Resuscitation 125 (2018) 118–125

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Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation

Clinical paper

Trends in care processes and survival following prehospital resuscitation T

improvement initiatives for out-of-hospital cardiac arrest in British
Columbia, 2006–2016
⁎
Brian Grunaua,b,c, , Takahisa Kawanob,d, William Dicka,e, Ronald Straighte, Helen Connollyc,
Robert Schlampe, Frank X. Scheuermeyera,b, Christopher B. Fordycef,g, David Barbica,b,
John Tallona,e,f, Jim Christensona,b
a
Department of Emergency Medicine, University of British Columbia, Canada
b
St. Paul’s Hospital, Vancouver, B.C., Canada
c
Providence Healthcare Research Institute, Vancouver, B.C., Canada
d
The Department of Emergency Medicine, University of Fukui Hospital, Fukui Prefecture, Japan
e
BC Emergency Health Services, Vancouver, B.C., Canada
f
Vancouver General Hospital, Vancouver, B.C., Canada
g
Division of Cardiology, University of British Columbia, Canada

A B S T R A C T

Background: British Columbia (BC) Emergency Health Services implemented a strategy to improve outcomes for
out-of-hospital cardiac arrest (OHCA), focusing on paramedic-led high-quality on-scene resuscitation. We
measured changes in care metrics and survival trends.
Methods: This was a post-hoc study of prospectively identified consecutive non-traumatic ambulance-treated
adult OHCAs from 2006 to 2016 within BC’s four metropolitan areas. The primary outcome was survival to
hospital discharge; we also described available favourable neurological outcomes (mRS ≤3). We tested the
significance of year-by-year trends in baseline characteristics, and calculated risk-adjusted survival rates using
multivariable Poisson regression.
Results: We included 15 145 patients. In univariate analyses there were significant increases in bystander CPR,
chest compression fraction, advanced life support attendance, duration of resuscitation until advanced airway
placement, duration of resuscitation until termination, and overall scene time. There was a significant decrease
in initial shockable rhythms, bystander witnessed arrests, and transports initiated prior to ROSC. Survival and
the proportion of survivors with favourable neurological outcomes increased significantly. In adjusted analyses,
there was an improvement in return of spontaneous circulation (risk-adjusted rate 41% in 2006 to 51% in 2016;
adjusted rate ratio per year 1.02, 95% CI 1.01–1.02, p < 0.01 for trend) and survival at hospital discharge (risk-
adjusted rate 8.6% in 2006 to 16% in 2016; adjusted rate ratio per year 1.05, 95% CI 1.04–1.06, p < 0.01 for
trend).
Conclusion: From 2006 to 2016 BC’s provincial ambulance system prioritized paramedic-led on-scene re-
suscitation, during which time there were significant improvements in patient outcomes. Our data may assist
other systems, providing a model for prehospital resuscitation quality improvement.

Introduction broader US registry study of approximately 250,000 OHCAs between

North American emergency medical services (EMS) assess 111 out-
of-hospital cardiac arrests (OHCA) per 100 000 citizens annually [1].
Survival of EMS-treated OHCA varies from 8 to 12% in large registries
[2,3]. In regions participating in cardiac arrest surveillance, improve-
ments in survival over time have been demonstrated [2,3], however a
1995 and 2013 demonstrated no survival improvements [4].
Although the basic framework for OHCA management has remained
largely unchanged over the past decades [5–8], research has provided
insights into optimizing care including the role of bystander efforts [9],
the importance of early defibrillation [10], and chest compression
quality [11]. The optimal overall strategy however, in regards to

⁎
Corresponding author at: Department of Emergency Medicine, St. Paul’s Hospital, 1081 Burrard St., Vancouver BC, V6Z 1Y6, Canada.
E-mail address: Brian.Grunau2@vch.ca (B. Grunau).

https://doi.org/10.1016/j.resuscitation.2018.01.049
Received 22 September 2017; Received in revised form 23 January 2018; Accepted 29 January 2018
0300-9572/ © 2018 Elsevier B.V. All rights reserved.
B. Grunau et al.
professional resuscitation location and provider, remains unclear with
significant variation in practice [10,12]. Prehospital providers range
from emergency medical technicians to critical care trained physicians,
and protocols range between “scoop and run” (short scene time and
transport to hospital) and “stay and play” (long scene time until either
termination or delayed transport to hospital) strategies [12–15]. There
is few data providing evidence for overall resuscitation practices, as
most prehospital studies attempt to isolate the effect of individual in-
terventions.
In 2005 the British Columbia (BC) EMS identified improving OHCA
survival as a strategic priority and as part of the Resuscitation
Outcomes Consortium (ROC) we established a cardiac arrest registry
[16]. Based on the belief that high-quality paramedic-led on-scene re-
suscitation optimized OHCA survival, we designed and implemented an
initiative to improve the quality of prehospital resuscitation. The aim of
this analysis was to (1) measure the temporal changes in prehospital
care processes since the implementation of this initiative; and (2)
quantify trends in survival.
Methods
Study setting and design
This was a secondary analysis of the British Columbia (BC) ROC
OHCA registry, including BC’s four metropolitan regions: Greater
Victoria and Nanaimo, Greater Vancouver, the Fraser Valley, and
Kelowna/Kamloops; collectively containing 3.3 million citizens (three
quarters of the province’s population) [17,18]. BC was a member of the
10-site North American ROC from 2005 to 2015 [16]. This study was
reported in accordance with STROBE guidelines [19].
EMS medical care
The EMS in BC is a coordinated effort between the provincial BC
Emergency Health Services (BCEHS) and municipal fire departments
(FD), triggered by a provincial 9-1-1 service (since 1981). Dispatch-
assisted cardiopulmonary resuscitation (CPR) and automated external
defibrillator (AED) instruction for bystanders has been provided since
2004. FD responders are trained in basic cardiopulmonary life-support
[8] including the use of AED’s (Appendix A). Paramedics have either
ALS [5] or BLS [8] certification and work in pairs, typically with the
same designation. BLS-certified paramedics provide basic cardio-
pulmonary life-support [8], including chest compressions, AED man-
agement, bag-mask ventilation, and the insertion of supraglottic air-
ways. ALS-certified paramedics provide full advanced cardiopulmonary
life-support [5] including orotracheal intubation, rhythm analysis and
defibrillation, intravenous or intraosseus vascular access and medica-
tion administration. In the ROC geographical catchment approximately
17% of paramedics are ALS-trained. All categories of responders are
dispatched to OHCAs, typically arriving in the following order: FD, BLS,
ALS. A BCEHS policy (enacted prior to 2006) dictates which patients
must be provided resuscitation (Appendix A) [20]. Mechanical CPR
devices were not used in any prehospital setting in BC during the study
period.
The institutional ethical review boards of Providence Health Care
and the University of British Columbia approved this study.
British Columbia OHCA quality improvement strategy
In 2005 the BC Emergency Health Services Commission enacted a
provincial OHCA improvement strategy, focused on measuring and
improving prehospital resuscitation and monitoring outcomes. A ROC-
funded research unit partnered with BCEHS and municipal FDs, col-
lecting care process data (including defibrillator impedance tracings
detailing chest compressions) and hospital discharge outcomes into a
registry. The research unit provided BCEHS reports detailing care
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Resuscitation 125 (2018) 118–125
Fig. 1. Study Flow.
processes and survival rates.
The strategy for improving resuscitation was of team-based training
and emphasis of four targets. First, the importance of maximizing chest
compression fraction was taught [11], and the CPR policy was changed
from 30:2 to continuous compressions without interruption for venti-
lations (given at 10 breaths per minute). Second, the prehospital setting
was taught as the optimal place for OHCA resuscitation; transport of
those in refractory arrest was recommended only if an obvious non-
cardiac cause was identified that could be amenable to hospital-specific
treatment (for example hemorrhage). Third, early placement of ad-
vanced airways was de-emphasized. Fourth, resuscitation efforts were
required for at least 30 min unless contrary to family wishes or a “do
not resuscitate” order was identified [20]. In 2006/2007 all paramedics
and FD first responders underwent a one-day training course in high
quality CPR and team-based resuscitation; training continued over the
subsequent decade (yearly training in resuscitation in addition to
training specific to ROC clinical trials), continually emphasizing the
importance of high quality CPR quality through advocacy, commu-
nication, and skill sessions. Physician approval for field termination was
required during the study period—historically provided by the closest
hospital, however in 2013 a BCEHS live medical oversight program
assumed this role.
Concurrent to these BCHES policy changes, a public access defi-
brillator (PAD) program was ongoing, which began in 2000 with the
PAD trial in Vancouver (Appendix B) [21]. An additional 797 PADs
were placed between 2013 and 2017, and in 2015 a BC AED Registry
was created. Regional standardized post-cardiac arrest protocols, based
on AHA guidelines [22], were implemented in the study regions in
2011–12. Medical care previous to this time period has been previously
described [23].
Data collection
Through a data-sharing agreement with BCEHS and FDs, the BC
ROC group prospectively identified consecutive EMS-treated non-trau-
matic OHCAs, defined as those with EMS-performed chest compressions
or defibrillation by a professional or lay rescuer. Cases were identified
by: (1) email alerts from dispatch sent to the registry staff; (2) CPR
process data downloaded from the monitor/defibrillator by paramedics
(Code-Stat, Physio-Control, Inc.); and, (3) weekly surveillance reports,
using an algorithm based on dispatch and diagnosis codes, run by
BCEHS with case reviews by ROC registry staff. BCEHS utilizes stan-
dardized template charting with fields based on Utstein variables [24].
BC ROC staff abstracted data to a structured electronic case record,
stored at the University of Washington. Pre-hospital data collection
included clinical providers, patient characteristics, and time-based
treatments administered. Chest compression fraction (CCF) was calcu-
lated from the first 5 or 10 min of process data (the duration of data
used varied depending on trial-specific ROC requirements). Hospital
charts were manually examined for discharge outcomes.
B. Grunau et al. Resuscitation 125 (2018) 118–125

Table 1
Patient Characteristics and Outcomes.

Year Group

2006–2009 2010–2013 2014–2016 P value for trend

(n = 5142) (n = 5902) (n = 4101)
Variable n or Median Mis. (%) n or Median Mis. (%) n or Median Mis. (%)

Non-modifiable characteristics
Age (IQR), years 68 (54–79) 97 (1.9) 68 (55–79) 37 (0.6) 67 (54–79) 68 (1.7) 0.16
Male sex (%) 3431 (67.1) 26 (0.5) 4036 (68.6) 18 (0.3) 2815 (68.9) 17 (0.4) 0.02
Initial rhythm (%) 265 (5.2) 111 (1.9) 131 (3.2)
shockable VF/pVT (%) 1351 (27.7) 1463 (25.3) 923 (23.3) < 0.01
Non-shockable Total (%) 3526 (72.3) 4328 (25.3) 3047 (76.8) –
-Asystole (%) 881 (18.1) 1115 (19.3) 771 (19.4) –
-PEA (%) 1689 (34.6) 2383 (41.2) 1705 (43.0) –
-AED no-shock (%) 835 (17.1) 809 (13.97) 564 (14.2) –
-Unclassifiable (%) 121 (2.5) 21 (0.4) 7 (0.2) –
Bystander witness (%) 2116 (41.2) – 2313 (39.2) – 1.601 (39.2) 13 (0.3) < 0.01
EMS witness (%) 481 (9.4) 2 (< 0.1) 590 (10.0) 1 (< 0.1) 405 (9.9) 14 (0.3) 0.26
Location (%) 10 (0.2) 10 (0.2) 14 (0.3)
Public location (%) 1007 (19.6) 1064 (18.1) 750 (81.7) 0.16
Non-public location (%) 4125 (80.4) 4828 (81.9) 3337 (81.2) –

Modifiable characteristics
Bystander CPR (%) 2023 (39.4) 3 (< 0.1) 2668 (45.2) 2 (< 0.1) 1999 (48.9) 13 (0.3) < 0.01
Bystander AED (%) 73 (1.4) 2 (< 0.1) 147 (2.5) 2 (< 0.1) 146 (3.6) – < 0.01
911 Call to EMS arrival (IQR), min 6.6 (5.1–8.6) 13 (0.3) 6.6 (5.3–8.3) 91 (1.5) 6.5 (5.2–8.3) 133 (3.2) 0.43
ALS involvement (%) 4439 (86.3) – 5551 (94.1) – 3964 (96.7) – < 0.01
Advanced Airway (%) 3513 (76.6) 554 (10.8) 4260 (81.0) 642 (10.9) 3050 (83.2) 435 (10.6) < 0.01
Time to Advanced Airway (IQR),1 min 12.9 (8.6–17.9) 2223 (36.7) 14.1 (10.6–19.1) 1492 (35.0) 14.9 (11.1–19.7) 381 (12.5) < 0.01
Time to TOR (IQR),1 min 27.3 (20.0–35.0) 726 (25.2) 29.0 (20.0–37.0) 502 (16.9) 31.9 (23.0–40.0) 299 (14.1) < 0.01
Scene time (IQR),2 min 27.0 (19.0–35.7) 48 (0.9) 29.7 (21.3–38.0) 117 (2.0) 32.0 (24.0–40.6) 172 (4.1) < 0.01
Transported to ED (%) 2800 (54.5) 2 (< 0.1) 2990 (50.7) – 2043 (49.9) 6 (0.1) < 0.01
Transported Prior to ROSC (%) 866 (16.9) 3 (< 0.1) 535 (9.1) – 266 (6.5) 6 (0.1) < 0.01
Time to Transport if Transported Prior to ROSC (IQR), 17.9 (13.1–25.4) – 22.0 (13.9 – 32.3) – 28.1 (14.5–39.0) – < 0.01
min
CC Fraction (IQR) 81.0 (69.6–87.0) 1874 (36.4) 85.0 (78.2–89.9) 1335 (22.6) 87.0 (71.9–91.7) 1626 < 0.01
(39.6)
Chest Compression rate per min (IQR) 114 (103–123) 1907 (37.1) 111 (104–118) 1104 (18.7) 110 (104–116) 646 (15.8) < 0.01

Outcomes
ROSC (%) 2258 (43.9) 3 (< 0.1) 2935 (49.7) – 1984 (48.4) – < 0.01
Survival at hospital discharge (%) 530 (10.4) 42 (0.8) 798 (13.6) 33 (0.6) 596 (14.9) 107 (2.6) < 0.01
Survivors with mRS ≤ 3 (%3) 157 (76.6) 325 (61.3) 516 (87.2) 206 (25.8) 255 (92.1) 319 (53.5) < 0.01

Mis, missing; IQR, inter-quartile range, “shockable” initial cardiac rhythms refer to ventricular fibrillation and pulseless ventricular tachycardia; EMS, emergency medical system; CPR,
cardiopulmonary resuscitation; AED, automatic external defibrillator; ALS, advanced life support paramedic; TOR, termination of resuscitation; ED, emergency department; CC, chest
compression; ROSC, return of spontaneous circulation; mRS, modified rankin scale.
1
Measured from commencement of professional resuscitation.
2
Measured from commencement of professional resuscitation to either termination of efforts or departure of scene for transport to hospital.
3
Denominator is the number of survivors.

Selection of participants
In this analysis we included all EMS-treated adult (age ≥18) pa-
tients from the BC ROC registry between January 2006 and March
2016. We excluded patients with a “do not resuscitate” order.
Outcome measures and variable definitions
The primary outcome was survival at hospital discharge [24]. Fa-
vourable neurological outcomes were defined as Modified Rankin Score
(mRS) ≤3 [24]. Data for neurologic outcomes at discharge were only
collected during periods of clinical trial enrolment [25–28].
Data analysis
We downloaded BC data from the central ROC database, and used
Microsoft Excel 2008 (Microsoft Corp, Redmond, WA, USA) and STATA
version 13.1 (STATA Corp, College Station, TX) for analysis. We cate-
gorized variables as either “non-modifiable” (age, sex, whether the
arrest was bystander- or EMS-witnessed, or in a public location, and
initial cardiac rhythm) or “modifiable” (bystander AED and CPR, time
to EMS arrival, chest compression fraction, ALS involvement, time to
termination of efforts in those who did not achieve ROSC, and whether
transport to hospital was initiated prior to any episodes of ROSC).
“Time to EMS arrival” was defined as the duration between 9-1-1 call
and first professional rescuer arrival (paramedic or FD first responder).
We evaluated temporal trends in patient characteristics and out-
comes, using the nonparametric test for trend of categorical variables
(an extension of the Wilcoxon rank-sum test [29]) and single linear
regression for continuous variables with the robust estimator of var-
iance, adjusting for non-normal distribution. As neurological outcome
data was only available for approximately half of survivors, we ex-
amined trends in the proportion of survivors with favourable neurolo-
gical outcomes.
To assess trends in survival, we conducted multivariable Poisson
regression with the robust estimator of variance, including cases with
complete data for the outcome and adjustment covariates. As the rate of
survival to discharge was estimated to be higher than 10%, rate ratio
instead of odds ratio was calculated to avoid a potential overestimation
[30,31]. We included calendar year (reference 2006) as an independent
variable. Yearly risk-adjusted rates for survival were calculated by
multiplying the observed survival rate for the reference year by the
adjusted risk ratio of the corresponding year. To assess the chron-
ological trend of adjusted rate ratio for survival, we conducted the same

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B. Grunau et al.
Fig. 2. Trends in Non-Modifiable Patient Characteristics.
EMS, emergency medical system; Shockable Initial Rhythm (includes ventricular fibrillation and pulseless ventricular tachycardia)
model, with calendar year as a continuous variable. By convention, we
adjusted with Utstein variables [24] age, sex, initial recorded cardiac
rhythm, location of the event (public or non-public), bystander and/or
EMS witnessed, bystander CPR, bystander AED, and time to EMS ar-
rival. We conducted the same analysis stratified by the initial rhythm
(shockable and non-shockable).
Results
Characteristics of study subjects
Between January 1, 2006 and March 31, 2016 there were 26 433
non-traumatic EMS-assessed OHCAs. Pediatric patients, untreated
cases, and those with DNR orders (n = 431, the year-by-year trend of
those with DNR orders is shown in Appendix C) were removed, leaving
15 145 included cases (Fig. 1). Survival status was ascertained in 99%
of subjects. System-based changes with dates are shown in Appendix B.
Univariate analyses
Univariate trend analyses of non-modifiable patient characteristics
are shown in Table 1 and Fig. 2. There was a significant decrease in the
proportion with initial shockable cardiac rhythms and bystander wit-
nessed arrests.
Univariate trend analyses of modifiable patient characteristics are
shown in Table 1 and Fig. 3. There were significant increases in by-
stander AED (p < 0.01), bystander CPR (p < 0.01), and the propor-
tion treated by ALS (p < 0.01). The median chest compression fraction
increased significantly (p < 0.01); the median chest compression rate
decreased significantly (p < 0.01) while remaining in the re-
commended range [8]. There was an increase in the proportion who
received advanced airways (p < 0.01), but these were placed at sig-
nificantly later time points in the resuscitation (p < 0.01).
The time interval to resuscitation termination among those who
never achieved ROSC increased significantly (p < 0.01), as well as the
overall scene time (p < 0.01). There was a significant decrease in the
proportion of patients transported to the ED overall (p < 0.01), and
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Resuscitation 125 (2018) 118–125
the proportion transported to the ED in the absence of ROSC
(p < 0.01). Among those transported to hospital in the absence of
ROSC, this occurred at a significantly later time in the resuscitation
effort (p < 0.01).
There was a significant increase in the proportion with ROSC
(p < 0.01), and overall survival (p < 0.01) to hospital discharge
(Table 1, Fig. 4). There was a significant increase in the proportion of
favourable neurological outcomes among survivors (p < 0.01).
Adjusted analyses
The multivariable Poisson regression model demonstrated sig-
nificant associations between survival and the covariates age, initial
shockable rhythm, bystander witnessed and EMS witnessed arrest,
public location, bystander CPR, bystander AED application, and time to
EMS arrival (Appendix D). Over the study period there was a significant
improvement in ROSC (risk-adjusted rate of 41% in 2006–51% in 2016;
adjusted rate ratio per year 1.02, 95% CI 1.01–1.02, p < 0.01 for
trend) and survival at hospital discharge (risk-adjusted rate 8.6% in
2006–16% in 2016; adjusted rate ratio/year 1.05, 95% CI 1.04–1.06,
p < 0.01 for trend) (Table 2). Both subgroups of initial shockable and
non-shockable cardiac rhythms demonstrated survival improvement.
Discussion
Over a period from 2006 to 2016, health agencies in British
Columbia maintained a prospective registry with detailed prehospital
time-based data of consecutive non-traumatic OHCAs in BC’s me-
tropolitan areas, treated by a single ambulance service. During this time
a quality improvement initiative was implemented, with the aim of
improving prehospital resuscitation within a model of high-quality
paramedic-led on-scene resuscitation for adequate durations. Chest
compression fraction and the proportion treated by ALS paramedics
increased. Paramedics stayed on scene longer and also continued
treatment longer until termination of efforts. During this time we ob-
served crude and adjusted improvements in patients achieving ROSC.
Concurrently, there were ongoing advocacy for improved post
B. Grunau et al.
Fig. 3. Trends in Modifiable Patient Treatment Characteristics.
*AED, automated external defifrillator; ROSC, return of spontaneous circulation; CCF, chest compression fraction; CPR, cardiopulmonary resuscitation; ALS, advanced life support; EMS,
emergency medical system; TOR, termination of resuscitation (elapsed time from start of professional resuscitation until termination); Advanced Airway is defined as tracheal or
supraglottic airway
resuscitation in-hospital care. Importantly, we found that crude cardiac
arrest survival at hospital discharge improved by approximately 40%
during this time period; further, the proportion of survivors with fa-
vourable neurologic outcomes increased. Although these findings do
not indicate causality, the trends and biologic plausibility argue for the
likelihood that these changes played a role in the clinical outcome
improvements. Our data may assist other systems in providing a model
for prehospital resuscitation that may lead to improved survival.
The BCEHS OHCA resuscitation paradigm is based on high-quality
paramedic-delivered on-scene treatments with prehospital cessation of
efforts for the majority unsuccessful resuscitations (after a minimum of
30 min). This is a controversial strategy with some advocating that all
or select OHCAs in refractory arrest should be transported to hospital
[32–34]. However, as most resuscitative therapies are available in the
prehospital environment, routine transport of OHCA patients in re-
fractory arrest to be treated with the same algorithms in hospital [5],
may provide dubious benefits while potentially endangering paramedic
and public safety [12,35]. Our data demonstrate a significant decrease
in the proportion of patients transported to hospital in the absence of
ROSC, however a significant increase in the time afforded to on-scene
efforts among those with prehospital termination. Among the minority
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Resuscitation 125 (2018) 118–125
who were transported to hospital without prior ROSC, this occurred
significantly later in the resuscitation effort. Although our data de-
monstrates an overall decreasing proportion of patients transported to
hospital, we report an overall increasing proportion of patients who
achieved ROSC, and an increasing proportion who were discharged
from hospital alive and neurologically intact.
Studies evaluating ALS management have shown conflicting results
[26–38]. Our data shows increasing access to ALS care with time.
BCEHS utilizes a tiered BLS-ALS system, with only 1/6 of paramedics of
ALS designation. This low ratio may increase the time to ALS arrival in
comparison to systems with ALS-trained paramedics on each unit,
however may increase the experience and skill in this smaller group of
paramedics. Further research is required to investigate the trade-off
between paramedic experience and arrival time.
Trends in non-EMS based characteristics may have also had impacts
on the survival trends. Consistent with previous reports [3], we found
that there was a declining proportion of patients with initial shockable
rhythms, a covariate highly associated with survival. There was also a
significant decrease in bystander-witnessed arrests, which in our study
and others has been shown to have strong negative prognostic im-
plications [3]. Although the relationships were weaker, both bystander
B. Grunau et al. Resuscitation 125 (2018) 118–125

Fig. 4. Trends in overall outcomes, and stratified by rhythm and witnessed status.
*VF, ventricular fibrillation or pulseless ventricular tachycardia initial rhythms; NS, non-shockable initial rhythms; EMS, emergency medical system; “Survivors with mRS
≤3” = survivors at hospital discharge with MRS ≤3/total survivors at hospital discharge.

Table 2
Yearly Outcome trend analysis.

Outcome Risk-Adjusted Rates Adjusted Rate Ratio per Year (95% CI) P Value for Trend

Number 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

ROSC 14,214 40.7 45.8 47.3 46.2 45.0 62.5 48.8 49.0 51.3 49.5 51.4 1.02 (1.01–1.02) < 0.01
Survival 14,081 8.6 11.4 11.9 10.8* 13.5 14.0 14.2 13.3 15.2 15.6 16.0 1.05 (1.04–1.06) < 0.01

Stratified by rhythm
Shockable
ROSC 3632 67.1 70.9* 72.8* 68.4* 72.0* 79.9 71.6* 71.7* 71.6* 75.1 74.6* 1.01 (1.00–1.01) 0.03
Survival 3559 24.6 31.9 33.0 23.3* 35.7 36.8 37.2 34.4 36.5 41.4 44.4 1.04 (1.03–1.06) < 0.01

Nonshockable
ROSC 10,582 29.8 35.4 36.7 36.9 34.3 55.0 39.7 39.8 42.5 39.2 41.9 1.03 (1.02–1.03) < 0.01
Survival 10,522 2.2 3.2* 3.5* 5.0 4.7 5.2 5.2 4.9 6.7 5.5 5.2 1.08 (1.05–1.11) < 0.01

ROSC, return of spontaneous circulation.

*no statistical significance.

CPR and bystander AED application (with or without shock) were as-
sociated with survival, both of which increased during the study period.
Increasing bystander efforts may have be related to the local PAD
program, efforts to increase bystander CPR training and advocacy, and
increased implementation of dispatch-assisted CPR. Further efforts to
increase the proportion of those undergoing bystander resuscitative
efforts are warranted.
Although we were able to calculate the association of traditional
Utstein characteristics [24] with survival, for many care process metrics
this is not feasible. For example, it is not possible to include “time to
termination of resuscitation” in the model as it is only applicable to
unsuccessful resuscitations and is a group devoid of survivors. One
could examine “total duration of resuscitation” which is available for all
patients, however this covariate in individual patients would demon-
strate association with non-survival (as is a marker of unsuccessful ef-
forts) [39]. The critical question is: does an EMS which systematically
provides longer durations of attempted resuscitation improve overall
outcomes? Using one strategy to evaluate this, Goldberger et al.
compared the resuscitation practices at different hospitals and reported
higher overall survival in centers with longer resuscitation attempts
[40]. An alternate strategy is to examine chronical trends of re-
suscitation practices and survival, as we have done in this analysis.
Our data contrasts with a recent report of 250 000 US OHCAs from
1995 to 2013, that failed to demonstrate survival improvements [4].
Similarly, a meta-analysis including 142 740 patients over three dec-
ades reported no changes in survival [41]. A recent study of 38 378
patients with initial non-shockable rhythms over 10 years found no
outcomes improvements [42]. Conversely, ROC sites reported im-
proving outcomes between 2006 and 2010, overall and within rhythm-
based subgroups [3]. Whereas ROC clinical trials of specific therapies
have not demonstrated benefits [25–28], improving overall survival
may in part be related to the Hawthorne effect with increased attention
to OHCA resuscitation, especially high quality CPR [11]. Similarly, the
“Cardiac Arrest Registry to Enhance Survival” registry sites have de-
monstrated outcome improvements [2]. Simply monitoring OHCA
outcomes, a component of our quality improvement strategy, may have

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played a role in the improvements within our system. Regardless, im-
provements in quality were the desired effect of our initiative, the
process and data from which may be used to assist efforts to improve
outcomes in other regions.
Our study is subject to several limitations. It was an observational
analysis performed in metropolitan areas in one province; patient
characteristics, EMS structure, medical management may differ in other
regions. We are unable to make conclusions based on individual prac-
tice changes, however within our single large ambulance service we
were able to describe the EMS structure and care provided, and track
survival changes with evolution of practices. The BCEHS criteria out-
lining who must be provided resuscitative treatments (Appendix A) may
differ from other regions. Our data indicates that paramedics treated
60% of EMS-assessed adult non-traumatic OHCA’s; a previous large
study of 129 EMS agencies including 86 912 EMS-assessed patients
reported that overall 55% underwent attempts at resuscitation [43],
suggesting that our results are not biased towards higher outcomes due
to a reluctance to attempt resuscitation in those with unfavourable
characteristics. We are unable to make conclusions causality: it is
possible that medical management unrelated to the prehospital care
was responsible for survival improvements (including in-hospital care
such as angiography and targeted temperature management, data for
which was not available). However, we observed crude and adjusted
increases in the proportion who were successfully resuscitated, which is
unrelated to downstream care. It is possible that temporal improve-
ments may have occurred irrespective of any medical interventions.
Missing data, and the need to exclude those with missing data from the
adjusted analysis, is a limitation. We lacked neurological outcome data
for just under half of survivors and CCF data in approximately one-third
of patients. We did not have data on chest compression depth and peri-
shock pause. Finally, labour action within BCEHS took place in for
seven months 2009, which may have affected cardiac arrest identifi-
cation and data quality; the observed decline in outcomes during that
year may have been a true decline or due to selection bias of patients
identified.
Conclusion
Over a 10-year period BC’s provincial ambulance system empha-
sized high quality paramedic-led on-scene resuscitation, which trans-
lated into improvements in desired care metrics. During this time there
were significant improvements in patient outcomes. Our data may assist
other systems in providing a model for prehospital resuscitation quality
improvement that may lead to improved survival.
Conflict of interest
None.
Funding
The BC Canadian Resuscitation Outcomes Consortium research of-
fice is supported by the Heart & Stroke Foundation, Provincial Health
Services Authority, and Providence Health Care.
Acknowledgements
We would like to acknowledge the commitment and dedication of
BC Emergency Health Services paramedics, local fire department first
responders, hospital-based clinicians, and the BC Canadian
Resuscitation Outcomes Consortium research office, to the best possible
treatment of cardiac arrest victims. We would like to thank Robert
Schmicker (University of Washington) for his assistance with data
aquisition, as well as the Resuscitation Outcomes Consortium.
124
Resuscitation 125 (2018) 118–125
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in the
online version, at https://doi.org/10.1016/j.resuscitation.2018.01.049.
References
[1] Mozaffarian D, Benjamin EJ, Go AS, et al. Executive summary heart disease and
stroke statistics–2016 update: a report from the American Heart Association.
Circulation 2016;133(4):447–54. http://dx.doi.org/10.1161/CIR.
0000000000000366.
[2] Chan PS, McNally B, Tang F, Kellermann A. CARES Surveillance Group. Recent
trends in survival from out-of-hospital cardiac arrest in the United States.
Circulation 2014;130(21):1876–82. http://dx.doi.org/10.1161/
CIRCULATIONAHA.114.009711.
[3] Daya MR, Schmicker RH, Zive DM, et al. Out-of-hospital cardiac arrest survival
improving over time: results from the Resuscitation Outcomes Consortium (ROC).
Resuscitation 2015;91:108–15. http://dx.doi.org/10.1016/j.resuscitation.2015.02.
003.
[4] Eid SM, Abougergi MS, Albaeni A, Chandra-Strobos N. Survival, expenditure and
disposition in patients following out-of-hospital cardiac arrest: 1995–2013.
Resuscitation 2017;113:13–20. http://dx.doi.org/10.1016/j.resuscitation.2016.12.
027.
[5] Link MS, Berkow LC, Kudenchuk PJ, et al. Part 7: adult advanced cardiovascular life
support: 2015 American Heart Association guidelines update for cardiopulmonary
resuscitation and emergency cardiovascular care. Circulation 2015;132(18 Suppl.
2):S444–64. http://dx.doi.org/10.1161/CIR.0000000000000261.
[6] Neumar RW, Otto CW, Link MS, et al. Part 8: adult advanced cardiovascular life
support: 2010 American Heart Association guidelines for cardiopulmonary re-
suscitation and emergency cardiovascular care. Circulation 2010;122(18 Suppl
3):S729–67. http://dx.doi.org/10.1161/CIRCULATIONAHA.110.970988.
[7] Berg RA, Hemphill R, Abella BS, et al. Part 5: adult basic life support: 2010
American Heart Association guidelines for cardiopulmonary resuscitation and
emergency cardiovascular care. Circulation 2010;122(18 Suppl. 3):S685–705.
http://dx.doi.org/10.1161/CIRCULATIONAHA.110.970939.
[8] Kleinman ME, Brennan EE, Goldberger ZD, et al. Part 5: adult basic life support and
cardiopulmonary resuscitation quality: 2015 American Heart Association guidelines
update for cardiopulmonary resuscitation and emergency cardiovascular care.
Circulation 2015;132(18 Suppl. 2):S414–35. http://dx.doi.org/10.1161/CIR.
0000000000000259.
[9] Kragholm K, Wissenberg M, Mortensen RN, et al. Bystander efforts and 1-year
outcomes in out-of-hospital cardiac arrest. N Engl J Med 2017;376(18):1737–47.
http://dx.doi.org/10.1056/NEJMoa1601891.
[10] Kitamura T, Kiyohara K, Sakai T, et al. Public-access defibrillation and out-of-
hospital cardiac arrest in Japan. N Engl J Med 2016;375(17):1649–59. http://dx.
doi.org/10.1056/NEJMsa1600011.
[11] Christenson J, Andrusiek D, Everson-Stewart S, et al. Chest compression fraction
determines survival in patients with out-of-hospital ventricular fibrillation.
Circulation 2009;120(13):1241–7. http://dx.doi.org/10.1161/CIRCULATIONAHA.
109.852202.
[12] Zive D, Koprowicz K, Schmidt T, et al. Variation in out-of-hospital cardiac arrest
resuscitation and transport practices in the Resuscitation Outcomes Consortium:
ROC Epistry-Cardiac Arrest. Resuscitation 2011;82(3):277–84. http://dx.doi.org/
10.1016/j.resuscitation.2010.10.022.
[13] Kang K, Kim T, Ro YS, Kim YJ, Song KJ. Shin S Do Prehospital endotracheal in-
tubation and survival after out-of-hospital cardiac arrest: results from the Korean
nationwide registry. Am J Emerg Med 2016;34(2):128–32. http://dx.doi.org/10.
1016/j.ajem.2015.09.036.
[14] Belohlavek J, Kucera K, Jarkovsky J, et al. Hyperinvasive approach to out-of hos-
pital cardiac arrest using mechanical chest compression device, prehospital in-
traarrest cooling, extracorporeal life support and early invasive assessment com-
pared to standard of care. A randomized parallel groups compa. J Transl Med
2012;10(1):163. http://dx.doi.org/10.1186/1479-5876-10-163.
[15] Karam N, Marijon E, Dumas F, et al. Characteristics and outcomes of out-of-hospital
sudden cardiac arrest according to the time of occurrence. Resuscitation
2017;116:16–21. http://dx.doi.org/10.1016/j.resuscitation.2017.04.024.
[16] Morrison LJ, Nichol G, Rea TD, et al. Rationale, development and implementation
of the resuscitation outcomes consortium epistry-cardiac arrest. Resuscitation
2008;78(2):161–9. http://dx.doi.org/10.1016/j.resuscitation.2008.02.020.
[17] Statistics Canada. Focus on Geography Series. Ottawa, Ontario: 2011 Census; 2012.
[18] BC Statistics Population Estimates. 2018 Accessed March 3, 2017 http://www.
bcstats.gov.bc.ca/StatisticsBySubject/Demography/PopulationEstimates.aspx.
[19] von Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of
Observational Studies in Epidemiology (STROBE) statement: guidelines for re-
porting observational studies. J Clin Epidemiol 2008;61(4):344–9. http://dx.doi.
org/10.1016/j.jclinepi.2007.11.008.
[20] Resuscitation of Critically Ill Patients: Service Policy Number 6.4.13 2. Vancouver,
B.C: British Columbia Emergency Health Services; 2010.
[21] Hallstrom AP, Ornato JP, Weisfeldt M, et al. Public-access defibrillation and sur-
vival after out-of-hospital cardiac arrest. N Engl J Med 2004;351(7):637–46. http://
dx.doi.org/10.1056/NEJMoa040566.
[22] Peberdy MA, Callaway CW, Neumar RW, et al. Part 9: post-cardiac arrest care: 2010
American Heart Association guidelines for cardiopulmonary resuscitation and
emergency cardiovascular care. Circulation 2010;122(18 Suppl. 3):S768–86.
B. Grunau et al.
http://dx.doi.org/10.1161/CIRCULATIONAHA.110.971002.
[23] Grunau BE, Reynolds JC, Scheuermeyer FX, et al. Comparing the prognosis of those
with initial shockable and non-shockable rhythms with increasing durations of CPR:
informing minimum durations of resuscitation. Resuscitation 2016(February).
http://dx.doi.org/10.1016/j.resuscitation.2016.01.021.
[24] Perkins GD, Jacobs IG, Nadkarni VM, et al. Cardiac arrest and cardiopulmonary
resuscitation outcome reports: update of the utstein resuscitation registry templates
for out-of-hospital cardiac arrest: a statement for healthcare professionals from a
task force of the International Liaison Committee. Resuscitation 2015;96:328–40.
http://dx.doi.org/10.1016/j.resuscitation.2014.11.002.
[25] Aufderheide TP, Nichol G, Rea TD, et al. A trial of an impedance threshold device in
out-of-hospital cardiac arrest. N Engl J Med 2011;365(9):798–806. http://dx.doi.
org/10.1056/NEJMoa1010821.
[26] Stiell IG, Nichol G, Leroux BG, et al. Early versus later rhythm analysis in patients
with out-of-hospital cardiac arrest. N Engl J Med 2011;365(9):787–97. http://dx.
doi.org/10.1056/NEJMoa1010076.
[27] Kudenchuk PJ, Brown SP, Daya M, et al. Amiodarone, lidocaine, or placebo in out-
of-hospital cardiac arrest. N Engl J Med 2016;374(18):1711–22. http://dx.doi.org/
10.1056/NEJMoa1514204.
[28] Nichol G, Leroux B, Wang H, et al. Trial of continuous or interrupted chest com-
pressions during CPR. N Engl J Med 2015;373(23):2203–14. http://dx.doi.org/10.
1056/NEJMoa1509139.
[29] Cuzick J. A Wilcoxon-type test for trend. Stat Med 2016;4(1):87–90http://www.
ncbi.nlm.nih.gov/pubmed/3992076.
[30] Greenland S. Model-based estimation of relative risks and other epidemiologic
measures in studies of common outcomes and in case-control studies. Am J
Epidemiol 2004;160(4):301–5. http://dx.doi.org/10.1093/aje/kwh221.
[31] Zou G. A modified poisson regression approach to prospective studies with binary
data. Am J Epidemiol 2004;159(7):702–6http://www.ncbi.nlm.nih.gov/pubmed/
15033648.
[32] Kellermann AL, Staves DR, Hackman BB. In-hospital resuscitation following un-
successful prehospital advanced cardiac life support: heroic efforts or an exercise in
futility? Ann Emerg Med 1988;17(6):589–94http://www.ncbi.nlm.nih.gov/
pubmed/3377287.
[33] Xiong Y, Zhan H, Lu Y, et al. Out-of-hospital cardiac arrest without return of
spontaneous circulation in the field: who are the survivors? Resuscitation
2017;112:28–33. http://dx.doi.org/10.1016/j.resuscitation.2016.12.013.
125
Resuscitation 125 (2018) 118–125
[34] Morrison LJ, Kierzek G, Diekema DS, et al. Part 3: ethics: 2010 American Heart
Association guidelines for cardiopulmonary resuscitation and emergency cardio-
vascular care. Circulation 2010;12:2. http://dx.doi.org/10.1161/
CIRCULATIONAHA.110.970905.
[35] Kahn CA, Pirrallo RG, Kuhn EM. Characteristics of fatal ambulance crashes in the
United States: an 11-year retrospective analysis. Prehosp Emerg Care
1997;5(3):261–9 Accessed August 21, 2014 http://www.ncbi.nlm.nih.gov/
pubmed/11446540.
[36] Bakalos G, Mamali M, Komninos C, et al. Advanced life support versus basic life
support in the pre-hospital setting: a meta-analysis. Resuscitation
2011;82(9):1130–7. http://dx.doi.org/10.1016/j.resuscitation.2011.04.006.
[37] Sanghavi P, Jena AB, Newhouse JP, Zaslavsky AM. Outcomes after out-of-hospital
cardiac arrest treated by basic vs advanced life support. JAMA Intern Med
2015;175(2):196–204. http://dx.doi.org/10.1001/jamainternmed.2014.5420.
[38] Stiell IG, Wells GA, Field B, et al. Advanced cardiac life support in out-of-hospital
cardiac arrest. N Engl J Med 2004;351(7):647–56. http://dx.doi.org/10.1056/
NEJMoa040325.
[39] Reynolds JC, Grunau BE, Rittenberger JC, Sawyer KN, Kurz MC, Callaway CW.
Association between duration of resuscitation and favorable outcome after out-of-
hospital cardiac arrest: implications for prolonging or terminating resuscitation.
Circulation 2016;134(25):2084–94. http://dx.doi.org/10.1161/
CIRCULATIONAHA.116.023309.
[40] Goldberger ZD, Chan PS, Berg RA, et al. Duration of resuscitation efforts and sur-
vival after in-hospital cardiac arrest: an observational study. Lancet
2012;380(9852):1473–81. http://dx.doi.org/10.1016/S0140-6736(12)60862-9.
[41] Sasson C, Rogers MAM, Dahl J, Kellermann AL. Predictors of survival from out-of-
hospital cardiac arrest: a systematic review and meta-analysis. Circ Cardiovasc Qual
Outcomes 2010;3(1):63–81. http://dx.doi.org/10.1161/CIRCOUTCOMES.109.
889576.
[42] Andrew E, Nehme Z, Lijovic M, Bernard S, Smith K. Outcomes following out-of-
hospital cardiac arrest with an initial cardiac rhythm of asystole or pulseless elec-
trical activity in Victoria, Australia. Resuscitation 2014;85(11):1633–9. http://dx.
doi.org/10.1016/j.resuscitation.2014.07.015.
[43] Brooks SC, Schmicker RH, Cheskes S, et al. Variability in the initiation of re-
suscitation attempts by emergency medical services personnel during out-of-hos-
pital cardiac arrest. Resuscitation 2017;117:102–8. http://dx.doi.org/10.1016/j.
resuscitation.2017.06.009.