Improved outcome for patients with a cardiac arrest by supervision of the emergency medical services system.

BACKGROUND: The outcome for patients with an out-of-hospital cardiac arrest can only be improved through optimal pre-hospital therapy by the emergency medical services (EMS) system. So far it is not clear if physician supervision of the EMS system is necessary for an optimal result. METHODS: In a retrospective and prospective case series we describe the changes in outcome for patients with an out-of-hospital cardiac arrest after the implementation of limited physician supervision of the EMS system. We also analysed the factors that were responsible for these changes. RESULTS: We studied 479 consecutive patients with an out-of-hospital cardiac arrest. In the pre-intervention period, the survival rate for patients with an out-of-hospital cardiac arrest was 13%. This increased to 21.6% when physician supervision was implemented (p = 0.013). This increase in survival coincided with an improvement in pre-hospital advanced cardiac life support with an increase in the number of patients who arrived with a stable cardiac rhythm in the emergency department (p < 0.001). CONCLUSIONS: Limited physician supervision of an EMS system in a non-metropolitan area may improve the outcome for patients with an out-of-hospital cardiac arrest.

Evaluation of an emergency medical system. The prognosis in patients with an out-of-hospital cardiac arrest.

In a retrospective chart review, we evaluated the efficiency of the emergency medical system of the Leiden area in patients with an out-of-hospital cardiac arrest. A total of 309 adult patients were included. Two hundred patients (64.7%) died in the emergency department and 67 (21.7%) died during subsequent hospital stay. Finally, 42 patients (13.6%) survived after hospital discharge. Favourable prognostic factors were the presence of witnesses at the time of arrest, a short call-response interval, an initial cardiac rhythm of ventricular fibrillation or tachycardia, and adequate advanced cardiac life support provided by the emergency medical system. We detected several shortcomings in the system such as an unacceptably prolonged call-response interval for some patients at the periphery of the Leiden area and a delay in the first defibrillation attempt. Improvement of this "pre-hospital chain of survival" is likely to result in a better outcome for these patients.

Prolonged resuscitation efforts for cardiac arrest patients who cannot be resuscitated at the scene: who is likely to benefit?

STUDY OBJECTIVE: To determine who may benefit from prolonged resuscitation efforts after therapy by emergency medical services system (EMS) personnel has failed to restore vital signs. DESIGN: Retrospective chart review. TYPE OF PARTICIPANTS: Two hundred sixteen consecutive adult patients with out-of-hospital cardiac arrest who were admitted to the emergency department without vital signs. METHODS: Identification of prehospital resuscitation data, therapy in the ED, hospital course, and final outcome. RESULTS: Thirty-nine patients (18.1%) were resuscitated successfully. The odds ratio of successful resuscitation in the ED for the patients with ventricular fibrillation at the scene versus those with asystole or electromechanical dissociation was 3.4 (95% confidence interval, 1.5, 7.9). All patients with asystole or electromechanical dissociation, either at the scene or in the ED, died (95% confidence interval, 0, 4.3). CONCLUSION: Prolonged resuscitation efforts in the ED for patients with asystole or electromechanical dissociation usually are futile after previous efforts by the EMS personnel have failed to restore vital signs. Transportation to the hospital may not be indicated. However, for patients with persistent ventricular fibrillation, transport is indicated.