SPECIAL CONTRIBUTION

cardiac arrest, out-of-hospital;

resuscitation, reporting guidelines;
Utstein Consensus Conference

Recommended Guidelines for Uniform

Reporting of Data From Out-of-Hospital
Cardiac Arrest: The Utstein Style

[Cummins RO, Chamberlain DA, Abramson NS, Allen M, Baskett P, Task Force of the American Heart
Becket L, Bossaert L, Delooz H, Dick W, Eisenberg M, Evans T, Holmberg Association, the European Resuscitation
S, Kerber R, Mullie A, Ornate JP, Sandoe E, Skulberg A, Tunstall-Pedoe H, Council, the Heart and Stroke Foundation
of Canada, and the Australian
Swanson R, Theis WH: Recommended guidelines for uniform reporting of
Resuscitation Council
data from out-of-hospital cardiac arrest: The Utstein Style. Ann Emerg
Med August 1991;20:861-874.]
Cochairmen: Richard O Cummins,
Douglas A Chamberlain
INTRODUCTION
Resuscitation has become an important multidisciplinary branch of
Members: Norman S Abramson, Mervyn
medicine, demanding a spectrum of skills and attracting a plethora of spe- Allen, Peter Baskett, Lance Becker, Leo
cialties and organizations, each of which claims a legitimate interest in the Bossaert, Herman Delooz, Wolfgang Dick,
science and practice of resuscitation. This complex background has hin- Mickey Eisenberg, Thomas Evans, Stig
dered the development of a uniform pattern or set of definitions for report- Holmberg, Richard Kerber, Arsene Mullie,
ing results. Different systems cannot readily be compared or contrasted Joseph P Ornate, Eric Sandoe, Andreas
because data are rarely compatible. Representatives from the American Skulberg, Hugh TunstalI-Pedoe, Richard
Heart Association, the European Resuscitation Council, the Heart and Swanson, William H Thies
Stroke Foundation of Canada, and the Australian Resuscitation Council
recently met to establish uniform terms and definitions for out-of-hospital This document was approved by the
resuscitation. American Heart Association SAC/Steering
The American Heart Association has supported resuscitation activities Committee on February 13, 1991, and the
since 1977. The European Resuscitation Council was formed in August European Resuscitation Council in January
1991. It was also approved by the Heart
1989 as a multidisciplinary group of representatives from the European So-
and Stroke Foundation of Canada and the
ciety of Cardiology, the European Academy of Anesthesiology, the Euro- Australian Resuscitation Council.
pean Society for Intensive Care Medicine, and related national societies. In
June 1990 members of these organizations attended an international resus- This report is also being published in the
citation meeting at the historic Utstein Abbey, located on a small island August 1991 issue of Circu/atien, the
near Stavanger, Norway. Participants discussed the widespread problem of September 1991 issue of Resuscitation,
nomenclature and the lack of standardized language in reports. A second and in translation in the German journals
meeting, with participants from Canada and Australia, was held in Decem- Notfatlmedizin and Intesivmedizin und
ber 1990, in Surrey, England. The delegates voted unanimously to call the Notfa/tmedizin.
second meeting the Utstein Consensus Conference. The task force offers
these new recommendations as a starting point for more effective ex- Address for reprints: Office of Scientific
change of information and to improve international audit. It is hoped that Affairs, American Heart Association, 7320
these recommendations will carry the name of the ancient abbey; the Greenville Avenue, Dallas, Texas 75231.
"Utstein Style" may be a suitable designation.
Uniform reporting of data from in-hospital cardiac arrest will be the sub-
ject of a future conference and publication. This report focuses on out-of-
hospital cardiac arrest and includes a glossary of terms, a template for re-
porting data from resuscitation studies to ensure comparability, definitions
for time points and time intervals related to cardiac resuscitation, defini-
tions of individual clinical items and outcomes that should be included in
reports, and recommendations for the description of emergency medical
resuscitation systems.

GLOSSARY OF TERMS
The nomenclature of cardiac arrest presents a classic problem in seman-
tics - the same term has different meanings to different people. The Ut-
stein recommendations are an attempt to solve this problem by presenting
consensus definitions. Previous publications provided a useful starting
point. M° The Utstein recommendations focus on poorly defined areas of

20:8 August 1991 Annals of Emergency Medicine 861/69

UTSTEIN STYLE
Cummins et al
FIGURE i. The four clocks of sudden
cardiac arrest.
clinical epidemiology and data that
emergency personnel and clinicians
should acquire as a tool to improve
both knowledge and treatment.
The definitions may deviate in nu-
ance from traditional and textbook
terminology since practical usage in
different settings produces an evolu-
tionary drift in meaning. During dis-
cussions at the consensus confer-
ence, task force members repeatedly
emphasized the need to remove am-
biguity, provide specificity, and pro-
mote valid comparisons.
Cardiac arrest. Cardiac arrest is
the cessation of cardiac mechanical
activity, confirmed by the absence of
a detectable pulse, unresponsiveness,
and apnea (or agonal, gasping respira-
tions).3,6,11 For the purposes of the
Utstein Style, no comment on time
or "suddenness" is recommended. 3
B y s t a n d e r CPR, l a y r e s p o n d e r
CPR, or citizen CPR. While these
terms are s y n o n y m o u s , the con-
sensus conference participants prefer
bystander CPR, which is an attempt
to perform basic cardiopulmonary re-
suscitation (CPR) by someone who is
not part of an organized emergency
response system. In general, this will
be the person who witnessed the ar-
rest. Thus, in certain situations, phy-
sicians, nurses, and paramedics may
perform bystander or, more appro-
priately, professional first responder
CPR.
Emergency personnel. Persons who
respond to a medical emergency in
an official capacity as part of an orga-
nized response team are called emer-
gency personnel. By this definition,
physicians, nurses, or paramedics
who witness a cardiac arrest in a pub-
lic setting and initiate CPR but do
not respond as part of an organized
team are not emergency personnel.
C a r d i o p u l m o n a r y resuscitation.
CPR is a broad term meaning an at-
tempt to restore spontaneous circula-
tion. CPR can be classified as suc-
cessful or unsuccessful and basic or
advanced (see below).
Basic CPR. Basic CPR is the at-
tempt to restore effective circulation
with external compressions of the
chest wall, plus expired air inflation
of the lungs. Rescuers can provide
ventilation through airway adjuncts
and face shields appropriate for use
by the lay public. This definition ex-
70/862
Patient collapse
CPR bystander
R EMS personnel
MS care
Circulationrestored
espirationrestored
Call received
Call processed
~/arrival
~.~,,'" ~
/ / ~ ~
~ , ~ ~ "
~ \
-- ~ .'departed ff .......
cludes the bag-valve-mask, invasive
techniques of airway maintenance
such as intubation of the airway, and
airway devices that pass the pharynx.
Basic cardiac life support. In the
United States especially, this term
has an expanded meaning beyond ba-
sic CPR. It describes an educational
program that provides information
about access to the emergency medi-
cal services (EMS) system and recog-
nition of cardiac arrest as well as ba-
sic CPR. 12
Advanced CPR or advanced cardi-
ac life support (ACLS). 13,14 These
terms refer to attempts to restore
spontaneous circulation with basic
CPR plus advanced airway manage-
ment and ventilation techniques, de-
fibrillation, and intravenous or endo-
tracheal medications. There are sev-
eral possible intermediate levels of
care defined by the number and types
of i n t e r v e n t i o n s provided. Rather
than provide specific titles for this
entire list of possibilities, consensus
conference participants have recom-
mended specific descriptions of inter-
ventions that are permitted (see "De-
scription of EMS Systems").
Cardiac etiology (presumed). Car-
diac arrest presumed to be related to
heart disease is a major focus of most
prehospital EMS systems. It is im-
practical for researchers to accurately
determine the specific cause of car-
diac arrest for all attempted resus-
citations. Growing acceptance of the
biological model of sudden cardiac
death places little value in attempts
Annals of Emergency Medicine
j vehiclemobile mT"l
/ vehicle stopped
patient's side
CPR(alreadyongoing?) ~ ~ '",,~
first shock ff-" "~',~
Iotubation achieved
IV line achieved
medicationadm, I ~ ' ~ arrivalat
I / v " emergency dept.
arrivedat hospital i admittedto ICU/ward
discharged from hospital
to discriminate between thrombotic
and electrophysiological cardiac ar-
rest.15,16 In this model, many func-
tional factors may interact with a host
of underlying structural abnormalities
to initiate lethal arrhythmias.
For the purposes of the Utstein
Style Template, researchers should
classify cardiac arrests as presumed
cardiac etiology if this is likely, based
on available information. In the best
of circumstances, this can include
autopsy data and hospital records.
However, this frequently becomes a
diagnosis of exclusion. Patients who
do not fit in the more readily defined
category cardiac arrest of noncardiac
etiology are included in this category.
Noncardiac etiology. Noncardiac
causes of cardiac arrest are often ob-
vious and easy to determine. Specific
subcategories include sudden infant
death syndrome, drug overdose, sui-
cide, drowning, hypoxia, exsanguina-
tion, cerebrovascular accident, sub-
arachnoid hemorrhage, and trauma.
Call-response interval. This term
replaces response time, one of the
most frequently, yet inconsistently,
used terms in resuscitation. The call-
response interval is the period from
receipt of call by the emergency re-
sponse dispatchers to the m o m e n t
the emergency response vehicle stops
moving (Figures 1 and 2). Note that
this interval does not begin when the
emergency response vehicle begins to
move. The call-response interval in-
cludes the time required to process
the call, dispatch emergency person-
20:8 August 1991
UTSTEIN STYLE
Cummins et al
TIME ~C°llapse/Rec°gniti°n
moo RmtC~;Byst~'s
Vehiclemobile
"---I~="~%J Arrivalat patient'sside
R=mmended
~ e um~ m
Supplementaltimesto
recordif possible
nel, move personnel from their quar-
ters to the emergency vehicle, start
the vehicle in motion, and travel to
the scene. Note that this interval
does not extend to arrival at the pa-
tient's side or to time of defibrilla-
tion. Recently published data show
that the intervals from the time the
vehicle stops to arrival at the pa-
tient's side and to delivery of first de-
fibrillatory shock may be too long
and may play a major role in deter-
mining survival.17, Is
Automated external defibrillators.
The generic term automated exter-
nal defibrillator refers to a defibrilla-
tor that performs rhythm analysis of
the patient's surface electrocardio-
gram. T h i s r h y t h m a n a l y s i s is
dichotomous - either ventricular fi-
brillation/ventricular tachycardia or
nonventricular fibrillation. An auto-
mated external defibrillator provides
information to the operator when it
detects v e n t r i c u l a r fibrillation or
rapid ventricular tachycardia. This
information is also dichotomous -
either " s h o c k " or "no shock indi-
cated."
Times versus intervals. Imprecise
20:8 August 1991
._~".-,,,,,
Intubationachieved
ROSventilation
IV Accessachieved .
Medicationadministered
[ Departurefromscene L
and inconsistent use of the terms
times and intervals has produced
much confusion and misunderstand-
ing in literature about cardiac arrest.
Interval, not time, refers to the pe-
riod between two events. The defini-
tion of the interval should be clear
from the expression used and should
not be dependent on EMS jargon. The
format for expression of intervals
should be event-to-event interval,
with an explicit statement of the two
anchor events. For example, various
authors have used downtime to refer
to either the collapse-to-start of CPR
interval, the collapse-to-first defi-
brillatory shock interval, or the col-
lapse-to-return of spontaneous circu-
lation interval. N u m e r o u s authors
have also used time-to-definitive
care to establish the importance of
short intervals between collapse and
intervention. In practice, however,
this term has meant only the arrival
at the scene of advanced life support
personnel who can deliver definitive
care. The true times of delivery (and
related intervals) for the specific ele-
ments of definitive care (defibrilla-
tory shocks, intubation, and vasoac-
Annals of Emergency Medicine
%%% CPR aba~oned/death
Arrivalat EM Dept.
TIME
X:XX
FIGURE 2. Events associated with
out-of-hospital cardiac arrest resus-
citation attempts.
tive medications) remain unknown.
TEMPLATE FOR REPORTING
DATA FROM CARDIAC
ARREST
The Template Approach
The consensus conference partici-
pants recommend the template ap-
proach to reporting data - especially
outcome data - relating to cardiac
arrest (Figures 3 and 4). Figure 3 is a
graphic representation of data on car-
diac arrest r e s u s c i t a t i o n that re-
searchers should report. The denomi-
nator begins with cardiac arrest pa-
tients w i t h cardiac e t i o l o g y and
displays how this group will pro-
gressively decrease to the proportion
alive at one year.
Figure 4 presents the Utstein Style
Template for collection of all cardiac
arrest data. A specific number must
be inserted for each level to permit
researchers to c a l c u l a t e m u l t i p l e
rates. The n u m b e r at each level
863/71
UTSTEIN STYLE
Cummins et al
FIGURE 3. Utstein II r e c o m m e n d a -
tions on data to be reported on car-
diac arrest resuscitation.
serves two functions: the denomina-
tor for levels above and the numera-
tor for levels below.
The template begins with the pop-
ulation served by the EMS system
and displays various exit points be-
fore arrival at the cardiac etiology pa-
tients presented in Figure 3. Some
items included in the template are
defined in the Glossary of this report;
others are discussed below. Use of
this scheme by EMS systems will
permit immediate comparisons with
other systems that have used the
template and have published or dis-
tributed their results.
Consensus conference participants
could have selected different branch
points at different levels with equal
validity. For example, patients could
have been classified as having ven-
tricular fibrillation rhythms or non-
ventricular fibrillation r h y t h m s at
the point just below "resuscitations
attempted" (Figure 4), providing a
g r o u p of p a t i e n t s c l a s s i f i e d by
rhythm alone. However, there would
also have been a large group of pa-
tients in ventricular fibrillation of
both cardiac and n o n c a r d i a c eti-
ologies. As presented in Figure 4, the
template has the advantage of en-
couraging widespread standardiza-
tion and uniformity.
Further divisions are not displayed
below the shaded exit points to the
left. Nevertheless, all downstream
subsets remain possible. For exam-
ple, researchers could analyze cardiac
arrests of noncardiac etiology in de-
tail, asking whether bystanders or
emergency personnel witnessed the
arrest and what the initial rhythms
and various clinical outcomes were.
The template does not display all
possible outcomes, even though col-
lection of the recommended individ-
ual clinical data would permit de-
tailed analyses and presentations.
The Issue of Outcomes
Evaluators can calculate a large va-
riety of outcomes from the reporting
template since multiple combina-
tions of denominators and numera-
tors are possible. Reported outcomes
should be presented as rates or per-
centages, for example, the rate of
successful admissions per total resus-
citations attempted. The best out-
72/864
Recommended detail level
R e s u s c i t a t i o n attempted by emergency personnel
]E . . . .
•
Bystander CPR prowded
......................... ~ - - ",~;~
Spontaneous /
Admitted ICU/ /
ward .%
• Minimum data level
1) Subgroups with a~ add~or~ survival potential which may be ana(yzed using a~ identical pattern, i.e. broken into the lower steps in the template
2) For purposes of uniform repotting the recommended "106%', or denominator g¢o~o, is resuscitations attsmpted on cardiac arrests of cardiac etioidgy
3) VI" shouid be reported as a separate group
3
come to report may differ among
various systems and locations. Most
authors recommend reporting
the number discharged alive divided
by the n u m b e r of p e r s o n s w i t h
w i t n e s s e d cardiac arrest, in ven-
tricular fibrillation, of cardiac etiolo-
gy h8,17,19 This single rate would be
most practical for multiple inter-
system comparisons and was recom-
mended by the consensus conference
participants. Although core informa-
tion, this rate indicates only a small
proportion of a system's total activ-
ities and thus fails to capture the
c o m p l e x i t y of EMS r e s u s c i t a t i o n
activities.
The reporting template supports
multiple comparisons and may help
detect clinically interesting subsets
of patients. For example, a new treat-
ment may help a higher percentage of
persons who are initially asystolic
achieve return of spontaneous circu-
lation in the field but may produce
no improvement in overall survival.
If only discharged alive rates are re-
ported, this p o t e n t i a l l y i m p o r t a n t
benefit will be overlooked.
The Utstein Style encourages the
use of core data and s u p p l e m e n t a r y
data. Core data are data w i t h o u t
w h i c h analyses and c o m p a r i s o n s
would be difficult or meaningless.
These data are generally easier to col-
lect and in some systems are rou-
tinely collected. Supplementary data
are more comprehensive and more
specific and s h o u l d be r e p o r t e d
w h e n e v e r possible. T h e y p e r m i t
more detailed comparisons and more
precise analyses of outcomes. How-
ever, they are generally more difficult
Annals of Emergency Medicine
t.
N = ..
7
.
100% zl
to collect and tend to be less precise
than core data.
Template Sections
1. P o p u l a t i o n served. The tem-
plate starting point is the population
served, which permits calculation of
population-based incidence as well as
population-based survival rates. The
total population of a community is a
useful figure only when the entire
population resides within the spe-
cific EMS system service area. The
methodology section of any manu-
script or report on cardiac arrest out-
comes should include a description
of the community served. Core data
to include for out-of-hospital cardiac
arrests are total population served by
the EMS system, geographic area
served (in square kilometers), and
percentage of the population more
than 65 years old.
Supplementary data should include
special problems or unique circum-
stances within a community, for ex-
ample, the presence of many high-
rise residential buildings, multiple
languages, unusual geography or cli-
mate, narrow roads, and unique traf-
fic regulations or other conditionsJ7
To provide an optimal picture of the
c o m m u n i t y served by an EMS sys-
tem, the Utstein Consensus Confer-
ence participants recommend report-
ing the following:
• Gender: percentages of men and
women in the total population
FIGURE 4. R e c o m m e n d e d U t s t e i n
Style Template for reporting data on
cardiac arrest.
20:8 August 1991
UTSTEINSTYLE
Cumminset al

1. Population served by
EMS system N=

2. Confirmed cardiac arrests

~ . Resuscitalions

~8. Arrestnot withessecl

h ~ 7. Arrest witnessed ~ 9. Arrestwitnessed l

~12. Initialrhythm "~ ~

= ~ I 10.~ Initial~N=__
rhythm 11. Initial rhythm
V F VT**N=__ S 13.Otherinitial
- ~

E
~/f16. Neverachievedh ~ 15. Any Return of Spontaneous

/I7 .o so d
a.expiredinfield N=___ }
I ~(~."o~. /

~y9. Expiredin hospitah

a.totatN = |

21.Expiredwithin ~'~
oneyearof |

*VFand VTshouldbe reported separatelythrough template

4
20:8August1991 Annals of EmergencyMedicine 865/73
UTSTEIN STYLE
Cummins et al
• Educational level: average level of
education, percentage of persons w h o
continue their education past the
c o m p u l s o r y school level, or both
• Socioeconomic status: percentage
of persons b e l o w the p o v e r t y level
(the d e f i n i t i o n of this p o v e r t y level
m u s t be stated for each c o m m u n i t y )
• Age: m e a n age of the population
provides little useful information.
The percentage of the p o p u l a t i o n in
e a c h of t h e f o l l o w i n g age g r o u p s
should be stated: 0 - 12 months, 1 -
4 years, 5 - 14 years, 15 - 24 years,
25 - 34 years, 35 - 44 years, 45 - 54
years, 55 - 64 years, 65 - 74 years, 75
- 84 years, and m o r e than 85 years.
• Total n u m b e r of annual deaths in
the c o m m u n i t y
• Percentage of deaths attributable
to i s c h e m i c or coronary heart disease
( I n t e r n a t i o n a l C l a s s i f i c a t i o n of Dis-
eases [ICD] codes 410 - 414)
• D e a t h s p e r 100,000 p o p u l a t i o n
per year from all causes
• A n n u a l deaths per 100,000 popu-
lation from ICD codes 410 - 414 for
m e n (aged 55 - 64) and w o m e n (aged
55 - 64)
• Total n u m b e r of persons in the
EMS s y s t e m c o m m u n i t y w h o have
c o m p l e t e d CPR t r a i n i n g ( A m e r i c a n
H e a r t A s s o c i a t i o n or Red Cross) in
the past year and over the past five
years. This figure relates to another
r e c o m m e n d e d i t e m to r e p o r t : t h e
percentage of cardiac arrests in w h i c h
bystanders initiated CPR.
2. Confirmed cardiac arrests con-
sidered for resuscitation. All unre-
sponsive, breathless, and pulseless
patients for w h o m the EMS s y s t e m is
activated are included in this section.
Emergency personnel must confirm
c a r d i a c arrests. T h e n u m b e r of pa-
t i e n t s w h o h a d r e s u s c i t a t i o n s at-
t e m p t e d (ventilation attempts, chest
c o m p r e s s i o n s , or both) by lay res-
cuers but were observed by the emer-
gency personnel to have a pulse upon
arrival s h o u l d be noted. This addi-
t i o n a l s u b g r o u p p e r m i t s an assess-
m e n t of possible lay person "saves"
but m a y i n c l u d e false-positive car-
diac arrests and r e s p i r a t o r y arrests.
This group should be tabulated sep-
arately and not included in the total
of c o n f i r m e d cardiac arrests consid-
ered for resuscitation.
3. Resuscitations not attempted.
Resuscitation a t t e m p t s for some pa-
tients in cardiac arrest are inappropri-
ate and should not be initiated. The
local criteria for such patients should
74/866
be stated in reports of out-of-hospital
cardiac arrests. Such criteria include
o b v i o u s e v i d e n c e of i r r e v e r s i b l e
death, such as decapitation, incinera-
tion, decomposition, rigor mortis, or
dependent cyanosis. This group also
includes people w i t h "do not resusci-
tate orders" or living wills, provided
that no resuscitation efforts were
made.
4. R e s u s c i t a t i o n s a t t e m p t e d .
This group includes all persons
whom emergency system personnel
a t t e m p t e d to resuscitate (other than
basic assessment). A resuscitation at-
tempt refers to some effort at basic
CPR. This definition m a n d a t e s that
this section of the t e m p l a t e will in-
clude persons w i t h do-not-resuscitate
o r d e r s or l i v i n g w i l l s or t h o s e for
w h o m s e n i o r a t t e n d a n t s h a l t e d re-
suscitation efforts upon their arrival.
W i t h the goal of precision and stan-
dardization, consensus conference
participants recognize that overall
success rates will be slightly lowered
by a d e n o m i n a t o r that includes those
in w h o m there is no p o s s i b i l i t y of
successful CPR.
5. Cardiac etiology (see Glossa-
ry). Emergency personnel should de-
t e r m i n e the presence and duration of
antecedent signs and s y m p t o m s of is-
chemia. T h i s p e r m i t s d i s c u s s i o n of
the suddenness of the arrest and con-
sideration of the m e c h a n i s m s of ar-
r e s t , s u c h as p r i m a r y e l e c t r i c a l
e v e n t s in c o n t r a s t to i s c h e m i c or
t h r o m b o t i c events. However, bound-
aries between these groups are often
blurred, both clinically and physi-
ologically, and are not required for re-
porting of cardiac arrest data.
6. Noncardiac etiology (see Glos-
sary). The template shows non-
c a r d i a c e t i o l o g y as an e x i t e v e n t .
However, consensus conference par-
ticipants strongly r e c o m m e n d the ac-
quisition of m o r e detailed data about
this group to p e r m i t recording and re-
porting of all features of the t e m p l a t e
listed below cardiac etiology (eg, wit-
nessed, rhythms, outcomes).
7. W i t n e s s e d a n d 8. arrest n o t
witnessed. T h e r e c o m m e n d e d focus
of the U t s t e i n Style T e m p l a t e is wit-
nessed arrests, in w h i c h the p a t i e n t ' s
collapse was seen or heard by a by-
s t a n d e r or e m e r g e n c y p e r s o n n e l or
both. T h e U t s t e i n S t y l e T e m p l a t e
displays u n w i t n e s s e d arrests and ar-
rests of noncardiac etiology as 'exit'
categories. However, s u p p l e m e n t a r y
recording and reporting includes
Annals of Emergency Medicine
r h y t h m i d e n t i f i c a t i o n , p r e s e n c e of
b y s t a n d e r CPR, a n d c l i n i c a l o u t -
comes for u n w i t n e s s e d arrests.
9. Arrests after arrival of emer-
gency personnel. Most reports of car-
diac arrest n o t e t h a t a p p r o x i m a t e l y
10% of out-of-hospital cardiac arrests
occur after the arrival of emergency
personnel. 17,19-~1 The U t s t e i n Style
r e c o m m e n d s that arrest after arrival
be s e p a r a t e d f r o m u n w i t n e s s e d ar-
rests and bystander-witnessed arrests
(Figure 4).
There are two reasons for this sep-
aration. First, the presence or absence
of bystander CPR and the length of
c a l l - r e s p o n s e i n t e r v a l s do n o t apply
to these patients. Inclusion of these
p a t i e n t s w o u l d d i s t o r t t a b u l a t i o n of
the p e r c e n t a g e of p a t i e n t s w h o re-
ceive b y s t a n d e r CPR and m e a s u r e -
m e n t of t h e c a l l - r e s p o n s e i n t e r v a l .
Second, the arrest-after-arrival sub-
group p r o v i d e s i m p o r t a n t i n f o r m a -
tion that should be analyzed and re-
ported separately. For example, some
researchers have suggested that sur-
vival rates for this subgroup are the
best current o u t c o m e measures w i t h
w h i c h to judge the performances of
ACLS p e r s o n n e l 17,2t since t i m e de-
lays are not a factor in the resuscita-
t i o n effort. O t h e r s h a v e s u g g e s t e d
that the underlying pathophysiology
of this group differs from the group
in w h o m collapses were sudden and
unexpected. 2~ Arrest-after-arrival pa-
tients have pain and s y m p t o m s that
led t h e m to call for emergency help,
s u g g e s t i n g a t h r o m b o t i c e v e n t . In
contrast, the patient w i t h sudden col-
lapse m a y have experienced an elec-
trical d y s r h y t h m i c arrest w i t h mini-
mal acute thromboses. However, the
biological m o d e l of s u d d e n cardiac
death suggests that both m e c h a n i s m s
are operative. Is A d d i t i o n a l descrip-
tion of the arrest-after-arrival group
should include rhythm identifica-
tion, the t i m e intervals indicated in
Figure 2, and the c l i n i c a l o u t c o m e s
indicated in the lower portions of the
U t s t e i n Style Template.
10. Initial r h y t h m ventricular fi-
brillation a n d 12. i n i t i a l r h y t h m
asystole. Subdivisions of ventricular
fibrillation such as fine, moderate, or
coarse have l i m i t e d c l i n i c a l useful-
ness.22, 23 However, a specific distinc-
tion between fine ventricular fibrilla-
tion and asystole, although clinically
and p h y s i o l o g i c a l l y i n d e t e r m i n a t e ,
should be m a d e for the purposes of
u n i f o r m reporting. 22,23 T h e U t s t e i n
20:8 August 1991
UTSTEIN STYLE
Cummins et al
Style recommends a specific discrim-
ination point between asystole and
fine ventricular fibrillation: a deflec-
tion on the surface electrocardiogram
of less than 1 m m amplitude (cali-
brated at 10 mm/mV) is asystole; 1
m m or more is ventricular fibrilla-
tion. Automated external defibrilla-
tors already use this criterion. 22,24-26
11. Ventricular t a c h y c a r d i a . Be-
cause its outcome spectrum is differ-
ent, consensus conference partici-
pants recommend that pulseless ven-
tricular tachycardia not be grouped
with ventricular fibrillation but in-
stead have a separate template path-
way. However, these patients make
up such a small proportion of out-of-
hospital cardiac arrests that they are
often combined with the much larger
n u m b e r of ventricular fibrillation
patients.
13. O t h e r r h y t h m s . This category
includes r h y t h m s in w h i c h some
electrical activity is observed in a pa-
tient in cardiac arrest. The activity
usually appears as ventricular escape
complexes that probably represent
the last electrical activity of a dying
heart. For persons in confirmed car-
diac arrest, there is little to be gained
by detailed refinement of this cate-
gory. E l e c t r o m e c h a n i c a l d i s s o c i a -
tion, a poorly defined term that is
undergoing redefinition,Z7, 2s should
be grouped with other r h y t h m s at
present.
I4. D e t e r m i n e p r e s e n c e o f by-
stander CPR (see Glossary). This sec-
tion of the template allows calcu-
lation of the percentage of cardiac ar-
rests in which bystanders initiated
CPR. A high percentage of early by-
stander-initiated CPR effort is associ-
ated with improved survival from
cardiac arrest. 7,19,29-3a T h e s e data
also assess other aspects of an EMS
system's "chain of survival" and are
important for program evaluation. .~1
Note that the template is arranged
for multiple analyses. For example,
researchers can determine survival
outcomes for persons in witnessed
ventricular fibrillation who received
early bystander CPR compared with
those who received only late CPR
from emergency personnel.
15. A n y return of spontaneous cir-
culation. The Utstein Style Template
(Figure 4) accepts return of any spon-
taneous palpable pulse and does not
require a specific pulse duration, for
example, more than five minutes. A
palpable pulse is detectable by man-
20:8 August 1991
ual palpation of a major artery, usu-
ally the carotid. This pulse implies a
systolic blood pressure of approxi-
mately 60 m m Hg. Return of sponta-
neous circulation is clearly an in-
termediate o u t c o m e that may be
evanescent. While it is less clinically
important than hospital admission or
eventual discharge, return of sponta-
neous circulation may be useful in
clinical trials and other intervention
studies. The number of patients who
16. never achieve return of sponta-
n e o u s c i r c u l a t i o n should be noted
(see template).
17. Efforts ceased: a. patient died
in the field or (if transported) b. in
the e m e r g e n c y d e p a r t m e n t . Several
studies confirm the futility of trans-
porting cardiac arrest patients who
have never achieved return of sponta-
neous circulation to emergency de-
partments.35, 36 Successful outcomes
for these patients are rare. Neverthe-
less, a number of systems require
emergency personnel to transport
victims with unsuccessful field re-
suscitations to the emergency depart-
ment. The reporting template allows
these patients to be recorded and per-
mits assessment of outcomes. The
template also allows notation of pa-
tients in whom emergency personnel
terminated resuscitation efforts in
the field without hospital transport.
This practice is becoming more fre-
quent in the United States..W,:~8
18. A d m i s s i o n to i n t e n s i v e care
unit~ward. This level of the template
refers to patients in whom return of
s p o n t a n e o u s circulation was sus-
tained long enough to merit admis-
sion to an intensive care unit/ward.
For the purposes of standardization,
consensus conference participants
define a successful hospital admis-
sion as a patient admitted to the hos-
pital with spontaneous circulation
and measurable blood pressure, with
or without vasopressors. The patient
may or may not be breathing sponta-
neously and may or may not be intu-
bated. The need for continuing CPR
or mechanical CPR devices implies
the absence of spontaneous circula-
tion, and such patients should be ex-
cluded. Artificial circulatory assists
such as emergency cardiopulmonary
b y p a s s and i n t r a - a o r t i c b a l l o o n
pumps imply that spontaneous circu-
lation is present, and such patients
should be included. There is no dura-
tion requirement on successful ad-
mission.
Annals of Emergency Medicine
19. Patient died in hospital: a. to-
tal and or b. w i t h i n first 24 hours.
R e s e a r c h e r s s h o u l d t a b u l a t e the
number of patients who die in the
hospital, with special notation of pa-
tients who die within the first 24
hours of admission. Patients who ex-
perience additional cardiac arrest
during the index hospitalization are
counted as a single person in the data
analysis, whether or not they are suc-
cessfully resuscitated.
20. Discharged alive. The number
of patients discharged from the hos-
pital alive should be noted. The dis-
charge destination should also be
noted - home, prearrest residence,
rehabilitation facility, extended care
facility (nursing home), and other du-
ration of hospitalization. If possible
and practical, researchers should re-
cord the "best-ever achieved" Cere-
bral Performance Category and Over-
a l l Performance Category (Table). If
best-ever achieved presents collec-
tion difficulties, the overall perfor-
mance and cerebral performance at
the time of discharge should be
noted. These categories are discussed
further under "Collection of Individ-
ual Clinical Data."
21. Death w i t h i n one year of dis-
charge. The date and cause of death
in the first year of discharge should
be recorded as core data to allow cal-
culation of length of survival. The
Overall Performance and Cerebral
Performance Categories near time of
death should be noted. The best over-
all performance and cerebral perfor-
mance achieved between discharge
and death should be recorded as sup-
plementary data, although this may
be difficult to determine.
22. Alive at one year The Overall
Performance Category and Cerebral
Performance Category of patients
who survive for more than one year
should be noted near the one-year
mark. The best Overall Performance
and Cerebral Performance Categories
ever achieved in that year should op-
timally be recorded as supplementary
data. In persons who experience addi-
tional out-of-hospital cardiac arrests
during their first year of survival,
each cardiac arrest and resuscitation
attempt should be treated as separate
events. 39 Thus, a second cardiac ar-
rest in the year after the index car-
diac arrest marks the end of survival
for the index event and is counted as
a death, whether or not the person
survived. If emergency personnel at-
867/75
UTSTEIN S T Y L E
C u m m i n s et a]
t e m p t e d to resuscitate this person in
l a t e r e v e n t s , t h a t p e r s o n w o u l d be
counted in the t e m p l a t e as an addi-
tional resuscitation attempted. If the
person lived to be discharged from
the hospital again, he or she w o u l d
still be counted as a separate person.
TIME POINTS A N D
TIME INTERVALS
Delay until treatment determines
the immediate, intermediate, and
o v e r a l l o u t c o m e s i n c a r d i a c ar-
rest.7,9,13,19,31,32,40 43 T h e m o s t pow-
erful d e t e r m i n a n t of restoration of a
b e a t i n g h e a r t is t i m e intervals, spe-
cifically, the t i m e interval from col-
l a p s e to i n i t i a t i o n of r e s u s c i t a t i v e
efforts. C o n c o m i t a n t l y , this interval
is the major d e t e r m i n a n t of u l t i m a t e
survival.S,8,29, 4° R e s e a r c h i n t o car-
diac arrest and evaluations of s y s t e m
performance depend on accurate de-
t e r m i n a t i o n of w h e n specific events
occurred and the t i m e i n t e r v a l s be-
t w e e n t h e s e e v e n t s . T h e r e f o r e , re-
searchers m u s t place great e m p h a s i s
on d e t e r m i n a t i o n of event t i m e s and
the associated t i m e intervals.
S y s t e m a t i c r e c o r d i n g of e v e n t
t i m e s s h o u l d be an integral part of
cardiac arrest management per-
f o r m e d by a r e c o g n i z e d m e m b e r of
the t e a m . As such, it s h o u l d figure
p r o m i n e n t l y in t r a i n i n g and t e s t i n g
of personnel. Training in citizen CPR
should stipulate m e m o r i z a t i o n of the
t i m e an arrest occurs and w h e n basic
CPR was started. Precision in record-
i n g t i m e e v e n t s is e s s e n t i a l , a n d
researchers should explore new
t e c h n o l o g i e s and m e t h o d s t h a t w i l l
i n c r e a s e a c c u r a c y . 44 H o w e v e r , i m -
proved data collection m u s t n o t in-
terfere w i t h care or i m p o s e non-care
w o r k on field personnel. 33
Figure 1 shows the c o m p l e x i t y of
recording t i m e intervals of cardiac ar-
rest. Four different clocks begin run-
ning w h e n a cardiac arrest occurs and
t h e EMS r e s p o n s e begins. T h e pa-
tient clock begins w i t h the patient's
collapse and runs u n t i l effective cir-
c u l a t i o n a n d r e s p i r a t i o n s a r e re-
stored. The dispatch center clock be-
gins w h e n the e m e r g e n c y call report-
ing the collapse is answered and ends
after p r e a r r i v a l i n s t r u c t i o n s , espe-
c i a l l y t e l e p h o n e - a s s i s t e d C P R in-
structions, are delivered to the caller.
The ambulance clock begins to run
when the response vehicle starts to
move and ends w h e n the patient ar-
rives at the hospital. Finally, the hos-
76/868
TABLE. Outcome of brain injury: The Glasgow-Pittsburgh CerebraJ Performaz~ce
and Overall Performance Categoriess4,65
Cerebral Performance Categories
1. Good cerebral performance. Conscious. Alert,
able to work and lead a normal life. May have
minor psychological or neurological deficits
(mild dysphasia, nonincapacitating hemiparesis,
or minor cranial nerve abnormalities).
2. Moderate cerebral disabilit~ Conscious. Sufficient
cerebral function for part time work in sheltered
environment or independent activities of daily
life (dressing, traveling by public transportation,
and preparing food). May have hemiplegia,
seizures, ataxia, dysarthria, dysphasia, or
permanent memory or mental changes.
3. Severe cerebral disability Conscious. Dependent
on others for daily support because of impaired
brain function (in an institution or at home with
exceptional family effort). At least limited
cognition. Includes a wide range of cerebral
abnormalities from ambulatory with severe
memory disturbance or dementia precluding
independent existence to paralytic and able to
communicate only with eyes, as in the locked-in
syndrome.
4. Coma, vegetative state. Not conscious. Unaware
of surroundings, no cognition. No verbal or
psychological interactions with environment.
5. Death, Certified brain dead or dead by traditional
criteria.
pital clock begins w i t h the patient's
arrival at the emergency d e p a r t m e n t
a n d e n d s w h e n t h e p a t i e n t is dis-
charged from the hospital or dies dur-
ing hospitalization.
Figure 2 a t t e m p t s to s i m p l i f y the
c o m p l e x t i m i n g d i s p l a y e d in Figure
3. It d e p i c t s t h e m a j o r e v e n t s asso-
ciated with resuscitation attempts
after cardiac arrest. These are the rec-
o m m e n d e d t i m e events that an emer-
gency s y s t e m should record. Each oc-
curs at a single m o m e n t . The period
b e t w e e n two t i m e events constitutes
the event-to-event interval. As noted
previously, researchers should always
use the t e r m interval, n o t time, to re-
fer to the t i m e that passes b e t w e e n
any t w o e v e n t s (see Glossary). T h e
label for the interval should state the
two anchor events. Neologisms, jar-
gon, and nonspecific terms that mis-
t a k e n l y use time instead of interval
should be avoided. Examples of such
t e r m s i n c l u d e downtime, response
time, and time to definitive care.
The stacked index card design in Fig-
ure 2 shows that these events can oc-
cur in different s e q u e n c e s w i t h dif-
ferent patients. In addition, variable
space (intervals) b e t w e e n the cards
for different p a t i e n t s is possible.
Recording the t i m e events d e p i c t e d
Annals of Emergency Medicine
Overall Performance Categories
Good overall performance. Healthy, alert, capable
of normal life. Good cerebral performance (CPC
1) plus no or only mild functional disability from
noncerebral organ system abnormalities.
2. Moderate overall disability. Conscious. Moderate
cerebral disability alone (CPC 2) or moderate
disability from noncerebraI system dysfunction
alone or both. Performs independent activities of
daily life (dressing, traveling, and food prepara-
tion). May be able to work part4ime in sheltered
environment but disabled for competitive work.
3. Severe overall disability Conscious. Severe
cerebral disability alone (CPC 3) or severe
disability from noncerebral organ system
dysfunction alone or both. Dependent on others
for daily support.
4. Same as CPC 4.
5. Same as CPC 5.
in Figure 2 permits the tabulation of a
large variety of intervals. Many, such
as t h e call r e c e i p t - t o - a r r i v a l at pa-
tient's side interval, are essential to
q u a l i t y a s s u r a n c e p l a n s and s y s t e m
evaluation, t7 However, the two m o s t
i m p o r t a n t intervals from the perspec-
tive of p a t i e n t s u r v i v a l are t h e col-
l a p s e - t o - f i r s t CPR a t t e m p t i n t e r v a l
and collapse-to-first defibrillatory
shock interval.~O, lS,16,19,25,30-32,45-51
M a n y EMS systems m a y decline to
p a r t i c i p a t e in m u l t i c e n t e r r e s e a r c h
p r o j e c t s and s h a r e d d a t a r e g i s t r i e s
and thus will not need the c o m p l e t e
supplementary detail recommended
in Figure 2. However, these systems
and responsible physicians will w a n t
to k n o w w h a t co~e data to collect for
c o m p a r i s o n of t h e i r p e r f o r m a n c e
w i t h t h a t of s i m i l a r c o m m u n i t i e s .
Figure 2 indicates the core t i m e s to
record: first b y s t a n d e r CPR, receipt
of d i s p a t c h call, v e h i c l e stops, first
CPR by EMS p e r s o n n e l , first defi-
b r i l l a t o r y shock, r e t u r n of s p o n t a -
n e o u s c i r c u l a t i o n , a n d CPR a b a n -
doned (death).
R e c o m m e n d e d Core and
Supplementary T i m e Events
to Be Recorded
Time of collapse/time of recogni-
20:8 August 1991
UTSTEIN STYLE
Cummins et al
tion. Despite its importance as core
information, imprecision surrounds
the estimated time of collapse. Emer-
gency personnel must ask additional
questions of bystanders to identify
this time. However, this information
is essential to u n d e r s t a n d the is-
chemic interval.4, 5 It should be noted
that time of collapse can be obtained
only for witnessed cardiac arrests.
The recommendations define a wit-
nessed arrest as one in which col-
lapse or signs of distress were seen
(or heard) by an identifiable witness.
Time of recognition is the time at
which an unwitnessed arrest was dis-
covered.
Time of call receipt (core). Modern
emergency dispatching records this
event automatically. If the message
is passed from one dispatcher to an-
other, the time the first operator was
contacted should be listed as the
time the call was received.
Time first emergency response ve-
hicle is mobile. For precise data col-
lection, this is defined as the mo-
ment when the emergency response
vehicle begins to move. Prolonged in-
tervals between the time the call was
received and the time the vehicle be-
gan to move may be due to long call-
processing intervals or slowness of
personnel.
Time vehicle stops (core). This is
the time when the emergency re-
sponse vehicle stops moving, at a lo-
cation as close as possible to the pa-
tient. This term replaces the com-
monly used phrase t i m e of scene
an'ival, whose meaning ranged from
destination visually spotted to per-
sonnel at patient's side.
Time of arrival at patient's side. If
possible, the m o m e n t of arrival at
the patient's side should be recorded.
However, it is difficult to determine
the time interval from leaving the
emergency response vehicle to begin-
ning resuscitation, though new defi-
brillator features now make this pos-
sible.
Time of first CPR attempts (core).
The time of first CPR a t t e m p t s
should be recorded b o t h for by-
stander-initiated CPR and for CPR
initiated by emergency personnel.
Note in Figure 2 that p e r s o n n e l
should also record the time when ad-
ditional CPR is considered futile and
chest compressions and ventilations
cease. Although this generally would
be time of death, some systems re-
quire that a physician officially pro-
20:8 August 1991
nounce death.
Time of first defibrillatory shock
(core). Early defibrillation is the
foundation for success in resuscita-
tion of patients in ventricular fi-
brillation. EMS systems should focus
attention toward recording the mo-
ment in real time when the first deft-
brillatory shock is delivered. The
time interval from collapse to first
defibrillatory shock serves as a key
evaluative measure for many other
components of an emergency system.
This time interval is reduced by the
competence of bystanders who recog-
nize a cardiac arrest and respond
with a rapid telephone call, the effi-
ciency of the dispatch system that
processes calls quickly and activates
the appropriate responding unit, and
the skills of early defibrillation units
that gain access to the patient and
perform their protocols rapidly. The
best way to obtain this information
is through automated external defi-
brillators or conventional defibrilla-
tors with automated event documen-
tation. These devices provide precise
details on initial rhythm, times, and
responses of heart rhythm to therapy.
The value of such technology is ob-
vious, and its use should be more
widespread.
Time of return of spontaneous cir-
culation (core). (See "Template Sec-
tions.")
Time intubation achieved. As with
defibrillation, airway management is
a critical intervention for CPR. Emer-
gency personnel should record the
time of intubation if they can do so
accurately and without interfering
with patient care. Return of sponta-
neous ventilation occurs when vol-
untary respiratory efforts, including
agonal-like gasping, begin. This may
be extremely difficult for field emer-
gency personnel to record accurately,
often because agonal-like gasping
may not have ceased before intuba-
tion.
Time intravenous access achieved
and time medications administered.
Research has not yet established the
true i n c r e m e n t a l value of intra-
venous or endotracheal medications
used in cardiac resuscitation. 52-54
Nevertheless, the effectiveness of
these agents is time dependent. Re-
cent evidence suggests that assign-
ment of defibrillation tasks to the
first responding emergency medical
technician personnel not only
shortens the interval from collapse to
Annals of Emergency Medicine
defibrillation for patients in ventricu-
lar fibrillation but also significantly
reduces intervals to intubation and
administration of medication. 5~ The
consensus conference participants
encourage documentation of these
time points.
T i m e CPR a b a n d o n e d / d e a t h
(core). Emergency personnel should
record the time at which resuscita-
tion efforts, specifically, chest com-
pressions and CPR ventilation ef-
forts, were terminated outside the
hospital.
Departure from scene and arrival
at e m e r g e n c y d e p a r t m e n t . Emer-
gency personnel can record these
times easily and accurately. Various
related intervals are key components
for effective quality assurance and
general management. These include
vehicle stops-departure from scene
i n t e r v a l , d e p a r t u r e f r o m scene-
arrival at hospital interval, and vehi-
cle rolling-departure from hospital
interval (so-called personnel out-of-
service interval, meaning personnel
are not available for other care activ-
ities).
C O L L E C T I O N OF I N D I V I D U A L
C L I N I C A L DATA
Clinical Outcomes
The clinical outcomes following
attempted resuscitations are the core
information required for system eval-
uation, intersystem comparisons, and
clinical trials. The chief goal of car-
diocerebral resuscitation is to return
the patient to his or her prearrest
level of neurological function. This
goal mandates that evaluation of re-
suscitation efforts cannot be com-
plete without assessment of neuro-
logical outcome in two dimensions,
quality5, s6 and duration.4~, s7-64 Elab-
orate efforts at improving survival
from cardiac arrest may yield only
short-term survival. Such patients
m a y ; s u r v i v e only after expensive
stays in intensive care units and re-
cover only to undesirable levels of
neurological function. Researchers
need these data to show that resus-
citation efforts have a net positive
benefit to society, to families, and to
patients.
The Glasgow-Pittsburgh
Outcome Categories
The Glasgow-Pittsburgh Outcome
Categories have become the most
widely used approach to evaluate
quality of life after successful resus-
869/77
UTSTEIN STYLE
Cummins et al
citation.S6, 65 C l i n i c i a n s designed
these categories to evaluate cardiac
arrest survivors. The categories dif-
ferentiate the cerebral effects of the
cardiac arrest from the morbidity of
underlying, noncerebral prob-
lems. 4°,65-67 T h e O v e r a l l Perfor-
mance Categories reflect cerebral and
noncerebral status and evaluate ac-
tual overall performance. The Cere-
bral Performance Categories evaluate
o n l y cerebral p e r f o r m a n c e capa-
bilities. These outcome categories
are reliable and easy to obtain and of-
ten require only a telephone call to
family members. An alternative and
even more simple approach is t o re-
cord the time of awakening or return
to c o n s c i o u s n e s s . S 9 , 60 B o t h t h e
Glasgow-Pittsburgh Outcome Cate-
gories and time of awakening have
the advantage of simplicity and prac-
ticality, especially when compared
with more elaborate interview and
physical assessment methods.6S, 69
The U t s t e i n Consensus Confer-
ence participants recommend use of
the Glasgow-Pittsburgh O u t c o m e
Categories to record prearrest status,
status at the time of discharge, and
status after one-year survival. The
Glasgow-Pittsburgh Outcome Cate-
gories feature two five-point parallel
scales, the Cerebral Performance Cat-
egories and the Overall Performance
Categories. Category 1 is conscious
and normal, without disability. Cate-
gory 2 is conscious with moderate
disability. Category 3 is conscious
with severe disability. Category 4 is a
comatose or vegetative state. Cate-
gory 5 is death. To illustrate, a con-
scious, mentally normal person who
is bedridden with severe heart dis-
ease would have a Cerebral Perfor-
mance Category of 1 and an Overall
Performance Category of 3. The Ta-
ble describes the Glasgow-Pittsburgh
Outcome Categories in detail.
A single data collection form.
Many experts recommend the devel-
opment of a single form for data col-
lection for use in all EMS systems.
Such a form, called a cardiac arrest
registry form, run report, run record,
or medical incident report, allows
shared data bases, patient registries,
and true multicenter studies. These
forms must record clinical, epidemi-
ological, and evaluative data. How-
ever, in most systems, incident re-
port forms must also provide data for
medico-legal, administrative, man-
agement, and personnel tasks. These
78/870
s y s t e m - s p e c i f i c tasks i n c l u d e re-
source allocation, staffing, and per-
sonnel scheduling. A single data col-
lection form cannot serve all func-
tions for all EMS systems. However,
the data collection form for individ-
ual patients can at least provide the
core data that will allow completion
of the clinical portions of the Utstein
Style Template.
R e c o m m e n d e d clinical data. The
Utstein Consensus Conference par-
ticipants recommend that responsi-
ble personnel should attempt to re-
cord the clinical data listed below for
each attempted resuscitation:
• Site of cardiac arrest (core): home,
street, public place, work place, mass
gatherings, ambulance, nursing
home, or other long-term care facility
• Prearrest clinical status (supple-
mentary): Overall Performance Cate-
gory and Cerebral Performance Cate-
gory
• Witnessed arrest before arrival of
emergency personnel (core): yes or no
• Precipitating event (supplemen-
tary) (determined as best possible at
the scene): a c u t e c a r d i a c e v e n t ,
trauma, exsanguination, hypoxia, in-
tracranial event, intoxication (drug
ingestion), m e t a b o l i c , drowning,
sepsis, or sudden infant death syn-
drome. An attempt should be made
to classify the arrest as cardiac or
noncardiac core data.
• Clinical status of patient when
ambulance arrives (core): breathing
(yes/no), palpable pulse (yes/no), by-
stander CPR (yes/no)
• Arrest after arrival of emergency
personnel (core): yes or no
• Initial recorded r h y t h m (core):
ventricular fibrillation, ventricular
tachycardia, asystole, and other
• T r e a t m e n t (core): The specific
protocols used by a system should be
listed when the EMS system is de-
scribed. However, for individual pa-
tients, personnel should record the
specific interventions used. As core
information, personnel should record
the type of respiratory support pro-
vided ( m o u t h - t o - m o u t h or m a s k
breathing, endotracheal intubation,
or other type of airway management),
whether intubation was successful,
n u m b e r of d e f i b r i l l a t o r y s h o c k s
given, and medications administered.
The strong association between un-
successful resuscitation attempts and
numerous interventions is obvious -
the more difficult a resuscitation, the
more i n t e r v e n t i o n s u s e d : - C o n s e -
Annals of Emergency Medicine
quently, an account of interventions
in unsuccessful attempts provides
l i t t l e i n f o r m a t i o n of value. Re-
searchers must therefore emphasize
all i n t e r v e n t i o n s used for persons
who regained spontaneous circula-
tion.
• Final patient status at the scene
(core): This refers to the condition of
the patient when either transport be-
gins or efforts terminate. The recom-
mended categories are return of spon-
taneous circulation, continuing CPR,
or death (CPR efforts stopped; spe-
cific time recorded).
• Status on arrival at emergency de-
partment (supplementary): This in-
formation reflects a change in status
during transport. The possibilities
are c o n t i n u i n g CPR, p r o n o u n c e d
dead on arrival (record specific time),
or the presence of spontaneous circu-
lation. If the return of spontaneous
circulation lasts more than five min-
utes, blood pressure, respiratory rate,
and the Glasgow Coma Score should
be recorded. The patient's tempera-
ture should also be recorded, espe-
cially in arrests associated with hy-
pothermia.
• Status after t r e a t m e n t in the
emergency department (core): The
possibilities are admission to the
hospital intensive care unit or alter-
native location or pronounced dead
with termination of efforts (specific
time recorded).
• Status on admission to hospital
unit (supplementary): The Glasgow
Coma Score, blood pressure, rate of
spontaneous respirations (if any), and
basic brain-stem reflexes should be
recorded.
• Discharged alive (core): If the pa-
tient died in the hospital, the date
and time of death and length of sur-
vival after return of spontaneous cir-
culation should be recorded. Patients
who died within 24 hours should be
noted (in exact time). The Overall
Performance Category and Cerebral
Performance Category at time of dis-
charge should also be recorded (sup-
plementary). If the person dies before
surviving one year, the best score
achieved in the week before death
should be recorded. Supplementary
data to be recorded should include
the best-ever outcome achieved dur-
ing hospitalization and in the year af-
ter the arrest, although these data
may be difficult to gather in a practi-
cal manner.
• Discharge destination {supple-
20:8 August 1991
UTSTEIN STYLE
Cummins et al
mentary): If the patient is discharged,
researchers should record the dis-
charge destination: home (or prear-
rest residence), rehabilitation facility,
extended care facility (nursing home),
or other.
• Alive at one year (yes/no) (core):
If yes, Overall Performance Category
and Cerebral Performance Category
scores at one year s h o u l d be re-
corded. Personnel can often obtain
these scores through telephone inter-
views with family members. If the
person dies in the first year, the date
of death and the length of survival
should be recorded. Supplementary
data include the best Cerebral Perfor-
mance Category achieved.
DESCRIPTION OF EMS
SYSTEMS
The organization of a community's
EMS system has a major effect on
cardiac arrest outcomes, l°,29,7° The
Utstein Consensus Conference par-
ticipants recommend that a report of
cardiac arrest survival describe the
c o m m u n i t y ' s EMS system.7,8,17, 7~
Researchers should describe the dis-
patch component of an EMS system
as well as the various response tiers.
These descriptions should state who
makes up each tier, what interven-
tions and actions they provide, how
they provide those interventions (and
how well), and when they deliver
their care. 72 Described below are the
many dimensions of an EMS system
that researchers and system man-
agers s h o u l d k n o w . A l t h o u g h it
would be impractical to report each
of these details in every publication,
as much of the recommended core
data as possible should be provided.
The Dispatch System
Who (supplementary). It should be
stated w h e t h e r d i s p a t c h e r s m u s t
have special skills, such as emer-
gency medical technician, paramedic,
nurse, or physician training, and
whether they are full-time salaried
employees or volunteers. The average
number of hours of training received
should be d e s c r i b e d as w e l l as
whether a formal emergency medical
dispatching course is required. 78 In
addition, the report should state the
average n u m b e r of medical emer-
gency calls the EMS system handles
per year and the estimated number of
calls handled by each dispatcher each
year.
What (core). The dispatch system
20:8 August 1991
should be described in t e r m s of
whether it is dedicated to EMS only
if it also covers fire and police. The
type of communication system used
should be stated, that is, 911, en-
hanced 911, 999, a seven-digit num-
ber, or computer-aided dispatch.
How (supplementary). It should be
stated whether formal protocols for
dispatching are in use. Is dispatcher-
assisted CPR instruction offered to
callers who report potential cardiac
arrests? 74-76 Do dispatchers provide
prearrival instructions to callers? Is
simultaneous dispatching used for
cardiac arrest patients? Can dis-
patchers send emergency vehicles
during event interrogation? How are
calls routed, and how many operators
are involved from the time the call is
received until the vehicle starts to
move?
When (core). The median interval
for dispatch call processing, defined
as the time from when the call is
first received to when the emergency
vehicle leaves (call receipt-to-mobile
vehicle interval), should be stated.
First Tier: The First Emergency
Personnel to Arrive
Who (supplementary). Each system
should describe how personnel in
this response tier are d e s i g n a t e d
(physicians, nurses, ambulance per-
sonnel, emergency medical techni-
cians, or first responders). The orga-
nizational affiliation of the personnel
should be stated in terms of dedi-
cated EMS service, mixed EMS-fire
service, hospital based, private am-
b u l a n c e c o m p a n y , or o t h e r and
whether personnel are authorized to
transport patients. The following fea-
tures should also be described: total
number of personnel in this tier, sta-
tus (paid versus volunteer), number
of hours of training, number of team
members per response unit, number
of vehicles in service at a given time,
and number of responses per commu-
nity per year.
What (core). The major interven-
tions permitted for use in cardiac re-
suscitation should be described. In
broad categories these include CPR,
defibrillatory shocks, intravenous
medications, and technical airway
management. Each of these catego-
ries should be described in enough
detail to provide a clear picture of
what an EMS system does for some-
one in cardiac arrest.
A description of CPR should state
Annals of Emergency Medicine
w h e t h e r personnel use m a n u a l or
mechanical chest compression de-
vices. The method of technical air-
way m a n a g e m e n t used should be
stated, t h a t is, bag-valve-masks,
pocket face masks, or other upper air-
way devices. Are esophageal obtura-
tors, laryngeal masks, or pharyngo-
tracheal airways used? It should be
specifically stated if the EMS system
authorizes endotracheal intubation
or the use of paralytic agents in diffi-
cult intubations and whether person-
nel can perform cricothyrotomies. If
defibrillation is permitted, the ge-
neric type of defibrillator used should
be noted. These include automated
external defibrillators and conven-
tional (manual) defibrillators. It
should also be stated whether trans-
cutaneous pacing with free-standing
pacemakers or pacemakers combined
with the defibrillator is permitted.
If the use of p h a r m a c o l o g i c a l
agents is authorized, the routes of de-
livery should be described (intra-
muscular, intravenous, central line,
e n d o t r a e h e a l , and i n t r a o s s e o u s ) .
Medications that personnel can ad-
minister to patients in cardiac arrest
should be specified.
How (core). General resuscitation
p r o t o c o l s s h o u l d be described in
terms of sequence and type of inter-
vention and whether the protocols
adhere to those recommended by a
consensus group such as the Ameri-
can Heart Association ~3 or the Euro-
pean Resuscitation Council. Do per-
sonnel follow standing orders or do
they need to obtain radio or tele-
phone permission before initiating
therapy? 7z At what point must per-
sonnel contact the base station or
medical control physician? If field
personnel must transport patients
with continuing CPR, what are the
criteria for when they must begin to
prepare the patient for transport?
Does the EMS system permit field
personnel to cease resuscitation ef-
forts in the field? At what point do
the protocols permit cessation of ef-
forts, and what are the criteria for do-
ing so?
How well (supplementary). Re-
searchers should provide some state-
ments about the quality of personnel
performance. In regard to interven-
tions, the most i m p o r t a n t perfor-
mances to review are the percentage
of persons in ventricular fibrillation
who underwent defibrillation, the
percentage of attempted intubations
871/79
UTSTEIN STYLE
Cummins et al
that are successful, and the percent-
age of p e r s o n s for w h o m an i n t r a -
v e n o u s line is a c c o m p l i s h e d . In re-
gard to personnel, the m o s t i m p o r -
t a n t p e r f o r m a n c e d i m e n s i o n s to
report are success rates for a t t e m p t e d
i n t u b a t i o n s and for a t t e m p t e d intra-
venous lines. M e a s u r e m e n t s of these
p e r f o r m a n c e c r i t e r i a are o b v i o u s l y
fraught w i t h difficulties and report-
i n g i n a c c u r a c i e s a n d w i l l n o t be
a v a i l a b l e in all s y s t e m s and at all
times. The consensus conference rec-
o m m e n d a t i o n s focus on achieving as
m u c h o b j e c t i v i t y in t h e s e m e a s u r e s
as possible.
W h e n (core). T h e m e d i a n ( n o t
mean) call response interval for the
various tiers of the response s y s t e m
s h o u l d be described. (See Glossary.)
M e a n i n t e r v a l s are i n a p p r o p r i a t e l y
distorted by long times. T h e supple-
m e n t a r y data an EMS s y s t e m should
present is a cumulative response in-
terval curve. Such a curve should dis-
play t h e m e d i a n response i n t e r v a l s
for 25%, 50%, 75%, and 90% of car-
diac arrest responses, and the n u m b e r
of observations on w h i c h these me-
dian t i m e s are calculated should also
be stated.
Second and Third Tiers: The
Second and Third Types of
Emergency Personnel to Arrive
In m o s t l o c a t i o n s in t h e U n i t e d
States, paramedics c o m p o s e the sec-
ond tier of e m e r g e n c y p e r s o n n e l to
arrive. There is no third tier. 7 In Eu-
rope there often is a second or third
tier c o n s i s t i n g of e m e r g e n c y physi-
cians who respond outside the hospi-
tal. T h e s e a d d i t i o n a l tiers m u s t be
d e s c r i b e d in t h e s a m e d e t a i l a n d
same features as noted above for the
first responding tier (referring to core
and supplementary recommenda-
tions). In addition, a s u p p l e m e n t a r y
c o m m e n t on the m e t h o d used to ac-
t i v a t e this tier s h o u l d be provided.
Do dispatchers call this tier w h e n a
c a r d i a c a r r e s t is f i r s t r e p o r t e d , or
m u s t t h e s e c o n d t i e r a w a i t a call
from the first tier? H o w often does
the second tier arrive before the first?
DISCUSSION
This report presents r e c o m m e n d e d
guidelines for u n i f o r m r e p o r t i n g of
data from cardiac arrest. The concept
of a consensus conference to address
the topic of reporting guidelines and
n o m e n c l a t u r e h a s p r e c e d e n t s . In
1978 a group of b i o m e d i c a l journal
80/872
editors m e t in Vancouver, British Co-
l u m b i a , and d i s c u s s e d t h e s i m i l a r
p r o b l e m of i n c o n s i s t e n t p r e s e n t a t i o n
f o r m a t s and c o n t e n t s for s c i e n t i f i c
manuscripts.TS, 79 T h e i r r e c o m m e n -
d a t i o n s for u n i f o r m t e c h n i c a l re-
q u i r e m e n t s for m a n u s c r i p t s submit-
ted to b i o m e d i c a l journals are k n o w n
as the "Vancouver Style. ''80 The In-
t e r n a t i o n a l C o m m i t t e e of M e d i c a l
Journal Editors continues to publish
u p d a t e s of t h e o r i g i n a l V a n c o u v e r
Style.81,8~
The U t s t e i n Style as r e c o m m e n d e d
in this report m a y have a similar pos-
itive effect on m a n u s c r i p t s s u b m i t -
ted for p u b l i c a t i o n to m e d i c a l jour-
nals. s3 T h e a b s e n c e of u n i f o r m re-
porting has led to a tower of Babel 8 in
a r t i c l e s a b o u t c a r d i a c a r r e s t . Re-
s e a r c h e r s h a v e d o c u m e n t e d differ-
ences in survival rates among m a n y
different cities, differences t h a t re-
m a i n u n e x p l a i n e d because of incon-
sistent and obscure terminology. 7
W h e t h e r these variable survival rates
are due to differences in s y s t e m orga-
n i z a t i o n , d i f f e r e n c e s in t r e a t m e n t
protocols, or differences in the skill
l e v e l s of p e r s o n n e l r e m a i n s u n -
known.S
M a n y p r e v i o u s s t u d i e s f a i l e d to
p r o v i d e s u f f i c i e n t i n f o r m a t i o n to
help the reader u n d e r s t a n d h o w per-
sons in c a r d i a c a r r e s t are t r e a t e d .
O u t c o m e s are particularly difficult to
compare because the t e r m i n o l o g y in
reports is inconsistent. A successful
save or resuscitation m a y m e a n re-
turn of a pulse for at least five min-
utes in one system, admission to the
hospital in another, and discharged
alive f r o m the hospital in a t h i r d .
Even the terms CPR and cardiopul-
m o n a r y resuscitation have i m p o r t a n t
differences in usage. In one area, CPR
m e a n s the act of performing external
c h e s t c o m p r e s s i o n s and expired air
m o u t h - t o - m o u t h v e n t i l a t i o n ; in an-
other, it m e a n s the c o m p l e t e r e t u r n
of spontaneous circulation and ven-
t i l a t i o n . B e c a u s e of t h i s i n c o n s i s -
tency in reporting, no true standard
exists for the survival rate that can
(or should) be a c h i e v e d by c o m m u -
nities.
A n u m b e r of problems follow from
this confusion in n o m e n c l a t u r e . Re-
searchers, clinicians, and emergency
care m a n a g e r s c a n n o t i d e n t i f y t h e
r e l a t i v e benefits of different s y s t e m
approaches to the t r e a t m e n t of sud-
den cardiac arrest. EMS systems, hos-
pitals, and cardiac care unitg do not
Annals of Emergency Medicine
have adequate performance indica-
tors for their particular type of sys-
t e m , a n d t h e i r s y s t e m c a n n o t be
compared w i t h a r e c o m m e n d e d stan-
dard or other similar systems. There-
fore, t r u e q u a l i t y a s s u r a n c e is n o t
available.
In addition, it becomes impossible
to tell the relative m e r i t s of different
.organizational approaches. The
widely accepted and w i d e l y endorsed
" c h a i n of s u r v i v a l " c o n c e p t has ex-
panded the c o m p l e x i t y of our think-
ing a b o u t the o r g a n i z a t i o n of EMS
s y s t e m s . 31 A n e w c o m m u n i t y w i d e
CPR p r o g r a m or a n e w e a r l y defi-
brillation program m u s t be carefully
i n s e r t e d as a n e w l i n k in t h e EMS
continuum. This continuum in-
cludes early access, early CPR, early
defibrillation, and early advanced
care. However, s y s t e m managers find
it difficult to plan for reorganization
or the a d d i t i o n of n e w c o m p o n e n t s
because they lack information on the
i n c r e m e n t a l value of these n e w pro-
grams. N e w s y s t e m s h o p i n g to de-
velop a reasonably effective approach
c a n n o t r e v i e w the p u b l i s h e d m a t e -
rials on s y s t e m o r g a n i z a t i o n w i t h
confidence. T h e y w a n t to avoid du-
p l i c a t i o n of u n n e c e s s a r y a c t i v i t i e s
and r e p e t i t i o n of a v o i d a b l e errors,
a n d t h e y w a n t to k n o w q u i c k l y ,
given their local resources, w h i c h of
several EMS approaches will be m o s t
effective. The Utstein guidelines
s h o u l d s u p p o r t t h e p e r f o r m a n c e of
i n t r a s y s t e m and i n t e r s y s t e m evalua-
tions, i n t r a s y s t e m e v a l u a t i o n s sup-
porting local quality improvement
programs, and i n t e r s y s t e m c o m p a r i -
sons helping identify the relative
b e n e f i t s of d i f f e r e n t s y s t e m ap-
proaches.
S t a n d a r d i z a t i o n of n o m e n c l a t u r e
also provides the m e a n s to evaluate
important trends in emergency cardiac
care that are now under way. For ex-
ample, early defib;rillation is spreading
rapidly, s t i m u l a t e d by the new tech-
n o l o g y of a u t o m a t e d e x t e r n a l defi-
brillators.~4-26, 84 M a n y systems, in-
cluding hospital and o u t p a t i e n t set-
tings, are giving this approach serious
consideration.2S,26, ss~s7 H o w e v e r ,
they need to know the relative
m e r i t s of a l t e r n a t i v e a p p r o a c h e s .
Managers and m e d i c a l directors have
started to seriously e x a m i n e the eco-
n o m i c effect of w i d e s p r e a d u s e of
paramedics, in both the United
States and Europe, and a m b u l a n c e -
doctors in Europe. Do these services
20:8 August 1991
 UTSTEIN STYLE
Cummins et al
really produce enough clinical differ-
ences to justify their i m p l e m e n t a -
tion?88,s9
A trend in the opposite direction is
physician oversupply or "doctor-un-
employment" in s o m e parts of the
world. In t h e s e l o c a t i o n s , the ten-
dency of m a n a g e m e n t is to empha-
size the professional status of ambu-
lance-doctors. Physicians then con-
sider such positions more attractive
alternatives w h e n t h e y search for
clinically interesting work. This ten-
dency produces a reluctance to dele-
gate special physician skills such as
defibrillation and intubation to non-
physicians. 9° Paramedic and early de-
fibrillation programs c o n s e q u e n t l y
receive less support. Only the steady
accumulation of valid research and
reports can d e t e r m i n e the relative
m e r i t s of the r e s p e c t i v e s y s t e m s .
This research requires that all inves-
tigators start at the s a m e point, use
the s a m e v o c a b u l a r y , and c o l l e c t
comparable data.
A n u m b e r of other benefits w i l l
follow the use of a uniform terminol-
ogy and c o m m o n r e p o r t i n g ap-
proaches. T h e s e guidelines w i l l en-
courage studies that could yield a
better epidemiological picture of the
problem of cardiac arrest. Appropri-
ate studies could then focus on the
factors that determine survival. This
research m a y identify special high-
risk subgroups or specific interven-
tions to r e d u c e m o r t a l i t y . T h e s e
guidelines w o u l d also permit m o r e
r i g o r o u s s i n g l e and m u l t i c e n t e r
studies on c a r d i o p u l m o n a r y arrest.
Areas of research might include the
therapeutic effects of m e d i c a t i o n s ,
different s y s t e m o r g a n i z a t i o n a l ap-
proaches such as widespread first re-
sponder defibrillation, and innova-
tive i n t e r v e n t i o n s s u c h as m o r e
widespread public e d u c a t i o n about
early recognition of cardiac pain and
cardiac arrest.
The consensus conference partici-
pants recognize that their r e c o m m e n -
dations will have value only as they
are u s e d to e x a m i n e a v a r i e t y of
emergency medical systems. When a
number of locations use these recom-
mendations, in particular, the report-
ing template, a guiding standard or
overall p e r f o r m a n c e standard can
emerge. I m p r o v e m e n t can follow as
s y s t e m s adopt the approaches and
system designs that appear to be the
most successful. Continuous quality
improvement, a goal of all EMS sys-
20:8 August 1991
terns, can be achieved.
The consensus conference partici-
pants recognize that certain features
of the Utstein guidelines w~ll need to
be revised and supplemented. Com-
ments or questions on these recom-
mendations are welcome. Comments
from North America and Australia
should be sent to Richard 0 Cum-
mins, MD, MPH, MSc, Center for
Evaluation of Emergency Medical
Services, Seattle-King County De-
partment of Public Health, 110 Pre-
fontaine Place S, Suite 500, Seattle,
Washington 98122. Comments from
other parts of the world should be
sent to Douglas Chamberlain, MD,
Cardiac Department, Royal Sussex
C o u n t y Hospital, Eastern Road,
Brighton, East Sussex, England BN2
5BE. Letters from organizations that
wish to participate in future meet-
ings of the consensus conference
should be similady addressed.
These recommendations from the two
Utstein Consensus Conferences are dedi-
cated to Professor Peter Safar. Many of
our definitions and perspectives are based
on his contributions. Professor Safar has
brought new understanding to the patho-
physiology of cardiac arrest and resuscita-
tion. He continues to be an inspiration to
us all.
Peter Safar provided valuable insight
and comments for this special report. The
Laerdal Foundation for Acute Medicine
provided a grant to support the Utstein
Consensus Conferences.
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2. Dick W, Aitkenhead AR, Delooz H, Zideman D: Ani
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3. Green HL, Richardson DW, Barker AH, Rodeo DM,
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20:8 August 1991