Arthur L. Kellermann

Predictors of Survival From Out-of-Hospital Cardiac Arrest A Systematic Review and Meta-Analysis

Background—Prior studies have identified key predictors of out-of-hospital cardiac arrest (OHCA), but differences exist in the magnitude of these findings. In this meta-analysis, we evaluated the strength of associations between OHCA and key factors (event witnessed by a bystander or emergency medical services [EMS], provision of bystander cardiopulmonary resuscitation [CPR], initial cardiac rhythm, or the return of spontaneous circulation). We also examined trends in OHCA survival over time. Methods and Results—An electronic search of PubMed, EMBASE, Web of Science, CINAHL, Cochrane DSR, DARE, ACP Journal Club, and CCTR was conducted (January 1, 1950 to August 21, 2008) for studies reporting OHCA of presumed cardiac etiology in adults. Data were extracted from 79 studies involving 142 740 patients. The pooled survival rate to hospital admission was 23.8% (95% CI, 21.1 to 26.6) and to hospital discharge was 7.6% (95% CI, 6.7 to 8.4). Stratified by baseline rates, survival to hospital discharge was more likely among those: witnessed by a bystander (6.4% to 13.5%), witnessed by EMS (4.9% to 18.2%), who received bystander CPR (3.9% to 16.1%), were found in ventricular fibrillation/ventricular tachycardia (14.8% to 23.0%), or achieved return of spontaneous circulation (15.5% to 33.6%). Although 53% (95% CI, 45.0% to 59.9%) of events were witnessed by a bystander, only 32% (95% CI, 26.7% to 37.8%) received bystander CPR. The number needed to treat to save 1 life ranged from 16 to 23 for EMS-witnessed arrests, 17 to 71 for bystander-witnessed, and 24 to 36 for those receiving bystander CPR, depending on baseline survival rates. The aggregate survival rate of OHCA (7.6%) has not significantly changed in almost 3 decades. Conclusions—Overall survival from OHCA has been stable for almost 30 years, as have the strong associations between key predictors and survival. Because most OHCA events are witnessed, efforts to improve survival should focus on prompt delivery of interventions of known effectiveness by those who witness the event.

Gun ownership as a risk factor for homicide in the home

Background It is unknown whether keeping a firearm in the home confers protection against crime or, instead, increases the risk of violent crime in the home. To study risk factors for homicide in the home, we identified homicides occurring in the homes of victims in three metropolitan counties. Methods After each homicide, we obtained data from the police or medical examiner and interviewed a proxy for the victim. The proxies answers were compared with those of control subjects who were matched to the victims according to neighborhood, sex, race, and age range. Crude and adjusted odds ratios were calculated with matched-pairs methods. Results During the study period, 1860 homicides occurred in the three counties, 444 of them (23.9 percent) in the home of the victim. After excluding 24 cases for various reasons, we interviewed proxy respondents for 93 percent of the victims. Controls were identified for 99 percent of these, yielding 388 matched pairs. As compared with the controls, the victims more often ...

Emergency medical care in developing countries: is it worthwhile?

Prevention is a core value of any health system. Nonetheless, many health problems will continue to occur despite preventive services. A significant burden of diseases in developing countries is caused by time-sensitive illnesses and injuries, such as severe infections, hypoxia caused by respiratory infections, dehydration caused by diarrhoea, intentional and unintentional injuries, postpartum bleeding, and acute myocardial infarction. The provision of timely treatment during life-threatening emergencies is not a priority for many health systems in developing countries. This paper reviews evidence indicating the need to develop and/or strengthen emergency medical care systems in these countries. An argument is made for the role of emergency medical care in improving the health of populations and meeting expectations for access to emergency care. We consider emergency medical care in the community, during transportation, and at first-contact and regional referral facilities. Obstacles to developing effective emergency medical care include a lack of structural models, inappropriate training foci, concerns about cost, and sustainability in the face of a high demand for services. A basic but effective level of emergency medical care responds to perceived and actual community needs and improves the health of populations.

Access of Medicaid recipients to outpatient care

BACKGROUNDnVisits to the emergency department by Medicaid recipients for nonemergency problems are common and contribute to rising health care costs. However, such patients may have few alternatives. We conducted a telephone survey of 953 ambulatory care sites in 10 cities to determine the availability of appointments for Medicaid recipients with common problems.nnnMETHODSnResearch assistants telephoned all ambulatory care clinics and a stratified sample of private primary care practices in the catchment area served by the hospital emergency department in each city. The assistants identified themselves as Medicaid recipients seeking care for one of three problems (low back pain, dysuria, or sore throat) and asked a standardized series of questions. Data were collected on appointments or walk-in visits authorized at any time, within two days after the call, or after 5 p.m.; copayment requirements; and reasons appointments could not be made. If an appointment was made, it was canceled at the end of each call or shortly thereafter. Several weeks later, private-practice sites in six of the cities were recontacted; the research assistants identified themselves as patients with private insurance and the same problem.nnnRESULTSnAn appointment or an authorization for a walk-in visit was obtained from 418 of the 953 practice sites (44 percent); 47 of the sites (5 percent) could not be contacted. Appointment rates for the different types of sites ranged from 72 percent for free-standing urgent care centers to 34 percent for private practices. Not accepting Medicaid was the most common reason given for not granting an appointment or walk-in visit. Only 72 of the sites (8 percent) offered after-hours care within two working days after the call without a cash copayment. Sixty percent of the 330 private practices that were recontacted agreed to see a patient with private insurance within two working days, but only 26 percent agreed to see a patient with Medicaid within two days (P < 0.001).nnnCONCLUSIONSnMedicaid recipients in urban areas have limited access to outpatient care apart from that offered by hospital emergency departments.

Prehospital Termination of Resuscitation in Cases of Refractory Out-of-Hospital Cardiac Arrest

CONTEXTnIdentifying patients in the out-of-hospital setting who have no realistic hope of surviving an out-of-hospital cardiac arrest could enhance utilization of scarce health care resources.nnnOBJECTIVEnTo validate 2 out-of-hospital termination-of-resuscitation rules developed by the Ontario Prehospital Life Support (OPALS) study group, one for use by responders providing basic life support (BLS) and the other for those providing advanced life support (ALS).nnnDESIGN, SETTING, AND PATIENTSnRetrospective cohort study using surveillance data prospectively submitted by emergency medical systems and hospitals in 8 US cities to the Cardiac Arrest Registry to Enhance Survival (CARES) between October 1, 2005, and April 30, 2008. Case patients were 7235 adults with out-of-hospital cardiac arrest; of these, 5505 met inclusion criteria.nnnMAIN OUTCOME MEASURESnSpecificity and positive predictive value of each termination-of-resuscitation rule for identifying patients who likely will not survive to hospital discharge.nnnRESULTSnThe overall rate of survival to hospital discharge was 7.1% (n = 392). Of 2592 patients (47.1%) who met BLS criteria for termination of resuscitation efforts, only 5 (0.2%) patients survived to hospital discharge. Of 1192 patients (21.7%) who met ALS criteria, none survived to hospital discharge. The BLS rule had a specificity of 0.987 (95% confidence interval [CI], 0.970-0.996) and a positive predictive value of 0.998 (95% CI, 0.996-0.999) for predicting lack of survival. The ALS rule had a specificity of 1.000 (95% CI, 0.991-1.000) and positive predictive value of 1.000 (95% CI, 0.997-1.000) for predicting lack of survival.nnnCONCLUSIONnIn this validation study, the BLS and ALS termination-of-resuscitation rules performed well in identifying patients with out-of-hospital cardiac arrest who have little or no chance of survival.

In-hospital resuscitation following unsuccessful prehospital advanced cardiac life support: ‘Heroic Efforts’ or an exercise in futility?

From our emergency department logbook we identified 281 consecutive patients transported to the Regional Medical Center at Memphis following failed prehospital advanced cardiac life support (ACLS). Medical records were obtained for 240 cases (85.4%). Initial cardiac rhythms in the ED included ventricular fibrillation or pulseless ventricular tachycardia (29%), electromechanical dissociation (18%), and asystole (51%). Thirty-two patients (13.3%) were successfully resuscitated in the ED, but only four (1.7%) survived to hospital discharge. Two patients had good neurologic outcomes; both degenerated to cardiac arrest shortly prior to arrival in the ED. The remaining two survivors were discharged to nursing homes with severe neurologic deficits. Of the 41 cases for whom no medical records could be found, 39 were noted in our logbook to have died in the ED. No record of subsequent hospital admission could be found for the other two. Both are presumed to have died. Failure to respond to prehospital ACLS predicts nonsurvival and may warrant cessation of efforts in the field. Future programs and research efforts in the management of out-of-hospital cardiac arrest should be focused on optimal provision of prehospital care prior to the onset of irreversible deterioration.

CRITICAL DECISION MAKING : MANAGING THE EMERGENCY DEPARTMENT IN AN OVERCROWDED HOSPITAL

Hospital and emergency department overcrowding is a serious and growing problem nationwide. Although EDs are organized around the goals of rapid patient assessment, stabilization, and prompt admission to the hospital, an increasing number are being required to hold admitted floor and critical care patients for extended periods due to lack of vacant inpatient beds. Provision of acceptable patient care under such circumstances requires a fundamental reordering of ED priorities and procedures. Overcrowding is the result of inadequate funding for emergency health care services during a period of increasing demand. The initial focus of management strategies to resolve this problem is the inpatient area and includes evaluation of length of stay, intent to discharge policies, flexible bed designations, restriction of in-house transfers, and the use of over-census beds. If in-hospital management strategies fail, modifications in ED management may include staffing contingency plans, definition of physician responsibility, inpatient charts, revised pharmacy formulary, new floor plans, and modified accounting systems. Successful resolution of hospital and ED overcrowding may be the greatest challenge facing emergency medicine today.

Simple CPR: A Randomized, Controlled Trial of Video Self-Instructional Cardiopulmonary Resuscitation Training in an African American Church Congregation

STUDY OBJECTIVEnDespite the proven efficacy of cardiopulmonary resuscitation (CPR), only a small fraction of the population knows how to perform it. As a result, rates of bystander CPR and rates of survival from cardiac arrest are low. Bystander CPR is particularly uncommon in the African American community. Successful development of a simplified approach to CPR training could boost rates of bystander CPR and save lives. We conducted the following randomized, controlled study to determine whether video self-instruction (VSI) in CPR results in comparable or better performance than traditional CPR training.nnnMETHODSnThis randomized, controlled trial was conducted among congregational volunteers in an African American church in Atlanta, GA. Subjects were randomly assigned to receive either 34 minutes of VSI or the 4-hour American Heart Association Heartsaver CPR course. Two months after training, blinded observers used explicit criteria to assess CPR performance in a simulated cardiac arrest setting. A recording manikin was used to measure ventilation and chest compression characteristics. Participants also completed a written test of CPR-related knowledge and attitudes.nnnRESULTSnVSI trainees displayed a comparable level of performance to that achieved by traditional trainees. Observers scored 40% of VSI trainees competent or better in performing CPR, compared with only 16% of traditional trainees (absolute difference 24%, 95% confidence interval 8% to 40%). Data from the recording manikin confirmed these observations. VSI trainees and traditional trainees achieved comparable scores on tests of CPR-related knowledge and attitudes.nnnCONCLUSIONnThirty-four minutes of VSI can produce CPR of comparable quality to that achieved by traditional training methods. VSI provides a simple, quick, consistent, and inexpensive alternative to traditional CPR instruction, and may be used to extend CPR training to historically underserved populations.

CARES: Cardiac Arrest Registry to Enhance Survival

Despite 3 decades of scientific progress, rates of survival from out-of-hospital cardiac arrest remain low. The Cardiac Arrest Registry to Enhance Survival (CARES) was created to provide communities with a means to identify cases of out-of-hospital cardiac arrest, measure how well emergency medical services (EMS) perform key elements of emergency cardiac care, and determine outcomes through hospital discharge. CARES collects data from 3 sources-911 dispatch, EMS, and receiving hospitals-and links them to form a single record. Once data entry is completed, individual identifiers are stripped from the record. The anonymity of CARES records allows participating agencies and institutions to compile cases without informed consent. CARES generates standard reports that can be used to characterize the local epidemiology of cardiac arrest and help managers determine how well EMS is delivering out-of-hospital cardiac arrest care. After pilot implementation in Atlanta, GA, and subsequent expansion to 7 surrounding counties, CARES was implemented in 22 US cities with a combined population of 14 million people. Additional cities are interested in joining the registry. CARES currently contains more than 13,000 cases and is growing rapidly.

RISK FACTORS FOR SUICIDE ATTEMPTS AMONG AFRICAN AMERICAN WOMEN

The aim of this study was to examine psychological and interpersonal risk factors for suicidal behavior in low income, African American women; 285 African American women who reported being in a relationship with a partner in the past year were studied, 148 presented to the hospital following a suicide attempt, and 137 presented for general medical care. Cases were compared to controls with respect to psychological symptoms, alcohol and drug abuse, family violence (intimate partner abuse, childhood trauma), relationship discord, and social support. Psychological risk factors for suicide attempts at the univariate level included psychological distress [Crude Odds Ratio (COR) = 6.5], post traumatic stress disorder (PTSD) symptoms (COR = 3.8), hopelessness (COR = 7.7), and drug abuse (COR = 4.2). Interpersonal risk factors at the univariate level included relationship discord (COR = 4.0), physical partner abuse (COR = 2.5), nonphysical partner abuse (COR = 2.8), childhood maltreatment (COR = 3.2), and low levels of social support (COR = 2.6). A multivariate logistic regression model identified four variables that were strongly and independently associated with an increased risk for suicide attempts: psychological distress, hopelessness, drug abuse, and relationship discord. The model predicted suicide attempt status correctly 77% of the time. The results reveal that African American women who report high levels of psychological distress, hopelessness, drug use, and relationship discord should be assessed carefully for suicidal ideation and referred for appropriate mental health care. Depression and Anxiety 12:13–20, 2000.