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Critically ill patients must often be transferred between facilities to allow for higher levels of care. However, this phase of care may pose risks for complications and clinical deterioration due to exposure to out-of-hospital environments and decreased ability to monitor and intervene. This can nevertheless be mitigated by following general transport principles, with an adequate preparation, using a structured approach.

Emergency dispatch centres receive emergency calls and assign resources. Out-of-hospital cardiac arrests (OHCA) can be classified as appropriate (requiring emergent response) or inappropriate (requiring non-emergent response) for resuscitation. We sought to determine system accuracy in emergency medical services (EMS) OHCA response allocation.We analyzed EMS-assessed non-traumatic OHCA records from the British Columbia (BC) Cardiac Arrest registry (January 1, 2019-June 1, 2021), excluding EMS-witnessed cases. In BC the "Medical Priority Dispatch System" is used. We classified EMS dispatch as "emergent" or "non-emergent" and compared to the gold standard of whether EMS personnel decided treatment was appropriate upon scene arrival. We calculated sensitivity, specificity, and positive and negative predictive values (PPV, NPV), with 95% CI's.Of 15,371 non-traumatic OHCAs, the median age was 65 (inter quartile range 51-78), and 4834 (31%) were women; 7152 (47%) were EMS-treated, of whom 651 (9.1%) survived). Among EMS-treated cases 6923/7152 had an emergent response (sensitivity = 97%, 95% CI 96-97) and among EMS-untreated cases 3951/8219 had a non-emergent response (specificity = 48%, 95% CI, 47 to 49). Among cases with emergent dispatch, 6923/11191 were EMS-treated (PPV = 62%, 95% CI 61-62), and among those with non-emergent dispatch, 3951/4180 were EMS-untreated (NPV = 95%, 95% CI 94-95); 229/4180 (5.5%) with a non-emergent dispatch were treated by EMS.The dispatch system in BC has a high sensitivity and moderate specificity in sending the appropriate responses for OHCAs deemed appropriate for treatment by paramedics. Future research may address strategies to increase system specificity, and decrease the incidence of non-emergent dispatch to EMS-treated cases.

Systematic automated external defibrillator(AED) placement in schools may improve pediatric out-of-hospital cardiac arrest(OHCA) survival. To estimate their utility, we identified school-located pediatric and adult OHCAs to estimate the potential utilization of school-located AEDs. Further, we identified all OHCAs within an AED-retrievable distance of the school by walking, biking, and driving.We used prospectively collected data from the British Columbia(BC) Cardiac Arrest Registry(2013-2020), and geo-plotted all OHCAs and schools(n = 824) in BC. We identified adult and pediatric(age 18 years) OHCAs occurring in schools, as well as nearby OHCAs for which a school-based externally-placed AED could be retrieved by a bystander prior to emergency medical system(EMS) arrival.Of 16,409 OHCAs overall in the study period, 28.6 % occurred during school hours. There were 301 pediatric OHCAs. 5(1.7 %) occurred in schools, of whom 2(40 %) survived to hospital discharge. Among both children and adults, 28(0.17 %) occurred in schools(0.0042/school/year), of whom 21(75 %) received bystander resuscitation, 4(14 %) had a bystander AED applied, and 14(50 %) survived to hospital discharge. For each AED, an average of 0.29 OHCAs/year(95 % CI 0.21-0.37), 0.93 OHCAs/year(95 % CI 0.69-1.56) and 1.69 OHCAs/year(95 % CI 1.21-2.89) would be within the potential retrieval distance of a school-located AED by pedestrian, cyclist and automobile retrieval, respectively, using the median EMS response times.While school-located OHCAs were uncommon, outcomes were favourable. 11.1% to 60.9% of all OHCAs occur within an AED-retrievable distance to a school, depending on retrieval method. Accessible external school-located AEDs may improve OHCA outcomes of school children and in the surrounding community.

Extracorporeal life support (ECLS) is associated with high morbidity and mortality. Complications and mortality are higher at lower-volume centres. Most Canadian ECLS institutions are low-volume centres. Protocols offer one way to share best practices among institutions to improve outcomes. Whether Canadian centres have ECLS protocols, and whether these protocols are comprehensive and homogenous across centres, is unknown.Purposeful sampling with mixed methods was used. A Delphi panel defined key elements relevant to the ECLS process. Documentation used in the delivery of ECLS services was requested from programs. Institutional protocols were assessed using deductive coding to determine the presence of key elements.A total of 37 key elements spanning 5 domains (referral, initiation, maintenance, termination, and administration) were identified. Documentation from 13 institutions across 10 provinces was obtained. Institutions with heart or lung transplantation programs had more-complete documentation than did non-transplantation programs. Only 5 key elements were present in at least 50% of protocols (anticoagulation strategy, ventilation strategy, defined referral process, selection criteria, weaning process), and variation was seen in how institutions approached each of these elements.The completeness of ECLS protocols varies across Canada. Programs describe variable approaches to key elements. This variability might represent a lack of evidence or consensus in these areas and creates the opportunity for collaboration among institutions to share protocols and best practice. The key-element framework provides a common language that programs can use to develop ECLS programs, initiate quality-improvement projects, and identify research agendas.L’assistance cardiorespiratoire extracorporelle (ACRE) est associée à des taux élevés de morbidité et de mortalité. Les taux de complications et de mortalité sont plus élevés dans les centres à volume plus faible. La plupart des établissements qui offrent l’ACRE au Canada sont des centres à volume faible. Les protocoles constituent un moyen de partager des pratiques exemplaires entre les établissements afin d’améliorer les résultats. On ignore si les centres du Canada ont des protocoles d’ACRE, et si ces protocoles sont exhaustifs et homogènes dans tous les centres.Nous avons utilisé un échantillonnage dirigé par méthodes mixtes. Le panel Delphi a défini les éléments fondamentaux pertinents au processus d’ACRE. La documentation utilisée pour la prestation de services d’ACRE a été demandée aux programmes. Nous avons évalué les protocoles des établissements au moyen du processus inductif de codification pour déterminer la présence d’éléments fondamentaux.Nous avons relevé un total de 37 éléments fondamentaux couvrant cinq domaines (aiguillage, amorce, maintien, cessation et administration). La documentation provenait de 13 établissements de 10 provinces. Les établissements qui ont des programmes de transplantation cardiaque ou pulmonaire avaient une documentation plus complète que les programmes sans transplantation. Seuls cinq éléments fondamentaux étaient présents dans au moins 50 % des protocoles (stratégie d’anticoagulation, stratégie de ventilation, processus défini d’aiguillage, critères de sélection, processus de sevrage), et une variation était observée dans la façon dont les établissements considéraient chacun de ces éléments.Au Canada, l’exhaustivité des protocoles d’ACRE varie. Les programmes décrivent la variabilité des approches des éléments fondamentaux. Cette variabilité qui pourrait représenter le manque de données probantes ou de consensus dans ces domaines ouvre la voie à la collaboration des établissements au partage des protocoles et des pratiques exemplaires. Le cadre des éléments fondamentaux contribue à offrir un langage commun que peuvent utiliser les programmes pour élaborer des programmes d’ACRE, amorcer des projets d’amélioration de la qualité et établir des programmes de recherche.

Drone-delivered automated external defibrillators (AEDs) may reduce delays to defibrillation for out-of-hospital cardiac arrests (OHCAs). We sought to determine how integration of drones and selection of drone bases between emergency service stations (i.e., paramedic, fire, police) would affect 9-1-1 call-to-arrival intervals.We identified all treated OHCAs in southern Vancouver Island, British Columbia, Canada from Jan. 2014 to Dec. 2020. We developed mathematical models to select 1-5 optimal drone base locations from each of: paramedic stations, fire stations, police stations, or an unrestricted grid-based set of points to minimize drone travel time to OHCAs. We evaluated models on the estimated first response interval assuming that drones were integrated with existing OHCA response. We compared median response intervals with historical response, as well as across drone base locations.A total of 1610 OHCAs were included in the study with a historical median response interval of 6.4 minutes (IQR 5.0-8.6). All drone-integrated response systems significantly reduced the median response interval to 4.2-5.4 minutes (all P 0.001), with grid-based stations using 5 drones resulting in the lowest response interval (4.2 minutes). Median response times between drone base location types differed by 6-16 seconds, all comparisons of which were statistically significant (all P 0.02).Integrating drone-delivered AEDs into OHCA response may reduce first response intervals, even with a small quantity of drones. Implementing drone response with only one emergency service resulted in similar response metrics regardless of the emergency service hosting the drone base and was competitive with unrestricted drone base locations.

Half of out-of-hospital cardiac arrests (OHCA) are deemed inappropriate for resuscitation by emergency medical services (EMS). We investigated patient characteristics and reasons for non-treatment of OHCAs, and determined the proportion involving illicit drug use.We reviewed consecutive EMS-untreated OHCA from the British Columbia Cardiac Arrest Registry (2019-2020). We abstracted patient characteristics and categorized reasons for EMS non-treatment: (1) prolonged interval from the OHCA to EMS arrival ("non-recent OHCA") with or without signs of "obvious death"; (2) do-not-resuscitate (DNR) order; (3) terminal disease; (4) verbal directive; and (5) unspecified. We abstracted clinical details regarding a history of, or evidence at the scene of, illicit drug use.Of 13 331 cases, 5959 (45%) were not treated by EMS. The median age was 67 (IQR 54-81) and 1903 (32%) were female. EMS withheld resuscitation due to: non-recent OHCA, with and without signs of "obvious death" in 4749 (80%) and 108 (1.8%), respectively; DNR order in 952 (16%); terminal disease in 77 (1.3%); family directive in 41 (0.69%); and unspecified in 32 (0.54%). Overall and among those with non-recent OHCA, 695/5959 (12%) and 691/4857 (14%) had either a history of or evidence of recent illicit drug use, respectively.A prolonged interval from the OHCA until EMS assessment was the predominant reason for withholding treatment. Innovative solutions to decrease this interval may increase the proportion of OHCA that are treated by EMS and overall outcomes. Targeted interventions for illicit-drug use-related OHCAs may add additional benefit.

Study objective We hypothesized that the use of intramuscular ketamine would result in a clinically relevant shorter time to target sedation. Methods We conducted a randomized clinical trial comparing the rapidity of onset, level of sedation, and adverse effect profile of ketamine compared to a combination of midazolam and haloperidol for behavioral control of emergency department patients with severe psychomotor agitation. We included patients with severe psychomotor agitation measured by a Richmond Agitation Score (RASS) ≥+3. Patients in the ketamine group were treated with a 5 mg/kg intramuscular injection. Patients in the midazolam and haloperidol group were treated with a single intramuscular injection of 5 mg midazolam and 5 mg haloperidol. The primary outcome was the time, in minutes, from study medication administration to adequate sedation, defined as RASS ≤-1. Secondary outcomes included the need for rescue medications and serious adverse events. Results Between June 30, 2018, and March 13, 2020, we screened 308 patients and enrolled 80. The median time to sedation was 14.7 minutes for midazolam and haloperidol versus 5.8 minutes for ketamine (difference 8.8 minutes [95% confidence interval (CI) 3.0 to 14.5]). Adjusted Cox proportional model analysis favored the ketamine arm (hazard ratio 2.43, 95% CI 1.43 to 4.12). Five (12.5%) patients in the ketamine arm and 2 (5.0%) patients in the midazolam and haloperidol arm experienced serious adverse events (difference 7.5% [95% CI -4.8% to 19.8%]). Conclusion In ED patients with severe agitation, intramuscular ketamine provided significantly shorter time to adequate sedation than a combination of intramuscular midazolam and haloperidol.

There is substantial regional variation in out-of-hospital cardiac arrest (OHCA) survival. We investigated whether regional emergency medical services (EMS) intra-arrest transport (IAT) practices are associated with patient outcomes.We performed a secondary analysis of a multi-center North American clinical trial dataset, which enrolled EMS-treated adult OHCA cases from 49 regional population-based clusters. The exposure of interest was regional-level intra-arrest transport (IAT), calculated as the proportion of cases in each cluster transported to hospital prior to return of spontaneous circulation, examined as quartiles and as a continuous variable. Multilevel mixed-effects logistic regression modeling estimated the association between regional IAT with survival to hospital discharge and favorable neurologic status (modified Rankin Scale ≤ 3) at hospital discharge.Of 26,148 subjects (median age 68 years; 36% female; 23% shockable initial rhythm) 2424 (9.3%), survived to hospital discharge and 1993 (7.6%) had favourable neurological outcomes. Across regional clusters, IAT ranged from 0.84% to 75% (quartiles6.2%, 6.2-19.6%, 19.6-30.4%, and ≥30.4%). For each quartile, 13.3%, 7.9%, 7.4%, and 4.8% survived, and 10.4%, 7.8%, 7.4%, and 4.8% had favourable neurological status. Regional IAT (per 10% change) was associated with decreased probability of survival (AOR 0.86, 95% CI 0.82-0.91) and favorable neurological outcome (AOR 0.80, 95% CI 0.76-0.85).Treatment within a region that utilizes IAT less frequently was associated with improved clinical outcomes at hospital discharge. These findings may account for some of the known regional variation in OHCA outcomes.

Introduction In pediatric out-of-hospital cardiac arrest (OHCA) the effect of intraosseous (IO) or intravenous (IV) access on outcomes is unclear. Methods We analyzed prospectively collected data of non-traumatic OHCA in the Resuscitation Outcomes Consortium registry from 2011 to 2015. We included EMS-treated patients ≤17 years of age, classified patients based on vascular access routes, and calculated success rates of IO and IV attempts. After excluding patients with obvious non-cardiac etiologies and those with unsuccessful vascular access or multiple routes, we fit a logistic regression model to evaluate the association of IO vascular access (reference IV access) with the primary outcome of survival, using multiple imputation to address missing data. We analyzed a subgroup of patients at least 2 years of age. Results There were 1549 non-traumatic OHCA: 895 (57.8%) patients had an IO line attempted with 822 (91.8%) successful; 488 (31.5%) had an IV line attempted with 345 (70.7%) successful (difference 21%, 95% CI 17 to 26%). Of the 761 patients included in our logistic regression, 601 received IO (30 [5.2%] survived) and 160 received IV (40 [25%] survived) vascular access. Intraosseous access was associated with a decreased probability of survival (adjusted OR 0.46; 95% CI 0.21–0.98). Patients at least 2 years of age showed a similar association (adjusted OR 0.36; CI 0.15–0.86). Conclusions Intraosseous access was associated with decreased survival among pediatric non-traumatic OHCA. These results are exploratory and support the need for further study to evaluate the effect of intravascular access method on outcomes.

Post-resuscitation prognostic biomarkers for out-of-hospital cardiac arrest (OHCA) outcomes have not been fully elucidated. We examined the association of acid-base blood values (pH) with patient outcomes and calculated the pH test performance to predict prognosis.This was a post-hoc analysis of data from the continuous chest compression trial, which enrolled non-traumatic adult emergency medical system-treated OHCA in Canada and the United States. We examined cases who survived a minimum of 24 h post hospital arrival. The independent variables of interest were initial pH, final pH, and the change in pH (δpH). The primary outcome was neurological status at hospital discharge, with favorable status defined as modified Rankin Scale (mRS) ≤ 3. We reported adjusted odds ratios for favorable neurological outcome using multivariable logistic regression models. We calculated the test performance of increasing pH thresholds in 0.1 increments to predict unfavorable neurological status (defined as mRS3) at hospital discharge.We included 4189 patients. 32% survived to hospital discharge with favorable neurological status. In the adjusted analysis, higher initial pH (OR 6.82; 95% CI 3.71-12.52) and higher final pH (OR 7.99; 95% CI 3.26-19.62) were associated with higher odds of favorable neurological status. pH thresholds with highest positive predictive values were initial pH 6.8 (92.5%; 95% CI 86.2 %-98.8%) and final pH 7.0 (100%; 95% CI 95.2 %-100%).In patients with OHCA, pH values were associated with patients' subsequent neurological status at hospital discharge. Final pH may be clinically useful to predict unfavorable neurological status at hospital discharge.

Longer emergency medical system cardiopulmonary-resuscitation-to-return of-spontaneous-circulation (EMS CPR-to-ROSC) interval has been associated with worse hospital discharge outcomes after out-of-hospital cardiac arrest (OHCA). We hypothesized that this association extends post-discharge in hospital survivors. We investigated whether pre-arrest co-morbidities influence the duration of resuscitation.We included EMS-treated adult OHCA (January 2009 - December 2016) from British Columbia Cardiac Arrest Registry linked to provincial databases. Pre-OHCA characteristics were compared by ≤10, 10-20, and20 min interval categories. Outcomes included survival and functional outcomes at hospital discharge and 1- and 3-year survival. We examined the relationship between CPR-to-ROSC intervals and survival using Kaplan-Meier. We examined the relationship between the CPR-to-ROSC interval (continuous variable) with all outcomes using regression models.Among 10,241 OHCA, 4604 (45%) achieved ROSC, with a median CPR-to-ROSC interval of 15.5 (IQR 9.0-22.9) minutes. Diabetes, chronic kidney disease, and prior myocardial infarction were associated with longer CPR-to-ROSC intervals. 1245 (12.2%) survived to hospital discharge. Among hospital survivors, Kaplan-Meier survival at 1- and 3-years were 92% [95% CI 90-93%] and 84% [95% CI 82-86%] respectively; survival curves stratified by CPR-to-ROSC intervals were not statistically different. Longer CPR-to-ROSC interval was non-linearly associated with lower survival and functional outcomes at hospital discharge but not with post-discharge outcomes.Longer CPR-to-ROSC interval was associated with lower survival at hospital discharge and was influenced by pre-arrest co-morbidities. However, these intervals were not associated with long-term survival or functional outcome among hospital survivors, suggesting early risk of longer CPR-to-ROSC intervals does not persist.

Introduction Extracorporeal cardiopulmonary resuscitation (ECPR) is an emerging invasive rescue therapy for treatment of refractory out-of-hospital cardiac arrests (OHCA). We aim to describe the incidence of traumatic and hemorrhagic complications among patients undergoing ECPR for OHCA and examine the association between CPR duration and ECPR-related injuries or bleeding. Methods We examined prospectively collected data from the Extracorporeal Resuscitation Outcomes Database (EROD), which includes ECPR-treated OHCAs from participating hospitals (October 2014 to August 2019). The primary outcome was traumatic or hemorrhagic complications, defined any of the following: pneumothorax, pulmonary hemorrhage, major bleeding, cannula site bleeding, gastrointestinal bleeding, thoracotomy, cardiac tamponade, aortic dissection, or vascular injury during hospitalization. The primary exposure was the cardiac arrest to ECPR initiation interval (CA-ECPR interval), measured as the time from arrest to initiation of ECPR. Descriptive statistics were used to compare demographic, cardiac arrest, and ECPR characteristics among patients with and without CPR-related traumatic or bleeding complications. Multivariable logistic regression was used to examine the association between CA-ECPR interval and traumatic or bleeding complications. Results A total of 68 patients from 4 hospitals receiving ECPR for OHCA were entered into EROD and met inclusion criteria. Median age was 51 (interquartile range 38–58), 81% were male, 40% had body mass index > 30, and 70% had pre-existing medical comorbidities. A total of 65% had an initial shockable cardiac rhythm, mechanical CPR was utilized in at least 29% of patients, and 27% were discharged alive. The median time from arrest to ECPR initiation was 73 min (IQR 60–104). A total of 37% experienced a traumatic or bleeding complication, with major bleeding (32%), vascular injury (18%), and cannula site bleeding (15%) being the most common. Compared to patients with shorter CPR times, patients with a longer CA-ECPR interval had 18% (95% confidence interval — 2–42%) higher odds of suffering a mechanical or bleeding complication, but this did not reach statistical significance (p = 0.08). Conclusions Traumatic injuries and bleeding complications are common among patients undergoing ECPR. Further study is needed to investigate the relation between arrest duration and complications. Clinicians performing ECPR should anticipate and assess for injuries and bleeding in this high-risk population.

Background Rapid emergency medical service (EMS) response after out-of-hospital cardiac arrest (OHCA) is a major determinant of survival, however this is typically measured until EMS vehicle arrival. We sought to investigate whether the interval from EMS vehicle arrival to patient attendance (curb-to-care interval [CTC]) was associated with patient outcomes. Methods We performed a secondary analysis of the “CCC Trial” dataset, which includes EMS-treated adult non-traumatic OHCA. We fit an adjusted logistic regression model to estimate the association between CTC interval (divided into quartiles) and the primary outcome (survival with favourable neurologic status at hospital discharge; mRS ≤ 3). We described the CTC interval distribution among enrolling clusters. Results We included 24,685 patients: median age was 68 (IQR 56–81), 23% had initial shockable rhythms, and 7.6% survived with favourable neurological status. Compared to the first quartile (≤62 seconds), longer CTC quartiles (63 to 115, 116 to 180, and ≥181 seconds) demonstrated the following associations with survival with favourable neurological status: adjusted odds ratios 0.95, 95% CI 0.83 to 1.09; 0.77, 95% CI 0.66 to 0.89; 0.66, 95% CI 0.56 to 0.77, respectively. Of the 49 study clusters, median CTC intervals ranged from 86 (IQR 58–130) to 179 seconds (IQR 112–256). Conclusion A lower CTC interval was associated with improved patient outcomes. These results demonstrate a wide range of access metrics within North America, and provide a rationale to create protocols to mitigate access obstacles. A two-minute CTC threshold may represent an appropriate target for quality improvement.

International audience; Aims: There are large differences between emergency medical systems, which may account for variability in outcomes. We seek to compare prehospital organizations, response modes, patient characteristics and outcomes after out-of-hospital cardiac arrest, between France and Canada, and discuss the need for the first European-North American prehospital research network on out-of-hospital cardiac arrest.Methods: Preliminary comparative description of data drawn from two nation-wide, population-based, Utstein-style prospectively implemented registries for out-of-hospital cardiac arrest in France and Canada (France: RéAC, Canada: CanROC), covering approximately 80 million people, and soon to be participating in an international research network in 2020.Results: Since creation, 103,722 cases were included in France and approximately 99,317 in Canada. Data used in this work were drawn from 2011 to 2016, and comprised around 33,688 adult, non-traumatic, treated cases in Canada, and 55,358 in France, leading to estimated incidence rates of 75.3/100,000 inhabitants in France and 83/100,000 in Canada. In both countries, out-of-hospital cardiac arrest predominantly occurred in male patients, in their late sixties, at home, of presumed cardiac aetiology. Bystander cardiopulmonary resuscitation was provided in half of the cases. First assessed cardiac rhythm was shockable in 16% (France) vs. 22% (Canada). Professional resuscitation was attempted in 82% (France) and 60% (Canada). Prehospital organizations and response modes differed in the constitution of responding teams (France: physician-led advanced life support, Canada: trained paramedics), in response time intervals (call to first professional responders' arrival at scene 6.5 min (interquartile range IQR [5.2-8.3]) (Canada) vs. 10 min [7-15] (France)), in on-scene interventions, type of referral at hospital (France: systematic bypass of emergency department, tertiary hospital first, Canada: occasional bypass, mainly closest hospital first), and in outcomes (overall survival at hospital discharge in France: 5% vs. Canada: 11%).Conclusion: Despite similarities in some out-of-hospital cardiac arrest Utstein variables, several differences exist between French and Canadian prehospital systems, and ultimately, between outcomes. The creation of the ReACanROC research network will facilitate the conduction of further analyses to better understand predictors of this variability.

Cardiac arrest (CA) is the cessation of circulation to vital organs that can only be reversed with rapid and appropriate interventions. Sensor technologies for early detection and activation of the emergency medical system could enable rapid response to CA and increase the probability of survival. We conducted a systematic review to summarize the literature surrounding the performance of sensor technologies in detecting OHCA.We searched the academic and grey literature using keywords related to cardiac arrest, sensor technologies, and recognition/detection. We included English articles published up until June 6, 2022, including investigations and patent filings that reported the sensitivity and specificity of sensor technologies to detect cardiac arrest on human or animal subjects. (Prospero# CRD42021267797).We screened 1666 articles and included four publications examining sensor technologies. One tested the performance of a physical sensor on human participants in simulated CA, one tested performance on audio recordings of patients in cardiac arrest, and two utilized a hybrid design for testing including human participants and ECG databases. Three of the devices were wearable and one was an audio detection algorithm utilizing household smart technologies. Real-world testing was limited in all studies. Sensitivity and specificity for the sensors ranged from 97.2 to 100% and 90.3 to 99.9%, respectively. All included studies had a medium/high risk of bias, with 2/4 having a high risk of bias.Sensor technologies show promise for cardiac arrest detection. However, current evidence is sparse and of high risk of bias. Small sample sizes and databases with low external validity limit the generalizability of findings.

BACKGROUND Out-of-hospital cardiac arrest (OHCA) is associated with poor in-hospital outcomes. However, the impact of pre- and in-hospital factors on long-term survival, healthcare utilization and functional outcomes is ill-defined, mainly related to challenges combining disparate data sources. METHODS AND RESULTS Adult non-traumatic OHCAs from the British Columbia Cardiac Arrest Registry (Jan 2009 to Dec 2016) were linked to provincial datasets comprising co-morbidities, medications, cardiac procedures, mortality, and hospital admission and discharge. Among hospital-discharge survivors, the 3-year endpoint of mortality or mortality and all-cause readmission was examined using the Kaplan-Meier (KM) method and multivariable Cox model for predictors. Functional status, defined as the use of publicly funded home care and community services (HCCS) within 1-year post-discharge, was evaluated by logistic regression. Of 10,876 linked, emergency medical services (EMS)-treated OHCAs, 3230 were admitted to hospital. Compared to hospital non-survivors (n=1905), hospital survivors (n=1325) had fewer co-morbidities and were more likely to have favorable resuscitation characteristics (shockable rhythm, witnessed arrest, bystander CPR). Among hospital survivors, 78.6% were treated with mechanical ventilation, 69.1% received coronary angiography, 37.5% and 10.3% were revascularized via PCI or CABG, respectively, and 24.8% received an intracardiac defibrillator (ICD) prior to discharge. At 3 years post-discharge, the estimated Kaplan-Meier (KM) survival rate was 84.1% [95% CI: 81.7%, 86.1%] and freedom from death and all-cause readmission was 31.8% (CI: 29.0%, 34.7%) (Figure). Predictors of post-discharge 3-year mortality included: older age, history of heart failure (HF), history of chronic kidney disease (CKD), non-public cardiac arrest location, initial non-shockable rhythm, and concomitant HF on admission; predictors of a lower risk of death included EMS witnessed arrest (HR 0.61, 95% CI: 0.40, 0.93), revascularization (HR 0.42, 95% CI: 0.28, 0.63), or ICD implant (HR 0.44, 95% CI: 0.27, 0.71). After excluding patients receiving HCCS prior to OHCA, 23.7% (n=289/1218) had poor functional outcome. Predictors of poor functional outcome included age > 75, female sex, history of CKD, non-public cardiac arrest location, initial non-shockable rhythm, and mechanical ventilation; ICD implantation was associated with a lower risk of poor functional status (OR 0.55, 95% CI: 0.38, 0.81). CONCLUSION While the long-term death or readmission risk persists even among OHCA hospital survivors, only 1 in 4 survivors accessed HCCS 1-year post-discharge, indicating overall good functional outcome. These results show that post-discharge outcomes are strongly influenced by both pre- and in-hospital factors, and supports efforts to improve care processes to increase survival to hospital discharge.

Jurisdictions have reported COVID-19-related increases in the incidence and mortality of non-traumatic out-of-hospital cardiac arrest (OHCA). We hypothesized that changes in suicide incidence during the COVID-19 pandemic may have contributed to these changes. We investigated whether the COVID-19 pandemic was associated with changes in the: (1) incidence of suicide-related OHCA, and (2) characteristics and outcomes of such cases.We used the provincial British Columbia Cardiac Arrest Registry, including non-traumatic emergency medical system (EMS)-assessed OHCA, to compare suicide-related OHCA (defined as clear self-harm orOf 13,785 EMS-assessed OHCA, we included 274/6430 (4.3%) pre-pandemic and 221/7355 (3.0%) pandemic-period suicide-related cases. The median age was 43 years (IQR 30-57), 157 (32%) were female, and 7 (1.4%) survived with favourable neurological status. Suicide-related OHCA incidence decreased from 5.4 pre-pandemic to 4.3 per 100 000 person-years (-1.1, 95% CI -2.0 to -0.28). Hanging-related OHCA incidence also decreased. Patient characteristics and hospital discharge outcomes between periods were similar.Suicide-related OHCA incidence decreased with the COVID-19 pandemic and we did not detect changes in patient characteristics or outcomes, suggesting that suicide is not a contributor to increases in COVID-related OHCA incidence or mortality. Overall suicide-related OHCA outcomes in both time periods were poor.

Background Intra-resuscitation antiarrhythmic drugs may improve resuscitation outcomes, in part by avoiding rearrest, a condition associated with poor out-of-hospital cardiac arrest (OHCA) outcomes. However, antiarrhythmics may also alter defibrillation threshold. The objective of this study was to investigate the relationship between rearrest and intra-resuscitation antiarrhythmic drugs in the context of the Resuscitation Outcomes Consortium (ROC) amiodarone, lidocaine, and placebo (ALPS) trial. Hypothesis Rearrest rates would be lower in cases treated with amiodarone or lidocaine, versus saline placebo, prior to first return of spontaneous circulation (ROSC). We also hypothesized antiarrhythmic effects would be quantifiable through analysis of the prehospital electrocardiogram. Methods We conducted a secondary analysis of the ROC ALPS trial. Cases that first achieved prehospital ROSC after randomized administration of study drug were included in the analysis. Rearrest, defined as loss of pulses following ROSC, was ascertained from emergency medical services records. Rearrest rate was calculated overall, as well as by ALPS treatment group. Multivariable logistic regression models were constructed to assess the association between treatment group and rearrest, as well as rearrest and both survival to hospital discharge and survival with neurologic function. Amplitude spectrum area, median slope, and centroid frequency of the ventricular fibrillation (VF) ECG were calculated and compared across treatment groups. Results A total of 1144 (40.4%) cases with study drug prior to first ROSC were included. Rearrest rate was 44.0% overall; 42.9% for placebo, 45.7% for lidocaine, and 43.0% for amiodarone. In multivariable logistic regression models, ALPS treatment group was not associated with rearrest, though rearrest was associated with poor survival and neurologic outcomes. AMSA and median slope measures of the first available VF were associated with rearrest case status, while median slope and centroid frequency were associated with ALPS treatment group. Conclusion Rearrest rates did not differ between antiarrhythmic and placebo treatment groups. ECG waveform characteristics were correlated with treatment group and rearrest. Rearrest was inversely associated with survival and neurologic outcomes.

Background Prior observational studies suggest no additional benefit from advanced life support (ALS) when compared with providing basic life support (BLS) for patients with out-of-hospital cardiac arrest (OHCA). We compared the association of ALS care with OHCA outcomes using prospective clinical data from the Resuscitation Outcomes Consortium (ROC). Methods Included were consecutive adults OHCA treated by participating emergency medical services (EMS) agencies between June 1, 2011, and June 30, 2015. We defined BLS as receipt of cardiopulmonary resuscitation (CPR) and/or automated defibrillation and ALS as receipt of an advanced airway, manual defibrillation, or intravenous drug therapy. We compared outcomes among patients receiving: 1) BLS-only; 2) BLS + late ALS; 3) BLS + early ALS; and 4) ALS-first care. Using multivariable logistic regression, we evaluated the associations between level of care and return of spontaneous circulation (ROSC), survival to hospital discharge, and survival with good functional status, adjusting for age, sex, witnessed arrest, bystander CPR, shockable initial rhythm, public location, EMS response time, CPR quality, and ROC site. Results Among 35,065 patients with OHCA, characteristics were median age 68 years (IQR 56–80), male 63.9%, witnessed arrest 43.8%, bystander CPR 50.6%, and shockable initial rhythm 24.2%. Care delivered was: 4.0% BLS-only, 31.5% BLS + late ALS, 17.2% BLS + early ALS, and 47.3% ALS-first. ALS care with or without initial BLS care was independently associated with increased adjusted ROSC and survival to hospital discharge unless delivered greater than 6 min after BLS arrival (BLS + late ALS). Regardless of when it was delivered, ALS care was not associated with significantly greater functional outcome. Conclusion ALS care was associated with survival to hospital discharge when provided initially or within six minutes of BLS arrival. ALS care, with or without initial BLS care, was associated with increased ROSC, however it was not associated with functional outcome.

Study objective We seek to determine the effect of intraosseous over intravenous vascular access on outcomes after out-of-hospital cardiac arrest. Methods This secondary analysis of the Resuscitation Outcomes Consortium Prehospital Resuscitation Using an Impedance Valve and Early Versus Delayed (PRIMED) study included adult patients with nontraumatic out-of-hospital cardiac arrests treated during 2007 to 2009, excluding those with any unsuccessful attempt or more than one access site. The primary exposure was intraosseous versus intravenous vascular access. The primary outcome was favorable neurologic outcome on hospital discharge (modified Rankin Scale score ≤3). We determined the association between vascular access route and out-of-hospital cardiac arrest outcome with multivariable logistic regression, adjusting for age, sex, initial emergency medical services–recorded rhythm (shockable or nonshockable), witness status, bystander cardiopulmonary resuscitation, use of public automated external defibrillator, episode location (public or not), and time from call to paramedic scene arrival. We confirmed the results with multiple imputation, propensity score matching, and generalized estimating equations, with study enrolling region as a clustering variable. Results Of 13,155 included out-of-hospital cardiac arrests, 660 (5.0%) received intraosseous vascular access. In the intraosseous group, 10 of 660 patients (1.5%) had favorable neurologic outcome compared with 945 of 12,495 (7.6%) in the intravenous group. On multivariable regression, intraosseous access was associated with poorer out-of-hospital cardiac arrest survival (adjusted odds ratio 0.24; 95% confidence interval 0.12 to 0.46). Sensitivity analyses revealed similar results. Conclusion In adult out-of-hospital cardiac arrest patients, intraosseous vascular access was associated with poorer neurologic outcomes than intravenous access.

Purpose Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) may provide benefit to patients in refractory cardiac arrest and cardiogenic shock. We aim to summarize our center's 6-year experience with resuscitative VA-ECMO. Materials and methods A retrospective medical record review (April 2009 to 2015) was performed on consecutive non-cardiotomy patients who were managed with VA-ECMO due to refractory in- or out-of-hospital cardiac (IHCA/OHCA) arrest (E-CPR) or refractory cardiogenic shock (E-CS) with or without preceding cardiac arrest. Our primary outcome was survival to hospital discharge and good neurological status (Cerebral Performance Category 1–2). Results There were a total of 22 patients who met inclusion criteria of whom 9 received E-CPR (8 IHCA, 1 OHCA) and 13 received E-CS. The median age for E-CPR patients was 52 [IQR 45, 58] years, and 54 [IQR 38, 64] years for E-CS patients. Cardiac arrest duration was 70.33 (SD 39.56) min for the E-CPR patients, and 24.67 (SD 26.73) min for the 9 patients treated with E-CS who had previously arrested. Initial cardiac arrest rhythms were pulseless electrical activity (39%), ventricular fibrillation (33%), or ventricular tachycardia (28%). A total of 18/22 patients were successfully weaned from VA-ECMO (78%); 16 patients survived to hospital discharge (73%) with 15 in good neurological condition. Conclusion The initiation of VA-ECMO at our center for treatment of refractory cardiac arrest and cardiogenic shock yielded a high proportion of survivors and favorable neurological outcomes.

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

Out-of-hospital cardiac arrest (OHCA) affects 134 per 100,000 citizens annually. Extracorporeal cardiopulmonary resuscitation (ECPR), providing mechanical circulatory support, may improve the likelihood of survival among those with refractory OHCA. Compared with in-hospital ECPR candidates, those in the out-of-hospital setting tend to be sudden unexpected arrests in younger and healthier patients. The aims of this review were to summarize, and identify the limitations of, the evidence evaluating ECPR for OHCA, and to provide an approach for ECPR program application. Although there are many descriptions of ECPR-treated cohorts, we identified a paucity of robust data showing ECPR effectiveness compared with conventional resuscitation. However, it is highly likely that ECPR, provided after a prolonged attempt with conventional resuscitation, does benefit select patient populations compared with conventional resuscitation alone. Although reliable data showing the optimal patient selection criteria for ECPR are lacking, most implementations sought young previously healthy patients with rapid high-quality cardiopulmonary resuscitation. Carefully planned development of ECPR programs, in high-performing emergency medical systems at experienced extracorporeal membrane oxygenation centres, may be reasonable as part of systematic efforts to determine ECPR effectiveness and globally improve care. Protocol evaluation requires regional-level assessment, examining the incremental benefit of survival compared with standard care, while accounting for resource utilization.

Objective To determine if arterial oxygen and carbon dioxide abnormalities in the first 24 h after return of spontaneous circulation (ROSC) are associated with increased mortality in adult out-of-hospital cardiac arrest (OHCA). Methods We used data from the Resuscitation Outcomes Consortium (ROC), including adult OHCA with sustained ROSC ≥1 h after Emergency Department arrival and at least one arterial blood gas (ABG) measurement. Among ABGs measured during the first 24 h of hospitalization, we identified the presence of hyperoxemia (PaO2 ≥ 300 mmHg), hypoxemia (PaO2 50 mmHg) and hypocarbia (PaCO2 Results Among 9186 OHCA included in the analysis, hospital mortality was 67.3%. Hyperoxemia, hypoxemia, hypercarbia, and hypocarbia occurred in 26.5%, 19.0%, 51.0% and 30.6%, respectively. Initial hyperoxemia only was not associated with hospital mortality (adjusted OR 1.10; 95% CI: 0.97–1.26). However, final and any hyperoxemia (1.25; 1.11–1.41) were associated with increased hospital mortality. Initial (1.58; 1.30–1.92), final (3.06; 2.42–3.86) and any (1.76; 1.54–2.02) hypoxemia (PaO2 50 mmHg) were associated with increased hospital mortality. Initial (1.13; 0.90–1.41), final (1.19; 1.04–1.37) and any (1.01; 0.91–1.12) hypocarbia (PaCO2 Conclusions In the first 24 h after ROSC, abnormal post-arrest oxygen and carbon dioxide tensions are associated with increased out of-hospital cardiac arrest mortality.

Aim Estimate prevalence of ECPR-eligible subjects in a large, North American, multi-center cohort, describe natural history with conventional resuscitation, and predict optimal timing of transition to ECPR. Methods Secondary analysis of clinical trial enrolling adults with non-traumatic OHCA. Primary outcome was survival to discharge with favorable outcome (mRS 0–3). Subjects were additionally classified as survival with unfavorable outcome (mRS 4–5), ROSC without survival (mRS 6), or without ROSC. We plotted subject accrual as a function of resuscitation duration (CPR onset to return of spontaneous circulation (ROSC) or termination of resuscitation), and estimated time-dependent probabilities of ROSC and mRS 0–3 at discharge. Adjusted logistic regression models tested the association between resuscitation duration and survival with mRS 0–3. Results Of 11,368 subjects, 1237 (10.9%; 95%CI 10.3–11.5%) were eligible for ECPR, Of these, 778 (63%) achieved ROSC, 466 (38%) survived to discharge, and 377 (30%) had mRS 0–3 at discharge. Half with eventual mRS 0–3 achieved ROSC within 8.8 min (95%CI 8.3–9.2 min) of resuscitation, and 90% within 21.0 min (95%CI 19.1–23.7 min). Time-dependent probabilities of ROSC and mRS 0–3 declined over elapsed resuscitation, and the likelihood of additional cases with mRS 0–3 beyond 20 min was 8.4% (95%CI 5.9–11.0%). Resuscitation duration was independently associated with survival to discharge with mRS 0–3 (OR 0.95; 95%CI 0.92–0.97). Conclusion Approximately 11% of subjects were eligible for ECPR. Only one-third survived to discharge with favorable outcome. Performing 9–21 min of conventional resuscitation captured most ECPR-eligible subjects with eventual mRS 0–3 at hospital discharge.

Aim The COVID-19 pandemic may influence the willingness of bystanders to engage in resuscitation for out-of-hospital cardiac arrest. We sought to determine if and how the pandemic has changed willingness to intervene, and the impact of personal protective equipment (PPE). Methods We distributed a 12-item survey to the general public through social media channels from June 4 to 23, 2020. We used 100-point scales to inquire about participants’ willingness to perform interventions on “strangers or unfamiliar persons” and “family members or familiar persons”, and compared mean willingness during time periods prior to and during the COVID-19 pandemic using paired t-tests. Results Survey participants (n = 1360) were from 26 countries; the median age was 38 years (IQR 24–50) and 45% were female. Compared to prior to the pandemic, there were significant decreases in willingness to check for breathing or a pulse (mean difference −10.7% [95%CI −11.8, −9.6] for stranger/unfamiliar persons, −1.2% [95%CI −1.6, −0.8] for family/familiar persons), perform chest compressions (−14.3% [95%CI −15.6, −13.0], −1.6% [95%CI −2.1, −1.1]), provide rescue breaths (−19.5% [95%CI −20.9, −18.1], −5.5% [95%CI −6.4, −4.6]), and apply an automated external defibrillator (−4.8% [95%CI −5.7, −4.0], −0.9% [95%CI −1.3, −0.5]) during the COVID-19 pandemic. Willingness to intervene increased significantly if PPE was available (+8.3% [95%CI 7.2, 9.5] for stranger/unfamiliar, and +1.4% [95%CI 0.8, 1.9] for family/familiar persons). Conclusion Willingness to perform bystander resuscitation during the pandemic decreased, however this was ameliorated if simple PPE were available.

Aim There is little data to inform the appropriate duration of resuscitation attempts for out-of-hospital cardiac arrest (OHCA). We assessed the relationship of elapsed duration since commencement of resuscitation and outcomes, highlighting differences between initial shockable and non-shockable rhythms. Methods We examined consecutive adult non-traumatic EMS-treated OHCA in a single health region. We plotted the time-dependent accrual of patients with ROSC, as well as dynamic estimates of outcomes as a function of duration from commencement of professional resuscitation, and compared subgroups dichotomized by initial rhythm. Logistic regression tested the association between time-to-ROSC and outcomes. Results Of 1627 adult EMS-treated cases of OHCA, 1617 patients were included; 14% survivors and 10% with favorable neurological outcomes. Time-to-ROSC (per minute increase) was independently associated with survival in those with initial shockable (aOR 0.95, 95% CI 0.92–0.97) and non-shockable (aOR 0.83; 95% CI 0.78–0.88) rhythms. Similar associations were seen with favorable neurologic outcome. The elapsed duration at which the probability of survival fell below 1% was 48 and 15 min in the shockable and non-shockable groups, respectively. Median time-to-termination of resuscitation was 36 and 26 min in the shockable and non-shockable groups, respectively. Conclusion The subgroup of initial shockable rhythms showed a less pronounced association of time-to-ROSC with outcomes, and demonstrated higher resilience for neurologically intact survival after prolonged periods of resuscitation. This data can guide minimum durations of resuscitation, however should not be considered as evidence for termination of resuscitation as survival in this cohort may have been improved with longer resuscitation attempts.

Background While coronary CT angiography (coronary CTA) may be comparable to standard care in diagnosing acute coronary syndrome (ACS) in emergency department (ED) chest pain patients, it has traditionally been obtained prior to ED discharge and a strategy of delayed outpatient coronary CTA following an ED visit has not been evaluated. Objective To investigate the safety of discharging stable ED patients and obtaining outpatient CCTA. Methods At two urban Canadian EDs, patients up to 65 years with chest pain but no findings indicating presence of ACS were further evaluated depending upon time of presentation: (1) ED-based coronary CTA during normal working hours, (2) or outpatient coronary CTA within 72 hours at other times. All data were collected prospectively. The primary outcome was the proportion of patients who had an outpatient coronary CTA ordered and had a predefined major adverse cardiac event (MACE) between ED discharge and outpatient CT; secondary outcome was the ED length of stay in both groups. Results From July 1, 2012 to June 30, 2014, we enrolled 521 consecutive patients: 350 with outpatient CT and 171 with ED-based CT. Demographics and risk factors were similar in both cohorts. No outpatient CT patients had a MACE prior to coronary CTA. (0.0%, 95% CI 0 to 0.9%) The median length of stay for ED-based evaluation was 6.6 hours (interquartile range 5.4 to 8.3 hours) while the outpatient group had a median length of stay of 7.0 hours (IQR 6.0 to 9.8 hours, n.s.). Conclusions In ED chest pain patients with a low risk of ACS, performing coronary CTA as an outpatient may be a safe strategy.

Study objective Corticosteroids (steroids) are often used to mitigate symptoms and prevent subsequent reactions in emergency department (ED) patients with allergic reactions, despite a lack of evidence to support their use. We sought to determine the association of steroid administration with improved clinical outcomes. Methods Adult allergy-related encounters to 2 urban EDs during a 5-year period were identified and classified as "anaphylaxis" or "allergic reaction." Regional and provincial databases identified subsequent ED visits or deaths within a 7-day period. The primary outcome was allergy-related ED revisits in the steroid- and nonsteroid-exposed groups, adjusting for potential confounders with a propensity score analysis; secondary outcomes included the number of clinically important biphasic reactions and deaths. Results Two thousand seven hundred one encounters (473 anaphylactic) were included; 48% were treated with steroids. Allergy-related ED revisits occurred in 5.8% and 6.7% of patients treated with and without steroids, respectively (adjusted odds ratio [OR] 0.91; 95% confidence interval [CI] 0.64 to 1.28), with a number needed to treat (NNT) to benefit of 176 (95% CI NNT to benefit 39 to ∞ to NNT to harm 65). The adjusted OR in the anaphylaxis subgroup was 1.12 (95% CI 0.41 to 3.27). In the allergic reaction group, the adjusted OR was 0.91 (95% CI 0.63 to 1.31), with an NNT to benefit of 173 (95% CI NNT to benefit 38 to ∞ to NNT to harm 58). In the steroid and nonsteroid groups, there were 4 and 1 clinically important biphasic reactions, respectively. There were no deaths. Conclusion Among ED patients with allergic reactions or anaphylaxis, corticosteroid use was not associated with decreased relapses to additional care within 7 days.

Survival varies among those resuscitated from out-of-hospital cardiac arrest (OHCA). Evidence-based performance measures have been used to describe hospital quality of care in conditions such as acute coronary syndrome and major trauma. It remains unclear if adherence to performance measures is associated with better outcome in patients hospitalized after OHCA.To assess whether a composite performance score based on evidence-based guidelines for care of patients resuscitated from OHCA was independently associated with clinical outcomes.Included were 3252 patients with OHCA who received care at 111 U.S. and Canadian hospitals participating in the Resuscitation Outcomes Consortium (ROC-PRIMED) study between June 2007 and October 2009. We calculated composite performance scores for all patients, aggregated these at the hospital level, then associated them with patient mortality and favorable neurological status at discharge.Composite performance scores varied widely (median [IQR] scores from lowest to highest hospital quartiles, 21% [20%, 25%] vs. 59% [55%, 64%]. Adjusted survival to discharge increased with each quartile of performance score (from lowest to highest: 16.2%, 20.8%, 28.5%, 34.8%, P0.01), with similar findings for adjusted rates of good neurologic status. Hospital score was significantly associated with outcome after risk adjustment for established baseline factors (highest vs. lowest adherence quartile: adjusted OR of survival 1.64; 95% CI 1.13, 2.38).Greater survival and favorable neurologic status at discharge were associated with greater adherence to recommended hospital based post-resuscitative care guidelines. Consideration should be given to measuring, reporting and improving hospital adherence to guideline-based performance measures, which could improve outcomes following OHCA.

OBJECTIVES: Diabetes is increasing in prevalence across Canada. In the continuously evolving primary care landscape, practitioners from varied training paths are claiming rights to care for patients, including those with diabetes. Little is known about patient exposure to complementary and alternative medicine (CAM) providers, or about such providers' use of guideline-based monitoring and treatment recommendations. The purpose of this study was to examine compliance with 4 recommendations (influenza vaccination, eye examination, glycated hemoglobin measurement and foot exam) by patients with diabetes who use CAM providers compared to those who exclusively use primary care physicians. METHODS: We analyzed data on 7209 patients with diabetes using the Canadian Community Health Survey. Patients with exposure to CAM providers were compared with individuals who were exposed to a family physician only. Multivariate logistic regression was conducted adjusted for age, sex, duration of diabetes, insulin/oral antihyperglycemic agent use and education. RESULTS: Approximately 4% of persons had been exposed to CAM providers in the preceding year. The odds ratio for receiving influenza vaccination among those exposed to a CAM provider was 0.94 (95% CI 0.74–1.17). The odds ratios for eye examinations in the preceding 24 months, and for foot examinations and glycated hemoglobin tests in the preceding 12 months were 1.02 (95% CI 0.69–1.48), 1.18 (0.83–1.67) and 1.09 (95% CI 0.71–1.66), respectively. CONCLUSION: Our results did not show statistical significance in any of the 4 outcomes analyzed. This study supports others suggesting that persons using CAM providers do so to complement traditional medical care, rather than as an alternative to such care.

Study objective Fentanyl overdoses are increasing and few data guide emergency department (ED) management. We evaluate the safety of an ED protocol for patients with presumed fentanyl overdose. Methods At an urban ED, we used administrative data and explicit chart review to identify and describe consecutive patients with uncomplicated presumed fentanyl overdose (no concurrent acute medical issues) from September to December 2016. We linked regional ED and provincial vital statistics databases to ascertain admissions, revisits, and mortality. Primary outcome was a composite of admission and death within 24 hours. Other outcomes included treatment with additional ED naloxone, development of a new medical issue while in the ED, and length of stay. A prespecified subgroup analysis assessed low-risk patients with normal triage vital signs. Results There were 1,009 uncomplicated presumed fentanyl overdose, mainly by injection. Median age was 34 years, 85% were men, and 82% received out-of-hospital naloxone. One patient was hospitalized and one discharged patient died within 24 hours (combined outcome 0.2%; 95% confidence interval [CI] 0.04% to 0.8%). Sixteen patients received additional ED naloxone (1.6%; 95% CI 1.0% to 2.6%), none developed a new medical issue (0%; 95% CI 0% to 0.5%), and median length of stay was 173 minutes (interquartile range 101 to 267). For 752 low-risk patients, no patients were admitted or developed a new issue, and one died postdischarge; 3 (0.4%; 95% CI 0.01% to 1.3%) received ED naloxone. Conclusion In our cohort of ED patients with uncomplicated presumed fentanyl overdose—typically after injection—deterioration, admission, mortality, and postdischarge complications appear low; the majority can be discharged after brief observation. Patients with normal triage vital signs are unlikely to require ED naloxone.

Study objective The Universal Termination of Resuscitation Rule (TOR Rule) was developed to identify out-of-hospital cardiac arrests eligible for field termination of resuscitation, avoiding futile transportation to the hospital. The validity of the rule in emergency medical services (EMS) systems that do not routinely transport out-of-hospital cardiac arrest patients to the hospital is unknown. We seek to validate the TOR Rule in British Columbia. Methods This study included consecutive, nontraumatic, adult, out-of-hospital cardiac arrests treated by EMS in British Columbia from April 2011 to September 2015. We excluded patients with active do-not-resuscitate orders and those with missing data. Following consensus guidelines, we examined the validity of the TOR Rule after 6 minutes of resuscitation (to approximate three 2-minute cycles of resuscitation). To ascertain rule performance at the different time junctures, we recalculated TOR Rule classification accuracy at subsequent 1-minute resuscitation increments. Results Of 6,994 consecutive, adult, EMS-treated, out-of-hospital cardiac arrests, overall survival was 15%. At 6 minutes of resuscitation, rule performance was sensitivity 0.72, specificity 0.91, positive predictive value 0.98, and negative predictive value 0.36. The TOR Rule recommended care termination for 4,367 patients (62%); of these, 92 survived to hospital discharge (false-positive rate 2.1%; 95% confidence interval 1.7% to 2.5%); however, this proportion steadily decreased with later application. The TOR Rule recommended continuation of resuscitation in 2,627 patients (38%); of these, 1,674 died (false-negative rate 64%; 95% confidence interval 62% to 66%). Compared with 6-minute application, test characteristics at 30 minutes demonstrated nearly perfect positive predictive value (1.0) and specificity (1.0) but a lower sensitivity (0.46) and negative predictive value (0.25). Conclusion In this cohort of adult out-of-hospital cardiac arrest patients, the TOR Rule applied at 6 minutes falsely recommended care termination for 2.1% of patients; however, this decreased with later application. Systems using the TOR Rule to cease resuscitation in the field should consider rule application at points later than 6 minutes.