Ottawa: From Sprained Ankles to Cardiac Arrest — A Great Place to Keep Living
July 1, 1999 3 minutes read
Ottawa: From Sprained Ankles to Cardiac Arrest— A Great Place to Keep Living
ABSTRACT & COMMENTARY
Source: Stiell IG, et al. Improved out-of-hospital cardiac arrest survival through the inexpensive optimization of an existing defibrillation program: OPALS study phase II. JAMA 1999;281:1175-1181.
It seems obvious to say that emergency medical systems make a difference to communities, but proving how and why has always been difficult. In this article, Stiell and colleagues try to determine if shortening the time to defibrillation can improve survival from pre-hospital cardiac arrest. Their study took place in and
around Ontario (an area with 2.7 million people), and examined the implementation and outcomes of a rapid defibrillation program in a large, multicenter, emergency medical services (EMS) system with an existing basic life support and defibrillation (BLS-D) level of care. They compared survival for 36 months before and 12 months after system optimization and included all patients who had out-of-hospital cardiac arrest and for whom resuscitation was attempted by emergency responders. The goal was for EMS systems to be on
scene with a defibrillator in eight minutes or less for 90% of cardiac arrest cases. The program tried to optimize the process by reducing dispatch time intervals, more efficiently deploying existing ambulances, having firefighters defibrillate, subjecting response intervals to continuous quality improvement, as well as revising and implementing standard dispatch policies. The outcome measured was survival to hospital discharge. The results from more than 6000 cases were impressive. The proportion of cases meeting the eight-minute response criterion improved (76.7% vs 92.5%; P < 0.001) as did most median response intervals. Overall survival to hospital discharge for all rhythm groups combined improved from 3.9% to 5.2% (P = 0.03). In addition, rates of admission to the hospital improved (7.2% to 9.6%) and more patients had return of spontaneous circulation (9.8% vs 12.2%). The neurologic outcome was also satisfying, as 79.7% of the 66 patients who were resuscitated and lived at least a year had scored at level 1 on a five-point cerebral performance scale. The 33% relative increase in survival represents an additional 21 lives saved each year in the study communities (approximately 1 life per 120,000 residents). The costs were estimated to be $46,900 (U.S.) per life saved for establishing the rapid defibrillation program and $2400 (U.S.) per life saved annually for maintaining the program.
Comment by Richard J. Hamilton, MD, FAAEM, ABMT
This study should prove helpful to EMS and ED directors who are instituting an automatic external defibrillator (AED) program. When funds for EMS systems are limited, making choices about new initiatives are often difficult. The data presented here can detail the costs in startup and the payoff in very concrete terms. Note that other studies do not always show a benefit from an AED program, but they do not study the effect of a system-wide effort at early defibrillation, which appears to be the key. One difficulty with this
study is best described by the "Hawthorn" effect, which essentially states that human performance often improves when it is being measured. Thus, the benefits of this program might decrease when the new system is no longer under investigation. Ultimately, the scientific breakthrough may be that time to defibrillation is a discrete measurement of quality of care, and the AED may be one of several tools to improve.
The implementation of a rapid EMS defibrillation program was shown by Stiell and colleagues to:
a. significantly improve survival to hospital discharge.
b. have no significant effect on survival to hospital admission or discharge.
c. significantly improve survival to hospital admission, but not to discharge.
d. significantly improve survival to hospital discharge in selected rhythm groups.
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