Bystander cardiopulmonary resuscitation (B-CPR) and defibrillation for out-of-hospital cardiac arrest (OHCA) vary by sex, with women being less likely to receive these interventions in public. It is ...unknown whether sex differences persist when considering neighborhood racial and ethnic composition. We examined the odds of receiving B-CPR stratified by location and neighborhood. We hypothesized that women in predominantly Black neighborhoods will have a lower odds of receiving B-CPR.
We conducted a retrospective study using the Cardiac Arrest Registry to Enhance Survival (CARES). Neighborhoods were classified by census tract. We modeled the odds of receipt of B-CPR (primary outcome), automatic external defibrillation application, and survival to hospital discharge (secondary outcomes) by sex. CARES collected 457 621 arrests (2013-2019); after appropriate exclusion, 309 662 were included. Women who had public OHCA had a 14% lower odds of receiving B-CPR (odds ratio OR, 0.86 95% CI, 0.82-0.89), but effect modification was not seen by neighborhood (
=not significant). In predominantly Black neighborhoods, women who had public OHCA had a 13% lower odds of receiving B-CPR (adjusted OR, 0.87 95% CI, 0.76-0.98) and 12% lower odds of receiving automatic external defibrillation application (adjusted OR, 0.88 95% CI, 0.78-0.99). In predominantly Hispanic neighborhoods, women who had public OHCA were less likely to receive B-CPR (adjusted OR, 0.83 95% CI, 0.73-0.96) and less likely to receive automatic external defibrillation application (adjusted OR, 0.74 95% CI, 0.64-0.87).
Women with public OHCA have a decreased likelihood of receiving B-CPR and automatic external defibrillation application. Findings did not differ significantly according to neighborhood composition. Despite this, our work has implications for considering strategies to reduce disparities around bystander response.
Recent reports from communities severely affected by the coronavirus disease 2019 (COVID-19) pandemic found lower rates of sustained return of spontaneous circulation (ROSC) for out-of-hospital ...cardiac arrest (OHCA). Whether the pandemic has affected OHCA outcomes more broadly is unknown.
To assess the association between the COVID-19 pandemic and OHCA outcomes, including in areas with low and moderate COVID-19 disease burden.
This study used a large US registry of OHCAs to compare outcomes during the pandemic period of March 16 through April 30, 2020, with those from March 16 through April 30, 2019. Cases were geocoded to US counties, and the COVID-19 mortality rate in each county was categorized as very low (0-25 per million residents), low (26-100 per million residents), moderate (101-250 per million residents), high (251-500 per million residents), or very high (>500 per million residents). As additional controls, the study compared OHCA outcomes during the prepandemic period (January through February) and peripandemic period (March 1 through 15).
The COVID-19 pandemic.
Sustained ROSC (≥20 minutes), survival to discharge, and OHCA incidence.
A total of 19 303 OHCAs occurred from March 16 through April 30 in both years, with 9863 cases in 2020 (mean SD age, 62.6 19.3 years; 6040 men 61.3%) and 9440 in 2019 (mean SD age, 62.2 19.2 years; 5922 men 62.7%). During the pandemic, rates of sustained ROSC were lower than in 2019 (23.0% vs 29.8%; adjusted rate ratio, 0.82 95% CI, 0.78-0.87; P < .001). Sustained ROSC rates were lower by between 21% (286 of 1429 20.0% in 2020 vs 305 of 1130 27.0% in 2019; adjusted RR, 0.79 95% CI, 0.65-0.97) and 33% (149 of 863 17.3% in 2020 vs 192 of 667 28.8% in 2019; adjusted RR, 0.67 95% CI, 0.56-0.80) in communities with high or very high COVID-19 mortality, respectively; however, rates of sustained ROSC were also lower by 11% (583 of 2317 25.2% in 2020 vs 740 of 2549 29.0% in 2019; adjusted RR, 0.89 95% CI, 0.81-0.98) to 15% (889 of 3495 25.4% in 2020 vs 1109 of 3532 31.4% in 2019; adjusted RR, 0.85 95% CI, 0.78-0.93) in communities with very low and low COVID-19 mortality. Among emergency medical services agencies with complete data on hospital survival (7085 total patients), survival to discharge was lower during the pandemic compared with 2019 (6.6% vs 9.8%; adjusted RR, 0.83 95% CI, 0.69-1.00; P = .048), primarily in communities with moderate to very high COVID-19 mortality (interaction P = .049). Incidence of OHCA was higher than in 2019, but the increase was largely observed in communities with high COVID-19 mortality (adjusted mean difference, 38.6 95% CI, 37.1-40.1 per million residents) and very high COVID-19 mortality (adjusted mean difference, 28.7 95% CI, 26.7-30.6 per million residents). In contrast, there was no difference in rates of sustained ROSC or survival to discharge during the prepandemic and peripandemic periods in 2020 vs 2019.
Early during the pandemic, rates of sustained ROSC for OHCA were lower throughout the US, even in communities with low COVID-19 mortality rates. Overall survival was lower, primarily in communities with moderate or high COVID-19 mortality.
Prior research shows a greater disease burden, lower BCPR rates, and worse outcomes in Black and Hispanic patients after OHCA. Female OHCA patients have lower rates of BCPR compared to men and other ...survival outcomes vary. The influence of the COVID-19 pandemic on OHCA incidence and outcomes in different health disparity populations is unknown.
We used data from the Texas Cardiac Arrest Registry to Enhance Survival (CARES). We determined the association of both prehospital characteristics and survival outcomes with the pandemic period in each study group through Pearson’s χ2 test or Fisher’s exact tests. We created mixed multivariable logistic regression models to compare odds of cardiac arrest care and outcomes between 2019 and 2020 for the study groups.
Black OHCA patients (aOR = 0.73; 95% CI: 0.65 – 0.82) had significantly lower odds of BCPR compared to White OHCA patients, were less likely to achieve ROSC (aOR = 0.86; 95% CI: 0.74 – 0.99) or have a good CPC score (aOR = 0.47; 95% CI: 0.29 – 0.75). Compared to White patients with OHCA, Hispanic persons were less likely to have a field TOR (aOR = 0.86; 95% CI: 0.75 – 0.99) or receive BCPR (aOR = 0.78; 95% CI: 0.69 – 0.87). Female OHCA patients had higher odds of surviving to hospital admission compared to males (aOR = 1.29; 95% CI: 1.15 – 1.44).
Many OHCA outcomes worsened for Black and Hispanic patients. While some aspects of care worsened for women, their odds of survival improved compared to males.
The Cardiac Arrest Registry to Enhance Survival (CARES) was created in 2004 in collaboration with the Centers for Disease Control and Prevention (CDC) and Emory University School of Medicine’s ...Department of Emergency Medicine. The registry allows local communities to benchmark their performance, enhance the quality of care, and increase survival rates for out-of-hospital cardiac arrest (OHCA).
CARES enrolls patients who experience a non-traumatic, EMS-treated OHCA. For each case, data is collected from three sources: 911 call center data, EMS data, and hospital data. CARES data is de-identified and stored in a secured web-based cloud platform and maintains confidentiality throughout the process. CARES data is subjected to an internal auditing system that oversees both local and regional levels. The variables in CARES adhere with the Utstein style reporting system and the National EMS Information System (NEMSIS) standard.
As of 2023, CARES captures data from a population base of over 178 million people which accounts for 53% of the total U.S. population. Over the past two decades, CARES has consistently been a part of public health surveillance for OHCA and serves as a quality improvement tool to improve cardiac arrest outcomes. Moreover, CARES commits to facilitate observational research on OHCA, continues to modernize its software platform, and comprehensively expands its coverage for the entire U.S.
How frequently out-of-hospital cardiac arrest (OHCA) occurs within a reasonable walking distance to the nearest public automated external defibrillator (AED) has not been well studied.
As Kansas ...City, Missouri has a comprehensive city-wide public AED registry, we identified adults with an OHCA in Kansas City during 2019–2022 in the Cardiac Arrest Registry to Enhance Survival. Using AED location data from the registry, we computed walking times between OHCAs and the nearest registered AED using the Haversine formula, a mapping algorithm to calculate walking distance in miles from one location to another. Results were stratified by OHCA location (home vs. public) and by whether the patient received bystander cardiopulmonary resuscitation (CPR).
Of 1,522 OHCAs, 1,291 (84.8%) occurred at home and 231 (15.2%) in public. Among at-home OHCAs, 634 (49.1%) received bystander CPR and no patients had an AED applied even as 297 (23.0%) were within a 4-minute walk to the closest public AED. Among OHCAs in public, 108 (46.8%) were within a 4-minute walk to the closest public AED. For public OHCAs within a 4-minute walk, bystanders applied an AED in 13 (12.0%) of these cases and in 24.5% (13/53) of those who received bystander CPR.
In one U.S. city with a publicly available AED registry, there were no instances in which a bystander accessed a public AED for an OHCA at home. For OHCAs in public, nearly half occurred within a 4-minute walk to the closest AED but bystander use of an AED was low.
Survival for out-of-hospital cardiac arrest (OHCA) varies across emergency medical service (EMS) agencies. Yet, little is known about resuscitation response and quality improvement activities at EMS ...agencies. We describe herein a novel survey to EMS agencies in a U.S. registry for OHCA.
Using data from the Cardiac Arrest Registry to Enhance Survival (CARES), we identified 577 EMS agencies with ≥10 OHCA cases annually between 2015 and 2019 that remained active in CARES. We administered a survey to EMS directors regarding agency characteristics, cardiac arrest response, relationships with first responders and dispatchers, quality improvement activities and perceived barriers in the community.
Of eligible EMS agencies, 470 (81.5%) completed the survey. The high completion rate was likely due to frequent personalized emails and phone calls, liaising with CARES state coordinators to encourage survey response, and multiple periodic drawings of an automated external defibrillator during the survey period for participating EMS agencies. The survey examined rates of resuscitation training modalities; use of resuscitation equipment and devices in the field; frequency of simulation; non-EMS stakeholder response to OHCA (dispatchers, fire, police); quality improvement; and community factors affecting bystander response to OHCA.
In this study design paper on the RED-CASO survey, we provide summary data on EMS agency characteristics in the U.S. Upon linkage to CARES patient-level data, this survey will provide critical insights into ‘best practices’ at EMS agencies with the highest OHCA survival rates as well as provide insights into current disparities in outcomes.
•Out-of-hospital cardiac arrest (OHCA) treatment and outcomes vary significantly by municipality in Connecticut.•Municipality population size greater than 100,000 and predominantly ...non-English-speaking communities were associated with lower rates of bystander CPR.•Non-English-speaking, low per capita income and Hispanic communities were associated with lower rates of bystander AED use.•High population size, low English language use, low per capita income and increased Hispanic community make-up were associated with decreased survival with favorable neurological function.•Statewide and community OHCA outcomes in Connecticut might be improved by campaigns targeting urban population centers and Hispanic communities with culturally sensitive, low or no-cost CPR and AED educational programs using instructional languages other than English.
Prior reports have demonstrated underutilization of bystander cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use in patients with witnessed out-of-hospital cardiac arrest (OHCA) in Connecticut. This study aimed to identify community-level risk factors that contribute to low rates of bystander intervention to improve statewide OHCA outcomes.
We analyzed 2,789 adult patients with witnessed, non-traumatic OHCA submitted to the Connecticut Cardiac Arrest Registry to Enhance Survival (CARES) between 2013–2022. Patients were grouped by zip code, and associated municipal characteristics were acquired from 2022 United States Census Bureau data. Use of bystander CPR, attempted bystander AED defibrillation, and patient survival with favorable neurological function were determined for 19 of the 20 most populous cities and towns. Pearson correlation tests and linear regression were used to determine associations between OHCA treatment and outcomes with population size, racial/ethnic demographics, language use, income, and educational level.
Bystander CPR was lower in municipalities with population size > 100,000 and in communities where > 40% of residents are non-English-speaking. AED use was also lower in these municipalities, as well as those with per capita incomes < $40,000 or > 1/3 Hispanic residents. Communities with populations > 100,000, > 40% non-English-speaking, per capita income < $40,000, and > 1/3 Hispanic residents were all associated with lower survival rates.
OHCA pre-hospital treatment and outcomes vary significantly by municipality in Connecticut. Community outcomes might be improved by specifically targeting urban population centers and Hispanic communities with culturally sensitive, low, or no-cost CPR and AED educational programs, using instructional languages other than English.
Large variation exists for out-of-hospital-cardiac-arrest (OHCA) prehospital care, but less is known about variations in post-arrest care. We sought to evaluate variation in post-arrest care in Texas ...as well as factors associated with higher performing hospitals.
We analyzed data in Texas Cardiac Arrest Registry to Enhance Survival (TX-CARES), including all adult, non-traumatic OHCAs from 1/1/2014 through 12/31/ 2020 that survived to hospital admission. We first evaluated variability in provisions of post-arrest care and outcomes. We then stratified hospitals into quartiles based on their rate of survival and evaluated the association between improving quartiles and care. Lastly, we evaluated for outliers in post-arrest care and outcomes using a mixed-effect regression model.
We analyzed 7,842 OHCAs admitted to 146 hospitals. We identified large variations in post-arrest care, including targeted temperature management (TTM) (IQR 7.0–51.1%), left heart catheterization (LHC) (IQ 0–25%), and percutaneous coronary intervention (PCI) (IQR 0–10.3%). Higher performing hospital quartiles were associated with higher rates of TTM (aOR 1.42, 95% CI 1.36–1.49), LHC (aOR 2.07, 95% CI 1.92–2.23), and PCI (aOR 2.02, 95% CI 1.81–2.25); but lower rates of bystander CPR (aOR 0.90, 95% CI 0.87–0.94). We identified numerous performance outlier hospitals; 39 for TTM, 34 for PCI, 9 for survival to discharge, and 24 for survival with good neurologic function.
Post-arrest care varied widely across Texas hospitals. Hospitals with higher rates of survival to discharge had increased rates of TTM, LHC, and PCI but not bystander CPR.
Variations in the impact of the COVID-19 pandemic on out-of-hospital cardiac arrest (OHCA) have been reported. We aimed to, using population-based registries, compare community response, Emergency ...Medical Services (EMS) interventions and outcomes of adult, EMS-treated, non-traumatic OHCA in Singapore and metropolitan Atlanta, before and during the pandemic. Associations of OHCA characteristics, pre-hospital interventions and pandemic with survival to hospital discharge were analyzed using logistic regression. There were 2084 cases during the pandemic (17 weeks from the first confirmed COVID-19 case) and 1900 in the pre-pandemic period (corresponding weeks in 2019). Compared to Atlanta, OHCAs in Singapore were older, received more bystander interventions (cardiopulmonary resuscitation (CPR): 65.0% vs. 41.4%; automated external defibrillator application: 28.6% vs. 10.1%), yet had lower survival (5.6% vs. 8.1%). Compared to the pre-pandemic period, OHCAs in Singapore and Atlanta occurred more at home (adjusted odds ratio (aOR) 2.05 and 2.03, respectively) and were transported less to hospitals (aOR 0.59 and 0.36, respectively) during the pandemic. Singapore reported more witnessed OHCAs (aOR 1.96) yet less bystander CPR (aOR 0.81) during pandemic, but not Atlanta (p < 0.05). The impact of COVID-19 on OHCA outcomes did not differ between cities. Changes in OHCA characteristics and management during the pandemic, and differences between Singapore and Atlanta were likely the result of systemic and sociocultural factors.
Prior studies have identified socio-cultural barriers in laypersons performing high-quality cardiopulmonary resuscitation (CPR) in women. Whether the effect of layperson bystander CPR on survival ...from out-of-hospital cardiac arrest (OHCA) differs by patients’ sex is unknown.
Using data during 2013–2020 from an OHCA registry in the U.S., we identified adult patients with non-traumatic OHCA. The primary outcome was favorable neurological survival and the secondary outcome was survival to discharge. Multivariable logistic regression models evaluated the interaction between patients’ sex and bystander CPR with survival, adjusted for patient and cardiac arrest characteristics.
Of 420,671 patients with OHCA, 151,145 (35.9 %) occurred in women and 269,526 (64.1 %) in men. Rates of layperson bystander CPR were similar between women (38.3 %) and men (40.0 %). Rates of favorable neurological survival were 11.4 % in those with bystander CPR and 5.6 % in those without, but the association between bystander CPR and favorable neurological survival was weaker for women than men (women: adjusted OR, 1.33 95 % CI: 1.27–1.39; men: adjusted OR, 1.55 95 % CI: 1.51–1.61; interaction p < 0.001). Rates of survival to discharge were 13.1 % and 7.3 % in those with and without layperson bystander CPR, and the association between bystander CPR was weaker for women than men (women: adjusted OR, 1.21 95 % CI: 1.16–1.26; men: adjusted OR, 1.43 95 % CI: 1.39–1.47; interaction p < 0.001).
For OHCA, bystander CPR was associated with higher survival in women and men. However, as currently practiced, the association between bystander CPR and higher survival was weaker for women as compared with men.
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