ADVANCED RESCUER- VERSUS CITIZEN-WITNESSED CARDIAC ARREST: IS THERE A DIFFERENCE IN OUTCOME?

Amy H. Kaji, MD, PhD, Arslan M. Hanif, MD, James T. Niemann, MD

ABSTRACT Background. Substantial nancial and human resources are invested in training and maintaining advanced life support (ALS) skills of paramedics who are deployed to the eld in response to out-of-hospital cardiac arrest. It would be expected that patients who experience cardiac arrest in the presence of a trained health care practitioner, such as a paramedic, have better outcomes. Objective. To compare the rates of return of spontaneous circulation (ROSC), survival to hospital admission (SHA), and survival to hospital discharge (SHD) between paramedic-witnessed out-of-hospital cardiac arrest vs. citizen-witnessed out-of-hospital cardiac arrest. Methods. In this retrospective cohort study, the records of all out-of-hospital nontraumatic cardiac arrest patients presenting to a municipal teaching hospital from November 1, 1994, through June 30, 2008, were reviewed. The age, gender, race, rhythm on paramedic arrival, presence of bystander cardiopulmonary resuscitation (CPR), whether it was a witnessed arrest and, if witnessed, whether it was a paramedicwitnessed arrest, site of the arrest, and the rate of SHD were noted. A univariate odds ratio was computed to describe the association between paramedic-witnessed out-ofhospital cardiac arrest vs.citizen-witnessed out-of-hospital cardiac arrest and SHD. A multivariable logistic regression analysis was also performed, controlling for age, gender, arrest rhythm, bystander CPR, and site of arrest. Results. Of the total cohort of 1,294 out-of-hospital cardiac arrests, 750 (52.6%) were either paramedic-witnessed (154/750 = 20.5%) or citizen-witnessed (596/750 = 79.5%). Among the witnessed cardiac arrests, overall the SHD was 53 of 750 (7.1%). On univariate analysis, the ROSC, SHA, or SHD rates were not statistically signicantly different between paramedicand citizen-witnessed arrests. Even after multivariable adjustment, the ROSC, SHA, and SHD rates were not significantly different between paramedic- and citizen-witnessed arrests. Conclusions. Among our study population of out-ofhospital cardiac arrest victims, paramedic-witnessed arrests did not appear to have improved survival rates when compared with citizen-witnessed arrests. Key words: cardiac arrest; cardiopulmonary resuscitation; advanced life support; basic life support PREHOSPITAL EMERGENCY CARE 2011;15:5560

INTRODUCTION
The goal in the management of cardiac arrest is to achieve return of spontaneous circulation (ROSC) as quickly as possible and to ultimately achieve a meaningful survival outcome. The four links in the chain of survival model, advocated by the American Heart Association (AHA), remain the standard of care for the management of out-of-hospital cardiac arrest.1 The AHA-recommended interventions include early access, early cardiopulmonary resuscitation (CPR), Advanced Cardiac Life Support (ACLS), and debrillation. While emergency medical technicians (EMTs) and paramedics are both trained in basic life support (BLS), only paramedics who are trained in advanced life support (ALS) can administer cardiac medications and perform endotracheal intubation. The Utstein guidelines recommend that emergency medical services (EMS)-witnessed cardiac arrest be analyzed separately from other cardiac arrest cases; it has further been demonstrated that EMS-witnessed cardiac arrest cases presenting with chest pain and dyspnea are important predictors of survival.2 Training paramedics to achieve and maintain prociency in ALS skills warrants tremendous resources for continued education, nancial expense, and training time. In this era of limited health care resources, it is critical to prioritize and optimize the use of resources for a local emergency response system. Thus, it would be important to know whether the investment of resources and time in maintaining paramedic prociency in ALS results in a survival benet among paramedic-witnessed cardiac arrests, when compared with citizen-witnessed cardiac arrests. Unfortunately, whether the provision of ALS for out-of-hospital cardiac arrest results in improved survival outcomes is unclear, as some studies suggest a benet, whereas others suggest no benet.35 Callaham and Madesne demonstrated no difference in survival and neurologic outcome among a cohort of out-of-hospital cardiac 55

Received January 19, 2010, from the Department of Emergency Medicine, HarborUCLA Medical Center, Torrance, California (JTN, AHK, AMH); the Los Angeles Biomedical Research Institute at HarborUCLA Medical Center, Torrance, California (JTN, AHK); and the David Geffen School of Medicine at UCLA, Los Angeles, California (JTN, AHK). Revision received June 7, 2010; accepted for publication June 11, 2010. Presented in part at the 2010 National Association of EMS Physicians annual meeting, Phoenix, Arizona, January 2010. None of the authors have any conicts of interests with other people or organizations that could inappropriately inuence this work. There were no study sponsors. Address correspondence and reprint requests to: James T. Niemann, MD, Department of Emergency Medicine, HarborUCLA Medical Center, 1000 West Carson Street, Box 21, Torrance, CA 90509. e-mail: jniemann@emedharbor.edu doi: 10.3109/10903127.2010.514089

56 arrest patients in San Francisco with the provision of ALS.6 Similarly, one of the most widely cited studies is the Ontario Prehospital Advanced Life Support (OPALS) study, in which Phase III of the study found no improvement in survival rates when ALS was added to regions where BLS and rapid debrillation were already in place.3 Multivariable analysis of the OPALS database demonstrated only the following factors to be independently associated with survival: age, bystander-witnessed cardiac arrest, bystander CPR, CPR administered by reghters or police, and response interval.7 In contrast, in a recent study, Markel et al. demonstrated that a shorter BLS-to-ALS arrival interval in King County, Washington, increased the likelihood of survival to hospital discharge (SHD) after out-of-hospital cardiac arrest due to ventricular brillation, suggesting that ALS interventions may provide additional benet over BLS interventions in a two-tiered EMS system already optimized for rapid debrillation.8 An analysis of EMS-witnessed cardiac arrest cases compared with bystander-witnessed and unwitnessed cases stratied by bystander CPR from the Resuscitation Outcomes Consortium (ROC) also demonstrated only a small improvement in survival rates among EMS-witnessed cases, when compared with bystander-witnessed cardiac arrests with bystander CPR.9 None of the aforementioned studies, however, specically assessed the efcacy of ALS interventions for witnessed out-of-hospital cardiac arrest. The objective of our study was to evaluate the efcacy of ALS, which includes the administration of ACLS medications and airway adjuncts, as utilized by paramedics, for witnessed out-of-hospital cardiac arrest. Thus, survival outcomes among paramedic-witnessed cardiac arrests were compared with those among citizenwitnessed cardiac arrests.

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residents. The hospital catchment area is approximately 27 square miles, serving a predominantly underserved community. The Los Angeles County EMS system is based on a two-tiered response activated by a central dispatch 91-1 network. First-responder engine units are manned by reghter EMT-1 personnel with automated external debrillators. In Los Angeles County, reghter EMT-1 paramedics and EMT-2 ambulance units, which are considered BLS units, are dispatched simultaneously, and thus, there is little to no distinction between ALS paramedicwitnessed and BLS EMT-2witnessed cardiac arrests. Paramedics are certied ACLS providers, and they are trained in cardiac rhythm recognition, endotracheal intubation, debrillation, and pharmacologic interventions. When indicated, paramedics are trained to administer countershocks, administer CPR, perform intubation, establish intravenous (IV) access, and initiate pharmacologic therapy prior to base station contact. Subsequent interventions are directed via radio or phone by certied nurses or emergency medicine residents under emergency medicine faculty supervision.

Data Collection
Data from November 1, 1994, to June 30, 2008, were contemporaneously entered and retrospectively reviewed from eld rescue reports completed by paramedics, verbal reports from paramedics, which are included in nursing and physician notes, the emergency department cardiac arrest ow sheet, the emergency department record, and in-hospital records for all patients who survived to hospital admission. All data sources for each patient were abstracted by the investigators and entered into a database for later review. All patients transported to this hospital who have had an out-of-hospital medical or traumatic arrest, as well as all in-hospital deaths, are catalogued separately, thereby minimizing the chances for missing any out-of-hospital cardiac arrests. Two abstractors reviewed the charts of all patients who had outof-hospital arrests, and selected out the cardiac arrests. The abstractors were trained to review and cull data from paramedic run sheets, nursing charts, and physician medical records. Neither abstractor was blinded to the objective of the study. Exclusion criteria were as follows: documented do not resuscitate status, unwitnessed cardiac arrest, age <18 years, and cardiac arrest due to trauma or drowning or related to a drug overdose. The abstractors used a standardized form to record data, which included the following: age, gender, race, rst documented rhythm, whether it was a citizen-witnessed or a paramedic-witnessed arrest, site of the arrest, whether there was bystander CPR, ROSC, SHA, and SHD. Questions about data entry elds or disagreements between abstractors were discussed until consensus was achieved.

METHODS
Study Design
This was an observational study of a retrospective cohort of all witnessed, consecutive adult (>18 years of age) patients with out-of-hospital nontraumatic cardiac arrests presenting to a single municipal teaching hospital in Los Angeles County between November 1, 1994, and June 30, 2008. The Research Committee and Human Subjects Committee of our institution approved the study, and it was deemed exempt from informed consent.

Study Setting
The study site is a 553-bed general municipal hospital located in southwestern Los Angeles County, which has a population of approximately 11 million

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Statistical Analysis
Data were entered into a Microsoft Excel (Microsoft Corp., Redmond, WA) spreadsheet, and DBMS Copy was used to convert the le into a SAS version 9.2 (SAS Institute Inc., Cary, NC) database. Simple descriptive statistics were used to describe continuous and categorical variables. The Wilcoxon rank sum test was then used to compare the median values and interquartile ranges (IQRs) of continuous variables if the data were not normally distributed, whereas a univariate odds ratio was computed to describe the association between paramedic-witnessed versus citizenwitnessed out-of-hospital cardiac arrests and survival rates. A multivariable logistic regression analysis was then performed, including all variables based on established evidence (e.g., race), as well as those that were found to be statistically signicant predictors of survival in the univariate analysis (e.g., age, gender, rhythm on paramedic arrival, site of arrest, and whether there was bystander CPR).9 Rather than simply including variables that are found to be statistically signicant in univariate testing, a well-accepted tenet of biostatistics is to consider literature-based, known predictors, even when they are not found to be predictive on univariate analysis.10 Existing research demonstrates that patients with an initial arrest rhythm of ventricular brillation (VF) or ventricular tachycardia (VT) are more likely to survive than patients with other presenting rhythms, and bystander and rstresponder CPR positively impacts survival.2 Because of research demonstrating similar survival outcomes for those with pulseless electrical activity (PEA) and asystole in of out-of-hospital cardiac arrest, experts in the eld have moved toward categorizing prehospital cardiac arrest into shockable and nonshockable rhythms.11 We have similarly grouped together asystole and PEA in one group, and VF and VT in another. Moreover, because of their increased comorbid risk factors, nursing home (skilled nursing facility) residents are likely to have decreased survival when compared with cardiac arrest victims who have an event at home, in the workplace, or at another public site. One study examining over 2,300 cardiac arrest cases (182 at a nursing home) demonstrated that nursing home residents were less likely to survive to hospital discharge (0% vs. 5.6%, p < 0.001).12 Thus, the site of arrest was further stratied according to whether it occurred in a nursing home or elsewhere. The goodness of t of the multivariable model would be determined by the Hosmer-Lemeshow test statistic. All odds ratios (ORs) are reported with 95% condence intervals (CIs). Finally, we performed a post-hoc power analysis assuming that we would have an SHD rate of approximately 13% in paramedic-witnessed vs. 5% in citizen-witnessed cardiac arrest using PASS 2002 Software (NCSS Corporation, Kaysville, UT). With
OOH-CA N = 1294

Witnessed N=750 (57.9%)

Unwitnessed N=544 (42.0%)

PW N=154 (20.5%)

CW N= 596 (79.5%)

ROSC = 74 (13.6%) SHA = 46 (8.5%) SHD = 3 (0.6%)

ROSC = 52 (33.8%) SHA = 29 (18.8%) SHD = 9 (5.8%)

ROSC = 183 (30.7%) SHA = 124 (20.8%) SHD = 44 (7.4%)

FIGURE 1. Flow diagram with results of witness subgroup types. CW = citizen-witnessed; OOH-CA = out-of-hospital cardiac arrest; PW = paramedic-witnessed; ROSC = return of spontaneous circulation; SHA = survival to hospital admission; SHD = survival to hospital discharge.

sample sizes of 153 and 597 in the paramedicwitnessed and citizen-witnessed groups, respectively, our study would achieve 87% power to detect an 8% difference at an alpha of 0.05.

RESULTS
A total of 1,294 nontraumatic cardiac arrests were reviewed, of which 750 (52.6%) were witnessed by either a paramedic or a citizen. Among the witnessed arrests, 154 (20.5%) were paramedic-witnessed and 596 (79.5%) were citizen-witnessed. A ow diagram of subgroups with survival outcomes is shown in Figure 1. Demographic data and resuscitation variables with outcomes and comparisons between the two cohorts are shown in Tables 1 and 2. When comparing paramedic-witnessed cardiac arrest and citizen-witnessed cardiac arrest, the median age of the paramedic-witnessed group was 72 years (IQR = 58, 83), whereas the median age of the citizen-witnessed group was 68 years (IQR = 55, 77), p = 0.002. For categorical comparisons between the two cohorts, there were signicant differences in gender, site of arrest, whether there was bystander CPR, and arrest rhythm. Among the paramedic-witnessed group, 60% had PEA. The citizen-witnessed group had a greater proportion of patients who presented with asystole, a near-terminal rhythm. Since existing research demonstrates that patients with an initial arrest rhythm of VF or VT are more likely to survive than patients with other presenting rhythms, we further divided the groups into VF/VT versus other presenting rhythm. A greater proportion of patients presenting with VF/VT was observed in the citizen-witnessed group (OR 2.0,

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TABLE 1. Population Demographics for Witnessed Cardiac Arrests

Variable Total Witnessed Population (n = 750) Paramedic-Witnessed (n = 154) Citizen-Witnessed (n = 596) Odds Ratio for the Difference (95% CI)

Agemedian (IQR) Gender Male Female Race/ethnicity Asian Black White Hispanic Other Site of cardiac arrest Home or other Nursing home

69 (56, 79) 455 (60.7%) 295 (39.3%) 130 (17.9%) 191 (26.3%) 274 (37.7%) 123 (16.9%) 8 (1.1%) 573 (76.4%) 177 (23.6%)

72 (58, 83) 81 (52.6%) 73 (47.4%) 25 (16.8%) 42 (28.2%) 57 (38.3%) 24 (16.1%) 1 (0.7%) 105 (68.2%) 49 (31.8%)

68 (55, 77) 374 (62.8%) 222 (37.3%) 105 (18.2%) 149 (25.8%) 217 (37.6%) 99 (17.2%) 7 (1.2%) 468 (78.5%) 128 (21.5%)

0.7 (0.5, 0.9)

1.7 (1.2, 2.5)

Note that we were unable to specically distinguish race from ethnicity. We recognize that race and ethnicity in the United States Census, as dened by the United States Census Bureau and the Federal Ofce of Management and Budget (OMB), are self-identication data items in which residents choose the race with which they most closely identify, and indicate whether or not they are of Hispanic or Latino origin. As these patients were cardiac arrest victims, racial and ethnic self-identication was not possible. Thus, these race/ethnicity categorizations are those assigned by the registration clerk. CI = condence interval; IQR = interquartile range.

95% CI 1.4, 2.8, p < 0.001). As would be expected, all but one paramedic-witnessed arrest victim had received CPR, provided by the paramedic, whereas less than half of the citizen-witnessed cardiac arrest patients had received bystander CPR. There was no statistically signicant difference in ROSC, SHA, or SHD between the citizen-witnessed and the paramedic-witnessed groups on univariate analysis. Multivariable logistic regression modeling, adjusting for age, race, gender, rhythm on presentation, whether there was bystander CPR, and site of arrest, still demonstrated no statistically signicant difference in SHD for paramedic-witnessed cardiac arrest vs. citizen-witnessed cardiac arrest, with an OR of 0.6 (95% CI 0.3, 1.6).

DISCUSSION
Paramedic-witnessed cases are an important subgroup of the out-of-hospital cardiac arrest population. Since these patients have the benet of immediate resuscitation by trained providers, it would be assumed that survival outcomes would be better among this cohort. Paramedics are trained in advanced airway techniques as well as the administration of IV cardiac medications. Because of the unique circumstances surrounding paramedic-witnessed cardiac arrest, the Utstein guidelines recommend separating this group from all other cardiac arrest victims. The guidelines contend that the inclusion of paramedic-witnessed arrest patients in the analysis of the total cardiac arrest

TABLE 2. Resuscitation Variables and Outcomes for Witnessed Cardiac Arrests

Variable Total Witnessed Population (n = 750) Paramedic-Witnessed (n = 154) Citizen-Witnessed (n = 596) Odds Ratio for the Difference (95% CI)

Rhythm Asystole or PEA VF/VT Bystander CPR Yes No ROSC Yes No SHA Yes No SHD Yes No

487 (65.2%) 260 (34.8%) 411 (55.2%) 334 (44.8%) 234 (31.2%) 516 (68.8%) 152 (20.3%) 598 (79.7%) 53 (7.1%) 697 (92.9%)

124 (80.4%) 30 (19.6%) 153 (99.4%) 1 (0.6%) 52 (33.8%) 102 (66.2%) 29 (18.8%) 125 (81.2%) 9 (5.8%) 145 (94.2%)

364 (61.3%) 230 (38.7%) 258 (43.7%) 333 (56.3%) 183 (30.6%) 415 (69.4%) 123 (20.6%) 473 (79.4%) 44 (7.4%) 552 (92.6%)

0.4 (0.3, 0.6)

197.5 (27.4, 1420.4)

1.16 (0.79, 1.68)

0.9 (0.6, 1.4)

0.8 (0.4, 1.6)

CI = condence interval; CPR = cardiopulmonary resuscitation; PEA = pulseless electrical activity; ROSC = return of spontaneous circulation; SHA = survival to hospital admission; SHD = survival to hospital discharge; VF/VT = ventricular brillation/ventricular tachycardia.

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patient pool distorts the calculation of EMS response intervals, presence of bystanders, and performance of citizen CPR.13 Our study results, however, demonstrated no statistically signicant difference in ROSC, SHA, or SHD rates among paramedic-witnessed, nontraumatic out-of-hospital cardiac arrest patients, when compared with citizen-witnessed out-of-hospital cardiac arrest patients, even after adjusting for age, gender, initial rhythm, site of arrest, and whether there was bystander CPR. Our results are in contrast to those of DeMaio et al., who demonstrated better survival for their EMS-witnessed cardiac arrest group.2 It may be that our cohort of paramedic-witnessed cardiac arrest patients had poor survival outcomes because the proportion with an initial arrest rhythm other than VF/VT was so high, although it is known that EMS-witnessed arrest patients are more likely to have PEA than VF/VT.11 In our study, the higher rates of PEA among paramedic-witnessed arrest patients may reect greater comorbid illness, and the fact that even if VF/VT were the presenting rhythm in citizenwitnessed arrests, it might degenerate into the terminal rhythms of PEA/asystole by the time the paramedics arrived on scene. The OPALS trial evaluated differences in survival outcomes after adding ALS (e.g., endotracheal intubation and IV drug therapy) to a system where early debrillation was already being practiced. Conversely, other studies have evaluated the effect of early debrillation provided by ALS providers, such as paramedics. Many have questioned the relative costeffectiveness of providing an early debrillation program versus that of training, equipping, and paying ALS personnel for intubation techniques, learning rhythm interpretation, and administering IV drugs. The majority of out-of-hospital cardiac arrest victims fail to achieve ROSC after debrillation. Even when ROSC is achieved, the added benet of IV drug therapy in prehospital cardiac arrest is questionable.14,15 It may be that in urban settings where transport times are relatively short, the most and possibly only important paramedic skills to maintain for out-of-hospital cardiac arrest are those of providing effective CPR and debrillation. In this era of heated debate over health care reform and the absolute necessity to decrease costs, it behooves us as health care providers to reevaluate the costs and effectiveness of medical services, including those of maintaining ALS skills for paramedic providers, specically for the management of out-ofhospital cardiac arrest. As we develop terminationof-resuscitation criteria for out-of-hospital cardiac arrest, a better understanding of the incremental survival benet and costeffectiveness of each intervention is needed to decrease expenditure of funds and resources allocated to futile measures.

LIMITATIONS
Our study has several limitations, most importantly that the retrospective, observational design does not allow us to conclude that any causal relationships exist. A randomized controlled trial is optimal for identifying a causal relationship between an intervention (e.g., immediate ALS provided by paramedics in response to witnessed cardiac arrest). However, the logistic and ethical challenges posed by such a study design would likely be insurmountable. Although we did not nd any survival benet among paramedic-witnessed cardiac arrest, this does not necessarily indicate that ALS training is not effective for other disease presentations in different settings. Our data are collected from a single urban hospital system, and the generalizability of our results to rural areas where transport times are lengthy is unknown. Furthermore, the geographic variation in outof-hospital cardiac arrest survival outcomes is well known and clearly system-dependent.16,17 There is also the possibility for misclassication, since patients transferred to other facilities were classied as survivors, and these patients may not have survived to hospital discharge. The data collection also occurred over a prolonged period of 14 years, during which time three sets of ACLS guideline changes were implemented. Clearly, other secular changes during this period may have also contributed to our ndings. For example, great efforts have been made toward promoting citizen awareness of the benets of early access and early CPR. Finally, since Glasgow Coma Scale (GCS) scores were not available to us, we did not assess neurologic outcome, and it is possible that the small number of paramedic-witnessed survivors had more favorable neurologic outcomes.

CONCLUSION
When compared with citizen-witnessed out-ofhospital cardiac arrest, paramedic-witnessed out-ofhospital cardiac arrest did not appear to improve survival to hospital discharge in our particular urban system. Many out-of-hospital cardiac arrest cases witnessed by paramedics occur in nursing homes, and shockable (e.g., VF/VT) rhythms are less frequent in this chronically ill population.

References
1. 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2005;112:IV1IV203. 2. DeMaio VJ, Stiell IG, Wells GA, Spaite DW. Cardiac arrest witnessed by emergency medical services personnel:

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