OHCAR
Out of Hospital Cardiac Arrest Register
Ireland
Annual Report 2014
OHCAR Annual Report 2014
Contents
Introduction
2
The National Out-of-Hospital Cardiac Arrest Register (OHCAR)
OHCAR governance and organisation
Aim of OHCAR
Inclusion criteria
Source of OHCAR data
Data collection
Data completeness and quality control
Data Elements
OHCAR reporting to Service Providers
OHCAR meetings and representations
OHCAR presentations
OHCAR Research
OHCAR Publications
Future developments in OHCAR
2
3
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Results – all OHCA cases 2014
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OHCAR Comparator Subset 2014
21
OHCAR Key Messages 2014
24
References
25
Appendix 1: OHCAR Publications
26
Appendix 2: Utstein comparator subset 2014 – Regional Results
27
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OHCAR Annual Report 2014
Introduction
The National Out-of-Hospital Cardiac Arrest Register (OHCAR)
The National Out-of-Hospital Cardiac Arrest Register (OHCAR) project was established in June 2007
in response to a recommendation in the Report of the Task Force on Sudden Cardiac Death”1. The
need for OHCAR has been reinforced in the policy docume t Changing Cardiovascular Health” 2 and
the Emergency Medicine Programme Strategy” 3. Since 2012, OHCAR became one of only three
national OHCA registries in Europe. The other two countries with fully established national OHCA
registries in Europe are Sweden and Denmark. Many other European countries operate out of
hospital cardiac arrest registers with partial geographical and/or intermittent coverage.
Figure 1: Ireland, Denmark and Sweden operate fully established national out of hospital cardiac
arrest registries. Other European countries operate registries with partial or intermittent
coverage. Source: EuReCaONE (modified)
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OHCAR Annual Report 2014
OHCAR governance and organisation
OHCAR is hosted by the Department of Public Health Medicine in the HSE West (North West region)
and is jointly funded by the Pre-Hospital Emergency Care Council (PHECC) and the National
Ambulance Service (NAS). It is administered and supported by the Department of General Practice,
School of Medicine, NUI Galway.
The OHCAR Steering Group is responsible for ensuring that the aims of OHCAR are fulfilled and for
advising on its organisation and direction. The Steering Group includes representatives from all four
supporting organisations. The membership as per January 2016 is:
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Dr. Peter Wright, Director of Public Health Medicine, HSE West (NW area) (CHAIR)
Prof. Gerard Bury, UCD Centre for Immediate Care
Dr. John Dowling, North West Immediate Care Programme
Dr. Conor Deasy, Consultant in Emergency Medicine, Cork University Hospital
Ms. Jacqueline Egan, Programme Development Officer, PHECC
Dr. Joseph Galvin, Cardiologist, Mater Hospital
Prof. Andrew Murphy, Department of General Practice, NUI Galway
D . Cathal O Do ell, Medi al Di e to , Natio al A ulance Service
Mr. Gerry Clarke, Operational Support and Resilience Manager, NAS
David Hennelly Clinical Development Manager, National Ambulance Service, HSE
Dr. David Menzies CFR Ireland & Consultant in Emergency Medicine St Vincent's
University Hospital & Clinical Lead, Emergency Medical Science, UCD, Centre for
Emergency Medical Science
Ma ti O ‘eilly, Dist i t Offi e , EM“ “uppo t Offi e , Du li Fi e B igade
Siobhan Masterson, HRB Research Fellow
Mette Jensen, OHCAR Manager
The Steering Group met four times from October 2014 to November 2015.
The OHCAR Manager reports directly to the OHCAR Director (Director of Public Health Medicine) and
is accommodated in the Department of Public Health Medicine, HSE North West and the Discipline
of General Practice, NUI Galway. The OHCAR Manager is guided in her work by the Steering Group
and also receives academic support from the Discipline of General Practice, NUI Galway.
Aim of OHCAR
The overall aim of OHCAR is to facilitate improved outcomes from out of hospital cardiac arrest
(OHCA) in Ireland by way of
- Collecting information on the population who suffer an OHCA and the circumstances of the
arrest
- Collecting information on the pre-hospital treatment of OHCA patients
- Registering the survival of OHCA patients
- Establishing a sufficiently large patient database to enable identification of the best
treatment methods for OHCAs and organisation of services
- Providing regular feedback to service providers
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OHCAR Annual Report 2014
Inclusion criteria
OHCAR registers all patients who suffer a witnessed or unwitnessed out-of-hospital cardiac arrest
in Ireland hi h is o fi ed a d atte ded y E e ge y “e i es a d esus itatio atte pted”.
A resuscitation attempt is defined as CPR and/or defibrillation.
Incidents attended by the Emergency Services where resuscitation is not attempted due to either
obvious signs of death, injuries incompatible with life or a do ot esus itate order in place are not
included in OHCAR.
The current scope does not include patients who suffer an OHCA and who are not attended at
any stage by Emergency Services. This means that a sub-group of patients are likely to be
excluded from OHCAR, for example cases attended by a GP where resuscitation is attempted
but death is confirmed and the ambulance is stood down by the GP.
Source of OHCAR data
The primary source of OHCAR data is the Patient Care Records (PCR) and ambulance dispatch data
from the two statutory ambulance services, the National Ambulance Service (NAS) and the Dublin
Fire Brigade (DFB). OHCAR has data sharing agreements with other organisations including the Red
Cross, Civil Defence and Irish Coastguard and Order of Malta but presently almost all data is
provided from statutory services. Acute hospitals in Ireland provide information on survival status
and CPC score.
Data collection
OHCAR collects data using the internationally agreed Utstein dataset4.
National Ambulance Services: PCRs are collected from ambulance stations on a monthly basis,
scanned electronically and stored on a central database by IMSCAN (Ireland) Ltd. PCRs for OHCA
incidents are prioritised by NAS staff and fast-tracked in order to facilitate OHCAR. IMSCAN enter
OHCAR data elements onto a preliminary database file and forward this and copies of the electronic
PCRs to OHCAR. OHCAR staff uploads the data onto the OHCAR database. Ambulance dispatch data
is sourced separately from the central ambulance control centre at Tallaght and added to the OHCAR
database. From September 2015, EMS dispatch for NAS has been centralised and OHCAR receives
national dispatch data monthly with the exception of data pertaining to DFB calls.
Dublin Fire Brigade (DFB): PCRs are sourced by DFBs EMS support Unit and data provided to OHCAR
on a quarterly basis in a summarised electronic format and (since July 2015) with electronic copies of
PCRs.
Hospitals: OHCAR has a data sharing agreement with all hospitals who receive OHCA patients except
C u li Ou Lady s Child e s Hospital. Colle tio of data f o hospitals is fa ilitated y a a ge of
hospital staff including administrators, resuscitation officers, clinical nurse managers and
consultants.
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OHCAR Annual Report 2014
Data completeness and quality control
The Utstei guideli es state that, o ga ise s of out-of-hospital cardiac arrest (OHCA) registries
should implement monitoring and remediation for completeness of case aptu e” 4. OHCAR has
i ple e ted a issi g ase sea h syste , hi h is pe fo ed o a o thly asis a d agai
annually in order to identify cases that are not processed through the OHCAR data collection system
and hence not reported to OHCAR directly. Missing case identification was introduced to OHCAR
during 2012 and 2013 and a full systematic process has been in operation since January 2014.
The accuracy and completeness of data elements of each OHCAR case is vital to the usefulness of the
register. The responsibility for accurate and comprehensive data recording onto patient PCRs is that
of the emergency services that attend the scene of the cardiac arrest. OHCAR works with NAS and
DFB to enhance completeness by providing quarterly reports which include a summary of the
availability of some core data elements. NAS then devises and circulates OHCAR summary reports to
ambulance stations on a quarterly basis. The purpose of this is to highlight the importance of data
completeness and to stimulate greater compliance.
Withi OHCA‘ s data a age e t syste , the follo i g data uality he ks a e u de take :
- Case duplicate searches
- Checking for inconsistent and/or conflicting data values
- Validation of initial data entries and checks against OHCAR inclusion criteria.
- Clinical expertise is provided on a case by case basis by members of the OHCAR Steering
Group when required
Data Elements
Since its inception, OHCAR has strived to collect data in accordance with the Utstein Resuscitation
Registry Templates for Out-of-Hospital Cardiac Arrest (REF). The template was updated in 2014/154
and key changes for OHCAR include:
New aetiology categorisation: Medical (presumed cardiac or unknown, other medical aetiologies),
trauma, drug overdose, drowning, electrocution, asphyxia (external)
Core data elements: Core times in the new template a e li ited to espo se ti e a d ti e of fi st
defi illatio . Othe ti es a e supple e ta y. A o gst the e o e data ele e ts a e dispatcher
identified cardiac arrest and dispatcher assisted CPR .
Reporting The new template suggests the primary reporting by systems should state the outcomes
of all EMS treated cardiac arrests and those that are bystander witnessed and the first rhythm is
shockable. This means that the Utstein comparator subset should no longer sepa ate out p esu ed
a dia ases . Aetiology should e epo ted as pa t of the o e all des iptio of EM“ t eated a dia
arrests.
OHCAR has changed the aetiology categorisation in line with the above with effect from cases logged
from January 1 2014. This report applies the 2015 definition of the Utstein comparator subset.
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OHCAR Annual Report 2014
OHCAR reporting to Service Providers
Monthly/quarterly summary reports
Since July 2014, OHCAR has provided monthly summary reports of OHCAR cases and outcomes of
Utstein comparator cases to the National Ambulance Service. In addition, quarterly summary
reports have been provided from the fourth quarter of 2014. The outcomes of the Utstein
comparator group in the quarterly reports are a component of the NAS key performance indicators.
Quarterly regional reports
OHCAR re-instated detailed regional reports to the NAS from data logged in quarter four of 2014.
These include descriptive data elements and outcome variables at regional level and constitute the
data source for reports circulated by NAS to stations from November 2015 onwards.
A quarterly report is provided to DFB with outcome data and descriptive information.
OHCAR meetings and representations
- OHCAR Research Consortium meetings December 2014 and May 2015
- European Resuscitation Congress, Prague, October 2015
- EuReCa Meetings: Stavanger June 2015, Frankfurt September 2015
- Cardiac First Responder (CFR) Consortium launch January 2015, Dublin
- OHCAR steering group meetings December 2014, April 2015, Aug 2015 and November 2015
OHCAR presentations
- National Out-of-Hospital Cardiac Arrest Register OHCAR, PHR and HSR Alliance, NUI Galway,
January 2015
The i po ta e of CF‘ i OHCA‘”. RESPOND 2015 – National Cardiac First Responder
Conference. Tullamore, March 2015
OHCAR Research
Research projects approved by OHCAR Steering Group Dec 2014 – Nov 2015:
Principal Investigator
Title
Dr. Richard Tanner
Resuscitation of out of hospital cardiac arrests in the older
population survival rates and the factors influencing survival
Cardiac first responders in Ireland – their role in out-of hospital
cardiac arrest and how this can be monitored
Medical Emergency Responder Integration & Training 3
(MERIT3). Utilisation of a novel Ambulance Service alerting
system to prompt GP first responders to nearby cardiac arrests.
Dr. Eve Robinson
Prof. Gerard Bury
European Registry of Cardiac Arrest Study ONE (EuReCa ONE)
EuReCa ONE is a study of the European Resuscitation Council (ERC) and is a prospective, multicentre, one month survey of epidemiology, treatment and outcome of patients suffering an out-ofhospital cardiac arrest in Europe (REF Protocol). OHCAR provided OHCA data for incidents in Ireland
during October 2014 for the EuReCa One study5. The OHCAR Director is the EuReCa ONE National
Coordinator for Ireland and the former OHCAR Manager Siobhan Masterson is part of the EuReCa
ONE Study Management Team. OHCAR representatives have attended several EuReCa ONE meetings
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OHCAR Annual Report 2014
in the past twelve months as well as attending regular teleconferences with the other National
Coordinators and the Study Management Team.
A geographic model for improving out-of-hospital cardiac arrest survival in Ireland
Ms Siobhan Masterson has commenced a three year HRB Research Training Fellowship in January
e titled A geographic model for improving out-of-hospital cardiac arrest survival in Ireland’.
Research Consortium
The OHCAR Research Consortium is a forum established by the OHCAR Steering Group. Its first
meetings were held in December 2014 and May 2015. The aim of the consortium is to foster and
support researchers and research in out-of-hospital cardiac arrest. The OHCAR research
consortium meetings were attended by members of the OHCAR Steering Group, researchers
and others with an interest in OHCA. Past research with OHCAR involvement was presented
and opportunities for future projects, collaborators and funding discussed.
OHCAR Publications
Since the issuing of the 2013 OHCAR Annual Report, the following papers have been published:
-
Masterson S, Jensen M. Complying with Utstein guidelines: Comprehensive case identification
in the Irish national out-of-hospital cardiac arrest register. Resuscitation. [IN PRESS]
-
Moran, Patrick S., et al. "Cost-effectiveness of a national public access defibrillation
programme." Resuscitation 91 (2015): 48-55.
-
Masterson, S., et al. "Urban and rural differences in out-of-hospital cardiac arrest in Ireland."
Resuscitation 91 (2015): 42-47.
-
Gräsner, Jan-Thorsten, and Siobhán Masterson. "EuReCa and international resuscitation
registries." Current opinion in critical care 21.3 (2015): 215-219.
-
Wnent J*, Masterson S*, Gräsner JT, Böttiger BW, Herlitz J, Koster RW, Rosell Ortiz F,
Tjelmeland I, Maurer H, Bossaert L. EuReCa ONE - 27 Nations, ONE Europe, ONE Registry: a
prospective observational analysis over one month in 27 resuscitation registries in Europe the EuReCa ONE study protocol. Scand J Trauma Resusc Emerg Med. 2015 Jan 24;23:7. doi:
10.1186/s13049-015-0093-3. *Joint lead authors
-
Masterson, Siobhán, et al. "General practitioner contribution to out-of-hospital cardiac arrest
outcome: A national registry study." Europea Jou al of Ge e al P a ti e” (2014): 1-7.
-
Nishiyama, Chika, et al. "Apples to apples or apples to oranges? International variation in
reporting of process and outcome of care for out-of-hospital cardiac arrest." Resuscitation
85.11 (2014): 1599-1609.
-
Gräsner, Jan-Thorsten, Bernd W. Böttiger, and Leo Bossaert. "EuReCa ONE–ONE month–ONE
Europe–ONE goal." Resuscitation 10.85 (2014): 1307-1308.
Appendix 1 includes a list of publications with OHCAR involvement to date.
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OHCAR Annual Report 2014
Future developments in OHCAR
OHCAR datahub
A centralised web enabled database is required to improve the data capture, efficiency of operating
the register and data quality of OHCAR. NAS is implementing an electronic PCR and funding has been
secured to develop an OHCAR database which will be aligned with the electronic PCR system.
Missing cases and data quality
Continued effort is required to improve the reporting of OHCAs by the emergency services to
OHCAR. About twenty percent of logged cases were not reported through the OHCAR reporting
system and found by missing case searches in 2014. OHCAR is working with NAS and DFB to
communicate the importance of timely and comprehensive reporting of cases to OHCAR.
Data accuracy and completeness can be improved by encouraging emergency practitioners who
attend the scene and dispatchers to give a complete and accurate account of the cardiac arrest
event. Electronic PCRs, more comprehensive dispatch data and electronic data from defibrillators is
likely to enhance the patient data in the future.
Research
OHCAR has now almost four years of national patient data in the register. The growing database
increases the capacity for research. The following research activities are planned:
-
EuReCaTWO. The European Resuscitation Council (ERC) plan to conduct a two month study
in 2017 similar in design to EuReCaONE. OHCAR will contribute national data to this project.
The OHCAR Research Consortium and OHCAR Steering Group will continue to support
ongoing research and foster new ideas for OHCA research.
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OHCAR Annual Report 2014
RESULTS – all OHCA cases 2014
INCIDENCE
In 2014, a total of 1984 OHCA resuscitation attempts attended by the National Ambulance
Service, Dublin Fire Brigade and Dublin Airport Authority were either reported directly to
OHCAR (81%) or identified during missing case searches (19%). Nationally, this equates to 43
OHCA resuscitation attempts per 100,000 persons during 2014. In Europe, the incidence of
out-of-hospital cardiac arrest is estimated at between 38 and 86 per 100,000 per year. 6,7
The majority of OHCA incidents were presumed to be of medical aetiology (38/100,000
persons) compared to a small proportion of cases of non-medical aetiology (5/100,000
persons). There was a slight variation in incidence between the three National Ambulance
Service Areas, with the South Area reporting the highest incidence of 48/100,000 persons.
Census of Population 2011 figures were used as denominator data in the calculation of all
incidence rates.
West
•Overall – 45
•Medical– 39
•Non-medical – 6
East
•Overall – 40
•Medical– 35
•Non-medical – 5
South
•Overall – 48
•Medical– 42
•Non-medical – 6
Figure 2: Incidence of OHCA with resuscitation attempts per 100,000 in 2014 by wider region
URBAN RURAL DIFFERENCES

The geographical coordinates of incidence locations were identified using the HSE
appli atio

Health Atlas .
Urban and rural areas are classified according to the definition used by the Central
Statistics Office in Census 2011
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OHCAR Annual Report 2014

The majority of incidents occurred in urban areas (n=1244; 63%), 684 incidents occurred
in rural areas (34%) and 56 cases (3%) were unmatched to rural/urban location. The
incidence of cases per 100,000 cases was 44/100,000 in urban areas and 39/100,000 in
rural areas.
Figure 3: Geographical location of OHCA incidents with rural/urban classification
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OHCAR Annual Report 2014
PATIENT DEMOGRAPHY

1374 patients were male (69%) and 606 were female (31%). Gender was not specified for
four patients

Patients ranged in age from less than one to 98 years old (median age 66 years). Age was
missing for 58 patients.

In 2014, the median age of female patients was 74 years for females and 64 for male
patients.

The median age of patients in urban and rural areas was 65 years and 69 years
respectively.
350
male
Number of OHCA patients
300
female
250
200
150
100
50
0
< 18 18 - 30 31 -40 41 -50 51 -60 61-70 71 -80 81 -90
>90
Age of patients in years
Figure 4: Age distribution by gender in 2014
PRESUMED AETIOLOGY

The majority of incidents were presumed to be of medical aetiology (n=1736; 88%). This
category includes cardiac aetiologies, unknown aetiologies and other medical aetiologies.

Non-medical aetiologies included: Trauma (n=86, 4%); asphyxial i.e. hanging, foreign body
airway obstruction and other external asphyxiations (n=95, 5%); submersion (n=21, 1%)
and drug overdose (n=46, 2%).

Of all OHCAR cases, 85% of male patients had a presumed medical aetiology compared to
92% of female patients

The median age of patients with a presumed medical aetiology was 68 years and 35 years
for all other aetiologies
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OHCAR Annual Report 2014
2%
1%
5%
4%
Medical
Trauma
Asphyxial
Drug overdose
Submersion (Drowning)
88%
Figure 5: Presumed aetiology of all OHCA patients in 2014 (n=1984)
TRANSPORT TO HOSPITAL

Just over half of patients were transported to either an Emergency Department or a
catheterisation laboratory (n=1006; 51%)

There was variation in the proportion of patients transported to hospital across the
regions. The percentage of patients who were transported to hospital was 37% in the
West, 65% in the East and 38% in the South.

Patients in urban areas were more likely to be transported than patients in rural areas
(61% vs. 31%)
100%
Percentage of OHCA patients
90%
80%
70%
60%
50%
Not transported
40%
Transported
30%
20%
10%
0%
East
West
South
National
Figure 6: Transportation to hospital by region and nationally in 2014
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OHCAR Annual Report 2014
EVENT LOCATION

Of the 1970 cases for which data was available, two-thirds of incidents occurred at home
(n=1315; 67%)

Eight percent occurred in a residential institution (n=154). Ten percent occurred in a
street/road (n=192). One percent of arrests occurred in the ambulance (n=28).

More than one in five incidents occurred in a public place (n=443; 22%)

In urban settings, a higher proportion of patients collapsed in a public place compared to
rural settings (23% vs. 18%; p<0.01).

In rural settings 70% of patients collapsed at home compared to 67% in urban settings
Home 67%
Industrial place 2%
Public Building 4%
GP Surgery 1%
Farm 1%
Recreational or sports facility incl hotels 3%
Residential Institution 8%
Street or road 10%
In ambulance 1%
Other 3%
Figure 7: Incident location (n=1970)
WITNESS STATUS

Of the 1933 events for which data was available, 1036 incidents were witnessed by a
bystander and 116 events were witnessed by Ambulance Service personnel (EMS
witnessed). A total of 781 incidents were not witnessed. Data was missing for 51 incidents

The percentage of patients who had a bystander-witnessed arrest was 53% in urban and
57% in rural settings.
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OHCAR Annual Report 2014
40%
Bystander witnessed
EMS witnessed
Not witnessed
54%
6%
Figure 8: Witnessed status of all OHCAs (n=1933)
CALL RESPONSE INTERVAL
The call response interval (CRI) is the time from the call received at the dispatch centre to
arrival of EMS or other dispatch responder at the scene. Call response interval is an important
element of out of hospital cardiac arrest analysis. Because of methodological issues, it is not
possible to provide this data in a standardised way in this report. It is intended to do so in
future reports when these issues are resolved.
FIRST MONITORED RHYTHM

Of the 1949 cases for which data was available 471 patients (24%) were in a shockable
rhythm at time of first rhythm analysis.

Patients with a presumed medical aetiology were more likely to present in a shockable
rhythm than patients with a non-medical aetiology (27% vs. 6%; p 0.001)

There was a difference in the percentage of patients presenting in a shockable rhythm
according to urban or rural setting (26% vs. 21%; p = 0.03).
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OHCAR Annual Report 2014
% of events in rhythm category
70%
60%
50%
40%
30%
20%
10%
0%
VF
pVT
Unknown
rhythm shock
advised
Asystole
PEA
Unknown
rhythm -no
shock
advised
Figure 9: First monitored rhythm (n=1838)
BYSTANDER CPR

Of the 1817 cases that were not EMS-witnessed, data on bystander CPR was available for 1774
cases. Bystander CPR was attempted in 71% of these cases. This is an increase of 11 % points
from 2012 figures.

Of non EMS witnessed events, a higher proportion of patients in a rural setting received
bystander CPR (482/618) compared to urban settings (735/1116) (78% vs. 66%; p 0.001)
80%
69%
71%
2013
2014
70%
60%
60%
50%
40%
30%
20%
2012
Figures 10: Percentage of patients receiving bystander CPR before arrival of EMS, years 2012 – 2014
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OHCAR Annual Report 2014
MECHANICAL CPR

Use of a mechanical CPR device was reported in 91 cases. Information on whether
mechanical CPR device was used was unavailable for 169 cases.
DEFIBRILLATION

Of the 1951 patients for whom data was available, 738 had defibrillation attempted (38%)
– the same proportion as in 2013

There was no difference in the proportion of patients who had defibrillation in urban and
rural areas (38% in both settings)

In the 727 cases for which identity of assistance was available, the first shock was
delivered before ambulance services arrived in 114 cases (16%).

In the 1912 cases where defibrillator pads were applied and data available, the pads were
applied before EMS arrival in 290 cases (15%)
ADVANCED AIRWAY ADJUNCTS
 Of the 1846 cases for which data was available, advance airway techniques i.e.
supraglottic airway device or intubation were used in 1203 cases (65%)
No advanced
airway
35%
Supraglottic
airway
40%
Intubation
25%
Figure 11: Adjunct airway management (n=1846)
CANNULATION

Of the 1972 cases for which data was available, cannulation was performed in 1431 cases
(73%)

Intraosseous cannulation only was performed in 42% of cases (n=817), while intravenous
cannulation only was performed in one in five cases (n=397; 20%). A combination of both
techniques was used in 197 cases (10%)
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OHCAR Annual Report 2014
Intravenous 20%
Intraosseous 42%
Both IV and IO 10%
No cannulation 28%
Figure 12: Cannulation method (n=1953)
CARDIAC ARREST MEDICATION

Of the 1972 cases for which data was available, epinephrine was administered in 1341
cases (68%)

Data on the number of epinephrine doses given to each patient was available for 1326
patients. The number of doses given ranged from one to fourteen.
250
Number of patients
200
150
100
50
0
1
2
3
4
5
6
7
8
9
Number of Epinephrine doses (1:1000)
Figure 13: Number of Epinephrine doses (n=1326)

Of the 1966 cases for which data was available, 236 patients were administered
amiodarone (12%)
ROSC AT ANY STAGE

Of the 1953 cases for which data was available, 25% had return of spontaneous circulation
(ROSC) at any stage pre-hospital (n=481). Data on ROSC was missing for 31 patients.

Of patients with a presumed medical aetiology 25% achieved ROSC at any stage. 21% of
patients with a presumed non-medical aetiology achieved ROSC at any stage.
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OHCAR Annual Report 2014

Patients in urban areas were significantly more likely to achieve ROSC at some stage prehospital compared to patients in rural settings (28% vs. 18% p 0.001)
35%
30%
23%
23%
2012
2013
% of patients
25%
25%
20%
15%
10%
5%
0%
2014
Figure 14: ROSC at any stage pre-hospital, all patients. Years 2012 – 2014 (n=1953)
ROSC ON ARRIVAL AT THE EMERGENCY DEPARTMENT

Of the 1936 patients for whom data was available, 351 (18%) had ROSC on arrival at the
Emergency Department (ED). Data was missing for 48 patients.

Patients with a presumed medical aetiology were as likely to have ROSC on arrival in ED as
patients with a non-medical aetiology (18% for both groups).

Patients in an urban setting were significantly more likely to have ROSC on arrival at ED
compared to patients in a rural setting (21% vs. 12%; p 0.001).
35%
30%
% of patients
25%
20%
17%
18%
2013
2014
16%
15%
10%
5%
0%
2012
Figure 15: ROSC at ED, all patients. Years 2012 – 2014 (n=1936)
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OHCAR Annual Report 2014
DISCHARGED ALIVE FROM HOSPITAL

Of the 1957 patients for whom data was available, 129 patients were discharged alive
from hospital (6.6%). Data on 27 patients who were transported to hospital could not be
obtained.
20%
% of all patients
15%
10%
6.4%
6.6%
5.2%
5%
0%
2012
2013
2014
Figure 16: Percentage survival to discharge, all patients. Years 2012 – 2014 (n=1957)

Surviving patients were younger than non-surviving patients (median age 59 years vs. 67
yea s p 0.001))

Survival in the presumed medical aetiology group was 7.2% (n=124) compared with 2.1%
(n=5) in the non-medical group (p .
). The presumed aetiology was medical for 96% of
survivors.

Survival of patients collapsing in a public vs in a private location was 18.3% (n=78) vs. 3.3%
(n=50) (p .

Survival of patients collapsing in an urban vs a rural setting was 8.2% (n=100) vs. 3.5%
(n=24) (p .

). The location of collapse was public for 61% of survivors.
). The location of collapse was urban for 81% of survivors.
Survival of patients with a shockable first rhythm was 22.3% (n=103) compared with 1.6%
(n=23) in the non-sho ka le g oup p .
). The first monitored rhythm was shockable in
82% of survivors.

In the non-EMS witnessed group of survivors (n=110)
o
94% had a witnessed arrest
o
84% received bystander CPR
o
38% had defibrillation attempted (defibrillator pads applied) prior to EMS
arrival (n=42) and 31% were shocked before EMS arrival (n=34).
19
OHCAR Annual Report 2014
Neurological Function at Discharge

The Cerebral Performance Category (CPC) Score is an instrument developed to assess both
traumatic and anoxic cerebral injuries. It is classified as a core Utstein data element for
recording of both in and out-of-hospital cardiac arrest patients.

The CPC score has five categories:
CPC 1: Good cerebral performance
CPC 2: Moderate cerebral disability: conscious, sufficient cerebral function for independent
activities of daily life.
CPC 3: Severe cerebral disability: Dependent on others for daily support because of impaired
brain function.
CPC 4: Coma or vegetative state
CPC 5: Brain death

CPC score data was available for 88 surviving patients. Of the patients for whom data was
available, 88% of patients had a CPC score of one ie a good cerebral performance.
Percentage of survivors 2014
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
1
2
3
CPC Score
Figure 17: Cerebral Performance Score at discharge for surviving patients in 2014 (n=87)
20
OHCAR Annual Report 2014
OHCAR Comparator Subset 2014
The OHCAR comparator subset (Utstein comparator subset) is a subgroup of patients with the
following characteristics



Adult 8 yea s of age
Bystander witnessed
First monitored rhythm shockable
There is wide variation of circumstances around a cardiac arrest and patient characteristics. Using
the comparator subset allows for a more cohesive comparison of patients outcomes between
systems and time periods.
The 2015 Utstein definition includes all aetiologies in the comparator subset. Previous OHCAR
reports have selected patients with presumed cardiac aetiology only.
Total number of OHCAs in 2014: n=1984
Adults ≥
years: n=
Bystander Witnessed: n=987
Shockable first rhythm: n=337
ROSC at any stage: n=163
ROSC at ED: n=126
Figure 18: Flowchart of the 2014 comparator subset and ROSC outcomes
In 2014, the comparator subset included 337 patients and accounted for 17% of all OHCAs
(337/1984).
CARDIAC ARREST RECOGNITION
Of the 315 cases for which data was available, 208 cases (66%) were recognised as cardiac arrest at
the time of ambulance dispatch. Calls with ECHO or 09 dispatch codes were classified as arrest calls.
21
OHCAR Annual Report 2014
OUTCOMES

Of the 334 cases for which data was available, 163 patients achieved ROSC at some stage
pre-hospital (49%)

Of the 324 cases for which data was available, 126 patients had ROSC on arrival at the
Emergency Department (39%)

Of the 329 cases for which data was available, 79 patients were discharged alive from
hospital (24%)

Of the 57 patients for whom CPC score was available, 49 patients had a CPC score of one
(86%).
Percentage of patients in Utstein subset
60%
49%
50%
44%
43%
39%
40%
35%
36%
% ROSC at any stage
30%
21%
24%
23%
% ROSC at ED
Discharged alive
20%
10%
0%
2012
2013
2014
Figure 19: Outcomes in the Utstein comparator group years 2012-2014.
Characteristics and circumstances of survivors:

Survival of patients collapsing in an urban vs a rural setting was 28% (n=61) vs.
%

=
p .
. 79% of surviving patients collapsed in an urban location.
Survival of patients collapsing in a public vs a private setting was 40% (n=50) vs.
%
= 8 p . 01). The percentage of surviving patients who collapses in a
public location was 63% vs 30% of non survivors.

Bystander CPR was performed in 86% of surviving patients and in 78% of nonsurviving patients (difference not statistically significant)

All 79 surviving patients had defibrillation attempted pre-hospital. In 42% of these
cases (n=33), defibrillation was attempted before Ambulance Service arrival.

Surviving patients were less likely to be administered epinephrine than nonsurviving patients (39% vs. 81%; p .
)
22
OHCAR Annual Report 2014

Surviving patients were less likely to be intubated than non-surviving patients
(13% vs. 31%; p
.
).
23
OHCAR Annual Report 2014
OHCAR Key messages 2014
All OHCA patients:
 There were 1984 OHCA cases in 2014
 The number of patients discharged alive in 2014 was 129. The percentage overall survival
was 6.6% and slightly higher than in 2013.
 The cerebral function was good for 88% of surviving patients.
 The percentage of patients who achieved ROSC at any stage pre-hospital was 25% and ROSC
at ED 18%.
 In line with 2012 and 2013 outcomes, surviving patients were more likely to
o be younger than non surviving patients
o have a presumed medical aetiology
o have collapsed in a public as well as in an urban location
o have a witnessed arrest
o present in a shockable rhythm
o receive bystander CPR
 Bystander CPR in the non EMS witnessed group of patients was 71%. This is a welcome
increase from 60% in 2012.
 Defibrillation was attempted before EMS arrival to the scene in 15% of incidents.
Comparator Subset:
 The comparator subset includes adult patients who have a witnessed cardiac arrest and the
first monitored rhythm is shockable.
 In 2014, there were 337 patients in the comparator subset.
 In the comparator subset, 126 patients had ROSC on arrival at the Emergency
Department
 The number of patients discharged alive in the comparator subset was 79 in 2014.
Percentage survival in the Utstein subset was 24%, similar to 2013 figures
 Surviving patients were more likely to collapse in an urban and public location
 In surviving patients, 42% had defibrillation attempted prior to ambulance arrival
24
OHCAR Annual Report 2014
References
1.
Children' DoHa. Reducing the Risk: A Strategic Approach. The Report of the Task Force on
Sudden Cardiac Death. 2006.
2.
Children DoHa. Changing Cardiovascular Health: National Cardiovascular Health Policy 201020192010.
3.
HSE I-T, IAEM, College of Emergency Medicin. The National Emergency Medicine
Programme: A Strategy to improve Safety, Quality Access and Value in Emergency Medicine
Ireland.2012.
4.
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 on Resuscitation (American Heart Association, European Resuscitation Council,
Australian and New Zealand Council on Resuscitation, Heart and Stroke Foundation of Canada,
InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, Resuscitation Council of
Asia); and the American Heart Association Emergency Cardiovascular Care Committee and the
Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation. Circulation
2015;132:1286-300.
5.
Wnent J, Masterson S, Gräsner J-T, et al. EuReCa ONE–27 Nations, ONE Europe, ONE
Registry: a prospective observational analysis over one month in 27 resuscitation registries in
Europe–the EuReCa ONE study protocol. Scandinavian journal of trauma, resuscitation and
emergency medicine 2015;23:1-6.
6.
Atwood C, Eisenberg MS, Herlitz J, Rea TD. Incidence of EMS-treated out-of-hospital cardiac
arrest in Europe. Resuscitation 2005;67:75-80.
7.
Berdowski J, Berg RA, Tijssen JG, Koster RW. Global incidences of out-of-hospital cardiac
arrest and survival rates: systematic review of 67 prospective studies. Resuscitation 2010;81:147987.
25
OHCAR Annual Report 2014 - Appendices
Appendix 1 - OHCAR publications
Masterson S, Jensen M. Complying with Utstein guidelines: Comprehensive case identification in the
Irish national out-of-hospital cardiac arrest register. Resuscitation. [IN PRESS]
Moran, Patrick S., et al. "Cost-effectiveness of a national public access defibrillation programme."
Resuscitation 91 (2015): 48-55.
Masterson, S., et al. "Urban and rural differences in out-of-hospital cardiac arrest in Ireland."
Resuscitation 91 (2015): 42-47.
Gräsner, Jan-Thorsten, and Siobhán Masterson. "EuReCa and international resuscitation registries."
Current opinion in critical care 21.3 (2015): 215-219.
Wnent J*, Masterson S*, Gräsner JT, Böttiger BW, Herlitz J, Koster RW, Rosell Ortiz F, Tjelmeland I,
Maurer H, Bossaert L. EuReCa ONE - 27 Nations, ONE Europe, ONE Registry: a prospective
observational analysis over one month in 27 resuscitation registries in Europe - the EuReCa ONE
study protocol. Scand J Trauma Resusc Emerg Med. 2015 Jan 24;23:7. doi: 10.1186/s13049-0150093-3.
*Joint lead authors
Masterson, Siobhán, et al. "General practitioner contribution to out-of-hospital cardiac arrest
outcome: A national registry study." European Journal of General Practice” (2014): 1-7.
Nishiyama, Chika, et al. "Apples to apples or apples to oranges? International variation in reporting
of process and outcome of care for out-of-hospital cardiac arrest." Resuscitation 85.11 (2014): 15991609.
Gräsner, Jan-Thorsten, Bernd W. Böttiger, and Leo Bossaert. "EuReCa ONE–ONE month–ONE
Europe–ONE goal." Resuscitation 10.85 (2014): 1307-1308.
Masterson, Siobhán, et al. "Out-of-hospital cardiac arrest (OHCA) survival in rural Northwest Ireland:
17 years' experience." Emergency Medicine Journal (2010): emj-2009.
26
OHCAR Annual Report 2014 - Appendices
Appendix 2
OHCAR comparator subset 2014 – Regional results
Number of OHCAR Comparator subset patients by region 2014 (n=337):
180
160
Number of patients
140
120
100
80
60
40
20
0
EAST
WEST
SOUTH
Urban/rural incident location by region (n=331):
140
Number of patients
120
100
80
urban
60
rural
40
20
0
EAST
WEST
SOUTH
27
OHCAR Annual Report 2014 - Appendices
Dispatcher recognition of cardiac arrest at time of ambulance dispatch (n=315):
Percentage of calls dispatched as arrest
100%
90%
80%
69%
65%
70%
61%
60%
50%
40%
30%
20%
10%
0%
EAST
WEST
SOUTH
82%
82%
WEST
SOUTH
Percentage of cases with bystander CPR:
100%
Percentage bystander CPR
90%
80%
78%
70%
60%
50%
40%
30%
20%
10%
0%
EAST
ROSC at any stage, ROSC at ED and discharge alive:
60%
50% 50%
50%
44%
41%
38%
40%
31%
East
28%
30%
20%
22%
20%
10%
0%
% ROSC at any stage
% ROSC at ED
Discharged alive
28
West
South