Terry P. Brown

Background: The PROTECTeD study sought to develop an evidence-based termination of resuscitation guideline for use within United Kingdom ambulance services. Methods: This mixed-methods study comprised several work packages: Work package 1 – diagnostic test accuracy meta-analysis of termination of resuscitation rules Work package 2 – modelling performance of termination of resuscitation rules using data from the Out of Hospital Cardiac Arrest Outcomes registry Work package 3 – review of ambulance service practices Work package 4 – qualitative interviews with ambulance clinicians, emergency department clinicians and relatives of non-survivors Work package 5 – stakeholder consensus conference to develop a new termination of resuscitation guideline. Results: We described the performance of 42 different termination of resuscitation rules. Our meta-analysis suggests the best performing termination of resuscitation rule is the Universal termination of resuscitation. We modelled the performance of 29 termination of resuscitation rules and found that none would be suitable for implementation within a United Kingdom context. We identified significant variation in how the termination of resuscitation guideline was implemented across the United Kingdom (UK) ambulance services. Ambulance clinicians experience conflict between what the guideline permits them to do and being able to act in the patient’s best interest. They felt obliged to follow the guideline. Most emergency department staff believed that paramedics should be empowered to stop resuscitation where appropriate. However, some felt that more senior emergency department clinicians should make these decisions. Relatives needed to be informed about the resuscitation attempt and must feel confident that every effort had been made to save their relative. They also believed that they were able to provide useful information to inform paramedic decision-making. We drafted a new termination of resuscitation guideline in conjunction with clinical experts and multiple stakeholders at a consensus conference. We employed nominal group techniques to determine content and formulate treatment recommendations. Discussion: Termination of resuscitation decisions are complex, requiring consideration of several important aspects, including what is in the patient’s best interest. Our work suggests that the current ambulance guideline may restrict the paramedics ability to act in the patient’s best interest, increasing the potential for moral injury. Conclusion: Paramedic decision-making is informed by both clinical and best interest considerations. Relatives are confident that paramedics do everything possible to save their loved one, and they are able to provide paramedics with information to guide decision-making. We developed a new evidence-based termination of resuscitation guideline, employing nominal group techniques, in collaboration with multiple stakeholders. Limitations: The evidence comprises observational studies that must be interpreted with caution. We captured the views of multiple stakeholders and patients with personal experience of cardiac arrest. Their insights may not be representative of the wider population who have not had the same experience. Future work: Future research should encompass alternative predictors of poor outcome (e.g. clinical frailty) as well as technology (e.g. ultrasound) to enhance decision-making. Better understanding of how cardiac arrest transport decisions impact system performance and crew safety would be helpful. Little is known about paramedic decision-making in relation to unfavourable neurological outcome rather than fatal outcome. Paramedics may benefit from a decision-making framework. Funding: This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number 17/99/34.

BackgroundOut-of-hospital cardiac arrest (OHCA) outcomes (OHCAO) vary due to various circumstances, including socioeconomic, geographic, and demographic disparities. Previous research identified high-risk areas in England determined by high OHCA incidence and low bystander cardiopulmonary resuscitation (CPR) rates. This study updates the identification of these areas to continue to inform future public health interventions.MethodsThis is a retrospective analysis of observational data collected by the OHCAO registry (2018–2023), geocoded case locations, and linked them to 2021 Census neighbourhood characteristics. Low and high-risk areas were identified using incidence and bystander CPR rates. Return of spontaneous circulation (ROSC) and survival rates in these areas were also explored. Spatial patterns were visualised using choropleth maps in ArcGIS.ResultsBetween 2018–2023, 165,701 OHCA patients were mapped to postcode districts. High-risk areas were more urban, deprived, and ethnically diverse, with lower shockable rhythm and public access defibrillation rates. Despite this, ROSC (27.4% vs 26.5%) and survival (8.2% vs 7.9%) rates were slightly higher. However, 23.6% of postcode districts remain high-risk, although the geographic patterns have slightly shifted since 2013–2015.Discussion/ConclusionThis analysis highlights persistent geographic and socioeconomic disparities in OHCA incidence, bystander CPR rates and survival across England that remain unchanged since 2015. Identifying local patterns in bystander CPR and understanding community-specific characteristics can guide more effective, equitable CPR training. Targeted, community-based interventions—especially in high-risk areas—are needed to reduce mortality.

Background: Out-of-hospital cardiac arrest (OHCA) primarily affects older adults. Individuals in nursing homes are often elderly with significant comorbidities. Nursing homes are staffed by healthcare workers, able to respond immediately to cardiac arrest, including provision of bystander cardiopulmonary resuscitation (CPR). We aimed to describe the characteristics, treatments and outcome of individuals sustaining an OHCA in nursing and care home settings in England. Methods: Patients ≥18 years between 2015 and 2021 with a recorded location of either a nursing or care home from the ‘Out-of-hospital Cardiac Arrest Outcomes’ registry for England were included. We present descriptive statistics and compare groups, where appropriate, using a χ ² test. Results: We included 4779 patients, of which 2474 (52.5%) were female and 3910 (81.8%) were aged ≥70. Cardiac arrest was witnessed by a bystander in 51.1% (n=2390) of cases. Overall, 80.2% (n=3698) of patients received bystander CPR and where an automated external defibrillator (AED) was available, 77.7% (n=331) were treated with an AED. Return of spontaneous circulation (ROSC) at any time was reported in 1614 (36.7%) and ROSC sustained to hospital handover in 1061 (22.3%) patients. Survival to hospital discharge or 30 days was observed in 97 (2.1%) patients. As age increased, there was a decrease in survival and ROSC sustained to hospital handover. Conclusion: Survival after OHCA in a nursing home setting was low, despite high rates of key interventions, such as bystander CPR. There may be an opportunity to optimise the availability of AEDs within nursing homes.

Background: Ambulance services treat over 32,000 patients sustaining an out-of-hospital cardiac arrest annually, receiving over 90,000 calls. The definitive treatment for out-of-hospital cardiac arrest is defibrillation. Prompt treatment with an automated external defibrillator can improve survival significantly. However, their location in the community limits opportunity for their use. There is a requirement to identify the optimal location for an automated external defibrillator to improve out-of-hospital cardiac arrest coverage, to improve the chances of survival. Methods: This was a secondary analysis of data collected by the Out-of-Hospital Cardiac Arrest Outcomes registry on historical out-of-hospital cardiac arrests, data held on the location of automated external defibrillators registered with ambulance services, and locations of points of interest. Walking distance was calculated between out-of-hospital cardiac arrests, registered automated external defibrillators and points of interest designated as potential sites for an automated external defibrillator. An out-of-hospital cardiac arrest was deemed to be covered if it occurred within 500 m of a registered automated external defibrillator or points of interest. For the optimisation analysis, mathematical models focused on the maximal covering location problem were adapted. A de novo decision-analytic model was developed for the cost-effectiveness analysis and used as a vehicle for assessing the costs and benefits (in terms of quality-adjusted life-years) of deployment strategies. A meeting of stakeholders was held to discuss and review the results of the study. Results: Historical out-of-hospital cardiac arrests occurred in more deprived areas and automated external defibrillators were placed in more affluent areas. The median out-of-hospital cardiac arrest – automated external defibrillator distance was 638 m and 38.9% of out-of-hospital cardiac arrests occurred within 500 m of an automated external defibrillator. If an automated external defibrillator was placed in all points of interests, the proportion of out-of-hospital cardiac arrests covered varied greatly. The greatest coverage was achieved with cash machines. Coverage loss, assuming an automated external defibrillator was not available outside working hours, varied between points of interest and was greatest for schools. Dividing the country up into 1 km² grids and placing an automated external defibrillator in the centre increased coverage significantly to 78.8%. The optimisation model showed that if automated external defibrillators were placed in each points-of-interest location out-of-hospital cardiac arrest coverage levels would improve above the current situation significantly, but it would not reach that of optimisation-based placement (based on grids). The coverage efficiency provided by the optimised grid points was unmatched by any points of interest in any region. An economic evaluation determined that all alternative placements were associated with higher quality-adjusted life-years and costs compared to current placement, resulting in incremental cost-effectiveness ratios over £30,000 per additional quality-adjusted life-year. The most appealing strategy was automated external defibrillator placement in halls and community centres, resulting in an additional 0.007 quality-adjusted life-year (non-parametric 95% confidence interval 0.004 to 0.011), an additional expected cost of £223 (non-parametric 95% confidence interval £148 to £330) and an incremental cost-effectiveness ratio of £32,418 per quality-adjusted life-year. The stakeholder meeting agreed that the current distribution of registered publicly accessible automated external defibrillators was suboptimal, and that there was a disparity in their location in respect of deprivation and other health inequalities. Conclusions: We have developed a data-driven framework to support decisions about public-access automated external defibrillator locations, using optimisation and statistical models. Optimising automated external defibrillator locations can result in substantial improvement in coverage. Comparison between placement based on points of interest and current placement showed that the former improves coverage but is associated with higher costs and incremental cost-effectiveness ratio values over £30,000 per additional quality-adjusted life-year. Study registration: This study is registered as researchregistry5121. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR127368) and is published in full in Health and Social Care Delivery Research; Vol. 13, No. 5. See the NIHR Funding and Awards website for further award information.