University of Texas Southwestern Medical Center, Dallas.
University of Iowa Carver College of Medicine, Iowa City.
JAMA Cardiol. 2024 Aug 1;9(8):683-691. doi: 10.1001/jamacardio.2024.1189.
Survival for out-of-hospital cardiac arrest (OHCA) varies widely across emergency medical service (EMS) agencies in the US. However, little is known about which EMS practices are associated with higher agency-level survival.
To identify resuscitation practices associated with favorable neurological survival for OHCA at EMS agencies.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study surveyed EMS agencies participating in the Cardiac Arrest Registry to Enhance Survival (CARES) with 10 or more OHCAs annually during January 2015 to December 2019; data analyses were performed from April to October 2023.
Survey of resuscitation practices at EMS agencies.
Risk-standardized rates of favorable neurological survival for OHCA at each EMS agency were estimated using hierarchical logistic regression. Multivariable linear regression then examined the association of EMS practices with rates of risk-standardized favorable neurological survival.
Of 577 eligible EMS agencies, 470 agencies (81.5%) completed the survey. The mean (SD) rate of risk-standardized favorable neurological survival was 8.1% (1.8%). A total of 7 EMS practices across 3 domains (training, cardiopulmonary resuscitation [CPR], and transport) were associated with higher rates of risk-standardized favorable neurological survival. EMS agencies with higher favorable neurological survival rates were more likely to use simulation to assess CPR competency (β = 0.54; P = .05), perform frequent reassessment (at least once every 6 months) of CPR competency in new staff (β = 0.51; P = .04), use full multiperson scenario simulation for ongoing skills training (β = 0.48; P = .01), perform simulation training at least every 6 months (β = 0.63; P < .001), and conduct training in the use of mechanical CPR devices at least once annually (β = 0.43; P = .04). EMS agencies with higher risk-standardized favorable neurological survival were also more likely to use CPR feedback devices (β = 0.58; P = .007) and to transport patients to a designated cardiac arrest or ST-segment elevation myocardial infarction receiving center (β = 0.57; P = .003). Adoption of more than half (≥4) of the 7 practices was more common at EMS agencies in the highest quartile of favorable neurological survival rates (70 of 118 agencies [59.3%]) vs the lowest quartile (42 of 118 agencies [35.6%]) (P < .001).
In a national registry for OHCA, 7 practices associated with higher rates of favorable neurological survival were identified at EMS agencies. Given wide variability in neurological survival across EMS agencies, these findings provide initial insights into EMS practices associated with top-performing EMS agencies in OHCA survival. Future studies are needed to validate these findings and identify best practices for EMS agencies.
在美国，不同的紧急医疗服务（EMS）机构之间的院外心脏骤停（OHCA）生存率存在很大差异。然而，对于哪些 EMS 实践与更高的机构水平生存率相关，知之甚少。
确定与 EMS 机构 OHCA 有利神经生存相关的复苏实践。
设计、设置和参与者：本队列研究调查了参与心脏骤停登记以增强生存（CARES）的 EMS 机构，该研究在 2015 年 1 月至 2019 年 12 月期间每年有 10 例或更多 OHCA；数据分析于 2023 年 4 月至 10 月进行。
对 EMS 机构的复苏实践进行调查。
使用分层逻辑回归估计每个 EMS 机构 OHCA 有利神经生存的风险标准化率。然后，多变量线性回归检查了 EMS 实践与风险标准化有利神经生存率之间的关联。
在 577 个符合条件的 EMS 机构中，有 470 个机构（81.5%）完成了调查。风险标准化有利神经生存的平均（SD）率为 8.1%（1.8%）。共有 7 项 EMS 实践涉及 3 个领域（培训、心肺复苏术[CPR]和运输）与更高的风险标准化有利神经生存率相关。具有更高有利神经生存率的 EMS 机构更有可能使用模拟来评估 CPR 能力（β=0.54；P=0.05）、对新员工进行至少每 6 个月一次的 CPR 能力频繁重新评估（β=0.51；P=0.04）、使用全面的多人情景模拟进行持续技能培训（β=0.48；P=0.01）、至少每 6 个月进行一次模拟培训（β=0.63；P<0.001）以及至少每年进行一次机械 CPR 设备使用培训（β=0.43；P=0.04）。具有更高风险标准化有利神经生存的 EMS 机构也更有可能使用 CPR 反馈设备（β=0.58；P=0.007），并将患者转运到指定的心脏骤停或 ST 段抬高型心肌梗死接收中心（β=0.57；P=0.003）。在神经生存的风险标准化率最高的 EMS 机构（118 个机构中的 70 个[59.3%]）中，采用了 7 项实践中的 4 项以上（≥4）的比例高于风险标准化率最低的 EMS 机构（118 个机构中的 42 个[35.6%]）（P<0.001）。
在一项针对 OHCA 的全国性登记研究中，确定了与更高的有利神经生存率相关的 7 项 EMS 实践。鉴于 EMS 机构之间神经生存的差异很大，这些发现为 OHCA 生存中表现最佳的 EMS 机构的 EMS 实践提供了初步见解。未来的研究需要验证这些发现并确定 EMS 机构的最佳实践。
