Health systems developments and predictors of bystander CPR in Ireland.

Aims: To explore predictors of bystander CPR (i.e. any CPR performed prior to EMS arrival) in Ireland over the period 2012-2020. To examine the relationship between bystander CPR and key health system developments during this period. Methods: National level out-of-hospital cardiac arrest (OHCA) registry data relating to unwitnessed, and bystander witnessed OHCA were interrogated. Logistic regression models were built, then refined by fitting predictors, performing stepwise variable selection and by adding pairwise interactions that improved fit. Missing data sensitivity analyses were conducted using multiple imputation. Results: The data included 18,177 OHCA resuscitation attempts of whom 77% had bystander CPR. The final model included ten variables. Four variables (aetiology, incident location, time of day, and who witnessed collapse) were involved in interactions. The COVID-19 period was associated with reduced adjusted odds of bystander CPR (OR 0.77, 95% CI 0.65, 0.92), as were increasing age in years (OR 0.992, 95% CI 0.989, 0.994) and urban location (OR 0.52, 95% CI 0.47, 0.57). Increasing year over time (OR 1.23, 95% CI 1.16, 1.29), and an increased call response interval in minutes (OR 1.017, 95% CI 1.012, 1.022) were associated with increased adjusted odds of bystander CPR. Conclusions: Bystander CPR increased over the study period, and it is likely that health system developments contributed to the yearly increases observed. However, COVID-19 appeared to disrupt this positive trend. Urban OHCA location was associated with markedly decreased odds of bystander CPR compared to rural location. Given its importance bystander CPR in urban areas should be an immediate target for intervention.

EuReCa - The European Registry of Cardiac Arrest and the related studies.

Out-of-hospital cardiac arrest (OHCA) is a major health issue throughout Europe. Due to limited knowledge about the epidemiology of OHCA in Europe, in 2011, the European Registry of Cardiac Arrest (EuReCa) project was established. Initially based on existing resuscitation registries in a few countries, the network expanded and in October 2014 the EuReCa ONE study was launched, bringing together 27 countries and showing that appropriate data acquisition (10,682 cases submitted) is feasible within Europe. EuReCa TWO was conducted from October to December 2017 and included 37,054 cases. EuReCa THREE data collection was carried out from September to November 2022 and data analysis is currently being conducted. EuReCa TWO and THREE studies generated more robust data, with both studies covering 3-month periods in 28 countries, respectively. While EuReCa TWO focused on the bystander, EuReCa THREE investigated the impact of time-related aspects (time from call to scene, time at scene, transport times and other) on resuscitation outcomes. EuReCa is a network supporting countries in their ambition to establishing continuously running registries as quality management tools and for scientific work.

Resuscitation for out-of-hospital cardiac arrest in Ireland 2012-2020: Modelling national temporal developments and survival predictors.

Aim: To explore potential predictors of national out-of-hospital cardiac arrest (OHCA) survival, including health system developments and the COVID pandemic in Ireland. Methods: National level OHCA registry data from 2012 through to 2020, relating to unwitnessed, and bystander witnessed OHCA were interrogated. Logistic regression models were built by including predictors through stepwise variable selection and enhancing the models by adding pairwise interactions that improved fit. Missing data sensitivity analyses were conducted using multiple imputation. Results: The data included 18,177 cases. The final model included seventeen variables. Of these nine variables were involved in pairwise interactions. The COVID-19 period was associated with reduced survival (OR 0.61, 95%CI 0.43, 0.87), as were increasing age in years (OR 0.96, 95% CI 0.96, 0.97) and call response interval in minutes (OR 0.97, 95% CI 0.96, 0.99). Amiodarone administration (OR 3.91, 95% CI 2.80, 5.48), urban location (OR 1.40, 95% CI 1.12, 1.77), and chronological year over time (OR 1.14, 95% CI 1.08, 1.20) were associated with increased survival. Conclusions: National survival from OHCA has significantly increased incrementally over time in Ireland. The COVID-19 pandemic was associated with decreased survival even after accounting for potential disruption to key elements of bystander and EMS care. Further research is needed to understand and address the discrepancy between urban and rural OHCA survival. Information concerning pre-event patient health status and inpatient care process may yield important additional insights in future.

Temporal trends of ambulance time intervals for suspected stroke/transient ischaemic attack (TIA) before and during the COVID-19 pandemic in Ireland: a quasi-experimental study.

OBJECTIVES: Time is a fundamental component of acute stroke and transient ischaemic attack (TIA) care, thus minimising prehospital delays is a crucial part of the stroke chain of survival. COVID-19 restrictions were introduced in Ireland in response to the pandemic, which resulted in major societal changes. However, current research on the effects of the COVID-19 pandemic on prehospital care for stroke/TIA is limited to early COVID-19 waves. Thus, we aimed to investigate the effect of the COVID-19 pandemic on ambulance time intervals and suspected stroke/TIA call volume for adults with suspected stroke and TIA in Ireland, from 2018 to 2021. DESIGN: We conducted a secondary data analysis with a quasi-experimental design. SETTING: We used data from the National Ambulance Service in Ireland. We defined the COVID-19 period as '1 March 2020-31 December 2021' and the pre-COVID-19 period '1 January 2018-29 February 2020'. PRIMARY AND SECONDARY OUTCOME MEASURES: We compared five ambulance time intervals: 'allocation performance', 'mobilisation performance', 'response time', 'on scene time' and 'conveyance time' between the two periods using descriptive and regression analyses. We also compared call volume for suspected stroke/TIA between the pre-COVID-19 and COVID-19 periods using interrupted time series analysis. PARTICIPANTS: We included all suspected stroke/TIA cases ≥18 years who called the National Ambulance Service from 2018 to 2021. RESULTS: 40 004 cases were included: 19 826 in the pre-COVID-19 period and 19 731 in the COVID-19 period. All ambulance time intervals increased during the pandemic period compared with pre-COVID-19 (p<0.001). Call volume increased during the COVID-19-period compared with the pre-COVID-19 period (p<0.001). CONCLUSIONS: A 'shock' like a pandemic has a negative impact on the prehospital phase of care for time-sensitive conditions like stroke/TIA. System evaluation and public awareness campaigns are required to ensure maintenance of prehospital stroke pathways amidst future healthcare crises. Thus, this research is relevant to routine and extraordinary prehospital service planning.

Tools and methods for evaluating the change to health service delivery due to pandemics or other similar emergencies: A rapid evidence review.

The novel coronavirus, SARS-CoV-2 and its associated disease COVID-19, were declared a pandemic in March 2020. Countries developed rapid response activities within their health services to prevent spread of the virus and protect their populations. Evaluating health service delivery change is vital to assess how adapted practices worked, particularly during times of crisis. This review examined tools and methods that are used to evaluate health service delivery change during pandemics and similar emergencies. Five databases were searched, including PubMed, CENTRAL, Embase, CINAHL, and PsycINFO. The SPIDER tool informed the inclusion criteria for the articles. Articles in English and published from 2002 to 2020 were included. Risk of bias was assessed using the Mixed-Methods Appraisal Tool (MMAT). A narrative synthesis approach was used to analyse the studies. Eleven articles met the inclusion criteria. Many evaluation tools, methods, and frameworks were identified in the literature. Only one established tool was specific to a particular disease outbreak. Others, including rapid-cycle improvement and PDSA cycles were implemented across various disease outbreaks. Novel evaluation strategies were common across the literature and included checklists, QI frameworks, questionnaires, and surveys. Adherence practices, experience with telehealth, patient/healthcare staff safety, and clinical competencies were some areas evaluated by the tools and methods. Several domains, including patient/practitioner safety and patient/practitioner experience with telemedicine were also identified in the studies.

Outcomes of out-of-hospital cardiac arrest in Ireland 2012-2020: Protocol for an observational study.

Background: Out-of-hospital cardiac arrest (OHCA) is a leading cause of preventable mortality that now affects almost 3,000 people each year in Ireland. Survival is low at 6-7%, compared to a European average of 8%. The Irish Out-of-Hospital Cardiac Registry (OHCAR) prospectively gathers data on all OHCA in Ireland where emergency medical services attempted resuscitation.The Irish health system has undergone several developments that are relevant to OHCA care in the period 2012-2020. OHCAR data provides a means of exploring temporal trends in OHCA incidence, care, and outcomes over time. It also provides a means of exploring whether system developments were associated with a change in key outcomes.This research aims to summarise key trends in available OHCAR data from the period 2012 - 2020, to explore and model predictors of bystander CPR, bystander defibrillation, and survival, and to explore the hypothesis that significant system level temporal developments were associated with improvements in these outcomes. Methods: The following protocol sets out the relevant background and research approach for an observational study that will address the above aims. Key trends in available OHCAR data (2012 - 2020) will be described and evaluated using descriptive summaries and graphical displays. Multivariable logistic regression will be used to model predictors of 'bystander CPR', 'bystander defibrillation' and 'survival to hospital discharge' and to explore the effects (if any) of system level developments in 2015/2016 and the COVID-19 pandemic (2020) on these outcomes. Discussion: The findings of this research will be used to understand temporal trends in the care processes and outcomes for OHCA in Ireland over the period 2012-2020. The results can further be used to optimise future health system developments for OHCA in both Ireland and internationally.

Effects of the COVID-19 Pandemic on Prehospital Emergency Care for Adults with Stroke and Transient Ischaemic Attack: A Systematic Review and Meta-Analysis.

INTRODUCTION: COVID-19 has challenged global health care systems and resulted in prehospital delays for time-sensitive emergencies, like stroke and transient ischemic attacks (TIA). However, there are conflicting international reports on the level of effect of the pandemic on ambulance response intervals and emergency call volumes for these conditions. OBJECTIVES: The purpose of this study was to synthesize the international evidence on the effect of COVID-19 on ambulance response intervals and emergency call volume for suspected stroke and TIA. METHODS: Following a published protocol, we conducted a systematic search of six databases through May 31, 2022. We re-ran this search on April 14, 2023, to check for any new papers. We considered for inclusion peer-reviewed quantitative studies comparing prehospital emergency care for adults with suspected stroke/TIA before and during the COVID-19 pandemic. Two authors screened title/abstract and full text articles. One author carried out data extraction, with a random selection of articles being checked by another author. We calculated overall pooled estimates of ambulance intervals (activation, response, patient care, and total prehospital intervals) and stroke/TIA emergency call volume. Subgroup and sensitivity analyses included location and stroke/TIA diagnosis. Two authors assessed study quality using the appropriate Joanna Briggs Institute tool. We worked with patient and public involvement contributors and clinical and policy stakeholders throughout the review. RESULTS: Of 4,083 studies identified, 52 unique articles met the inclusion criteria. Mean response interval (-1.29 min [-2.19 to -0.38]) and mean total prehospital interval (-6.42 min [-10.60 to -2.25]) were shorter in the pre-COVID-19 period, compared to the COVID-19 period. Furthermore, there was a higher incidence rate of emergency call volume for suspected stroke/TIA per day pre-COVID-19 compared with the COVID-19 period (log IRR = 0.17 [0.02 to 0.33]). Ambulance response interval definitions and terminology varied between regions and countries. CONCLUSIONS: Our review indicates that prehospital delays for suspected stroke/TIA increased during the COVID-19 pandemic. Furthermore, emergency call volume for suspected stroke/TIA decreased during this period. In order to minimize delays in future pandemics or other health care emergencies future research may involve understanding the potential reasons for these delays.

The Development of Helicopter Emergency Medical Services in the Republic of Ireland.

Helicopter emergency medical services (HEMS) have formed an integral component of the Irish health care system for the past decade; yet, the factors leading their commencement, their evolutions over this time, and the current model of service delivery have not been widely published. Aeromedical service provision may vary significantly from country to country and may also vary regionally within countries. A health system's necessities; capacity and maturity; the level of state, corporate, private, or community investment; and the capacity of the contracted service provider are all factors that influence the service provision. This research article describes the historic factors leading to a military and health system collaboration to HEMS during an era of health care reform. Over the past decade, the Irish health system has undergone significant reconfiguration and centralization of services, leading to increased demands on emergency medical ground and air medical services. Future advancements in aeromedical service provision require an innate understanding of the current model. This article adds to the knowledge base, informs policy makers, and supports decision making surrounding HEMS provision and the potential to explore military and health system collaborations and enhanced overall service provision.

Three-year trends in out-of-hospital cardiac arrest across the world: Second report from the International Liaison Committee on Resuscitation (ILCOR).

BACKGROUND: The International Liaison Committee on Resuscitation (ILCOR) Research and Registries Working Group previously reported data on systems of care and outcomes of out-of-hospital cardiac arrest (OHCA) in 2015 from 16 national and regional registries. To describe the temporal trends with updated data on OHCA, we report the characteristics of OHCA from 2015 through 2017. METHODS: We invited national and regional population-based OHCA registries for voluntary participation and included emergency medical services (EMS)-treated OHCA. We collected descriptive summary data of core elements of the latest Utstein style recommendation during 2016 and 2017 at each registry. For registries that participated in the previous 2015 report, we also extracted the 2015 data. RESULTS: Eleven national registries in North America, Europe, Asia, and Oceania, and 4 regional registries in Europe were included in this report. Across registries, the estimated annual incidence of EMS-treated OHCA was 30.0-97.1 individuals per 100,000 population in 2015, 36.4-97.3 in 2016, and 40.8-100.2 in 2017. The provision of bystander cardiopulmonary resuscitation (CPR) varied from 37.2% to 79.0% in 2015, from 2.9% to 78.4% in 2016, and from 4.1% to 80.3% in 2017. Survival to hospital discharge or 30-day survival for EMS-treated OHCA ranged from 5.2% to 15.7% in 2015, from 6.2% to 15.8% in 2016, and from 4.6% to 16.4% in 2017. CONCLUSION: We observed an upward temporal trend in provision of bystander CPR in most registries. Although some registries showed favourable temporal trends in survival, less than half of registries in our study demonstrated such a trend.

Did lockdown influence bystanders' willingness to perform cardiopulmonary resuscitation? A worldwide registry-based perspective.

AIM: Bystander cardiopulmonary resuscitation (CPR) significantly increases the survival rate after out-of-hospital cardiac arrest. Using population-based registries, we investigated the impact of lockdown due to Covid-19 on the provision of bystander CPR, taking background changes over time into consideration. METHODS: Using a registry network, we invited all registries capable of delivering data from 1. January 2017 to 31. December 2020 to participate in this study. We used negative binominal regression for the analysis of the overall results. We also calculated the rates for bystander CPR. For every participating registry, we analysed the incidence per 100000 inhabitants of bystander CPR and EMS-treated patients using Poisson regression, including time trends. RESULTS: Twenty-six established OHCA registries reported 742 923 cardiac arrest patients over a four-year period covering 1.3 billion person-years. We found large variations in the reported incidence between and within continents. There was an increase in the incidence of bystander CPR of almost 5% per year. The lockdown in March/April 2020 did not impact this trend. The increase in the rate of bystander CPR was also seen when analysing data on a continental level. We found large variations in incidence of bystander CPR before and after lockdown when analysing data on a registry level. CONCLUSION: There was a steady increase in bystander CPR from 2017 to 2020, not associated with an increase in the number of ambulance-treated cardiac arrest patients. We did not find an association between lockdown and bystanders' willingness to start CPR before ambulance arrival, but we found inconsistent patterns of changes between registries.

The urban-rural divide in cardiac arrest survival.

This paper provides a commentary on the recently published "The incidence and outcomes of out-of-hospital cardiac arrest in metropolitan versus rural locations: A systematic review and meta-analysis". The importance of this work due to the systematic search for the evidence and relative consistency of studies in terms of the direction of effect is highlighted. The commentary includes discussion on the variability between studies and the urban-rural differences in clinical care. Opportunities for future research are described, as well as the need to adequately characterise the local conditions and community engagement so that the applicability of research findings can be determined for local contexts.

"Older People Want to Be in Their Own Homes": A Service Evaluation of Patient and Carer Feedback after Pathfinder Responded to Their Emergency Calls.

OBJECTIVE: Older people experience high rates of adverse outcomes following emergency department (ED) presentation. There is growing evidence to support alternative care pathways for certain types of emergency medical services (EMS) calls. Pathfinder is one such service and targets patients aged 65 years and over, whose presenting issues can be safely managed at home by immediate paramedic, occupational therapy, and/or physiotherapy interventions. The aim of this service evaluation was to understand how older people feel about being treated at home as a result of EMS calls and to understand their experiences of the Pathfinder service. METHODS: This was a thematic analysis of open-ended responses recorded from telephone interviews during routine service evaluation with service users (patients or their next-of-kin). RESULTS: Of 573 service users, telephone interviews were conducted with 429 (75%). Five primary themes were identified: (1) professionalism of the multidisciplinary clinical team; (2) "the right service, in the right place, at the right time"; (3) role of Pathfinder in "getting the ball rolling"; (4) lasting effects of the experience on the patient and his or her next-of-kin; (5) value of skilled communication with the older person. CONCLUSION: Older people and their next-of-kin voiced a clear preference for hospital avoidance, and strongly valued the opportunity to be treated in their homes at the time of an EMS call rather than default conveyance to the ED. They appreciated the importance of a skilled multidisciplinary team with a follow-up service that effectively positions itself between the acute hospital and community services.

European Registry of Cardiac Arrest - Study-THREE (EuReCa THREE) - An international, prospective, multi-centre, three-month survey of epidemiology, treatment and outcome of patients with out-of-hospital cardiac arrest in Europe - The study protocol.

Background: The aim of the European Registry of Cardiac Arrest (EuReCa) network is to provide high quality evidence on epidemiology of out-of-hospital cardiac arrest (OHCA) in Europe by supporting and developing cardiac arrest registries and performing European-wide studies. To date, the EuReCa ONE and EuReCa TWO studies have involved around 28 countries, with population covered increasing from the first to the second study. The aim of the EuReCa THREE study is to build on previous work and to support the promotion of quality data collection on OHCA throughout Europe. Methods/design: EuReCa THREE will be the third prospective cohort study on epidemiology of OHCA and will involve around 30 European countries. The study will be conducted between 1st September and 30th November 2022. Data will be collected on cardiac arrest cases attended, resuscitation attempted, patient and cardiac arrest event characteristics and outcomes (including return of spontaneous circulation, status on hospital arrival and discharge). A particular focus for EuReCa THREE will be to describe key time intervals in OHCA management; time from call to EMS arrival on scene, time from cardiac arrest to start CPR, time from EMS arrival to delivery of patient to hospital.EuReCa THREE was registered with the German Registry of Clinical Trials Registration Number: DRKS00028591 searchable via WHO meta-registry (https://apps.who.int/trialsearch/). Discussion: The EuReCa THREE study will increase our knowledge on longitudinal OHCA epidemiology and provide new knowledge on crucial time intervals in OHCA management in Europe. However, the primary aim of building a network to support quality data on OHCA, remains the central tenant of the EuReCa project.

Are there socioeconomic disparities in geographic accessibility to community first responders to out-of-hospital cardiac arrest in Ireland?

Out-of-hospital cardiac arrest (OHCA) is a leading cause of death worldwide. Without appropriate early resuscitation interventions, the prospect of survival is limited. This means that an effective community response is a critical enabler of increasing the number of people who survive. However, while OHCA incidence is higher in more deprived areas, propensity to volunteer is, in general, associated with higher socioeconomic status. In this context, we consider whether there are socioeconomic disparities in geographic accessibility to volunteer community first responders (CFRs) in Ireland, where CFR groups have developed organically and communities self-select to participate. We use geographic information systems and propensity score matching to generate a set of control areas with which to compare established CFR catchment areas. Differences between CFRs and controls in terms of the distribution of catchment deprivation and social fragmentation scores are assessed using two-sided Kolmogorov-Smirnov tests. Overall we find that while CFR schemes are centred in more deprived and socially fragmented areas, beyond a catchment of 4 min there is no evidence of differences in area-level deprivation or social fragmentation. Our findings show that self-selection as a model of CFR recruitment does not lead to more deprived areas being disadvantaged in terms of access to CFR schemes. This means that community-led health interventions can develop to the benefit of community members across the socioeconomic spectrum and may be relevant for other countries and jurisdictions looking to support similar models within communities.

Effects of the COVID-19 pandemic on prehospital emergency care for adults with stroke and transient ischaemic attack: A protocol for a systematic review and meta-analysis.

Background: The COVID-19 pandemic impacted on health service provision worldwide, including care for acute time sensitive conditions. Stroke and transient ischaemic attacks (TIA) are particularly vulnerable to pressures on healthcare delivery as they require immediate diagnosis and treatment. The global impact of the COVID-19 pandemic on prehospital emergency care for stroke/TIA is still largely unknown. Thus, the aim of this study is to conduct a systematic review and meta-analysis to investigate the impact of the COVID-19 pandemic on prehospital emergency care for stroke and TIA. Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines, the review is registered on PROSPERO (registration number CRD42022315260). Peer-reviewed quantitative studies comparing prehospital emergency care for adults with stroke/TIA before and during the COVID-19 pandemic will be considered for inclusion. The outcomes of interest are ambulance times and emergency call volumes for stroke/TIA. A systematic search of databases including PubMed, Embase and Scopus will be conducted. Two authors will independently screen studies for inclusion based on predetermined inclusion and exclusion criteria. Data extraction and quality assessment will be conducted by two authors. Meta-analysis will be performed to calculate overall pooled estimates of ambulance times (primary outcome) and stroke/TIA call volumes (secondary outcome), where appropriate.  Where heterogeneity is low a fixed-effects model will be used and where heterogeneity is high a random-effects model will be used. Subgroup and sensitivity analyses will include location, stroke/TIA diagnosis and COVID-19 case numbers. Results: Data on primary and secondary outcomes will be provided. Results of subgroup/sensitivity analyses and quality assessment will also be presented. Conclusions: This review will identify existing evidence reporting the impact of the COVID-19 pandemic on prehospital emergency care for adult patients with stroke/TIA and provide summary estimates of effects on ambulance response times.

Quality improvement in a crisis: a qualitative study of experiences and lessons learned from the Irish National Ambulance Service response to the COVID-19 pandemic.

OBJECTIVES: The COVID-19 pandemic has produced radical changes in international health services. In Ireland, the National Ambulance Service established a novel home and community testing service that was central to the national COVID-19 screening programme. This service was overseen by a multidisciplinary response room. This research examined the response room service, particularly areas that performed well and areas requiring improvement, using a quality improvement (QI) framework. DESIGN: This was a qualitative study comprising semi-structured, individual interviews. Maximum variation sampling was used. The data were analysed using an established thematic analysis procedure. The analysis was guided by the framework, which comprised six QI drivers. SETTING: Response room employees, including clinicians, dispatchers and administrators, were interviewed via telephone. RESULTS: Leadership for quality: participants valued person-oriented leadership, including regular, open communication and consultation with staff. Person/family engagement: participants endeavoured to provide patient-centred care. Formal patient feedback mechanisms and shared decision-making could be beneficial in the future. Staff engagement: working in a response room could affect well-being, though it also provided networking and learning opportunities. Staff require support and teambuilding. Use of improvement methods: improvements were made in a relatively informal, ad hoc manner. The use of robust methods based on improvement science was not reported. Measurement for quality: data were collected to improve efficiency and accuracy. More rigorous measurement would be beneficial, especially formally collecting stakeholder feedback. Governance for quality: close alignment with collaborators and clear communication with staff are essential. Information and communications technology for quality: this seventh driver was added because the importance of information technology specially designed for pandemics was frequently highlighted. CONCLUSIONS: The study provides insights on what worked well and what required improvement in a pandemic response room. It can inform health services, particularly emergency services, in their preparation for additional COVID-19 waves, as well as future crises.

Community first response and out-of-hospital cardiac arrest: Identifying priorities for data collection, analysis, and use via the nominal group technique.

AIM: Community First Response (CFR) is an important component of Out-of-hospital Cardiac Arrest management in many countries, including Ireland. Reliable, strategic data collection and analysis are required to support the development of CFR. However, data on CFR are currently limited in Ireland and internationally. This research aimed to identify the most important CFR data to record, the most important uses of CFR data, and barriers and facilitators to CFR data collection and use. METHODS: The Nominal Group Technique structured consensus process was used. An expert panel comprising key stakeholders, including volunteers, clinicians, researchers, policy-makers, and a patient, completed a survey to generate lists of the most important CFR data to record and the most important uses of CFR data. Subsequently, they participated in a consensus meeting to agree the top ten priorities from each list. They also identified barriers and facilitators to CFR data collection and use. RESULTS: The top ten CFR data items to record included volunteer response time, interventions/activities completed by volunteers, and the mental/physical impact on volunteers. The top ten most important uses of CFR data included providing feedback to volunteers, improving volunteer training, and measuring CFR effectiveness. Barriers included time constraints and limited training. Facilitators included having appropriate software/equipment and collecting minimal data. CONCLUSION: The results can guide CFR research and inform the development of CFR data collection and analysis policy and practice in Ireland and internationally. Ultimately, improving CFR data collection and use will help to optimise this important intervention and enhance its evidence base.