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The Unacceptable Disparity in Cardiac Arrest Survival Among American Communities

2009; Elsevier BV; Volume: 54; Issue: 2 Linguagem: Inglês

10.1016/j.annemergmed.2009.01.008

1097-6760

Mickey S. Eisenberg, Roger D. White,

Disaster Response and Management

The community in which an individual lives is the biggest factor determining whether survival or death follows out-of-hospital cardiac arrest. Consider the facts. Survival (discharged alive from hospital) from ventricular fibrillation in US cities ranges from 0% to 46%. Ample studies during several decades, 1 Rea T.D. Eisenberg M.S. Sinibaldi G. et al. Incidence of EMS-treated out-of-hospital cardiac arrest in the United States. Resuscitation. 2004; 63: 17-24 Abstract Full Text Full Text PDF PubMed Scopus (380) Google Scholar , 2 Eisenberg M.S. Horwood B.T. Cummins R.O. et al. Cardiac arrest and resuscitation: a tale of 29 cities. Ann Emerg Med. 1990; 19: 179-186 Abstract Full Text PDF PubMed Scopus (763) Google Scholar including a recent publication from the Resuscitation Outcomes Consortium, 3 Nichol G. Thomas E. Callaway C.W. et al. Regional variation in out-of-hospital cardiac arrest incidence and outcome. JAMA. 2008; 300: 1423-1431 Crossref PubMed Scopus (1488) Google Scholar document this disparity: Detroit, 0% 4 Dunne R.B. Compton S. Zalenski R.J. et al. Outcomes from out-of-hospital cardiac arrest in Detroit. Resuscitation. 2007; 72: 59-65 Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar ; Chicago, 3% 5 Becker L.B. Ostrander M.P. Barrett J. et al. Outcome of CPR in a large metropolitan area—where are the survivors?. Ann Emerg Med. 1991; 20: 355-361 Abstract Full Text PDF PubMed Scopus (544) Google Scholar ; New York, 5% 6 Lombardi G. Gallagher J. Gennis P. Outcome of out-of-hospital cardiac arrest in New York City The Pre-Hospital Arrest Survival Evaluation (PHASE) Study. JAMA. 1994; 271: 678-683 Crossref PubMed Scopus (425) Google Scholar ; Los Angeles, 7% 7 Eckstein M. Stratton S.J. Chan L.S. Cardiac Arrest Resuscitation Evaluation in Los Angeles: CARE-LA. Ann Emerg Med. 2005; 45: 504-509 Abstract Full Text Full Text PDF PubMed Scopus (146) Google Scholar ; Alabama, 8% 3 Nichol G. Thomas E. Callaway C.W. et al. Regional variation in out-of-hospital cardiac arrest incidence and outcome. JAMA. 2008; 300: 1423-1431 Crossref PubMed Scopus (1488) Google Scholar ; Salt Lake City, 8% 8 Joyce S.M. Davidson L.W. Manning K.W. et al. Outcomes of sudden cardiac arrest treated with defibrillation by emergency medical technicians (EMT-Ds) or paramedics in a two-tiered urban EMS system. Prehosp Emerg Care. 1998; 2: 13-17 Crossref PubMed Scopus (17) Google Scholar ; Dallas, 10% 3 Nichol G. Thomas E. Callaway C.W. et al. Regional variation in out-of-hospital cardiac arrest incidence and outcome. JAMA. 2008; 300: 1423-1431 Crossref PubMed Scopus (1488) Google Scholar ; Rochester, NY, 10% 9 Fairbanks R.J. Shah M.N. Lerner E.B. et al. Epidemiology and outcomes of out-of-hospital cardiac arrest in Rochester, New York. Resuscitation. 2007; 72: 415-424 Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar ; Memphis, 12% 10 Kellermann A.L. Hackman B.B. Somes G. Predicting the outcome of unsuccessful prehospital advanced cardiac life support. JAMA. 1993; 270: 1433-1436 Crossref PubMed Scopus (170) Google Scholar ; Tucson, 12% 11 Valenzuela T.D. Roe D.J. Cretin S. et al. Estimating effectiveness of cardiac arrest. Circulation. 1997; 96: 3308-3313 Crossref PubMed Google Scholar ; San Francisco, 15% 12 Callaham M. Madsen C.D. Relationship of timeliness of paramedic advanced life support interventions to outcome in out-of-hospital cardiac arrest treated by first responders with defibrillators. Ann Emerg Med. 1996; 27: 638-648 Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar ; Fresno, 15% 13 Schwab T.M. Callaham M.L. Madsen C.D. et al. A randomized clinical trial of active compression-decompression CPR vs standard CPR in out-of-hospital cardiac arrest in two cities. JAMA. 1995; 273: 1261-1268 Crossref PubMed Scopus (144) Google Scholar ; Houston, 15% 14 Pepe P.E. Levine R.L. Fromm Jr, R.E. et al. Cardiac arrest presenting with rhythms other than ventricular fibrillation: contribution of resuscitative efforts toward total survivorship. Crit Care Med. 1993; 21: 1838-1843 Crossref PubMed Scopus (89) Google Scholar ; Minneapolis, 20% 15 Ho J. Held T. Heegaard W. et al. Automatic external defibrillation and its effects on neurologic outcome in cardiac arrest patients in an urban, two-tiered EMS system. Prehosp Disaster Med. 1997; 12: 284-287 PubMed Google Scholar ; Pittsburgh, 22% 3 Nichol G. Thomas E. Callaway C.W. et al. Regional variation in out-of-hospital cardiac arrest incidence and outcome. JAMA. 2008; 300: 1423-1431 Crossref PubMed Scopus (1488) Google Scholar ; Portland, OR, 23% 3 Nichol G. Thomas E. Callaway C.W. et al. Regional variation in out-of-hospital cardiac arrest incidence and outcome. JAMA. 2008; 300: 1423-1431 Crossref PubMed Scopus (1488) Google Scholar ; Iowa, 23% 3 Nichol G. Thomas E. Callaway C.W. et al. Regional variation in out-of-hospital cardiac arrest incidence and outcome. JAMA. 2008; 300: 1423-1431 Crossref PubMed Scopus (1488) Google Scholar ; Miami, 24% 16 Myerburg R.J. Fenster J. Velez M. et al. Impact of community-wide police car deployment of automated external defibrillators on survival from out-of-hospital cardiac arrest. Circulation. 2002; 106: 1058-1064 Crossref PubMed Scopus (160) Google Scholar ; Milwaukee 26% 3 Nichol G. Thomas E. Callaway C.W. et al. Regional variation in out-of-hospital cardiac arrest incidence and outcome. JAMA. 2008; 300: 1423-1431 Crossref PubMed Scopus (1488) Google Scholar , Seattle, 46% (L. Cobb, personal communication, January 2009 [data are quoted for witnessed cases of ventricular fibrillation]), Rochester, MN, 46% 17 White R.D. Bunch T.J. Hankins D.G. Evolution of a community-wide early defibrillation programme: experience over 13 years using police/fire personnel and paramedics as responders. Resuscitation. 2005; 65: 279-283 Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar ; and King County, 46%. 18 Rea T. Helbock M. Perry S. et al. Increasing use of cardiopulmonary resuscitation during out-of-hospital ventricular fibrillation arrest: survival implications of guideline changes. Circulation. 2006; 114: 2760-2765 Crossref PubMed Scopus (230) Google Scholar We include here only studies with at least 100 cases of ventricular fibrillation. Also, some of the above rates are for all cases of ventricular fibrillation and some used witnessed ventricular fibrillation for the denominator, but we think the point is clear. Variability in survival is only part of the problem. In more than 4 decades of out-of-hospital cardiac arrest research, it is notable that fewer than 50 communities have reported their experience. Is the situation in the rest of the country good, bad, or terrible? We simply don't know. Whatever the service or product, we expect a reasonable standard of quality and a reasonable level of consistency from community to community. For some products and services, we actually have national standards and national enforcement. But with cardiac arrest, we have no such standards, no agency monitoring the quality of service, no political groundswell demanding improvements, and no public outcry for change. Admittedly there are large differences in community resources between rural and urban communities, and any future standards must take these differences into account, much like the National Fire Protection Academy Standard 1710 proposes different performance standards for different types of fire departments. 19 National Fire Protection AssociationStandard for the Organization and Deployment of Fire Suppression Operations, Emergency Medical Operations, and Special Operations to the Public by Career Fire Departments (NFDA1710). National Fire Protection Association, Quincy, MA2001 Google Scholar It is likely that defined standards for management of cardiac arrest can serve as a template for system-wide improvement and consistency.