7%) received ACLS by physicians. The median times from collapse to CPR were 2 minutes in Group B and Group D with BCPR, and 10 minutes in Group A and Group C without BCPR.

Table 2 presents the 1-month survival rates and CPC rates of all the bystander-witnessed OHCA patients and those with initial VF of cardiac origin. Among the 95,072 bystander-witnessed OHCA patients, the 1-month survival was 8.1%, including 2.9% with good performance and 3.3% with vegetative status or worse. The rate of patients with vegetative status or worse among all survivors was 41.4% (3,171 out of 7,722). Significant differences were found in the 1-month survival and good cerebral performance between Group A and Group B (P < 0.01), between Group C and Group D (P < 0.01) and between Group B and Group D (P < 0.01). In comparisons of Group A and Group C, significant increases were found in the 1-month survival (6.7% vs. 11.6%, P < 0.01) and vegetative status or worse (3.1% vs. 6.1%, P < 0.01), while the difference in good performance was not significant (1.9% vs. 2.7%, P = 0.41). Among the 11,970 bystander-witnessed OHCA patients with initial VF of cardiac origin, the 1-month survival was 24.3%, including 12.0% with good performance and 6.4% with vegetative status or worse. Differences among the groups were similar to all the bystander-witnessed OHCA patients, and the rate of vegetative status or worse was highest in Group C (11.8%).

Table 3 presents the results of logistic regression analyses for the 1-month outcomes of all the bystander-witnessed OHCA patients and those with initial VF of cardiac origin. Among all of the bystander-witnessed OHCA patients, lower rates of overall survival and neurologically good-performance survival were significantly associated with older age and longer call-response interval. The rate of good-performance survival was significantly higher in Group B than in Group A (odds ratio (OR), 2.23; P < 0.001), but did not differ significantly between Group A and Group C (OR, 1.18; P = 0.317). Group D showed the highest good-performance survival (OR, 2.80; P < 0.001). The occurrence of vegetative status or worse was highest in Group C (OR, 1.87; P < 0.001). Similar trends were seen in patients with initial VF of cardiac origin, among whom Group D showed significantly improved good-performance survival (OR, 2.06; P < 0.001) while Group C showed a significantly higher occurrence of vegetative status or worse (OR, 1.56; P = 0.016).

Table 4 presents the demographics and outcomes of patients whose arrests were witnessed by EMS providers, and Table 5 presents logistic regression analyses for these patients. The group treated with ACLS by physicians showed higher overall survival (OR, 1.27; P = 0.013) and good-performance survival (OR, 1.47; P < 0.001), while the occurrence of vegetative status or worse did not differ between the two groups (OR, 0.92; P = 0.646).

Survival from OHCA remains poor in most countries [2‐8]. Numerous studies have suggested that BCPR is the most fundamental factor for improving the survival of OHCA patients [3-6,9]. In the present study, BCPR significantly improved survival with good cerebral performance, and an independent effect of BCPR for OHCA patients was demonstrated.

One of the significant findings of the present study was the improvement of both the overall 1-month survival and good neurological performance at 1 month in patients with ACLS by physicians. A previous report showed that a physician on board an ACLS unit was not an independent factor for improved survival, but the study only included 539 OHCA patients in a limited area [13]. To the best of our knowledge, the present study is the first to demonstrate the survival-improving effects of physician-manned ACLS in a nationwide setting.

Physician-staffed ambulances are in use in many European nations [9, 13, 21, 22], while paramedics in the United States are permitted to provide highly advanced support partially because physician-manned ambulances are considered an inefficient use of physician resources [9]. In Japan, extending the physician-staffed ambulance system may be practically difficult because of the shortage of emergency physicians [17].

Another important finding of the present study was the confirmation of high survival with poor neurological outcomes of bystander-witnessed OHCA patients treated with ACLS by physicians without BCPR. ACLS by physicians can reinforce the effects of preceding BCPR. In other words, the combination of BCPR and ACLS by physicians is considered the best way to achieve a patient's comeback from collapse and subsequent well-being. In the cases without BCPR, however, the crucial delay in receiving first aid presumably caused many survivors to suffer irreparable brain damage. Life support by physicians without preceding BCPR may cause an increase in unfavorable, and sometimes desperate, consequences. Our eyes must be opened to the fact that more than 40% of 1-month survivors among the bystander-witnessed OHCA patients were classified as vegetative status or de facto brain death. Great care should be taken of the fact that more than 50% of 1-month survivors among the bystander-witnessed OHCA patients who underwent ACLS by physicians without BCPR were of vegetative status or de facto brain death. These are the realities of EMS procedures for OHCA patients.

Of course, it is not the physician intervention that is detrimental, but the duration of no blood flow. Our study clearly shows that priority should be given to the enhancement of BCPR to improve the neurologically favorable outcomes of OHCA patients. Teaching on how to behave in emergency situations is a common public health problem worldwide. Training programs in the school curriculum could be the best way to train the whole population [23, 24]. In Japan, CPR training is performed for millions of citizens each year, and new driver license applicants have recently been obliged to undergo CPR training programs at driving schools [14]. Nevertheless, our study revealed that BCPR only occurred in 42% of bystander-witnessed OHCA cases in Japan. While this figure is relatively high compared with many countries [2, 25], there is much room for improvement. Efforts should be made to improve the quantity and quality of BCPR. Ideally, ACLS by physicians should be linked with preceding BCPR.

Several limitations of the present study should be acknowledged. A randomized trial is not feasible for this type of study owing to ethical and informed consent issues. Furthermore, a large-scale randomized trial looking at physician EMS versus nonphysician EMS is very challenging to perform. Although the groups were large, the present study was based on a nonrandomized observational study and thus jeopardized by several potential biases. First, and most importantly, prehospital physician EMS was only available in limited geographical areas around specific emergency medical centers. Although our data lacked information on the hospitals receiving the patients, it appears likely that most patients in the physician EMS groups (Group C and Group D) were brought to the specific hospitals to which the physicians on board were affiliated. It also seems likely that a relationship between physician EMS and outcomes could partly reflect differences in post-return of spontaneous circulation treatments available at receiving hospitals; including therapeutic hypothermia [26‐28], percutaneous coronary intervention, and a focus on goal-directed treatment for the reperfusion period [28]. These treatments are only available at some centers, potentially influencing outcomes. We were unable to adjust for this factor because we had no information on what treatments were performed at the receiving hospitals. Second, similar to all registry-based surveys, the validity and integrity of the data were potential limitations, although they were minimized by the large sample size collected with the population-based design. Finally, long-term outcomes such as the rate of discharge from hospital or 1-year survival could not be assessed.

BCPR significantly improved the survival of OHCA patients with good cerebral performance. The combination of BCPR and ACLS by physicians was the best way to improve the outcomes. ACLS by physicians without preceding BCPR, however, increased the incidence of neurologically unfavorable outcomes. Priority should be given to the enhancement of BCPR, and ACLS by physicians should ideally be linked with preceding BCPR.