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Public Access Defibrillation- Results from the Victorian Ambulance Cardiac Arrest Registry

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Public Access Defibrillation- Results from the Victorian Ambulance Cardiac Arrest Registry Public access defibrillation- Results from the Victorian Ambulance Cardiac Arrest Registry (VACAR) M Lijovic1,2, S Bernard1,2, Z Nehme1,2, T Walker1 and K Smith1,2,3, on behalf of the Victorian Ambulance Cardiac Arrest Registry Steering Committee 1Ambulance Victoria, 2Monash University, 3University of WA This presentation will address: • Burden of out-of-hospital cardiac arrest (OHCA) • Emergency medical services, public access defibrillation (PAD) programs and automated external defibrillator (AED) locations in Victoria, Australia • Victorian Ambulance Cardiac Arrest Registry (VACAR) Burden of out-of-hospital cardiac arrest • OHCA is a significant public health problem In Victoria, Australia, the annual incidence of adult OHCA attended by ambulance is 120.8 events per 100,000 population (Victorian Ambulance Cardiac Arrest Registry Annual Report 2013/14. 2014, Ambulance Victoria). • For every minute delay in response time, survival decreases by 9% (95% CI, 4-14%) Cardiac arrests of presumed cardiac aetiology, presenting in VF/VT and where resuscitation is attempted by emergency medical services (EMS) (Fridman et al. Resuscitation 2007) • Improved survival rates are possible, in spite of increasing response times, if bystanders perform CPR and defibrillate using an automated external defibrillator (AED) Public access defibrillation programs • The AHA, ERC and Australian and New Zealand Resuscitation Councils advocate defibrillation through PAD programs (Weisfeldt et al. Circulation, 1995; Australian and New Zealand Resuscitation Councils, 2011; Nolan et al. Resuscitation, 2010) AEDs in the community, particularly in locations with high incidence of arrests, to facilitate rapid defibrillation by laypersons prior to EMS arrival • Public AED programs have effectively been used in communities Survival to discharge: 31 - 69% (Hallstrom et al. NEJM, 2004; Kitamura et al. NEJM, 2010; Eckstein et al, Resuscitation, 2012; Nielsen et al. Resuscitation, 2013) AED application before EMS arrival increased likelihood of survival to discharge (AOR 1.75; 95% CI, 1.23-2.50) (Weisfeldt et al. J Am Coll Cardiol 2010) Bystander CPR+defib (30 survivors/128), bystander CPR (15 survivors/107) CPR+defib = More survivors (RR 2.0; 95% CI, 1.07-3.77) (Hallstrom et al) Limited Australian data • To date, one small study assessing impact of public AEDs in limited sites in Victoria showed its potential to improve patient survival (Wassertheil et al. 2000) St John first aid volunteers using AEDs at two public locations Of 28 patients, 24 (86%) survived ‘at scene’ & 20 (71%) discharged home • No population-based studies assessing impact of PAD in Victoria AIM • Retrospective analysis of adults suffering an OHCA using a population-based registry in Victoria • Assess the impact of first defibrillation by a bystander with a public AED compared to first defibrillation by EMS on survival- related outcomes STUDY SETTING Emergency medical services in Victoria • Ambulance Victoria is the major provider of emergency ambulance services in Victoria 5.7 million (population); 227,416 km2 (area) Follow Australian Resus Council guidelines • Victorian emergency medical services (EMS): AV (Advanced Life Support & MICA paramedics) Fire-fighters co-respond metro Melbourne & sections of outer Melbourne Community Emergency Response Teams (CERTs) in rural areas AV PAD program in Victoria • In 2002, the Victorian State Government announced it would fund a PAD program with Metropolitan Ambulance Service & Rural Ambulance Victoria (now Ambulance Victoria, AV) AV provides annual training at each site, ongoing support/ education, clinical debriefing and peer support following significant events & ‘skills refresher’ follow-up visits every 2 months AV PAD sites • Since mid 2002, AV has allocated and maintained 91 AEDs in 25 areas of high public attendance and/or site of arrests around Victoria Metropolitan region Rural region AV PAD Program No. AEDs AV PAD Program No. AEDs Melbourne Airport 34 Otway Fly 1 Wyndham Leisure Centre 1 Queenscliff Ferry 2 Ashburton Recreational Centre 1 Avalon Airport 3 Croydon Leisure Centre 2 Sovereign Hill 3 Federation Square 1 Mildura Airport 1 Kew Recreational Centre 1 Phillip Island Metro Trains (4 city stations) 9 >> Penguin Parade 2 NGV Aust- Fed Square 1 >> Seal Rock 1 NGV Inter- St Kilda Rd 2 >> Koala Park 1 Ringwood Aquatic Centre -- >> Churchill Island 1 Shrine 3 TOTAL Rural 15 Werribee Zoo 2 Healesville Sanctuary 2 Melbourne Zoo 2 Southern Cross Station 5 Chadstone Shopping Centre 10 TOTAL Metro 76 TOTAL Metro and Rural 91 Other AED locations in Victoria • AV also maintains a record of AED locations within the community “Opt in” AED registry The location of 1500 AEDs in the community have been registered with AV by the owner(s) of these AEDs via the website: http://www.registermyaed.com.au/ • AED locations are entered into the computer aided dispatch system so that ‘000’ callers can be alerted to a defibrillator located nearby Locations include businesses, sports clubs, community groups, other public venues (e.g. casino) • At some public sites, volunteer first-aid agencies have AEDs for use by trained staff VACAR • Data on all OHCA patients attended by ambulance in Victoria Data collection since 1999 (> 75,000 cases) Event Register AV Patient Care Records Computer Fire, CERT Aided Dispatch PCRs response data VACAR QOL AV ECG survey Death Audit Fire, CERT, Hospital/ AV PAD Registry coroners ECG data Information such as whether a patient is defibrillated by a member of the public with an AED is included in the VACAR RESULTS Study population Definition of bystander defibrillation • ‘First defibrillated by a bystander with a public AED’: Bystander using a public AED at a site maintained by the local EMS or maintained by another organisation or St John first aid volunteers using an AED at a public event • Of 153 patients first defibrillated by a bystander with a public AED, 25 cases AV-maintained PAD site 26 cases Public event (by a first-aid volunteer) 102 cases Site not maintained by AV Common sites where public AED used • Most common locations of arrest where individual first defibrillated with a public AED’: International airport in the capital city Melbourne (n=18, 12%) 2 sporting venues in Melbourne with large public events attended by St John first aid volunteers (n=18, 12%) Casino in the capital city (n=4, 2.5%) Remaining cases defibrillated at other sites around state (n=113, 74%) Public sites where individuals were defibrillated First shocked by First shocked by bystander with EMS public AED (n=2,117) (n=153) Location Frequency (%) Frequency (%) Street / car park / public road / motor vehicle 1167 ( 55% ) 33 ( 22% ) Recreation/ sporting complex 386 ( 18% ) 76 ( 50% ) Workplace 296 ( 14% ) 13 ( 8% ) Airport 0 ( 0% ) 18 ( 12% ) All other public places 268 ( 14% ) 13 ( 8% ) Population characteristics First shocked by First shocked by bystander with EMS public AED (n=2,117) (n=153) Frequency (%) Frequency (%) P value Age, years (median, IQR) 63 (53, 74) 63 (52, 71) 0.246 Unknown, n (%) 4 (0.2%) 0 (0%) Male gender, n (%) 1860 ( 88% ) 138 ( 88% ) 0.390 Cardiac precipitating event, n (%) 2058 ( 97% ) 148 ( 97% ) 0.729 Bystander witnessed, n (%) 1765 ( 84% ) 134 ( 88% ) 0.214 Unknown, n (%) 10 (0.5% ) 0 (0% ) Bystander CPR, n (%) 1571 ( 74% ) 146 ( 95% ) <0.001 EMS Response time, mins (median, IQR) 7.3 (5.8, 10.0) 8.0 (6.1, 10.9) 0.017 Unknown, n (%) 38 (2% ) 6 (4% ) Time to first shock, mins (median, IQR) 10.0 (8.0, 13.0) 5.2 (4.0, 8.0)^ <0.001 Unknown, n (%) 60 (3% ) 13 (8% ) Survival to hospital, n (%) 1059 ( 51% ) 99 ( 66% ) <0.001 Unknown, n (%) 26 (1% ) 2 (1% ) Survival to hospital discharge, n (%) 637 ( 31% ) 66 ( 45% ) 0.001 Unknown, n (%) 73 (3% ) 6 (4% ) Percentages exclude unk nown values. ^ Median time to first shock for patients first defibrillated with a public AED includes 41 cases (27%) where time to first shock was estimated from event chronology and applying an average time difference between being at the patient/ commencing CPR and first defibrillation. Excluding these 41 shock time estimates gives rise to a median (IQR) time to first shock of 5.4 (4.0-8.0) which is not significantly different from the estimate shown in the table. PAD outcomes in Victoria vs other PAD studies First shocked by bystander with Comparator PAD public AED study (n=153) Frequency (%) Frequency (%) Non-traumatic cases shocked with public AED, n 153 Eckstein et al. Survival to hospital discharge, n (%) 66 of 153 (45%) 27 of 29 (69%) " Weisfeldt et al. 64 of 170 (38%) Bystander witnessed & cardiac cause, n 130 Kitamura et al. Survival to hospital discharge, n (%) 56 of 124 (45%) 146 of 462 (32%) 30-day neurol-intact surv Bystander witnessed, n 134 Valenzuela et al. Survival to hospital discharge, n (%) 58 of 128 (45%) 53 of 90 (59%) If shock after >3 mins, 27 of 55 (49%) Presumed cardiac origin, n 148 Nielsen et al. Survival to hospital discharge, n (%) 63 of 142 (44%) 20 of 29 (69%) 30-day neurol-intact surv Cases defibrillated at airport, n 18 Caffrey et al. Survival to hospital discharge, n (%) 8 of 17 (47% ) 11 of 18 (61%) Eck stein et al. Resuscitation 2012;83(11):1411-2. Valenzuela et al. N Engl J Med 2000;343(17):1206-9. Weisfeldt et al. J Am Coll Cardiol 2010;55(16):1713-20. Nielsen et al. Resuscitation 2013;84(4):430-4. Kitamura et al. N Engl J Med 2010;362(11):994-1004. Caffrey et al. N Engl J Med 2002;347(16):1242-7. Logistic regression- Survival to discharge Predictor variable Odds ratio 95% CI P value Age 0.98 0.97 - 0.98 <0.001 EMS response time 0.87 0.85 - 0.90 <0.001 Bystander CPR 2.52 1.96 - 3.24 <0.001 Public witnessed 1.32 1.01 - 1.72 0.045 First defibrillation by bystander with 1.62 1.12 - 2.34 0.010 public AED Excluded from model: Male gender, cardiac precipitating event n.s Time to first shock First defibrillation with a public AED associated with improved odds for survival to hospital discharge, compared to first defibrillation by EMS 62% increase in chance of survival to hospital discharge [ Adjusted odds ratio 1.75 (95% CI, 1.23-2.50) Weisfeldt et al.
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