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Aim: We sought to describe the impact of the COVID-19 pandemic on the care provided by Canadian emergency medical system (EMS) clinicians to patients suffering out of hospital cardiac arrest (OHCA), and whether any observed changes persisted beyond the initial phase of the pandemic., Methods: We analysed cases of adult, non-traumatic, OHCA from the Canadian Resuscitation Outcome Consortium (CanROC) registry who were treated between January 27th, 2018, and December 31st, 2021. We used adjusted regression models and interrupted time series analysis to examine the impact of the COVID-19 pandemic (January 27th, 2020 - December 31st, 2021)on the care provided to patients with OHCA by EMS clinicians., Results: There were 12,947 cases of OHCA recorded in the CanROC registry in the pre-COVID-19 period and 17,488 during the COVID-19 period. We observed a reduction in the cumulative number of defibrillations provided by EMS (aRR 0.91, 95% CI 0.89 - 0.93, p < 0.01), a reduction in the odds of attempts at intubation (aOR 0.33, 95% CI 0.31 - 0.34, p < 0.01), higher rates of supraglottic airway use (aOR 1.23, 95% CI 1.16-1.30, p < 0.01), a reduction in vascular access (aOR for intravenous access 0.84, 95% CI 0.79 - 0.89, p < 0.01; aOR for intraosseous access 0.89, 95% CI 0.82 - 0.96, p < 0.01), a reduction in the odds of epinephrine administration (aOR 0.89, 95% CI 0.85 - 0.94, p < 0.01), and higher odds of resuscitation termination on scene (aOR 1.38, 95% CI 1.31 - 1.46, p < 0.01). Delays to initiation of chest compressions (2 min. vs. 3 min., p < 0.01), intubation (16 min. vs. 19 min., p = 0.01), and epinephrine administration (11 min. vs. 13 min., p < 0.01) were observed, whilst supraglottic airways were inserted earlier (11 min. vs. 10 min., p < 0.01)., Conclusion: The COVID-19 pandemic was associated with substantial changes in EMS management of OHCA. EMS leaders should consider these findings to optimise current OHCA management and prepare for future pandemics., Competing Interests: Declaration of competing interest 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., (Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.)

Clinical prediction models are created to help clinicians with medical decision making, aid in risk stratification, and improve diagnosis and/or prognosis. With growing availability of both prehospital and in-hospital observational registries and electronic health records, there is an opportunity to develop, validate, and incorporate prediction models into clinical practice. However, many prediction models have high risk of bias due to poor methodology. Given that there are no methodological standards aimed at developing prediction models specifically in the prehospital setting, the objective of this paper is to describe the appropriate methodology for the derivation and validation of clinical prediction models in this setting. What follows can also be applied to the emergency medicine (EM) setting. There are eight steps that should be followed when developing and internally validating a prediction model: (1) problem definition, (2) coding of predictors, (3) addressing missing data, (4) ensuring adequate sample size, (5) variable selection, (6) evaluating model performance, (7) internal validation, and (8) model presentation. Subsequent steps include external validation, assessment of impact, and cost-effectiveness. By following these steps, researchers can develop a prediction model with the methodological rigor and quality required for prehospital and EM research., (© 2023 The Authors. Academic Emergency Medicine published by Wiley Periodicals LLC on behalf of Society for Academic Emergency Medicine.)

Objectives: The objectives of this project were to collect and analyze clinical governance documents related to family-centred care and cardiac arrest care in Canadian EMS organizations; and to improve the family-centredness of out-of-hospital cardiac arrest care through experience-based co-design., Methods: We conducted qualitative document analysis of Canadian EMS clinical governance documents related to family-centred and cardiac arrest care, combining elements of content and thematic analysis methods. We then used experience-based co-design to develop a family-centred out-of-hospital cardiac arrest care policy and procedure template., Results: Thirty-five Canadian EMS organizations responded to our requests, representing service area coverage for 80% of the Canadian population. Twenty documents were obtained for review and six overarching themes were identified: addressing family in event of in-home death, importance of family, family member escort, provider discretion and family presence discouraged. Informed by our qualitative analysis we then co-designed a policy and procedure template was created that prioritizes patient care while promotes family-centredness., Conclusions: There were few directives to support family-centred care by Canadian EMS organizations. A family-centred out-of-hospital cardiac arrest care policy and procedure template was developed using experience-based co-design to assist EMS organizations improve the family-centredness of out-of-hospital cardiac arrest care., (© 2023. The Author(s).)

Background: The COVID-19 pandemic has resulted in unique pressures on the emergency services system. This study describes changes in the presentation, presenting severity and disposition of patients accessing emergency services in Calgary, Alberta, during the first wave of the pandemic., Methods: In this descriptive study, we constructed a population cohort of all patients who accessed emergency services by calling emergency medical services (EMS) (ambulance service that provides prehospital treatment and transport to medical facilities) or presenting directly to an emergency department (4 adult and 1 pediatric) or 2 urgent care centres in Calgary during the exposure period (December 2019 to June 2020) compared to 2 historical control periods (December to June, 2017-2018 and 2018-2019) combined. Outcomes included frequency of presentation, system flow indicators, patient severity, disposition and mortality. We used a locally estimated scatterplot smoothing function to visualize trends. We described differences at the maximum and minimum point of the exposure period compared to the control period., Results: A total of 1 127 014 patient encounters were included. Compared to the control period, there was a 61% increase in the number of patients accessing EMS and a 35% decrease in the number of those presenting to an adult emergency department or urgent care centre in the COVID-19 period. The proportion of EMS calls for the highest-priority patients remained stable, whereas the proportion of patients presenting to an emergency department or urgent care centre with the highest-priority triage classification increased transiently by 0.9 percentage points (increase of 89%). A smaller proportion of patients were transported by EMS (decrease of 21%), and a greater proportion of emergency department patients were admitted to hospital (increase of 25%). After the first case was reported, the mortality rate among EMS patients increased by 265% (3.4 v. 12.4 per 1000 patient encounters)., Interpretation: The first wave of the COVID-19 pandemic was associated with substantial changes in the frequency and disposition of patients accessing emergency services. Further research examining the mechanism of these observations is important for mitigating the impact of future pandemics., Competing Interests: Competing interests: None declared., (© 2021 CMA Joule Inc. or its licensors.)

Managing out-of-hospital cardiac arrest requires paramedics to perform multiple aerosol generating medical procedures in an uncontrolled setting. This increases the risk of cross infection during the COVID-19 pandemic. Modifications to conventional protocols are required to balance paramedic safety with optimal patient care and potential stresses on the capacity of critical care resources. Despite this, little specific advice has been published to guide paramedic practice. In this commentary, we highlight challenges and controversies regarding critical decision making around initiation of resuscitation, airway management, mechanical chest compression, and termination of resuscitation. We also discuss suggested triggers for implementation and revocation of recommended protocol changes and present an accompanying paramedic-specific algorithm., Competing Interests: None of the authors has any conflict of interest to declare., (© 2020 The Author(s).)

Objective: We evaluated the effect of chest compression fraction (CCF) on survival to hospital discharge and return of spontaneous circulation (ROSC) in out-of-hospital cardiac arrest (OHCA) patients with non-shockable rhythms., Methods: This is a retrospective analysis (completed in 2016) of a prospective cohort study which included OHCA patients from ten U.S. and Canadian sites (Resuscitation Outcomes Consortium Epistry and PRIMED study (2007-2011)). We included all OHCA victims of presumed cardiac aetiology, not witnessed by emergency medical services (EMS), without automated external defibrillator shock prior to EMS arrival, receiving > 1 min of CPR with CPR process measures available, and initial non-shockable rhythm. We measured CCF using the first 5 min of electronic CPR records., Results: Demographics of 12,928 adult patients were: mean age 68; male 59.9%; public location 8.5%; bystander witnessed 35.2%; bystander CPR 39.3%; median interval from 911 to defibrillator turned on 10 min:04 s; initial rhythm asystole 64.8%, PEA 26.0%, other non-shockable 9.2%; compression rate 80-120/min (69.1%); median CCF 74%; ROSC 25.6%; survival to hospital discharge 2.4%. Adjusted odds ratio (OR); 95% confidence intervals (95%CI) of survival for each CCF category were: 0-40% (2.00; 1.16, 3.32); 41-60% (0.83; 0.54, 1.24); 61-80% (1.02; 0.77, 1.35); and 81-100% (reference group). Adjusted (OR; 95%CI) of ROSC for each CCF category were: 0-40% (1.02; 0.79, 1.30); 41-60% (0.83; 0.72, 0.95); 61-80% (0.85; 0.77, 0.94); and 81-100% (reference group)., Conclusions: We observed an incremental benefit from higher CCF on the incidence of ROSC, but not survival, among non-shockable OHCA patients with CCF higher than 40%., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Numerous studies have shown significant neighbourhood level variation in out-of-hospital cardiac arrest (OHCA) incidence rates, however, few have provided an explanation for these disparities beyond traditional socioeconomic measures., Methods: This was a retrospective study using data from a large population-based OHCA database (Rescu Epistry). We included adults ≥20 years who experienced a non-traumatic OHCA and were treated by emergency medical services within Toronto, Canada between 2006-2012. The residential address of each OHCA patient was spatially mapped to 1 of 517 Toronto census tracts (CTs). Patient and CT level characteristics were included in multivariate regression models to assess their association with OHCA incidence per 100,000 persons., Results: Of the 7775 OHCAs occurring in the study area, 7692 (98.9%) were eligible for inclusion. OHCA incidence rates varied widely across CT quintiles, with rates differing almost 4-fold (109.1 per 100,000 yearly Q5 most deprived vs. 30.0 per 100,000 yearly Q1 least deprived p < 0.0001). Numerous areas of high incidence adjacent to areas of low incidence were observed. After adjustment, all variables except the Activity Friendly Index showed highly significant linear trends, with increasing age, sex ratio, diabetes prevalence, material deprivation and ethnic concentration being independently associated with increasing OHCA incidence. In contrast, we did not observe a linear relationship between high OHCA incidence and median household income., Conclusions: This study showed almost 4-fold OHCA incidence variability across a large metropolitan area. This variability was partially correlated with population and health data, but not typical socioeconomic predictors, such as median household income., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Introduction: The International Liaison Committee on Resuscitation prioritized the need to update the review on the use of targeted temperature management (TTM) in paediatric post cardiac arrest care. In this meta-analysis, the effectiveness of TTM at 32-36 °C was compared with no target or a different target for comatose children who achieve a return of sustained circulation after cardiac arrest., Methods: Electronic databases were searched from inception to December 13, 2018. Randomized controlled trials and non-randomized studies with a comparator group that evaluated TTM in children were included. Pairs of independent reviewers extracted the demographic and outcome data, appraised risk of bias, and assessed GRADE certainty of effects. A random effects meta-analysis was undertaken where possible., Results: Twelve studies involving 2060 patients were included. Two randomized controlled trials provided the evidence that TTM at 32-34 °C compared with a target at 36-37.5 °C did not statistically improve long-term good neurobehavioural survival (risk ratio: 1.15; 95% CI: 0.69-1.93), long-term survival (RR: 1.14; 95% CI: 0.93-1.39), or short-term survival (risk ratio: 1.14; 95% CI: 0.96-1.36). TTM at 32-34 °C did not show statistically increased risks of infection, recurrent cardiac arrest, serious bleeding, or arrhythmias. A novel analysis suggests that another small RCT might provide enough evidence to show benefit for TTM in out-of-hospital cardiac arrest., Conclusion: There is currently inconclusive evidence to either support or refute the use of TTM at 32-34 °C for comatose children who achieve return of sustained circulation after cardiac arrest. Future trials should focus on children with out-of-hospital cardiac arrest., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: The Resuscitation Outcomes Consortium (ROC)epidemiological registry (Epistry) provides opportunities to assess trends in out-of-hospital cardiac arrest treatment and outcomes., Methods: Patient, event, system, treatment, and outcome data from adult (≥18 years) out-of-hospital cardiac arrest (OHCA) from 10 geographically diverse North American ROC sites over four 12-month epochs, from July 1, 2011 to June 30, 2015, were assessed. Descriptive statistics were used to characterize the sample and logistic regression assessed the association of study epoch and key covariates on survival., Results: Overall, 85,553 patients were assessed by Emergency Medical Services (EMS) and 45,516 (53.2%, site range 30.4%-69.9%) had resuscitation attempted by EMS. Patient and event characteristics were consistent except for increases in bystander CPR (41.3%-44.9%) and bystander AED application (3.9%-5.2%). EMS CPR depth and compression fraction increased while pre-shock pause interval decreased. Targeted temperature management was performed in 51.1% of admitted patients and early coronary angiography in 30.2%. Survival to hospital discharge improved (from 10.9% to 11.3% across epochs) with epoch significantly associated with survival (p < 0.001) showing an increasing trend in survival over time. (p = 0.02). Marked site variation in survival persisted within and across epochs (overall site range: 4.2%-19.8%). Patients with an initially shockable rhythm (VT/VF) had an overall survival of 32.2% (site range: 11.9%-47.1%) while survival in bystander witnessed VT/VF was 35.8% (site range: 12.9%-53.1%)., Conclusions: Survival from adult OHCA in multiple large geographically-separate sites improved over the study period. Marked site differences in survival persist and addressing this variation is essential to improve outcomes from OHCA across North America., (Copyright © 2018 Elsevier B.V. All rights reserved.)

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., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Survival following out-of-hospital cardiac arrest (OHCA) with shockable rhythms can be improved with early defibrillation. Although shockable OHCA accounts for only ≈25% of overall arrests, ≈60% of public OHCAs are shockable, offering the possibility of restoring thousands of individuals to full recovery with early defibrillation by bystanders. We sought to determine the association of bystander automated external defibrillator use with survival and functional outcomes in shockable observed public OHCA., Methods: From 2011 to 2015, the Resuscitation Outcomes Consortium prospectively collected detailed information on all cardiac arrests at 9 regional centers. The exposures were shock administration by a bystander-applied automated external defibrillator in comparison with initial defibrillation by emergency medical services. The primary outcome measure was discharge with normal or near-normal (favorable) functional status defined as a modified Rankin Score ≤2. Survival to hospital discharge was the secondary outcome measure., Results: Among 49 555 OHCAs, 4115 (8.3%) observed public OHCAs were analyzed, of which 2500 (60.8%) were shockable. A bystander shock was applied in 18.8% of the shockable arrests. Patients shocked by a bystander were significantly more likely to survive to discharge (66.5% versus 43.0%) and be discharged with favorable functional outcome (57.1% versus 32.7%) than patients initially shocked by emergency medical services. After adjusting for known predictors of outcome, the odds ratio associated with a bystander shock was 2.62 (95% confidence interval, 2.07-3.31) for survival to hospital discharge and 2.73 (95% confidence interval, 2.17-3.44) for discharge with favorable functional outcome. The benefit of bystander shock increased progressively as emergency medical services response time became longer., Conclusions: Bystander automated external defibrillator use before emergency medical services arrival in shockable observed public OHCA was associated with better survival and functional outcomes. Continued emphasis on public automated external defibrillator utilization programs may further improve outcomes of OHCA., (© 2018 American Heart Association, Inc.)

Background: Considerable effort has gone into improving outcomes from out-of-hospital cardiac arrest (OHCA). Studies suggest that survival is improving; however, prior studies had insufficient data to pursue the relationship between markers of guideline compliance and temporal trends. The objective of the study was to evaluate trends in OHCA survival over an 8-year period that included the implementation of the 2005 and 2010 international cardiopulmonary resuscitation (CPR) guidelines., Methods and Results: This was a population-based cohort study of all consecutive treated OHCA patients of presumed cardiac cause between 2006 and 2013 in the City of Toronto, Canada, and surrounding regions. Temporal changes were measured by χ 2 trend test. The association between year of the OHCA and survival was evaluated using logistic regression and joinpoint analysis. A total of 23 619 patients with OHCA met study inclusion criteria. During the study period, survival to hospital discharge doubled (4.8% in 2006 to 9.4% in 2013; P <0.0001), and survival with good neurological outcome increased (6.2% in 2010 to 8.5% in 2013; P =0.005). Improvements occurred in the rates of bystander CPR and automated external defibrillator application, high-quality CPR metrics, and in-hospital targeted temperature management. After adjusting for the Utstein variables, survival to hospital discharge (odds ratio, 1.12; 95% confidence interval, 1.09-1.15) and survival with good neurological outcome (odds ratio, 1.13; 95% confidence interval, 1.05-1.22) increased with each year of study., Conclusions: Survival after OHCA has improved over time. This trend was associated with improved rates of bystander CPR, automated external defibrillator use, high-quality CPR metrics, and in-hospital targeted temperature management. The results suggest that multiple factors, each improving over time, may have contributed to the observed increase in survival., (© 2018 American Heart Association, Inc.)

Importance: We examined whether resuscitation care and outcomes vary by the racial composition of the neighborhood where out-of-hospital cardiac arrests (OHCAs) occur., Objective: To evaluate the association between bystander treatments (cardiopulmonary resuscitation and automatic external defibrillation) and timing of emergency medical services personnel on OHCA outcomes according to the racial composition of the neighborhood where the OHCA event occurred., Design, Setting, and Participants: This retrospective observational cohort study examined patients with OHCA from January 1, 2008, to December 31, 2011, using data from the Resuscitation Outcomes Consortium. Neighborhoods where OHCA occurred were classified by census tract, based on percentage of black residents: less than 25%, 25% to 50%, 51% to 75%, or more than 75%. Multilevel mixed-effects logistic regression modeling examined the association between racial composition of neighborhoods and OHCA survival, adjusting for patient, neighborhood, and treatment characteristics., Main Outcomes and Measures: Survival to discharge, return of spontaneous circulation on emergency department arrival, and favorable neurologic status at discharge., Results: We examined 22 816 adult patients with nontraumatic OHCA at Resuscitation Outcomes Consortium sites in the United States. The median age of patients with OHCA was 64 years (interquartile range [IQR], 51-78). Compared with patients who experienced OHCA in neighborhoods with a lower proportion of black residents, those in neighborhoods with more than 75% black residents were slightly younger, were more frequently women, had lower rates of initial shockable rhythm, and less frequently experienced OHCA in a public location. The percentage of patients with OHCA receiving bystander cardiopulmonary resuscitation or a lay automatic external defibrillation was inversely associated with the percentage of black residents in neighborhoods. Compared with OHCA in predominantly white neighborhoods (<25% black), those with OHCA in mixed to majority black neighborhoods had lower adjusted survival rates to hospital discharge (25%-50% black: odds ratio, 0.76; 95% CI, 0.61-0.93; 51%-75% black: odds ratio, 0.67; 95% CI, 0.49-0.90; >75% black: odds ratio, 0.63; 95% CI, 0.50-0.79; P < .001). There was similar mortality risk for black and white patients with OHCA in each neighborhood racial quantile. When the primary model included geographic site, there was an attenuated nonsignificant association between racial composition in a neighborhood and survival., Conclusions and Relevance: Those with OHCA in predominantly black neighborhoods had the lowest rates of bystander cardiopulmonary resuscitation and automatic external defibrillation use and significantly lower likelihood for survival compared with predominantly white neighborhoods. Improving bystander treatments in these neighborhoods may improve cardiac arrest survival.

Background: Cities worldwide have underground or above-ground enclosed walkway systems for pedestrian travel, representing unique environments for studying out-of-hospital cardiac arrests (OHCAs). The characteristics and outcomes of OHCAs that occur in such systems are unknown., Objective: To determine whether OHCAs occurring in enclosed pedestrian walkway systems have differing demographics, prehospital intervention, and survival outcomes compared to the encompassing city, by examining the PATH walkway system in Toronto., Methods: We identified all atraumatic, public-location OHCAs in Toronto from April 2006 to March 2016. Exclusion criteria were obvious death, existing DNR, and EMS-witnessed OHCAs. OHCAs were classified into mutually exclusive location groups: Toronto, Downtown, and PATH-accessible. PATH-accessible OHCAs were those that occurred within the PATH system between the first basement and third floor. We analyzed demographic, prehospital intervention, and survival data using t-tests and chi-squared tests., Results: We identified 2172 OHCAs: 1752 Toronto, 371 Downtown, and 49 PATH-accessible. Compared to Toronto, a significantly higher proportion of PATH-accessible OHCAs was bystander-witnessed (62.6% vs 83.7%, p=0.003), had bystander CPR (56.6% vs 73.5%, p=0.019), bystander AED use (11.0% vs 42.6%, p<0.001), shockable initial rhythm (45.5% vs 72.9%, p<0.001), and overall survival (18.5% vs 33.3%, p=0.009). Similar significant differences were observed when compared to Downtown., Conclusions: This study suggests that OHCAs in enclosed pedestrian walkway systems are uniquely different from other public settings. Bystander resuscitation efforts are significantly more frequent and survival rates are significantly higher. Urban planners in similar infrastructure systems worldwide should consider these findings when determining AED placement and public engagement strategies., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Public access defibrillation programs can improve survival after out-of-hospital cardiac arrest, but automated external defibrillators (AEDs) are rarely available for bystander use at the scene. Drones are an emerging technology that can deliver an AED to the scene of an out-of-hospital cardiac arrest for bystander use. We hypothesize that a drone network designed with the aid of a mathematical model combining both optimization and queuing can reduce the time to AED arrival., Methods: We applied our model to 53 702 out-of-hospital cardiac arrests that occurred in the 8 regions of the Toronto Regional RescuNET between January 1, 2006, and December 31, 2014. Our primary analysis quantified the drone network size required to deliver an AED 1, 2, or 3 minutes faster than historical median 911 response times for each region independently. A secondary analysis quantified the reduction in drone resources required if RescuNET was treated as a large coordinated region., Results: The region-specific analysis determined that 81 bases and 100 drones would be required to deliver an AED ahead of median 911 response times by 3 minutes. In the most urban region, the 90th percentile of the AED arrival time was reduced by 6 minutes and 43 seconds relative to historical 911 response times in the region. In the most rural region, the 90th percentile was reduced by 10 minutes and 34 seconds. A single coordinated drone network across all regions required 39.5% fewer bases and 30.0% fewer drones to achieve similar AED delivery times., Conclusions: An optimized drone network designed with the aid of a novel mathematical model can substantially reduce the AED delivery time to an out-of-hospital cardiac arrest event., (© 2017 American Heart Association, Inc.)

Background: Previous work has demonstrated that when out-of-hospital cardiac arrest (OHCA) patients achieve return of spontaneous circulation (ROSC), but subsequently have another cardiac arrest prior to hospital arrival (rearrest), the probability of survival to hospital discharge is significantly decreased. Additionally, few modifiable factors for rearrest are known. We sought to examine the association between rearrest and compression-to-ventilation ratio during cardiopulmonary resuscitation (CPR) and to confirm the association between rearrest and outcomes., Hypothesis: Rearrest incidence would be similar between cases treated with 30:2 or continuous chest compression (CCC) CPR, but inversely related to survival and good neurological outcome., Methods: We conducted a secondary analysis of a large randomized-controlled trial of CCC versus 30:2 CPR for the treatment of OHCA between 2011 and 2015 among 8 sites of the Resuscitation OUTCOMES: Consortium (ROC). Patients were randomized through an emergency medical services (EMS) agency-level cluster randomization design to receive either 30:2 or CCC CPR. Case data were derived from prehospital patient care reports, digital defibrillator files, and hospital records. The primary analysis was an as-treated comparison of the proportion of patients with a rearrest for patients who received 30:2 versus those who received CCC. In addition, we assessed the association between rearrest and both survival to hospital discharge and favorable neurological outcome (Modified Rankin Score≤3) in patients with and without ROSC upon ED arrival using multivariable logistic regression adjusting for age, sex, initial rhythm and measures of CPR quality., Results: There were 14,109 analyzable cases that were determined to have definitively received either CCC or 30:2 CPR. Of these, 4713 had prehospital ROSC and 2040 (43.2%) had at least one rearrest. Incidence of rearrest was not significantly different between patients receiving CCC and 30:2 (44.1% vs 41.8%; adjusted OR: 1.01; 95% CI: 0.88, 1.16). Rearrest was significantly associated with lower survival (23.3% vs 36.9%; adjusted OR: 0.46; 95%CI: 0.36-0.51) and worse neurological outcome (19.4% vs 30.2%; adjusted OR: 0.46; 95%CI: 0.38, 0.55)., Conclusion: Rearrest occurrence was not significantly different between patients receiving CCC and 30:2, and was inversely associated with survival to hospital discharge and MRS., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Previous studies have demonstrated significant associations between cardiopulmonary resuscitation (CPR) quality metrics and survival to hospital discharge. No adequately powered study has explored the relationship between location of resuscitation (scene vs. transport) and CPR quality., Methods: We analyzed CPR quality data from treated adult OHCA occurring over a 40 month period beginning January 1, 2013 from the Rescu Epistry-cardiac arrest database. High quality CPR was defined as chest compression fraction (CCF) >0.7, compression rate >100/min and compression depth >5.0cm. Our primary objective was to compare the proportion of resuscitations for which all CPR quality benchmarks were met between scene and transport phases of resuscitation. Our secondary objectives were to compare the quality of CPR between the scene phase and transport phase of resuscitation., Results: The proportion of patients with high quality CPR was similar on scene compared to during transport (45.8% vs. 42.5%; ∆ 3.3 %; 95% CI: -1.4, 8.1). Regarding individual CPR metrics, median compression rate was higher on scene compared to transport (105.8 compressions per minute (cpm) vs. 102.0cpm; ∆ 3.8cpm; 95% CI: 2.5, 4.0), while median compression depth (5.56cm vs. 5.33cm; ∆ 0.23cm; 95% CI: 0.12, 0.26) and median CCF (0.95 vs. 0.87; ∆ 0.08; 95% CI: 0.07, 0.08) were higher during the transport phase., Conclusions: High quality CPR metrics were similar in both (scene and transport) locations of resuscitation. These results suggest that high quality, manual compressions can be performed by prehospital providers regardless of location., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Drug overdose causes approximately 183,000 deaths worldwide annually and 50,000 deaths in Canada and the United States combined. Drug-related deaths are concentrated among young people, leading to a substantial burden of disease and loss of potential life years. Understanding the epidemiology, patterns of care, and prognosis of drug-related prehospital emergencies may lead to improved outcomes., Methods: We conducted a retrospective cohort study of out-of-hospital cardiac arrests with drug-related and presumed cardiac causes between 2007 and 2013 using the Toronto Regional RescuNet Epistry database. The primary outcome was survival to hospital discharge. We computed standardized case fatality rates, and odds ratios of survival to hospital discharge for cardiac arrests with drug-related versus presumed cardiac causes, adjusting for confounders using logistic regression., Results: The analysis involved 21,497 cardiac arrests, including 378 (1.8%) drug-related and 21,119 (98.2%) presumed cardiac. Compared with the presumed cardiac group, drug-related arrest patients were younger and less likely to receive bystander resuscitation, have initial shockable cardiac rhythms, or be transported to hospital. There were no significant differences in emergency medical service response times, return of spontaneous circulation, or survival to discharge. Standardized case fatality rates confirmed that these effects were not due to age or sex differences. Adjusting for known predictors of survival, drug-related cardiac arrest was associated with increased odds of survival to hospital discharge (OR1.44, 95%CI 1.15-1.81)., Interpretation: In out-of-hospital cardiac arrest, patients with drug-related causes are less likely than those with presumed cardiac causes to receive bystander resuscitation or have an initial shockable rhythm, but are more likely to survive after accounting for predictors of survival. The demographics and outcomes among drug-related cardiac arrest patients offers unique opportunities for prehospital intervention.

Aims: Improvement in resuscitation efforts has translated to an increasing number of survivors after out-of-hospital cardiac arrest (OHCA). Our objectives were to assess the long-term outcomes and predictors of mortality for patients who survived OHCA., Methods: We conducted a population-based cohort study linking the Toronto RescuNET cardiac arrest database with administrative databases in Ontario, Canada. We included patients with non-traumatic OHCA from December 1, 2005 to December 31, 2014. The primary outcomes were mortality at 1 year and 3 years. Cox proportional hazard models were constructed to evaluate the predictors of mortality., Results: Among the 28,611 OHCA patients who received treatment at the scene of arrest, 1591 patients survived to hospital discharge. During hospitalization, 36% received coronary revascularizations and 27% received an implantable cardioverter defibrillator. At one year after discharge, 12.6% of patients had died and 37.3% were readmitted. At 3 years, mortality rate was 20% and all-cause readmission rate was 54.1%. Older age and a history of cancer were associated with higher risk of 3-year mortality. Shockable rhythm at presentation (hazard ratio [HR] 0.62, 95% CI 0.45-0.85), use of coronary revascularization (HR 0.37, 95% CI 0.28-0.51) or implantable cardioverter defibrillator (HR 0.28, 95% CI 0.20-0.41) was associated with substantially lower 3-year mortality. Prior cardiac conditions and other arrest characteristics were not associated with long-term mortality., Conclusions: Survivors of OHCA face significant morbidity and mortality after hospital discharge. Clinical trials are needed to evaluate the potential benefits of invasive cardiac procedures in OHCA survivors., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Cardiopulmonary resuscitation (CPR) process measures research and quality assurance has traditionally been limited to the first 5 minutes of resuscitation due to significant costs in time, resources, and personnel from manual data abstraction. CPR performance may change over time during prolonged resuscitations, which represents a significant knowledge gap. Moreover, currently available commercial software output of CPR process measures are difficult to analyze., Objective: The objective was to develop and validate a software program to help automate the abstraction and transfer of CPR process measures data from electronic defibrillators for complete episodes of cardiac arrest resuscitation., Methods: We developed a software program to facilitate and help automate CPR data abstraction and transfer from electronic defibrillators for entire resuscitation episodes. Using an intermediary Extensible Markup Language export file, the automated software transfers CPR process measures data (electrocardiogram [ECG] number, CPR start time, number of ventilations, number of chest compressions, compression rate per minute, compression depth per minute, compression fraction, and end-tidal CO 2 per minute). We performed an internal validation of the software program on 50 randomly selected cardiac arrest cases with resuscitation durations between 15 and 60 minutes. CPR process measures were manually abstracted and transferred independently by two trained data abstractors and by the automated software program, followed by manual interpretation of raw ECG tracings, treatment interventions, and patient events. Error rates and the time needed for data abstraction, transfer, and interpretation were measured for both manual and automated methods, compared to an additional independent reviewer., Results: A total of 9,826 data points were each abstracted by the two abstractors and by the software program. Manual data abstraction resulted in a total of six errors (0.06%) compared to zero errors by the software program. The mean ± SD time measured per case for manual data abstraction was 20.3 ± 2.7 minutes compared to 5.3 ± 1.4 minutes using the software program (p = 0.003)., Conclusions: We developed and validated an automated software program that efficiently abstracts and transfers CPR process measures data from electronic defibrillators for complete cardiac arrest episodes. This software will enable future cardiac arrest studies and quality assurance programs to evaluate the impact of CPR process measures during prolonged resuscitations., (© 2016 by the Society for Academic Emergency Medicine.)

Background: Traumatic arrests have historically had poor survival rates. Identifying salvageable patients and ideal management is challenging. We aimed to (1) describe the management and outcomes of prehospital traumatic arrests; (2) determine regional variation in survival; and (3) identify Advanced Life Support (ALS) procedures associated with survival., Methods: This was a secondary analysis of cases from the Resuscitation Outcomes Consortium Epistry-Trauma and Prospective Observational Prehospital and Hospital Registry for Trauma (PROPHET) registries. Patients were included if they had a blunt or penetrating injury and received cardiopulmonary resuscitation. Logistic regression analyses were used to determine the association between ALS procedures and survival., Results: We included 2,300 patients who were predominately young (Epistry mean [SD], 39 [20] years; PROPHET mean [SD], 40 [19] years), males (79%), injured by blunt trauma (Epistry, 68%; PROPHET, 67%), and treated by ALS paramedics (Epistry, 93%; PROPHET, 98%). A total of 145 patients (6.3%) survived to hospital discharge. More patients with blunt (Epistry, 8.3%; PROPHET, 6.5%) vs. penetrating injuries (Epistry, 4.6%; PROPHET, 2.7%) survived. Most survivors (81%) had vitals on emergency medical services arrival. Rates of survival varied significantly between the 12 study sites (p = 0.048) in the Epistry but not PROPHET (p = 0.14) registries.Patients in the PROPHET registry who received a supraglottic airway insertion or intubation experienced decreased odds of survival (adjusted OR, 0.27; 95% confidence interval, 0.08-0.93; and 0.37; 95% confidence interval, 0.17-0.78, respectively) compared to those receiving bag-mask ventilation. No other procedures were associated with survival., Conclusions: Survival from traumatic arrest may be higher than expected, particularly in blunt trauma and patients with vitals on emergency medical services arrival. Although limited by confounding and statistical power, no ALS procedures were associated with increased odds of survival., Level of Evidence: Prognostic study, level IV.

Background: To date, 72% of variability in survival following out-of-hospital cardiac arrest (OHCA) is explained by the Utstein variables. Whether neighborhood factors further influence a return of spontaneous circulation or survival after OHCA is poorly understood., Methods: We completed a retrospective cohort study of all paramedic-treated OHCA within the City of Toronto's 531 census tracts between 2006 and 2014. Neighborhood variables included the Ontario Marginalization Index - a measure of poverty, ethnicity and instability - crime rate and the density of family physicians. Hierarchical logistic regression analysis explored the association between a patient's census tract (neighborhood) characteristics and survival to hospital discharge and a prehospital return of spontaneous circulation (ROSC). Receiver operator characteristics curves measured how the Utstein variables and neighborhood factors discriminate OHCA outcomes., Results: There were 23,067 OHCA during the study period, with 10,097 cases excluded due to obvious death, 896 from an obvious etiology and 2589 cases for other reasons, leaving 9485 patients for analysis. Of the neighborhood variables, only census tracts with a moderate ethnic concentration had an increased likelihood of survival-to-hospital discharge. The Utstein variables accounted for 89.2% of survival and 39.8% of prehospital ROSC. Adding all neighborhood factors to the Utstein model increased discrimination for survival to discharge to 89.8% (p=0.005) and of a prehospital ROSC to 40.8% (p=0.006)., Conclusions: Residential neighborhood factors marginally improve discrimination for outcomes after an OHCA, beyond the Utstein variables. Further research should explore the influence of other currently unmeasured neighborhood factors on OHCA outcomes., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Objectives: Relatively little is known about the context and location of firearm injury events. Using a prospective cohort of trauma patients, we describe and compare severe firearm injury events to other violent and nonviolent injury mechanisms regarding incident location, proximity to home, time of day, spatial clustering, and outcomes., Methods: This was a secondary analysis of a prospective cohort of injured children and adults with hypotension or Glasgow Coma Scale score ≤ 8, injured by one of four primary injury mechanisms (firearm, stabbing, assault, and motor vehicle collision [MVC]) who were transported by emergency medical services to a Level I or II trauma center in 10 regions of the United States and Canada from January 1, 2010, through June 30, 2011. We used descriptive statistics and geospatial analyses to compare the injury groups, distance from home, outcomes, and spatial clustering., Results: There were 2,079 persons available for analysis, including 506 (24.3%) firearm injuries, 297 (14.3%) stabbings, 339 (16.3%) assaults, and 950 (45.7%) MVCs. Firearm injuries resulted in the highest proportion of serious injuries (66.3%), early critical resources (75.3%), and in-hospital mortality (53.5%). Injury events occurring within 1 mile of a patient's home included 53.9% of stabbings, 49.2% of firearm events, 41.3% of assaults, and 20.0% of MVCs; the non-MVC events frequently occurred at home. While there was geospatial clustering, 94.4% of firearm events occurred outside of geographic clusters., Conclusions: Severe firearm events tend to occur within a patient's own neighborhood, often at home, and generally outside of geospatial clusters. Public health efforts should focus on the home in all types of neighborhoods to reduce firearm violence., (© 2016 by the Society for Academic Emergency Medicine.)

Background: The increasing number of people living in high-rise buildings presents unique challenges to care and may cause delays for 911-initiated first responders (including paramedics and fire department personnel) responding to calls for out-of-hospital cardiac arrest. We examined the relation between floor of patient contact and survival after cardiac arrest in residential buildings., Methods: We conducted a retrospective observational study using data from the Toronto Regional RescuNet Epistry database for the period January 2007 to December 2012. We included all adult patients (≥ 18 yr) with out-of-hospital cardiac arrest of no obvious cause who were treated in private residences. We excluded cardiac arrests witnessed by 911-initiated first responders and those with an obvious cause. We used multivariable logistic regression to determine the effect on survival of the floor of patient contact, with adjustment for standard Utstein variables., Results: During the study period, 7842 cases of out-of-hospital cardiac arrest met the inclusion criteria, of which 5998 (76.5%) occurred below the third floor and 1844 (23.5%) occurred on the third floor or higher. Survival was greater on the lower floors (4.2% v. 2.6%, p = 0.002). Lower adjusted survival to hospital discharge was independently associated with higher floor of patient contact, older age, male sex and longer 911 response time. In an analysis by floor, survival was 0.9% above floor 16 (i.e., below the 1% threshold for futility), and there were no survivors above the 25th floor., Interpretation: In high-rise buildings, the survival rate after out-of-hospital cardiac arrest was lower for patients residing on higher floors. Interventions aimed at shortening response times to treatment of cardiac arrest in high-rise buildings may increase survival., (© 2016 Canadian Medical Association or its licensors.)

Lethal cardiac arrhythmias such as ventricular fibrillation and pulseless ventricular tachycardia (VF/pVT) complicate up to 6% of all out-of-hospital STEMIs. Typically, paramedics respond to this by applying defibrillation pads and delivering a shock as soon as possible. A recently introduced "pads-on" protocol directed paramedics to apply defibrillation pads to all STEMI patients (regardless of clinical stability) with the aim of decreasing time to first shock. In this article we present two cases of prehospital STEMI complicated by VF to illustrate times to first shock for the two different protocols. One case each of a STEMI complicated by VF before implementation of the pads-on protocol and after the implementation of the protocol is presented. An important difference in the time to first shock is noted between the two patients with STEMI complicated by VF. While it took 2 min 43 s for the pads-off patient to be defibrillated, only 27 s elapsed before the pads-on patient was defibrillated. These two cases demonstrate that the application of defibrillation pads immediately following the diagnosis of prehospital STEMI has the potential to decrease the time to shock in patients suffering VF/pVT.

Background: 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., Objectives: 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., Methods: 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., Results: 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%, P<0.01), 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)., Conclusions: 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., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background: Out-of-hospital cardiac arrest (OHCA) remains a leading cause of death and a 2010 meta-analysis concluded that outcomes have not improved over several decades. However, guidelines have changed to emphasize CPR quality, minimization of interruptions, and standardized post-resuscitation care. We sought to evaluate whether OHCA outcomes have improved over time among agencies participating in the Resuscitation Outcomes Consortium (ROC) cardiac arrest registry (Epistry) and randomized clinical trials (RCTs)., Methods: Observational cohort study of 47,148 EMS-treated OHCA cases in Epistry from 139 EMS agencies at 10 ROC sites that participated in at least one RCT between 1/1/2006 and 12/31/2010. We reviewed patient, scene, event characteristics, and outcomes of EMS-treated OHCA over time, including subgroups with initial rhythm of pulseless ventricular tachycardia or ventricular fibrillation (VT/VF)., Results: Mean response interval, median age and male proportion remained similar over time. Unadjusted survival to discharge increased between 2006 and 2010 for treated OHCA (from 8.2% to 10.4%), as well as for subgroups of VT/VF (21.4% to 29.3%) and bystander witnessed VT/VF (23.5% to 30.3%). Compared with 2006, adjusted survival to discharge was significantly higher in 2010 for treated cases (OR = 1.72; 95% CI 1.53, 1.94), VT/VF cases (OR = 1.69; 95% CI 1.45, 1.98) and bystander witnessed VT/VF cases (OR = 1.65; 95% CI 1.36, 2.00). Tests for trend in each subgroup were significant (p < 0.001)., Conclusions: ROC-wide survival increased significantly between 2006 and 2010. Additional research efforts are warranted to identify specific factors associated with this improvement., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background: Traditional variables used to explain survival following out-of-hospital cardiac arrest (OHCA) account for only 72% of survival, suggesting that other unknown factors may influence outcomes. Research on other diseases suggests that neighbourhood factors may partly determine health outcomes. Yet, this approach has rarely been used for OHCA. This work outlines a methodology to investigate multiple neighbourhood factors as determinants of OHCA outcomes., Methods: A retrospective, observational cohort study design will be used. All adult non-emergency medical service witnessed OHCAs of cardiac etiology within the city of Toronto between 2006 and 2010 will be included. Event details will be extracted from the Toronto site of the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest, an existing population-based dataset of consecutive OHCA patients. Geographic information systems technology will be used to assign patients to census tracts. Neighbourhood variables to be explored include the Ontario Marginalization Index (deprivation, dependency, ethnicity, and instability), crime rate, and density of family physicians. Hierarchical logistic regression analysis will be used to explore the association between neighbourhood characteristics and 1) survival-to-hospital discharge, 2) return-of-spontaneous circulation at hospital arrival, and 3) provision of bystander cardiopulmonary resuscitation (CPR). Receiver operating characteristics curves will evaluate each model's ability to discriminate between those with and without each outcome. Discussion This study will determine the role of neighbourhood characteristics in OHCA and their association with clinical outcomes. The results can be used as the basis to focus on specific neighbourhoods for facilitating educational interventions, CPR awareness programs, and higher utilization of automatic defibrillation devices.

Introduction: Drowning is a major public health concern, yet little is known about the characteristics of drowning patients. The objectives of this study were to describe the demographic and clinical characteristics of out-of-hospital cardiac arrest (OHCA) attributed to drowning in Ontario and to compare the characteristics of OHCA attributed to drowning to those of presumed cardiac etiology., Methods: A retrospective, observational study was carried out of consecutive OHCA patients of drowning etiology in Ontario between August 2006 and July 2011. Bivariate analysis was used to evaluate differences between drowning and presumed cardiac etiologies., Results: A total of 31,763 OHCA patients were identified, and 132 (0.42%) were attributed to drowning. Emergency medical services treated 98 patients, whereas the remaining 34 met the criteria for legislative death. Overall, 5.1% of drowning patients survived to hospital discharge. When compared to patients of presumed cardiac etiology, drowning patients were younger and their arrest was more likely to be unwitnessed, present with a nonshockable initial rhythm, occur in a public location, and receive bystander cardiopulmonary resuscitation (CPR). A nonsignificant trend was noted for drowning cases to more frequently have a public access AED applied. There were no significant differences in the gender ratio or paramedic response times. Drowning patients were more likely to be transported to hospital but had a trend to be less likely to arrive with a return of spontaneous circulation. They were also more likely to be admitted to hospital but had no difference in survival to hospital discharge., Conclusions: Significant differences exist between OHCA of drowning and presumed cardiac etiologies. Most drownings are unwitnessed, occur in public locations, and present with nonshockable initial rhythms, suggesting that treatment should focus on bystander CPR. Future initiatives should focus on strategies to improve supervision in targeted locations and greater emphasis on bystander-initiated CPR, both of which may reduce drowning mortality.

Background: The basic life support (BLS) termination of resuscitation (TOR) rule recommends transport and continued resuscitation when cardiac arrest is witnessed by EMT-Ds, or there is a return of spontaneous circulation, or a shock is given, and prior studies have suggested the transport rate should fall to 37%., Methods and Results: This real-time prospective multi-center implementation trial evaluated the BLS TOR rule for compliance, transport rate and provider and physician comfort. Both provider and physician noted their decision-making rationale and ranked their comfort on a 5-point Likert scale. Functional survival was measured at discharge. Of 2421 cardiac arrests, 953 patients were eligible for the rule, which was applied correctly for 755 patients (79%) of which 388 were terminated. 565 patients were transported resulting in a reduction of the transport rate from 100% (historical control) to 59% (p<0.001). The BLS TOR rule was not followed in 198 eligible patients (21%) and they were all transported despite meeting the criteria to terminate. Providers cited 241 reasons for non-compliance: family distress, short transport time interval, younger age and public venue. All 198 transported patients, non-compliant with the rule, died. Both providers and physicians were comfortable with using the rule to guide TOR (median [IQR] of 5 [4,5]; p<0.001)., Conclusions: This implementation trial confirmed the accuracy of the BLS TOR rule in identifying futile out-of-hospital cardiac arrest (OHCA) resuscitations, significantly reduced the transport rate of futile OHCA and most providers and physicians were comfortable following the rule's recommendations., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Objectives: Bystander resuscitation efforts, such as cardiopulmonary resuscitation (CPR) and use of an automatic external defibrillator (AED), save lives in cardiac arrest cases. School training in CPR and AED use may increase the currently low community rates of bystander resuscitation. The study objective was to determine the rates of CPR and AED training in Toronto secondary schools and to identify barriers to training and training techniques., Methods: This prospective study consisted of telephone interviews conducted with key school staff knowledgeable about CPR and AED teaching. An encrypted Web-based tool with prespecified variables and built-in logic was employed to standardize data collection., Results: Of 268 schools contacted, 93% were available for interview and 83% consented to participate. Students and staff were trained in CPR in 51% and 80% of schools, respectively. Private schools had the lowest training rate (39%). Six percent of schools provided AED training to students and 47% provided AED training to staff. Forty-eight percent of schools had at least one AED installed, but 25% were unaware if their AED was registered with emergency services dispatch. Cost (17%), perceived need (11%), and school population size (10%) were common barriers to student training. Frequently employed training techniques were interactive (32%), didactic instruction (30%) and printed material (16%)., Conclusions: CPR training rates for staff and students were moderate overall and lowest in private schools, whereas training rates in AED use were poor in all schools. Identified barriers to training include cost and student population size (perceived to be too small to be cost-effective or too large to be implemented). Future studies should assess the application of convenient and cost-effective teaching alternatives not presently in use.

Background: Preventable harm from medical care has been extensively documented in the inpatient setting. Emergency medical services (EMS) providers care for patients in dynamic and challenging environments; prehospital emergency care is a field that represents an area of high risk for errors and harm, but has received relatively little attention in the patient safety literature., Objective: To identify the threats to patient safety unique to the EMS environment and interventions that mitigate those threats, we completed a systematic review of the literature., Methods: We searched MEDLINE, EMBASE, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) for combinations of key EMS and patient safety terms composed by a pan-canadian expert panel using a year limit of 1999 to 2011. We excluded commentaries, opinions, letters, abstracts, and non-english publications. Two investigators performed an independent hierarchical screening of titles, abstracts, and full-text articles blinded to source. We used the kappa statistic to examine interrater agreement. Any differences were resolved by consensus., Results: We retrieved 5,959 titles, and 88 publications met the inclusion criteria and were categorized into seven themes: adverse events and medication errors (22 articles), clinical judgment (13), communication (6), ground vehicle safety (9), aircraft safety (6), interfacility transport (16), and intubation (16). Two articles were randomized controlled trials; the remainder were systematic reviews, prospective observational studies, retrospective database/chart reviews, qualitative interviews, or surveys. The kappa statistics for titles, abstracts, and full-text articles were 0.65, 0.79, and 0.87, respectively, for the first search and 0.60, 0.74, and 0.85 for the second., Conclusions: We found a paucity of scientific literature exploring patient safety in EMS. Research is needed to improve our understanding of problem magnitude and threats to patient safety and to guide interventions.