Clinical paperCommunity lessons to understand resuscitation excellence (culture): Association between emergency medical services (EMS) culture and outcome after out-of-hospital cardiac arrest
Introduction
Out-of-hospital cardiac arrest (OHCA) is a leading cause of death globally.1 Survival from OHCA is poor (<10%) in most communities, but varies greatly across different populations, emergency medical services (EMS), and locations.2 Patient and process of care factors that were promoted as explaining differences in survival after OHCA across communities3 leave much of the survival variation unexplained.2, 4, 5, 6 Improved understanding of modifiable factors that contribute to the large variation in survival could guide efforts to improve survival.7
A ‘culture of excellence’ in resuscitation within an EMS agency is believed to foster higher quality care and improved survival after OHCA. The Global Resuscitation Alliance recommends EMS agencies work toward a culture of excellence as one of the ten steps to improve OHCA survival in their communities.8 The Global Resuscitation Alliance performance Goals for a culture of excellence include: convening leadership meetings once a month, analyzing data in partnership with operations and medical director, and using data to inform training and protocols. Within the EMS organizational environment, this can include practices such as measuring and reviewing cardiopulmonary resuscitation (CPR) quality. In the management of acute myocardial infarction (AMI), hospitals with lower risk-standardized mortality rates are characterized by organizational environments that foster higher quality care rather than just specific practices and protocols.9 But we have incomplete information about whether the EMS organizational structure and environment influences patient outcome.
We sought to determine whether a culture of excellence in resuscitation is associated with survival after OHCA.
Section snippets
Design
This study is a retrospective analysis of prospectively collected data from the Resuscitation Outcomes Consortium (ROC) Epistry – Cardiac Arrest linked with responses to a cross-sectional survey of ROC EMS agency medical directors. The University of Washington Human Subjects Division determined that this study was exempt from human subject research regulations.
Setting and data source
The study was conducted in regions of North America covered by EMS agencies participating in the ROC clinical research network. All
Results
Of the 46 medical directors surveyed, 38 responded (83%), of which 35 (76%) had complete responses. The complete responses group represented 123 EMS agencies out of 210 (59%) and 51,329 out of 66,597 (77%) patients with OHCA. The characteristics of included and excluded OHCA cases based on survey response were similar and there was no significant difference in survival to hospital discharge between these groups (Supplementary Table 1).
Discussion
Our study demonstrates that having an organizational goal to improve OHCA survival is independently associated with greater survival over several years among geographically diverse EMS agencies throughout North America. This domain included EMS agencies having an organizational goal to increase OHCA survival and having a quality improvement officer or team dedicated to measuring and improving OHCA survival.
Organizational culture remains an elusive concept but it ‘emerges from that which is
Conclusion
An organizational goal to improve OHCA survival was independently associated with improved survival. EMS agencies looking to develop a culture of excellence in resuscitation and improve OHCA survival should consider implementing an organizational goal to improve OHCA survival and employ quality improvement personnel to drive that goal.
Author credit statement
KD and GN conceived the study. KD, GN and MS adapted the survey. SPB and SM provided statistical advice on study design and KD analyzed the data. KD drafted the manuscript, and all authors contributed substantially to its revision. KD takes responsibility for the paper as a whole.
Conflict of interest statement
All authors have no financial or personal conflicts that could inappropriately influence (bias) their work to disclose.
Funding
N/A.
References (24)
- et al.
Global incidences of out-of-hospital cardiac arrest and survival rates: systematic review of 67 prospective studies
Resuscitation
(2010) - et al.
International variation in survival after out-of-hospital cardiac arrest: a validation study of the Utstein template
Resuscitation
(2019) - et al.
Predicting survival after out-of-hospital cardiac arrest: role of the Utstein data elements
Ann Emerg Med
(2010) - et al.
Variation in outcome in studies of out-of-hospital cardiac arrest: a review of studies conforming to the Utstein guidelines
Am J Emerg Med
(2003) - et al.
Part 8: education, implementation, and teams: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations
Resuscitation
(2015) - et al.
Audiovisual feedback device use by health care professionals during CPR: a systematic review and meta-analysis of randomised and non-randomised trials
Resuscitation
(2014) - et al.
Quality of out-of-hospital cardiopulmonary resuscitation with real time automated feedback: a prospective interventional study
Resuscitation
(2006) - et al.
Teamwork and leadership in cardiopulmonary resuscitation
J Am Coll Cardiol
(2011) - et al.
Effects of team coordination during cardiopulmonary resuscitation: a systematic review of the literature
J Crit Care
(2013) - et al.
Survival and variability over time from out of hospital cardiac arrest across large geographically diverse communities participating in the Resuscitation Outcomes Consortium
Resuscitation
(2018)
Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis
Circ Cardiovasc Qual Outcomes
Cardiac arrest and cardiopulmonary resuscitation outcome reports: update of the Utstein resuscitation registry templates for out-of-hospital cardiac arrest: a statement for healthcare professionals from a task force of the international liaison committee on resuscitation
Circulation
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2022, ResuscitationCitation Excerpt :Differences like these are likely to explain the variation seen EMS treated patients and outcomes. Differences in EMS practice and polices have also been reported internationally, most recently across 28 European countries,25 and a recent paper from the North American Resuscitation Outcomes Consortium identified EMS organisation goals and values as associated with OHCA outcomes.26 We aim to repeat our previous EMS survey, including all EMS in our region and updated with recent findings such organisation goals, to explore how we might improve EMS-related modifiable factors.
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2021, ResuscitationCitation Excerpt :These individuals had different demographics and event characteristics compared with those not lost to follow-up. Emergency Medical Services (EMS) medical directors were surveyed to assess whether a culture of excellence in resuscitation might help to explain the large geographical variation in outcome after OHCA beyond traditional EMS characteristics.14 The results showed a striking association between EMS culture strategies and OHCA survival to hospital discharge.
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2021, The Lancet Regional Health - EuropeCitation Excerpt :Implementation of an FR-system may be part of a combined approach of several initiatives to improve the OHCA-chain of care. [27] Therefore, the benefit of the presence of an FR-system may also be a result of other beneficial improvements in the chain of care (for example, having an organization goal).[28] This study has several strengths.
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