Elsevier

Resuscitation

Volume 156, November 2020, Pages 202-209
Resuscitation

Clinical paper
Community lessons to understand resuscitation excellence (culture): Association between emergency medical services (EMS) culture and outcome after out-of-hospital cardiac arrest

https://doi.org/10.1016/j.resuscitation.2020.09.020Get rights and content

Abstract

Background

The large geographic variation in outcome after out-of-hospital cardiac arrest (OHCA) is not well explained by traditional patient and emergency medical services (EMS) characteristics. A ‘culture of excellence’ in resuscitation within an EMS is believed to be an important factor that influences quality of care and outcome in patients with OHCA. However, whether a culture of excellence is associated with improved survival after OHCA is not known.

Methodology

We linked survey responses from EMS agency medical directors related to resuscitation culture to a retrospective analysis of prospectively collected data from the Resuscitation Outcomes Consortium (ROC) Epistry – Cardiac Arrest. We used a multivariable random effects model to assess whether EMS culture strategies were associated with OHCA survival to hospital discharge.

Results

Of the 46 EMS medical directors surveyed, 35 (76%) provided a complete response. Included were n = 66,597 cases of OHCA who received attempted resuscitation by one of n = 123 EMS agencies from July 1, 2010, through June 30, 2015. Overall survival to discharge was 11%. Organizational values and goals were independently associated with survival to hospital discharge in all OHCAs (adjusted odds ratio [AOR] 1.27, 95% confidence interval [CI] 1.09−1.48) and the subgroup restricted to bystander witnessed OHCAs with initial shockable rhythm (AOR 1.55, 95% CI 1.21−1.99).

Conclusions

An organizational goal to improve OHCA survival was independently associated with improved survival to discharge. EMS agencies looking to improve OHCA survival should consider implementing an organizational goal to improve OHCA survival and empower quality improvement personnel to drive that goal.

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)

  • C. Sasson et al.

    Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis

    Circ Cardiovasc Qual Outcomes

    (2010)
  • G.D. Perkins et al.

    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

    (2014)
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