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Background: Rapid public defibrillation with automated external defibrillators (AEDs) is critical to improving out-of-hospital cardiac arrest survival. Concerns about AED theft and vandalism have led to implementing security measures, including locked cabinets. This scoping review, conducted as part of the evidence review for the International Liaison Committee on Resuscitation, explores the impact of securing AEDs in locked cabinets., Methods: Searches of Medline, Embase, Cochrane, CINAHL (from database inception to 25/5/2024) and Google Scholar (first 200 articles). Studies of any type or design, published with an English abstract, examining the impact of locked AED cabinets were included. The included studies were grouped by outcomes, and an iterative narrative synthesis was performed., Results: We screened 2,096 titles and found 10 relevant studies: 8 observational studies (4 published as conference abstracts) and 2 simulation studies. No study reported patient outcomes. Studies reported data on between 36 and 31,938 AEDs. Most studies reported low rates (<2%) of theft/missing/vandalism, including AEDs that were accessible 24/7. The only study comparing unlocked and locked cabinets showed minimal difference in theft and vandalism rates (0.3% vs. 0.1%). Two simulation studies showed significantly slower AED retrieval when additional security measures, included locked cabinets, were used. A survey of first responders reported half (25/50) were injured while accessing an AED that required breaking glass to access., Conclusion: The limited literature suggests that vandalism and the loss of AEDs are rare and occur in locked and unlocked cabinets. Research on this topic is needed that focuses on real-life retrieval and patient outcomes., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. GDP is Editor-in-Chief and JEB is an Associate Editor of Resusciation Plus., (© 2024 The Author(s).)

Background: The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) includes agreed clinical recommendations for a person's care in a future emergency which have been informed by discussion of the person's preferences. Previous evaluation of ReSPECT plans in acute NHS hospitals found inconsistencies in recording patient's preferences and involvement in the plan, and infrequent justification for recommendations., Aim: To explore to what extent ReSPECT recommendations reflect individual preferences, as documented in the plan., Methods: ReSPECT plans of adults were collected from 11 General Practices in England. We adapted an evaluation tool used previously to analyse ReSPECT plans in acute settings. Free text sections for individual values/preferences and clinical recommendations were examined for clarity, consistency and congruency between them., Results: We retrieved 141 ReSPECT plans. Patients or those close to the patient were recorded as being consulted in most plans (94%). Individual preferences were completed in 57% of plans. Clinical recommendations reflected individual preferences by directly referencing the person and their preferences (31%), by being consistent with the documented preferences (30%), or by using the same wording as the preferences (6%)., Conclusion: While many clinical recommendations reflect individual preferences, the preferences themselves are only recorded in just over half of ReSPECT plans. This is problematic, because the recording of individual preferences facilitates person-centred care, both directly by informing recommendations and indirectly when used to guide decision-making in situations not anticipated in the plan. Future training for clinicians should emphasize the need to document the personal values section of the plan., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: GDP is a Vice President and a member of the ReSPECT subcommittee of the Resuscitation Council UK, a volunteer Director for the European Resuscitation Council and co-chair for the International Liaison Committee on Resuscitation, Editor for Resuscitation and Resuscitation Plus. GDP is supported by the National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) West Midlands. AS, FG, JH, CAH, GDP and MU have participated in other research projects funded by NIHR. CAH was involved in the development of the ReSPECT process and a member of the Resuscitation Council UK ReSPECT Research and Evaluation working group. MU is a co-investigator on grants funded by the Australian 10.13039/501100000925NHMRC and Norwegian MRC. He is a director and shareholder of Clinvivo Ltd that provides electronic data collection for health services research. He is a co-investigator on two current and one completed NIHR funded studies that have, or have had, additional support from 10.13039/100008894Stryker Ltd. AS joined the ReSPECT Stakeholder Group convened by Resuscitation Council UK in March 2024., (© 2024 The Author(s).)

Background: Early cardiopulmonary resuscitation and defibrillation is key to increasing survival following an out-of-hospital-cardiac-arrest (OHCA). However, automated external defibrillators (AEDs) are used in a very small percentage of cases. Despite large numbers of AEDs in the community, the absence of a unified system for registering their locations across the UK's ambulance services may have resulted in missed opportunities to save lives. Therefore, representatives from the resuscitation community worked alongside ambulance services to develop a single repository for data on the location of AEDs in the UK., Methods: A national defibrillator network, "The Circuit", was developed by the British Heart Foundation in collaboration with the Association of Ambulance Chief Executives, the UK ambulance services, the Resuscitation Council UK and St John Ambulance. The database allows individuals or organisations to record information about AED location, accessibility, and availability. The database synchronises with ambulance computer aided dispatch systems to provide UK ambulance services with real-time information on the nearest, available AED., Results: The Circuit was successfully rolled out to all 14 UK ambulance services. Since 2019, 82,108 AEDs have been registered. Of the AED data collected by The Circuit, 54% were not previously registered to any ambulance service, and are therefore new registrations., Conclusion: The Circuit provides ambulance services with a single point of access to AED locations in the UK. Since the launch of the system the number of defibrillators registered has doubled. Linking the Circuit data with patient outcome data will help understand whether improving the accessibility to AEDs is associated with increased survival., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: ‘Authors listed as affiliated to the BHF are employees of the BHF, a registered charity in England and Wales, Scotland and the Isle of Man. The BHF is the main funder of The Circuit and responsible for its administration. The author listed as affiliated to NHS England (NHSE) is a former employee of NHSE. NHSE is a co-funder of The Circuit. Authors listed as affiliated to the Resuscitation Council UK (RCUK) are employees of the Resuscitation Council UK a registered charity in England and Wales. The RCUK is a co-funder of The Circuit. Authors listed as affiliated to St John Ambulance (SJA) are employees of St John Ambulance a registered charity in England. SJA is a co-funder of The Circuit. Simon Dunn, Steve Irving, Sue Hampshire, Michael Bradfield, Charles Deakin, Simon Holmes, Stephanie Leckey, Nick Linker, Greg Lloyd, Julian Mark, Lisa McInnes, Simon Walsh, George Woods, Judy O’Sullivan and Gavin D Perkins are current or former members of The Circuit National Advisory Board. GDP holds research grants from the BHF, Resuscitation Council UK and the Laerdal Foundation, is a Trustee for the Resuscitation Council UK and Editor for Resuscitation and Resuscitation Plus journals.’., (© 2024 The Authors.)

Background: Ultraportable automated external defibrillators (AEDs) are a new generation of defibrillators that are small, lightweight, easy to carry on one's person, and affordable for personal and home use. They offer the opportunity to increase AED availability in case of out-of-hospital cardiac arrest (OHCA) and therefore improve outcomes.We aimed to review evidence supporting the potential effect on outcomes and the performance of these ultraportable AEDs., Methods: We searched Ovid Medline, Embase and Cochrane databases from 2012 to July 4th, 2024 to identify any studies related to ultraportable AED. The population was adult and children with OHCA who were treated with an ultra-portable AED. All outcomes were accepted. We limited study designs to randomized controlled trials and non-randomized studies. Data charting was done by the primary author using standardized data abstraction forms., Results: The search strategy identified 54 studies (Pubmed = 26, Embase = 28, with 19 duplicates). We included three articles in the final review. One study was a medico-economic simulation study including 600,000 simulated patients, one is the study protocol of cluster randomized trial of providing ultraportable AEDs to first responders and one is an abstract with preliminary results of this trial reporting 1805 community responders recruited, 903 allocated to ultraportable AED. No studies to date have reported patient outcomes., Conclusion: This review found no evidence of ultraportable AED device performance, clinical or safety outcomes. There is an urgent need for further research to determine the safety and effectiveness of ultraportable AEDs., (© 2024 The Author(s).)

Background and Objectives: Direct transport to a cardiac arrest centre following out-of-hospital cardiac arrest may be associated with higher survival. However, there is limited evidence available to support this within the New Zealand context. This study used a propensity score-matched cohort to investigate whether direct transport to a cardiac arrest centre improved survival in New Zealand., Methods: A retrospective cohort study was conducted using the Aotearoa New Zealand Paramedic Care Collection (ANZPaCC) database for adults treated for out-of-hospital cardiac arrest of presumed cardiac aetiology between 1 July 2018 to 30 June 2023. Propensity score-matched analysis was used to investigate survival at 30-days post-event according to the receiving hospital being a cardiac arrest centre versus a non-cardiac arrest centre., Results: There were 2,297 OHCA patients included. Propensity matching resulted in 554 matched pairs ( n  = 1108). Thirty-day survival in propensity score-matched patients transported directly to a cardiac arrest centre (56%) versus a non-cardiac arrest centre (45%) was not significantly different (adjusted Odds Ratio 0.78 95%CI 0.54, 1.13, p  = 0.19). Shockable presenting rhythm, bystander CPR, and presence of STEMI were associated with a higher odds of 30 day survival ( p  < 0.05). Māori or Pacific Peoples ethnicity and older age were associated with lower survival ( p  < 0.05)., Conclusions: This study found no statistically significant difference in outcomes for OHCA patients transferred to a cardiac arrest compared to a non-cardiac arrest centre. However, the odds ratio of 0.78, equivalent to a 22% decrease in 30-day mortality, is consistent with benefit associated with management by a cardiac arrest centre. Further research in larger cohorts with detailed information on known outcome predictors, or large randomised clinical trials are needed., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: [GDP is Editor in Chief of Resuscitation Plus and supported by NIHR ARC West Midlands. BD - Is a Co-guest editor for Resuscitation Plus. BD, EG, AB and T-Smith are employees of Hato Hone St John. Other authors, declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.]., (© 2024 The Authors.)

Background: We explored the feasibility of a large-scale UK ambulance services trial of optimal defibrillation shock energy for out-of-hospital cardiac arrest. The primary objective of this feasibility study was to establish the number of eligible patients and the number recruited. Secondary outcomes were adherence to allocated treatment and data completeness., Methods: We conducted a three-arm parallel group cluster randomised controlled feasibility study in a single ambulance service in southern England. Adult patients in out-of-hospital cardiac arrest treated for a shockable rhythm were included. Zoll X series defibrillators (clusters) were randomised to deliver 120-150-200 J, 150-200-200 J, or 200-200-200 J shock strategies., Results: Between March 2022 and February 2023, we randomised 38 eligible patients (120-150-200 J (n = 12), 150-200-200 J (n = 10), 200-200-200 J (n = 16)) to the study. The recruitment rate per cluster was 0.07 per month. The median patient age was 71 years (IQR 59-81 years); 79% were male. Twenty-eight cardiac arrests (74%) occurred in a private residence, 29 (76%) were witnessed and 32 (84%) patients received bystander CPR. Treatment adherence was 93% and completeness of clinical and electrical outcomes was 86%. At 30 days, 3/36 (8.3%) patients survived; we were unable to collect survival outcomes for two patients. Defibrillation data collection became difficult when defibrillators became separated from their allocated vehicles., Conclusion: We have demonstrated the feasibility of a cluster randomised controlled trial of optimal shock energy for defibrillation in a UK ambulance service. We have identified possible solutions to issues relating to trial design., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: HP is a member of the International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support task force committee. She holds a grant from the National Institute for Health and Social Care Research (NIHR)/Health Education England. GDP is Editor for Resuscitation and Resuscitation Plus and holds grants from the NIHR, British Heart Foundation, Resuscitation Council UK (RCUK) and Laerdal. He is an employee of University of Warwick, University Hospital of Coventry and Warwick, University Hospital Birmingham and West Midlands Ambulance Service and holds Leadership roles with ILCOR, the European Resuscitation Council, and RCUK. CDD, RL, DS, CS, FM, CH, JR, KS, MB, IR: Nil., (© 2024 The Author(s).)

Nurturing the development of the next generation of resuscitation scientists is essential for creating a vibrant and enabled community equipped with the necessary knowledge, attitudes, and skills to transform resuscitation practice and improve outcomes. In this concept paper we will describe the development and implementation of the first Young European Resuscitation Council Resuscitation Science Masterclass. The masterclass aims to connect, inspire, and support the growth of the next generation of resuscitation scientists through education, networking, and joint scientific work. The masterclass provides 20 international, multi-professional early career resuscitation scientists with the opportunity to expand their knowledge and network as well as conduct joint scientific work over the course of one year. This is achieved by interactive webinars, innovative online workshops, engaging online journal clubs as well as an educational in-person event to conclude the masterclass. The Young European Resuscitation Council Resuscitation Science Masterclass aims to strengthen the global resuscitation community and next generation of resuscitation scientists by facilitating opportunities of broader international initiatives and collaboration for early career resuscitation scientists, potentially leading to accelerated recruitment of future resuscitation leaders. Ultimately, this masterclass may enable early career researchers to produce high impact research that can shape the future of resuscitation science and improve cardiac arrest patient care globally., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: JW serves as the Interim Chair of the Young ERC; BK serves as the Young ERC Young Investigator Representative; RG serves as the ERC Director of Guidelines and ILCOR, and is the Task Force Chair Education, Implementation and Team of ILCOR. He is an editorial board member of Resuscitation Plus. GDP serves as the ERC Director of Science and Research and is the Editor-in-Chief of Resuscitation Plus; KGL serves as the Young ERC Neonatal Life Support Representative, Young ERC Resuscitation Plus Editor, and ERC Advanced Life Support Science and Education Committee member., (© 2023 The Author(s).)

Aims: The PARAMEDIC-3 trial evaluates the clinical and cost-effectiveness of an intraosseous first strategy, compared with an intravenous first strategy, for drug administration in adults who have sustained an out-of-hospital cardiac arrest., Methods: PARAMEDIC-3 is a pragmatic, allocation concealed, open-label, multi-centre, superiority randomised controlled trial. It will recruit 15,000 patients across English and Welsh ambulance services. Adults who have sustained an out-of-hospital cardiac arrest are individually randomised to an intraosseous access first strategy or intravenous access first strategy in a 1:1 ratio through an opaque, sealed envelope system. The randomised allocation determines the route used for the first two attempts at vascular access. Participants are initially enrolled under a deferred consent model.The primary clinical-effectiveness outcome is survival at 30-days. Secondary outcomes include return of spontaneous circulation, neurological functional outcome, and health-related quality of life. Participants are followed-up to six-months following cardiac arrest. The primary health economic outcome is incremental cost per quality-adjusted life year gained., Conclusion: The PARAMEDIC-3 trial will provide key information on the clinical and cost-effectiveness of drug route in out-of-hospital cardiac arrest.Trial registration: ISRCTN14223494, registered 16/08/2021, prospectively registered., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: GDP is co-chair of the International Liaison Committee on Resuscitation (ILCOR). CD and JPN are emeritus members of the ILCOR Advanced Life Support task force. KC and HP are current members of the ILCOR Advanced Life Support task force. GDP is editor-in-chief and JPN is founding editor of Resuscitation Plus. KC is associate editor of Resuscitation Plus and guest editor for the research methodology special edition., (© 2023 The Authors.)

Survival from in-hospital cardiac arrest is approximately 18%, but for patients who require advanced airway management survival is lower. Those who do survive are often left with significant disability. Traditionally, resuscitation of cardiac arrest patients has included tracheal intubation, however insertion of a supraglottic airway has gained popularity as an alternative approach to advanced airway management. Evidence from out-of-hospital cardiac arrest suggests no significant differences in mortality or morbidity between these two approaches, but there is no randomised evidence for airway management during in-hospital cardiac arrest. The aim of the AIRWAYS-3 randomised trial, described in this protocol paper, is to determine the clinical and cost effectiveness of a supraglottic airway versus tracheal intubation during in-hospital cardiac arrest. Patients will be allocated randomly to receive either a supraglottic airway or tracheal intubation as the initial advanced airway management. We will also estimate the relative cost-effectiveness of these two approaches. The primary outcome is functional status, measured using the modified Rankin Scale at hospital discharge or 30 days post-randomisation, whichever occurs first. AIRWAYS-3 presents ethical challenges regarding patient consent and data collection. These include the enrolment of unconscious patients without prior consent in a way that avoids methodological bias. Other complexities include the requirement to randomise patients efficiently during a time-critical cardiac arrest. Many of these challenges are encountered in other emergency care research; we discuss our approaches to addressing them. Trial registration: ISRCTN 17720457. Prospectively registered on 29/07/2022., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: GDP is Editor-in-Chief, and JPN, KC and JS are Editors of the journal Resuscitation Plus., (© 2023 The Author(s).)

Introduction: Bystanders' interventions improve chances of survival from out-of-hospital cardiac arrest (OHCA) before Emergency Medical Services arrive. Some areas in England are of concern. These high-risk areas have a higher incidence of cardiac arrest combined with lower-than-average bystander CPR rates and are characterised by higher proportions of minority ethnic group residents and deprivation.Collaborating with people from the Black African and Caribbean and South Asian minority communities in deprived areas of England, we aim to develop and evaluate the implementation of theoretically informed intervention(s) to address factors contributing to lower bystander intervention rates., Methods: The study is a collaborative realist enquiry, informed by the Theoretical Domains Framework and associated Behaviour Change Wheel. It consists of 1) a realist evidence synthesis to produce initial program theories developed from primary workshop data and published evidence. It will include identifying factors contributing to the issue and potential interventions to address them; 2) theoretically informed intervention development, using the initial program theories and behaviour change theory and 3) a realist mixed methods implementation evaluation with embedded feasibility.Public involvement (PPI) as study team and public advisory group members is key to this study.We will conduct realist evidence synthesis, qualitative and statistical analyses appropriate to the various methods used., Dissemination: We will develop a dissemination plan and materials targeted to members of the public in high-risk areas as well as academic outputs. We will hold an event for participating community groups and stakeholders to share findings and seek advice on next steps., Study Registration: ISRCTN90350842. Registration date 28.03.2023. The study was registered after its start date., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: CH, JRM, IV, GP SS and NP employers are in receipt of funding from the NIHR to conduct this study. GDP is a NIHR Senior Investigator and supported by the NIHR Applied Research Collaboration (ARC) West Midlands. GDP is also Editor in Chief of Resuscitation Plus but had no role in the review or decision making in relation to acceptance of this paper. JRM was the Programme Director of the NIHR HSDR Programme at the time this project was recommended for funding., (© 2023 The Authors.)

Objectives: The International Liaison Committee on Resuscitation, in collaboration with drowning researchers from around the world, aimed to review the evidence addressing seven key resuscitation interventions: 1) immediate versus delayed resuscitation; (2) compression first versus ventilation first strategy; (3) compression-only CPR versus standard CPR (compressions and ventilations); (4) ventilation with and without equipment; (5) oxygen administration prior to hospital arrival; (6) automated external defibrillation first versus cardiopulmonary resuscitation first strategy; (7) public access defibrillation programmes., Methods: The review included studies relating to adults and children who had sustained a cardiac arrest following drowning with control groups and reported patient outcomes. Searches were run from database inception through to April 2023. The following databases were searched Ovid MEDLINE, Pre-Medline, Embase, Cochrane Central Register of Controlled Trials. Risk of bias was assessed using the ROBINS-I tool and the certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation. The findings are reported as a narrative synthesis., Results: Three studies were included for two of the seven interventions (2,451 patients). No randomised controlled trials were identified. A retrospective observational study reported in-water resuscitation with rescue breaths improved patient outcomes compared to delayed resuscitation on land ( n  = 46 patients, very low certainty of evidence). The two observational studies ( n  = 2,405 patients), comparing compression-only with standard resuscitation, reported no difference for most outcomes. A statistically higher rate of survival to hospital discharge was reported for the standard resuscitation group in one of these studies (29.7% versus 18.1%, adjusted odds ratio 1.54 (95% confidence interval 1.01-2.36) (very low certainty of evidence)., Conclusion: The key finding of this systematic review is the paucity of evidence, with control groups, to inform treatment guidelines for resuscitation in drowning., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: This systematic review was part of the ILCOR continuous evidence evaluation process, which is guided by a rigorous conflict of interest policy (see www.ilcor.org). GDP declares roles as co-chair of ILCOR, Director of Science and Research for the European Resuscitation Council, Vice President of the Resuscitation Council UK and Editor roles with Resuscitation and Resuscitation Plus journals. He is supported by the National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) West Midlands. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. JB declares her role as an Associate Editor for Resuscitation Plus. The paper was handled by Associate Editor Keith Couper., (© 2023 The Author(s).)

Aim: To determine the impact of the COVID-19 pandemic on Resuscitation Council UK Advanced Life Support (ALS) and Immediate Life Support (ILS) course numbers and outcomes., Methods: We conducted a before-after study using course data from the Resuscitation Council UK Learning Management System between January 2018 and December 2021, using 23 March 2020 as the cut-off between pre- and post-pandemic periods. Demographics and outcomes were analysed using chi-squared tests and regression models., Results: There were 90,265 ALS participants (51,464 pre-; 38,801 post-) and 368,140 ILS participants (225,628 pre-; 142,512 post-). There was a sharp decline in participants on ALS/ILS courses due to COVID-19. ALS participant numbers rebounded to exceed pre-pandemic levels, whereas ILS numbers recovered to a lesser degree with increased uptake of e-learning versions. Mean ALS course participants reduced from 20.0 to 14.8 post-pandemic (P < 0.001).Post-pandemic there were small but statistically significant decreases in ALS Cardiac Arrest Simulation Test pass rates (from 82.1 % to 80.1 % (OR = 0.90, 95 % CI = 0.86-0.94, P < 0.001)), ALS MCQ score (from 86.6 % to 86.0 % (mean difference = -0.35, 95 % CI -0.44 to -0.26, P < 0.001)), and overall ALS course results (from 95.2 %to 94.7 %, OR = 0.92, CI = 0.85-0.99, P = 0.023). ILS course outcomes were similar post-pandemic (from 99.4 % to 99.4 %, P = 0.037)., Conclusion: COVID-19 caused a sharp decline in the number of participants on ALS/ILS courses and an accelerated uptake of e-learning versions, with the average ALS course size reducing significantly. The small reduction in performance on ALS courses requires further research to clarify the contributing factors., (© 2023 The Author(s).)

Aims: The Prehospital Optimal Shock Energy for Defibrillation (POSED) study will assess the feasibility of conducting a cluster randomised controlled study of clinical effectiveness in UK ambulance services to identify the optimal shock energy for defibrillation., Methods: POSED is a pragmatic, allocation concealed, open label, cluster randomised, controlled feasibility study. Defibrillators within a single UK ambulance service will be randomised in an equal ratio to deliver one of three shock strategies 120-150-200 J, 150-200-200 J, 200-200-200 J. Consecutive adults (≥18 years) presenting with out of hospital cardiac arrest requiring defibrillation will be eligible. The study plans to enrol 90 patients (30 in each group). Patients (or their relatives for non-survivors) will be informed about trial participation after the initial emergency has resolved. Survivors will be invited to consent to participate in follow-up (i.e., at 30 days or discharge).The primary feasibility outcome is the proportion of eligible patients who receive the randomised study intervention. Secondary feasibility outcomes will include recruitment rate, adherence to allocated treatment and data completeness. Clinical outcomes will include Return of an Organised Rhythm (ROOR) at 2 minutes post-shock, refibrillation rate, Return of Spontaneous Circulation (ROSC) at hospital handover, survival and neurological outcome at 30 days ., Conclusion: The POSED study will assess the feasibility of a large-scale trial and explore opportunities to optimise the trial protocol. Trial registration: ISRCTN16327029., Competing Interests: HP reports research funding from National Institute for Health and Care Research. CDD, RL, FM, AC, MAS, PK, AD, DES report no conflicts of interest. GDP reports research funding from National Institute for Health and Care Research, British Heart Foundation and Resuscitation Council UK. He has volunteer roles with Resuscitation Council UK, European Resuscitation Council and the International Liaison Committee on Resuscitation. He is an editor for the journals Resuscitation and Resuscitation Plus., (© 2022 The Author(s).)

Background: Current measures of health-related quality of life are neither sufficiently sensitive or specific to capture the complex and heterogenous nature of the recovery and survivorship associated with cardiac arrest. To address this critical practice gap, we plan a mixed-methods study to co-produce and evaluate a new cardiac arrest-specific patient/survivor-reported outcome measure (PROM)., Methods: International guidelines have informed a two-stage, iterative, and interactive process.Stage one will establish what is important to measure following cardiac arrest. A meta-ethnography of published qualitative research and a qualitative exploration of the experiences of survivors and their key supporters will inform the development of a measurement framework. This will be supplemented by existing, extensive reviews describing concepts that have previously been measured in this population. Focus groups with survivors, key supporters, and healthcare professionals, followed by further interviews with survivors and key supporters, will inform the iterative refinement of the framework, candidate items, and PROM structure.Stage two will involve a psychometric evaluation following completion by a large cohort of survivors. Measurement theory will inform: the identification of items that best measure important outcomes; item reduction; and provide robust evidence of measurement and practical properties., Discussion: An international, collaborative approach to PROM development will engage survivors, key supporters, researchers, and health professionals from study commencement. Successful co-production of the cardiac arrest survivorship and health-related quality of life (CASHQoL) measure will provide a robust, relevant, and internationally applicable measure, suitable for completion by adult survivors, and integration into research, registries, and routine care settings.Ethical approval: University of Warwick Biomedical & Scientific Research Ethics Committee (BSREC 22/20-21 granted 10/11/20)., (© 2022 The Authors.)

Introduction: This study sought to identify the availability of automated external defibrillators (AEDs) in schools in the region served by West Midlands Ambulance Service University NHS Trust (WMAS), United Kingdom, and the number of out-of-hospital cardiac arrests (OHCA) that occurred at or near to schools. A secondary aim was to explore the cost effectiveness of school-based defibrillators., Methods: This observational study used data from the national registry for OHCA (University of Warwick) to identify cases occurring at or near schools between January 2014 and December 2016 in WMAS region (n = 11,399). A school survey (n = 2,453) was carried out in September 2017 to determine the presence of AEDs and their registration status with WMAS. Geographical Information System mapping software identified OHCAs occurring within a 300-metre radius of a school. An economic analysis calculated the cost effectiveness of school-based AEDs., Results: A total of 39 (0.34%) of all OHCAs occurred in schools, although 4,250 (37.3%) of OHCAs in the region were estimated to have occurred within 300 metres of a school. Of 323 school survey responses, 184 (57%) had an AED present, of which 24 (13.0%) were available 24 h/day. Economic modelling of a school-based AED programme showed additional quality-adjusted life years (QALY) of 0.26 over the lifetime of cardiac arrest survivors compared with no AED programme. The incremental cost-effectiveness ratio (ICER) was £8,916 per QALY gained., Conclusion: Cardiac arrests in schools are rare. Registering AEDs with local Emergency Medical Services and improving their accessibility within their local community would increase their utility., (© 2022 The Author(s).)

Background: As an emergency care and treatment planning process (ECTP), a key feature of the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) is the engagement of patients and/or their representatives in conversations about treatment options including, but not limited to, cardiopulmonary resuscitation (CPR). However, qualitative research suggests that some ReSPECT conversations lead to partial or no decision-making about treatment recommendations. This paper explores why some ReSPECT conversations are left incomplete., Methods: Drawing on observation and interview data collected in four National Health Service (NHS) hospital sites in England, this paper offers an in-depth exploration of six case studies in which ReSPECT conversations were incomplete. Using thematic analysis, we triangulate fieldnote data documenting these conversations with interview data in which the doctors who conducted these conversations shared their perceptions and reflected on their decision-making processes., Results: We identified two themes, both focused on 'mismatch': (1) Mismatch between the doctor's clinical priorities and the patient's/family's immediate needs; and (2) mismatch between the doctor's conversation scripts, which included patient autonomy, the feasibility of CPR, and what medicine can and should do to prolong a patient's life, and the patient's/family's understandings of these concepts., Conclusions: This case study analysis of six ReSPECT conversations found that mismatch between doctors' priorities and understandings and those of patients and/or their relatives led to incomplete ReSPECT conversations. Future research should explore methods to overcome these mismatches., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: GDP and CAH are members of the ReSPECT national working group. A-MS, FG, CAH, and GDP received grants from the UK National Institute of Health Research during the study., (© 2022 The Authors.)

Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Claire A. Hawkes, Inès Kander, Terry P. Brown, Scott Booth, Abraham Contreras and Chen Ji, and Gavin D. Perkins are employed by the University of Warwick, which receives grants from the British Heart Foundation (BHF) and the Resuscitation Council (UK) for the conduct of the Out-of-Hospital Cardiac Arrest outcomes project. Terry P. Brown is supported by the National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) West Midlands. A. Niroshan Siriwardena currently receives research funding from the NIHR, the Medical Research Council, Health and Care Research Wales, and Health Education England. Rachael T. Forthergill is employed by the London Ambulance Service NHS Trust. Estelle Stephenson is employed by the British Hearth Foundation. Gavin D. Perkins is an Editorial Board Member for Resuscitation Plus and is supported by the National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) West Midlands and Director of Research for the Intensive Care Foundation. The remaining authors have no disclosures to report. The views expressed in this paper are those of the authors and not necessarily those of the NIHR, Department of Health and Social Care, the BHF, or the Resuscitation Council UK.

Aim: To determine the optimal first-shock energy level for biphasic defibrillation and whether fixed or escalating protocols for subsequent shocks are most effective., Methods: We searched Medline, Embase, Cochrane CENTRAL, CINAHL, the Web of Science and national and international trial registry databases for papers published from database inception to January 2022. We reviewed reference lists of key papers to identify additional references. The population included adults sustaining non traumatic out-of-hospital cardiac arrest subject to attempted defibrillation. Studies of internal or monophasic defibrillation and studies other than randomised controlled trials or prospective cohorts were excluded. Two reviewers assessed study relevance. Data extraction and risk of bias assessment, using the ROBINS-I tool, were conducted by one reviewer and checked by a second reviewer. Data underwent intention-to-treat analysis., Results: We identified no studies evaluating first shock energy. Only one study ( n  = 738) comparing fixed versus escalating energy met eligibility criteria: a prospective cohort analysis of a randomised controlled trial of manual versus mechanical CPR. High fixed (360 J) energy was compared with an escalating (200-200/300-360 J) strategy. Researchers found 27.5% (70/255) of patients in the escalating energy group and 27.61% (132/478) in the fixed high energy group survived to hospital discharge (unadjusted risk ratio 0.99, 95% CI 0.73, 1.23). Results were of very low certainty as the study was at serious risk of bias., Conclusion: This systematic review did not identify an optimal first-shock energy for biphasic defibrillation. We identified no survival advantage at 30 days when comparing 360 J fixed with 200 J escalating strategy., (© 2022 The Author(s).)

Background: Using straight-line distance to estimate the proximity of public-access Automated External Defibrillators (AEDs) or volunteer first-responders to potential out-of-hospital cardiac arrests (OHCAs) does not reflect real-world travel distance. The difference between estimates may be an important consideration for bystanders and first-responders responding to OHCAs and may potentially impact patient outcome., Objectives: To explore how calculating real-world travel routes instead of using straight-line distance estimates might impact the community response to OHCA., Methods: We mapped 4355 OHCA (01/04/2016-31/03/2017) and 2677 AEDs in London (UK), and 1263 OHCA (18/06/2017-17/06/2018) and 4704 AEDs in East Midlands (UK) using ArcGIS mapping software. We determined the distance from OHCAs to the nearest AED using straight-line estimates and real-world travel routes. We mapped locations of potential OHCAs (London: n = 9065, 20/09/2019-22/03/2020; East Midlands: n = 7637, 20/09/2019-17/03/2020) for which volunteer first-responders were alerted by the GoodSAM mobile-phone app, and calculated response distance using straight-line estimates and real-world travel routes. We created Receiver Operating Characteristic (ROC) curves and calculated the Area Under the Curve (AUC) to determine if travel distance predicted whether or not a responder accepted an alert., Results: Real-world travel routes to the nearest AED were (median) 219 m longer (623 m vs 406 m) than straight-line estimates in London, and 211 m longer (568 m vs 357 m) in East Midlands. The identity of the nearest AED changed on 26% occasions in both areas when calculating real-world travel routes. GoodSAM responders' real-world travel routes were (median) 222 m longer (601 m vs 379 m) in London, and 291 m longer (814 m vs 523 m) in East Midlands. AUC statistics for both areas demonstrated that neither straight-line nor real-world travel distance predicted whether or not a responder accepted an alert., Conclusions: Calculating real-world travel routes increases the estimated travel distance and time for those responding to OHCAs. Calculating straight-line distance may overestimate the benefit of the community response to OHCA., (© 2021 The Author(s).)

Introduction: The main objective was to present characteristics and outcome of patients without sustained field return of spontaneous circulation (ROSC) transported to hospital with ongoing cardiopulmonary resuscitation (CPR). Our secondary objectives were to investigate hospital-based interventions and the performance of the universal Termination of Resuscitation-rule (uTOR)., Methods: In this retrospective observational cohort study, out-of-hospital cardiac arrest (OHCA) patients arriving to the emergency department of a university hospital in Sweden during a six-year period (2010-2015) were identified using a prospectively recorded hospital-based registry. Additional data were retrieved from medical records and from the Swedish cardiopulmonary resuscitation registry., Results: Among 409 patients transported with ongoing CPR, 7 survived to hospital discharge (1.7%). Hospital-based interventions against a suspected cause of arrest were attempted during ongoing resuscitation in 34 patients (8.3%), of whom 3 survived to hospital discharge. The remaining 4 survivors had spontaneous in-hospital ROSC. Survivors presented with either a shockable rhythm ( n  = 4) or pulseless electrical activity ( n  = 3). The uTOR identified non-survivors with a positive predictive value (PPV) of 98.4% and a specificity of 71.4% for termination., Conclusion: Survival after OHCA where sustained prehospital ROSC is not achieved is rare and available in-hospital interventions are rarely utilised. No patient with asystole as the first recorded rhythm survived. The uTOR identified non-survivors with a PPV of 98.4% but showed poor specificity., (© 2021 The Authors.)

Background: The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) form, which supports the ReSPECT process, is designed to prompt clinicians to discuss wider emergency treatment options with patients and to structure the documentation of decision-making for greater transparency., Methods: Following an accountability for reasonableness framework (AFR), we analysed 141 completed ReSPECT forms (versions 1.0 and 2.0), collected from six National Health Service (NHS) hospitals in England during the early adoption of ReSPECT. Structured through an evaluation tool developed for this study, the analysis assessed the extent to which the records reflected consistency, transparency, and ethical justification of decision-making., Results: Recommendations relating to CPR were consistently recorded on all forms and were contextualised within other treatment recommendations in most forms. The level of detail provided about treatment recommendations varied widely and reasons for treatment recommendations were rarely documented. Patient capacity, patient priorities and preferences, and the involvement of patients/relatives in ReSPECT conversations were recorded in some, but not all, forms. Clinicians almost never documented their weighing of potential burdens and benefits of treatments on the ReSPECT forms., Conclusion: In most ReSPECT forms, CPR recommendations were captured alongside other treatment recommendations. However, ReSPECT form design and associated training should be modified to address inconsistencies in form completion. These modifications should emphasise the recording of patient values and preferences, assessment of patient capacity, and clinical reasoning processes, thereby putting patient/family involvement at the core of good clinical practice. Version 3.0 of ReSPECT responds to these issues., (© 2021 The Authors.)

Introduction: Restart a Heart (RSAH) is an annual CPR mass training initiative delivered predominantly by ambulance services in the UK. The aim of this study was to identify to what extent voluntary participation in the 2019 initiative delivered training to the population with the highest need., Methods: A cross-sectional observational study of location characteristics for RSAH training events conducted by UK ambulance services. Descriptive statistics were used to analyse event and area characteristics. National cardiac arrest registry data were used to establish proportions of training coverage in "hot spot" areas with above national median incidence of cardiac arrest and below median bystander CPR rates. The significance of observed differences were tested using chi-square for proportions and t-test for means., Results: Twelve of 14 UK ambulance services participated, training 236,318 people. Most of the events (82%) were held in schools, and schoolchildren comprised most participants (81%). RSAH events were held in areas that were less densely populated (p < 0.001), were more common in affluent areas (p < 0.001), and had a significantly lower proportion of black residents (p < 0.05) and higher proportion of white residents (p < 0.05). Events were held in 28% of known "hot spot" areas in England., Conclusion: With mandatory CPR training for school children in England, Scotland and Wales there is an opportunity to re-focus RSAH resources to deliver training for all age groups in OHCA "hot spots", communities with higher proportions of black residents, and areas of deprivation. In Northern Ireland, we recommend targeting schools in areas with similar characteristics., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Hawkes C.A –is employed by The University of Warwick which received a grant for the conduct of this research. Brown T –is employed by The University of Warwick which received a grant for the conduct of this research. Terry Brown is affiliated to the National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) West Midlands. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. Noor U – none reported. Carlyon J – is Restart a Heart Day Project Manager, Resuscitation Council UK. Davidson N – none reported. Soar J - is an editor of Resuscitation and receives payment from Elsevier, the publisher of Resuscitation Plus. Perkins G D- is an editor of Resuscitation and receives payment from Elsevier, the publisher of Resuscitation Plus. Smyth MA – none reported. Lockey A – is Vice President of the Resuscitation Council UK., (© 2021 The Author(s).)

Aim: There is an emerging potential link between the COVID-19 pandemic and incidence and outcomes from out-of-hospital cardiac arrest (OHCA). We aimed to describe the incidence, characteristics and outcomes from OHCA in London, UK during the first wave of the pandemic., Methods: We examined data for all OHCA patients attended by the London Ambulance Service from 1st March to 30th April 2020 and compared our findings to the previous year. We also compared OHCA characteristics and short-term outcomes for those suspected or confirmed to have COVID-19 with those who were not. Additionally, we investigated the relationship between daily COVID-19 cases and OHCA incidents., Results: We observed an 81% increase in OHCAs during the pandemic, and a strong correlation between the daily number of COVID-19 cases and OHCA incidents (r = 0.828, p < 0.001). We report an increase in OHCA occurring in a private location (92.9% vs 85.5%, p < 0.001) and an increased bystander CPR (63.3% vs 52.6%, p < 0.001) during the pandemic, as well as fewer resuscitation attempts (36.4% vs 39.6%, p = 0.03) and longer EMS response times (9.3 vs 7.2 min, p < 0.001). Survival at 30 days post-arrest was poorer during the pandemic (4.4% vs 10.6%, p < 0.001) and amongst patients where COVID-19 was considered likely (1.0% vs 6.3%, p < 0.001)., Conclusions: During the first wave of the COVID-19 pandemic in London, we saw a dramatic rise in the incidence of OHCA, accompanied by a significant reduction in survival. The pattern of increased incidence and mortality closely reflected the rise in confirmed COVID-19 infections in the city., (© 2020 The Author(s).)

Background: Newly-developed suction-based airway clearance devices potentially provide a novel way to improve outcome in patients with foreign body airway obstruction. We conducted a randomised controlled crossover manikin trial to compare the efficacy and usability of two of these devices with abdominal thrusts., Methods: We randomised participants from a UK medical school to one of six groups which determined the order in which participants attempted the three techniques (abdominal thrusts; LifeVac, Nesconset, New York, USA; Dechoker, Concord North Carolina, USA). Randomisation was performed using an online randomisation system. Following brief training, participants sought to remove a foreign body airway obstruction from a manikin using the allocated technique. The primary outcome was successful removal of the foreign body. Usability was assessed in a questionnaire following the three simulations., Results: We randomised and analysed data from 90 participants (58% male; 86% aged 18-29 years). Compared with abdominal thrusts, successful foreign body airway obstruction removal was achieved more frequently in manikins in the LifeVac group (odds ratio 47.32, 95% CI 5.75-389.40) but not in the Dechoker group (odds ratio 1.22, 95% CI 0.60-2.47). The usability of LifeVac and abdominal thrusts were generally evaluated more positively than the Dechoker., Conclusion: In this manikin study, we found that, compared with abdominal thrusts, the success rate for foreign body airway obstruction removal was higher in the LifeVac group but not in the Dechoker group., (© 2020 Published by Elsevier B.V.)

The data presented in this article are supplementary data related to the research article entitled "The Copenhagen Tool: A research tool for evaluation of BLS educational interventions" (Jensen et al., 2019). We present the following supplementary materials and data: 1) a standardized scenario used to introduce the test for gathering data on internal structure and additional response process; 2) test sheets used for rating test participant via video recordings; 3) interview-guide for collecting additional response process data; 4) items deemed relevant but not essential for laypersons, first responders and health personnel in the modified Delphi consensus process; 5) inter-rater reliability values for raters using the essential items of the tool to evaluate test participants via video recordings; 6) main themes from coding interviews with raters; 7) comparison of rater results and manikin software output., Competing Interests: The authors declare no competing interests., (© 2021 The Authors.)