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BACKGROUND: The NSW Clinical Excellence commission introduced the 'Between the Flags' programme, in response to the death of a young patient, as a system-wide approach for early detection and management of the deteriorating patient in all NSW hospitals. The impact of BTF implementation on the 35 larger hospitals with intensive care units (ICU) has not been reported previously. AIM: To assess the impact of 'Between the Flags' (BTF), a two-tier rapid response system across 35 hospitals with an ICU in NSW, on the incidence of in-hospital cardiac arrests and the incidence and outcome of patients admitted to an ICU following cardiac arrest and rapid response team activation. METHODS: This is a prospective observational study of the BTF registry (August 2010 to June 2016) and the Australian and New Zealand Intensive Care Society Adult Patient Database (January 2008 to December 2016) in 35 New South Wales public hospitals with an ICU. The primary outcome studied was the proportion of in-hospital cardiac arrests. Secondary outcomes included changes in the severity of illness and outcomes of cardiac arrest admissions to the ICU and changes in the volume of rapid response calls. RESULTS: The cardiac arrest rate per 1000 hospital admissions declined from 0.91 in the implementation period to 0.70. Propensity score analysis showed significant declines in ICU and hospital mortality and length of stay for cardiac arrest patients admitted to the ICU (all P < 0.001). CONCLUSIONS: The BTF programme was associated with a significant reduction in cardiac arrests in hospitals and ICU admissions secondary to cardiac arrests in 35 NSW hospitals with an ICU.

BACKGROUND: The surviving sepsis campaign recommends consideration for extracorporeal membrane oxygenation (ECMO) in refractory septic shock. We aimed to define the benefit threshold of ECMO in pediatric septic shock. METHODS: Retrospective binational multicenter cohort study of all ICUs contributing to the Australian and New Zealand Paediatric Intensive Care Registry. We included patients < 16 years admitted to ICU with sepsis and septic shock between 2002 and 2016. Sepsis-specific risk-adjusted models to establish ECMO benefit thresholds with mortality as the primary outcome were performed. Models were based on clinical variables available early after admission to ICU. Multivariate analyses were performed to identify predictors of survival in children treated with ECMO. RESULTS: Five thousand sixty-two children with sepsis and septic shock met eligibility criteria, of which 80 (1.6%) were treated with veno-arterial ECMO. A model based on 12 clinical variables predicted mortality with an AUROC of 0.879 (95% CI 0.864-0.895). The benefit threshold was calculated as 47.1% predicted risk of mortality. The observed mortality for children treated with ECMO below the threshold was 41.8% (23 deaths), compared to a predicted mortality of 30.0% as per the baseline model (16.5 deaths; standardized mortality rate 1.40, 95% CI 0.89-2.09). Among patients above the benefit threshold, the observed mortality was 52.0% (13 deaths) compared to 68.2% as per the baseline model (16.5 deaths; standardized mortality rate 0.61, 95% CI 0.39-0.92). Multivariable analyses identified lower lactate, the absence of cardiac arrest prior to ECMO, and the central cannulation (OR 0.31, 95% CI 0.10-0.98, p = 0.046) as significant predictors of survival for those treated with VA-ECMO. CONCLUSIONS: This binational study demonstrates that a rapidly available sepsis mortality prediction model can define thresholds for survival benefit in children with septic shock considered for ECMO. Survival on ECMO wa

Background Outcomes for pediatric cardiac surgery are commonly reported from international databases compiled from voluntary data submissions. Surgical outcomes for all children in a country or region are less commonly reported. We aimed to describe the bi-national population-based outcome for children undergoing cardiac surgery in Australia and New Zealand and determine whether the Risk Adjustment for Congenital Heart Surgery ( RACHS ) classification could be used to create a model that accurately predicts in-hospital mortality in this population. Methods and Results The study was conducted in all children's hospitals performing cardiac surgery in Australia and New Zealand between January 2007 and December 2015. The performance of the original RACHS -1 model was assessed and compared with an alternative RACHS - ANZ (Australia and New Zealand) model, developed balancing discrimination with parsimonious variable selection. A total of 14 324 hospital admissions were analyzed. The overall hospital mortality was 2.3%, ranging from 0.5% for RACHS category 1 procedures, to 17.0% for RACHS category 5 or 6 procedures. The original RACHS -1 model was poorly calibrated with death overpredicted (1161 deaths predicted, 289 deaths observed). The RACHS - ANZ model had better performance in this population with excellent discrimination (Az- ROC of 0.830) and acceptable Hosmer and Lemeshow goodness-of-fit ( P=0.216). Conclusions The original RACHS -1 model overpredicts mortality in children undergoing heart surgery in the current era. The RACHS - ANZ model requires only 3 risk variables in addition to the RACHS procedure category, can be applied to a wider range of patients than RACHS -1, and is suitable to use to monitor regional pediatric cardiac surgery outcomes.

Background: Heart disease significantly increases the risk of further cardiac events including out-of-hospital cardiac arrest (OHCA). Given the majority of OHCAs occur in the home, family members of those with heart disease should be trained in cardiopulmonary resuscitation (CPR). Aim: To describe CPR training rates in households with heart disease, and examine if training increases knowledge, confidence and willingness to perform CPR in this population. Methods: A cross-sectional, telephone survey was conducted with adults residing in Victoria, Australia. Findings: Of 404 respondents, 78 (19.3%) reported the presence of heart disease in their household. Prevalence of CPR training was the same among households with (67.9%) and without (67.8%) heart disease, with the majority (51.5%) receiving training more than five years ago. There were no significant differences in barriers to training- the most prevalent barrier was lack of awareness to seek training. Among households with heart disease, physical ability was the most common concern relating to the provision of CPR, while households without heart disease described decreased confidence. Those with heart disease in their household who were CPR trained, had higher self-ratings of CPR knowledge and confidence, and were more willing to perform CPR (all p < 0.05). Conclusions: A large proportion of Victorians with heart disease in their household did not have recent CPR training. CPR training should be targeted to high-risk households containing a member with heart disease, as knowledge and confidence in skills are increased. Cardiac health professionals are well placed to provide CPR training information during patient contacts.

PURPOSE: The Sepsis-3 consensus task force defined sepsis as life-threatening organ dysfunction caused by dysregulated host response to infection. However, the clinical criteria for this definition were neither designed for nor validated in children. We validated the performance of SIRS, age-adapted SOFA, quick SOFA and PELOD-2 scores as predictors of outcome in children. METHODS: We performed a multicentre binational cohort study of patients < 18 years admitted with infection to ICUs in Australia and New Zealand. The primary outcome was ICU mortality. SIRS, age-adapted SOFA, quick SOFA and PELOD-2 scores were compared using crude and adjusted area under the receiver operating characteristic curve (AUROC) analysis. RESULTS: Of 2594 paediatric ICU admissions due to infection, 151 (5.8%) children died, and 949/2594 (36.6%) patients died or experienced an ICU length of stay ≥ 3 days. A ≥ 2-point increase in the individual score was associated with a crude mortality increase from 3.1 to 6.8% for SIRS, from 1.9 to 7.6% for age-adapted SOFA, from 1.7 to 7.3% for PELOD-2, and from 3.9 to 8.1% for qSOFA (p < 0.001). The discrimination of outcomes was significantly higher for SOFA (adjusted AUROC 0.829; 0.791-0.868) and PELOD-2 (0.816; 0.777-0.854) than for qSOFA (0.739; 0.695-0.784) and SIRS (0.710; 0.664-0.756). CONCLUSIONS: SIRS criteria lack specificity to identify children with infection at substantially higher risk of mortality. We demonstrate that adapting Sepsis-3 to age-specific criteria performs better than Sepsis-2-based criteria. Our findings support the translation of Sepsis-3 into paediatric-specific sepsis definitions and highlight the importance of robust paediatric organ dysfunction characterization.

Background and Purpose- The Australian Stroke Foundation ran annual paid advertising between 2004 and 2014, using the FAST (Face, Arm, Speech, Time) campaign from 2006 and adding the message to call emergency medical services in 2007. In this study, we examined temporal trends in emergency medical services use and referrals from general practitioners in the Australian state of Victoria to evaluate the impact of these campaigns. Methods- Using data from 33 public emergency departments, contributing to the Victorian Emergency Minimum Dataset, we examined trends in emergency department presentations for 118?000 adults with an emergency diagnosis of stroke or transient ischemic attack between 2003 and 2015. Annual trends were examined using logistic regression using a precampaign period (January 2003 to August 2004) as reference and adjusting for demographic variables. Results- Compared with the precampaign period, significant increases in emergency medical services use were seen annually between 2008 and 2015 (all P<0.001, eg, 2015; adjusted odds ratio, 1.16; 95% CI, 1.10-1.23). In contrast, a decrease was seen in patients presenting via general practitioners across all campaign years (all P<0.001, eg, 2015; adjusted odds ratio, 0.48; 95% CI, 0.44-0.53). Conclusions- Since the Stroke Foundation campaigns began, a greater proportion of stroke and transient ischemic attack patients are presenting to hospital by emergency medical services and appear to be bypassing their general practitioners.

© 2018 Elsevier B.V. Introduction: Understanding regional variation in bystander cardiopulmonary resuscitation (CPR) is important to improving out-of-hospital cardiac arrest (OHCA) survival. In this study we aimed to identify barriers to providing bystander CPR in regions with low rates of bystander CPR and where OHCA was recognised in the emergency call. Methods: We retrospectively reviewed emergency calls for adults in regions of low bystander CPR in the Australian state of Victoria. Included calls were those where OHCA was identified during the call but no bystander CPR was given. A thematic content analysis was independently conducted by two investigators. Results: Saturation of themes was reached after listening to 139 calls. Calls progressed to the point of compression instructions before EMS arrival in only 26 (18.7%) of cases. Three types of barriers were identified: procedural barriers (time lost due to language barriers and communication issues; telephone problems), CPR knowledge (skill deficits; perceived benefit) and personal factors (physical frailty or disability; patient position; emotional factors). Conclusion: A range of factors are associated with barriers to delivering bystander CPR even in the presence of dispatcher instructions – some of which are modifiable. To overcome these barriers in high-risk regions, targeted public education needs to provide information about what occurs in an emergency call, how to recognise an OHCA and to improve CPR knowledge and skills.

Introduction: Since 2004, the Stroke Foundation have run annual public awareness campaigns in Australia −using the FAST (Face, Arm, Speech Time) message since 2006. The FAST campaigns have increased awareness of stroke symptoms and calls to ambulance for stroke. In this study we examined the impact of the campaigns on the way stroke and TIA patients present to Victorian public emergency departments (EDs). Methods: Using the Victorian Emergency Minimum Dataset (VEMD) provided by the Department of Health and Human Services, we examined trends in presentations for patients with an emergency diagnosis of stroke or TIA admitted between 2003 and 2014. Annual trends were examined using logistic regression adjusting for age, sex, metropolitan hospital and English as preferred language (adjusted odd ratios, AOR). Results: Of the 13,496,434 VEMD admissions, almost 0.9% received an ED diagnosis of stroke (n = 71,791) or TIA (n = 46,291). Compared to 2003, significant changes were seen in referral patterns and in the transport used in the years the FAST message featured: a decrease in patients presenting via local doctors (p < 0.001, in 2014 AOR = 0.51); an increase in patients self-referring (p < 0.001, in 2014 AOR = 1.62); and, an increase in ambulance use (p < 0.001, in 2014 AOR = 1.12). Similar trends were seen in stroke and TIA patients. In 2014, 80% of stroke patients presented to a stroke thrombolysis centre (77% in self-transported and 84% in ambulance-transported). Conclusion: Since the FAST campaigns began, a greater proportion of stroke and TIA patients are presenting to hospital via ambulance and are bypassing their local doctors.

Background This study aimed to understand factors associated with paramedics’ decision to attempt resuscitation in traumatic out-of-hospital cardiac arrest (OHCA) and to characterise resuscitation attempts =10 min in patients who die at the scene. Methods The Victorian Ambulance Cardiac Arrest Registry (VACAR) was used to identify all cases of traumatic OHCA between July 2008 and June 2014. We excluded cases <16 years of age or with a mechanism of hanging or drowning. Results Of the 2334 cases of traumatic OHCA, resuscitation was attempted in 28% of cases and this rate remained steady over time (p = 0.10). Multivariable logistic regression revealed that the arresting rhythm [shockable (adjusted odds ratio (AOR) = 18.52, 95% confidence interval (CI):6.68–51.36) or pulseless electrical activity (AOR = 12.58, 95%CI:9.06–17.45) relative to asystole] and mechanism of injury [motorcycle collision (AOR = 2.49, 95%CI:1.60–3.86), fall (AOR = 1.91, 95%CI:1.17–3.11) and shooting/stabbing (AOR = 2.25, 95%CI:1.17–4.31) relative to a motor vehicle collision] were positively associated with attempted resuscitation. Arrests occurring in rural regions had a significantly lower odds of attempted resuscitation relative to those in urban regions (AOR = 0.64, 95%CI:0.46–0.90). Resuscitation attempts =10 min represented 34% of cases in which resuscitation was attempted but the patient died at the scene. When these resuscitation attempts were selectively excluded from the overall EMS treated population, survival to hospital discharge non-significantly increased from 3.8% to 5.0% (p = 0.314). Conclusion Survival in our study was consistent with existing literature, however the large proportion of cases with resuscitation attempts =10 min may under-represent survival in those patients that receive full resuscitation attempts.

Background: Residential aged care facilities are common locations for out-of-hospital cardiac arrests to occur, yet survival to hospital discharge is poor. Aim: This study aims to examine preferences and perceived outcomes of cardiopulmonary resuscitation among Australians receiving aged care. Methods: A brief survey was provided to 187 residential aged care facilities and 34 home care providers throughout Australia for completion by aged care residents. Respondents were asked to answer three questions about understanding and desire for cardiopulmonary resuscitation on a five-point scale (from strongly agreed to strongly disagreed). Findings: A total of 1985 residents in 163 residential aged care facilities across Australia, and 277 older Australians receiving care in the home from 24 providers responded. The majority of respondents were female (67.4%), and respondents in residential aged care facilities were significantly older (82.6%. > . 75. years) than those receiving care in the home (70.4%. > . 75. years) (p. < . 0.001). Among 2262 respondents over 80% expressed a good understanding of cardiopulmonary resuscitation and its implications. Over half of respondents desired cardiopulmonary resuscitation if they were to experience an out-of-hospital cardiac arrest, and the desire for cardiopulmonary resuscitation was strongly associated and correlated (Pearson's R test = 0.759) with a view that they would likely fully recover. Conclusion: These findings highlight the need for older people to be better informed about cardiopulmonary resuscitation, including a clear understanding of what is involved in cardiopulmonary resuscitation and a realistic perception of outcomes.

Background: Given low survival rates in cases of traumatic out-of-hospital cardiac arrest (OHCA), there is a need to identify factors associated with outcomes. We aimed to investigate Utstein factors associated with achieving return of spontaneous circulation (ROSC) and survival to hospital in traumatic OHCA. Methods: The Victorian Ambulance Cardiac Arrest Registry (VACAR) was used to identify cases of traumatic OHCA that received attempted resuscitation and occurred between July 2008 and June 2014. We excluded cases aged < 16 years or with a mechanism of hanging or drowning. Results: Of the 660 traumatic OHCA patients who received attempted resuscitation, ROSC was achieved in 159 patients (24%) and 95 patients (14%) survived to hospital (ROSC on hospital handover). Factors that were positively associated with achieving ROSC in multivariable logistic regression models were age =65 years (adjusted OR (AOR)=1.56, 95% CI: 1.01 to 2.43) and arresting rhythm (shockable (AOR=3.65, 95% CI: 1.64 to 8.11) and pulseless electrical activity (AOR=2.15, 95% CI: 1.36 to 3.39) relative to asystole). Similarly, factors positively associated with survival to hospital were arresting rhythm (shockable (AOR=3.92, 95% CI: 1.64 to 9.41) relative to asystole), and the mechanism of injury (falls (AOR=2.16, 95% CI: 1.03 to 4.54) relative to motor vehicle collisions), while trauma type (penetrating (AOR=0.27, 95% CI: 0.08 to 0.91) relative to blunt trauma) and event region (rural (AOR=0.39, 95% CI: 0.19 to 0.80) relative to urban) were negatively associated with survival to hospital. Conclusions: Few patient and arrest characteristics were associated with outcomes in traumatic OHCA. These findings suggest there is a need to incorporate additional information into cardiac arrest registries to assist prognostication and the development of novel interventions in these trauma patients.

© 2017 The Authors. Background-Bystander cardiopulmonary resuscitation (CPR) more than doubles the chance of surviving an out-of-hospital cardiac arrest. Recent data have shown considerable regional variation in bystander CPR rates across the Australian state of Victoria. This study aims to determine whether there is associated regional variation in rates of CPR training and willingness to perform CPR in these communities. Methods and Results-We categorized each Victorian po stcode as either a low or high bystander CPR region using data on adult, bystander-witnessed, out-of-hospital cardiac arrests of presumed cardiac etiology (n=7175) from the Victorian Ambulance Cardiac Arrest Registry. We then surveyed adult Victorians (n=404) and compared CPR training data of the respondents from low and high bystander CPR regions. Of the 404 adults surveyed, 223 (55%) resided in regions with low bystander CPR. Compared with respondents from high bystander CPR regions, respondents residing in regions with low bystander CPR had lower rates of CPR training (62% versus 75%, P=0.009) and lower self-ratings for their overall knowledge of CPR (76% versus 84%, P=0.04). There were no differences between the regions in their reasons for not having undergone CPR training or in their willingness to perform CPR. Rates of survival for bystander-witnessed, out-of-hospital cardiac arrests were significantly lower in low bystander CPR regions (15.7% versus 17.0%, P < 0.001). Conclusions-This study found lower rates of CPR training and lower survival in regions with lower rates of bystander CPR in Victoria, Australia. Targeting these regions with CPR training programs may improve bystander CPR rates and out-of-hospital cardiac arrest outcomes.

BACKGROUND: Emergency medical services (EMS) transport to hospital is recommended in acute coronary syndrome (ACS) guidelines, but only half of patients with ACS currently use EMS. The recent Australian Warning Signs campaign conducted by the Heart Foundation addressed some of the known barriers against using EMS. Our aim was to examine the influence of awareness of the campaign on these barriers in patients with ACS. METHODS: Interviews were conducted with patients admitted to an Australian tertiary hospital between July 2013 and April 2014 with a diagnosis of ACS. Patient selection criteria included: aged 35-75 years, competent to provide consent, English speaking, not in residential care and medically stable. Multivariable logistic regression was used to examine factors associated with EMS use. RESULTS: Only 54% of the 199 patients with ACS interviewed used EMS for transport to hospital. Overall 64% of patients recalled seeing the campaign advertising, but this was not associated with increased EMS use (52.0%vs56.9%, p=0.49) or in the barriers against using EMS. A large proportion of patients (43%) using other transport thought it would be faster. Factors associated with EMS use for ACS were: age >65 years, ST-elevation myocardial infarction, a sudden onset of pain and experiencing vomiting. CONCLUSION: In medically stable patients with ACS, awareness of the Australian Warning Signs campaign was not associated with increased use of EMS or a change in the barriers for EMS use. Future education strategies could emphasise the clinical role that EMS provide in ACS.

© 2017 Australasian College for Emergency Medicine & Australasian Society for Emergency Medicine.Objective: We have previously established that paramedic exposure to out-of-hospital cardiac arrest (OHCA) is relatively rare, therefore clinical exposure cannot be relied on to maintain resuscitation competency. We aimed to identify the current practices within emergency medical services (EMS) for developing and maintaining paramedic resuscitation competency. Methods: We developed and conducted an online cross-sectional survey of Australian and New Zealand EMS in 2015. The survey was piloted by one EMS and targeted at education managers. Results: A total of nine of the 10 EMS responded to the survey. All EMS reported that they provide resuscitation training to paramedics at the commencement of their employment (median 16h, interquartile range [IQR]: 7-80). With the exception of one EMS that did not provide any refresher training, a median of 4h (IQR: 1-7) resuscitation training was provided to paramedics annually. All EMS used cardiac arrest simulations and skill stations to train paramedics. Paramedic exposure to OHCA was not taken into account to determine their training needs. Resuscitation competency was tested by EMS: annually (3/9), biennially (4/9) or not at all (2/9). Two EMS used CPR-feedback devices in clinical practice and only one EMS regularly performed formal debriefing after OHCA cases. Barriers to resuscitation competency included: difficulty removing paramedics from clinical duties for training and a lack of paramedic exposure to OHCA. Conclusion: All of the surveyed EMS provided initial resuscitation training to paramedics, but competency testing and refresher training practices varied between services. A lack of individual exposure to cardiac arrest and training time were identified as barriers to resuscitation competency.

© 2017 Australasian College for Emergency Medicine & Australasian Society for Emergency Medicine.Objectives: To provide contemporary Australian data on the public's training in cardiopulmonary resuscitation (CPR) and awareness of hands-only CPR. Methods: A cross-sectional telephone survey in April 2016 of adult residents of the Australian state of Victoria was conducted. Primary outcomes were rates of CPR training and awareness of hands-only CPR. Results: Of the 404 adults surveyed (mean age 55 ± 17 years, 59% female, 73% metropolitan residents), 274 (68%) had undergone CPR training. Only 50% (n = 201) had heard of hands-only CPR, with most citing first-aid courses (41%) and media (36%) as sources of information. Of those who had undergone training, the majority had received training more than 5 years previously (52%) and only 28% had received training or refreshed training in the past 12 months. Most received training in a formal first-aid class (43%), and received training as a requirement for work (67%). The most common reasons for not having training were: they had never thought about it (59%), did not have time (25%) and did not know where to learn (15%). Compared to standard CPR, a greater proportion of respondents were willing to provide hands-only CPR for strangers (67% vs 86%, P < 0.001). Conclusion: From an Australian perspective, there is still room for improvement in CPR training rates and awareness of hands-only CPR. Further promotion of hands-only CPR and self-instruction (e.g. DVD kits or online) may see further improvements in CPR training and bystander CPR rates.

BACKGROUND: Large populations are exposed to smoke from bushfires and planned burns. Studies investigating the association between bushfire smoke and health have typically used hospital or ambulance data and been done retrospectively on large populations. The present study is designed to prospectively assess the association between individual level health outcomes and exposure to smoke from planned burns. METHODS/DESIGN: A prospective cohort study will be conducted during a planned burn season in three locations in Victoria (Australia) involving 50 adult participants who undergo three rounds of cardiorespiratory medical tests, including measurements for lung inflammation, endothelial function, heart rate variability and markers of inflammation. In addition daily symptoms and twice daily lung function are recorded. Outdoor particulate air pollution is continuously measured during the study period in these locations. The data will be analysed using mixed effect models adjusting for confounders. DISCUSSION: Planned burns depend on weather conditions and dryness of 'fuels' (i.e. forest). It is potentially possible that no favourable conditions occur during the study period. To reduce the risk of this occurring, three separate locations have been identified as having a high likelihood of planned burn smoke exposure during the study period, with the full study being rolled out in two of these three locations. A limitation of this study is exposure misclassification as outdoor measurements will be conducted as a measure for personal exposures. However this misclassification will be reduced as participants are only eligible if they live in close proximity to the monitors.

© 2017 American College of Emergency Physicians.Study objective: Paramedic experience with intubation may be an important factor in skill performance and patient outcomes. Our objective is to examine the association between previous intubation experience and successful intubation. In a subcohort of out-of-hospital cardiac arrest cases, we also measure the association between patient survival and previous paramedic intubation experience. Methods: We analyzed data from Ambulance Victoria electronic patient care records and the Victorian Ambulance Cardiac Arrest Registry for January 1, 2008, to September 26, 2014. For each patient case, we defined intubation experience as the number of intubations attempted by each paramedic in the previous 3 years. Using logistic regression, we estimated the association between intubation experience and (1) successful intubation and (2) first-pass success. In the out-of-hospital cardiac arrest cohort, we determined the association between previous intubation experience and patient survival. Results: During the 6.7-year study period, 769 paramedics attempted intubation in 14,857 patients. Paramedics typically performed 3 intubations per year (interquartile range 1 to 6). Most intubations were successful (95%), including 80% on the first attempt. Previous intubation experience was associated with intubation success (odds ratio 1.04; 95% confidence interval 1.03 to 1.05) and intubation first-pass success (odds ratio 1.02; 95% confidence interval 1.01 to 1.03). In the out-of-hospital cardiac arrest subcohort (n=9,751), paramedic intubation experience was not associated with patient survival. Conclusion: Paramedics in this Australian cohort performed few intubations. Previous experience was associated with successful intubation. Among out-of-hospital cardiac arrest patients for whom intubation was attempted, previous paramedic intubation experience was not associated with patient survival.

© 2016 by the American College of Cardiology Foundation and the American Heart Association, Inc. BACKGROUND—: Patients successfully resuscitated by paramedics from out-of-hospital cardiac arrest (OHCA) often suffer severe neurological injury. Laboratory and observational clinical reports have suggested that induction of therapeutic hypothermia during cardiopulmonary resuscitation (CPR) may improve neurological outcomes. One technique for induction of mild therapeutic hypothermia during CPR is a rapid infusion of large-volume cold crystalloid fluid. METHODS—: In this multi-centre, randomized, controlled trial we assigned adults with OHCA undergoing CPR to either a rapid intravenous infusion of up to two-litres cold saline or standard care. The primary outcome measure was survival at hospital discharge; secondary end-points included return of a spontaneous circulation (ROSC). The trial was closed early (at 48% recruitment target) due to changes in temperature management at major receiving hospitals. RESULTS—: A total of 1198 patients were assigned to either therapeutic hypothermia during CPR (618 patients) or standard pre-hospital care (580 patients). Patients allocated to therapeutic hypothermia received a mean (SD) of 1193 (647) mL cold saline. For patients with an initial shockable cardiac rhythm, there was a decrease in the rate of ROSC in patients who received cold saline compared with standard care (41.2% compared with 50.6%, P=0.03). Overall 10.2% of patients allocated to therapeutic hypothermia during CPR were alive at hospital discharge compared with 11.4% who received standard care (P=0.71). CONCLUSIONS—: In adults with OHCA, induction of mild therapeutic hypothermia using a rapid infusion of large-volume, intravenous cold saline during CPR may decrease the rate of ROSC in patients with an initial shockable rhythm and produced no trend towards improved outcomes at hospital discharge. CLINICAL TRIAL REGISTRATION—: www.Clinicaltrials.gov. Identifier: NCT011733

BACKGROUND: Although out-of-hospital cardiac arrest (OHCA) is a major public health problem, individual paramedics are rarely exposed to these cases. In this study, we examined whether previous paramedic exposure to OHCA resuscitation is associated with patient survival. METHODS AND RESULTS: For the period 2003 to 2012, we linked data from the Victorian Ambulance Cardiac Arrest Registry to Ambulance Victoria's employment data set. We defined exposure as the number of times a paramedic attended an OHCA where resuscitation was attempted in the 3 years preceding each case. Using a multivariable model adjusting for known predictors of survival, we measured the association between paramedic OHCA exposure and patient survival to hospital discharge. During the study period, there were 4151 paramedics employed and 48?291 OHCAs (44% with resuscitation attempted). The median exposure of all paramedics was 2 (interquartile range 1-3) OHCAs/year. Eleven percent of paramedics were not exposed to any OHCA cases. Increased paramedic exposure was associated with reduced odds of attempted resuscitation (P<0.001). In the 3 years preceding each OHCA where resuscitation was attempted, the median exposure of the treating paramedics was 11 (interquartile range 6-17) OHCAs. Compared with patients treated by paramedics with a median of =6 exposures during the previous 3 years (7% survival), the odds of survival were higher for patients treated by paramedics with >6 to 11 (12%, adjusted odds ratio 1.26, 95% confidence interval 1.04-1.54), >11 to 17 (14%, adjusted odds ratio 1.29, 95% confidence interval 1.04-1.59), and >17 exposures (17%, adjusted odds ratio 1.50, 95% confidence interval 1.22-1.86). Paramedic years of experience were not associated with survival. CONCLUSIONS: Patient survival after OHCA significantly increases with the number of OHCAs that paramedics have previously treated.

© Author(s) 2016. Background: Rates of out-of-hospital cardiac arrest (OHCA) and bystander cardiopulmonary resuscitation (CPR) have been shown to vary considerably in Victoria. We examined the extent to which this variation could be explained by the sociodemographic and population health characteristics of the region. Methods: Using the Victorian Ambulance Cardiac Arrest Registry, we extracted OHCA cases occurring between 2011 and 2013. We restricted the calculation of bystander CPR rates to those arrests that were witnessed by a bystander. To estimate the level of variation between Victorian local government areas (LGAs), we used a two-stage modelling approach using random-effects modelling. Results: Between 2011 and 2013, there were 15 830 adult OHCA in Victoria. Incidence rates varied across the state between 41.9 to 104.0 cases/100 000 population. The proportion of the population over 65, socioeconomic status, smoking prevalence and education level were significant predictors of incidence in the multivariable model, explaining 93.9% of the variation in incidence among LGAs. Estimates of bystander CPR rates for bystander witnessed arrests varied from 62.7% to 73.2%. Only population density was a significant predictor of rates in a multivariable model, explaining 73% of the variation in the odds of receiving bystander CPR among LGAs. Conclusions: Our results show that the regional characteristics which underlie the variation seen in rates of bystander CPR may be region specific and may require study in smaller areas. However, characteristics associated with high incidence and low bystander CPR rates can be identified and will help to target regions and inform local interventions to increase bystander CPR rates.

Background and objective: Paramedic exposure to out-of-hospital cardiac arrest (OHCA) may be an important factor in skill maintenance and quality of care. We aimed to describe the annual exposure rates of paramedics in the state of Victoria, Australia. Methodology: We linked data from the Victorian Ambulance Cardiac Arrest Registry (VACAR) and Ambulance Victoria's employment dataset for 2003-2012. Paramedics were 'exposed' to an OHCA if they attended a case where resuscitation was attempted. Individual rates were calculated for average annual exposure (number of OHCA exposures for each paramedic/years employed in study period) and the average number of days between exposures (total paramedic-days in study/total number of exposures in study). Results: Over 10-years, there were 49,116 OHCAs and 5673 paramedics employed. Resuscitation was attempted in 44% of OHCAs. The typical 'exposure' of paramedics was 1.4 (IQR = 0.0-3.0) OHCAs per year. Mean annual OHCA exposure declined from 2.8 in 2003 to 2.1 in 2012 (p= 0.007). Exposure was significantly less in those: employed part-time (p< 0.001); in rural areas (p< 0.001); and with lower qualifications (p< 0.001). Annual exposure to paediatric and traumatic OHCAs was particularly low. It would take paramedics an average of 163 days to be exposed to an OHCA and up to 12.5 years for paediatric OHCAs, which occur relatively rarely. Conclusions: Exposure of individual paramedics to resuscitation is low and has decreased over time. This highlights the importance of supplementing paramedic exposure with other methods, such as simulation, to maintain resuscitation skills particularly in those with low exposure and for rare case types.

Aim: This study aims to describe and compare traumatic and medical out-of-hospital cardiac arrest (OHCA) occurring in Perth, Western Australia, between 1997 and 2014. Methods: The St John Ambulance Western Australia (SJA-WA) OHCA Database was used to identify all adult (≥16 years) cases. We calculated annual crude and age-sex standardised incidence rates (ASIRs) for traumatic and medical OHCA and investigated trends over time. Results: Over the study period, SJA-WA attended 1,354 traumatic OHCA and 16,076 medical OHCA cases. The mean annual crude incidence rate of traumatic OHCA in adults attended by SJA-WA was 6.0 per 100,000 (73.9 per 100,000 for medical cases), with the majority resulting from motor vehicle collisions (56.7%). We noted no change to either incidence or mechanism of injury over the study period (p > 0.05). Compared to medical OHCA, traumatic OHCA cases were less likely to receive bystander cardiopulmonary resuscitation (CPR) (20.4% vs. 24.5%, p = 0.001) or have resuscitation commenced by paramedics (38.9% vs. 44.8%, p < 0.001). However, rates of bystander CPR and resuscitation commenced by paramedics increased significantly over time in traumatic OHCA (p < 0.001). In cases where resuscitation was commenced by paramedics there was no difference in the proportion who died at the scene (37.2% traumatic vs. 34.3% medical, p = 0.17), however, fewer traumatic OHCAs survived to hospital discharge (1.7% vs. 8.7%, p < 0.001). Conclusions: Despite temporal increases in rates of bystander CPR and paramedic resuscitation, traumatic OHCA survival remains poor with only nine patients surviving from traumatic OHCA over the 18-year period.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) remains a major public health issue and research has shown that large regional variation in outcomes exists. Of the interventions associated with survival, the provision of bystander CPR is one of the most important modifiable factors. The aim of this study is to identify census areas with high incidence of OHCA and low rates of bystander CPR in Victoria, Australia. METHODS: We conducted an observational study using prospectively collected population-based OHCA data from the state of Victoria in Australia. Using ArcGIS (ArcMap 10.0), we linked the location of the arrest using the dispatch coordinates (longitude and latitude) to Victorian Local Government Areas (LGAs). We used Bayesian hierarchical models with random effects on each LGA to provide shrunken estimates of the rates of bystander CPR and the incidence rates. RESULTS: Over the study period there were 31,019 adult OHCA attended, of which 21,436 (69.1%) cases were of presumed cardiac etiology. Significant variation in the incidence of OHCA among LGAs was observed. There was a 3 fold difference in the incidence rate between the lowest and highest LGAs, ranging from 38.5 to 115.1 cases per 100,000 person-years. The overall rate of bystander CPR for bystander witnessed OHCAs was 62.4%, with the rate increasing from 56.4% in 2008-2010 to 68.6% in 2010-2013. There was a 25.1% absolute difference in bystander CPR rates between the highest and lowest LGAs. CONCLUSION: Significant regional variation in OHCA incidence and bystander CPR rates exists throughout Victoria. Regions with high incidence and low bystander CPR participation can be identified and would make suitable targets for interventions to improve CPR participation rates.

© 2015 American Heart Association, Inc. Background and Purpose - The National Stroke Foundation of Australia has run 12 public awareness campaigns since 2004. Campaign exposure and funding has varied annually and regionally during this time. The aim of this study was to measure the effect of campaigns on calls to ambulance for stroke across Australia in exposed regions (paid or pro bono advertising). Methods - All ambulance services in Australia provided monthly ambulance dispatch data between January 2003 and June 2014. We performed multivariable regression to measure the effect of campaign exposure on the volume of stroke-related emergency calls, after controlling for confounders. Results - The final model indicated that 11 of the 12 National Stroke Foundation campaigns were associated with increases in the volume of stroke-related calls (varying between 1% and 9.9%) in regions with exposure to advertising. This increase lasted ˜3 months, with an additional 10.2% relative increase in the volume of the calls in regions with paid advertising. We found no significant additional effect of the campaigns on stroke calls where ambulance services are publicly funded. Conclusions - The National Stroke Foundation stroke awareness campaigns are associated with increases to calls to ambulance for stroke in regions receiving advertising and promotion. Research is now required to examine whether this increased use in ambulance is for appropriate emergencies.

OBJECTIVES: To describe the temporal trends in rates of PICU admissions and mortality for out-of-hospital cardiac arrests and in-hospital cardiac arrests admitted to PICU over the last decade. DESIGN: Multicenter, retrospective analysis of prospectively collected binational data of the Australian and New Zealand Paediatric Intensive Care Registry. All nine specialist PICUs in Australia and New Zealand were included. PATIENTS: All children admitted between 2003 and 2012 to PICU who were less than 16 years old at the time of admission. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were a total of 71,425 PICU admissions between 2003 and 2012. Overall, cardiac arrest accounted for 1.86% of all admissions (1,329 cases), including 677 cases of in-hospital cardiac arrest (51.0%) and 652 cases of out-of-hospital cardiac arrest (49.0%). Over the last decade, there has been a 29.6% increase in the odds of PICU survival for all pediatric admissions (odds ratio, 1.30; 95% CI, 1.09-1.54). By contrast, there was no significant improvement in the risk-adjusted odds of survival for out-of-hospital cardiac arrest admissions (odds ratio, 1.03; 95% CI, 0.50-2.10; p = 0.94) or in-hospital cardiac arrest admissions (odds ratio, 1.03; 95% CI, 0.54-1.98; p = 0.92). CONCLUSIONS: Despite improvements in overall outcomes in children admitted to Australian and New Zealand PICUs, survival of children admitted with out-of-hospital cardiac arrest or in-hospital cardiac arrest did not change significantly over the past decade.

OBJECTIVES: To develop methods for distinguishing patients with in-hospital cardiac arrest (IHCA) from patients with out-of-hospital cardiac arrest (OHCA) in routinely collected intensive care unit registry data, and to explore the utility of the methods for describing trends in adult ICU cardiac arrest (CA) admissions and outcomes. DESIGN AND SETTING: A retrospective observational analysis of all ICU admissions entered in the Australian and New Zealand Intensive Care Society adult patient database between 2000 and 2011. Trends in admission and survival rates to hospital discharge over time were examined using eight different methods of classifying patients with IHCA and OHCA. RESULTS: There were 1 001 754 admissions to the ICUs between 2000 and 2011. Of these, postarrest admissions comprised 23 857 (2.4%), and increased annually by an average of 135 admissions (95% CI, 120-150 admissions). The annual volume of patients with IHCA as a fraction of total admissions declined by 0.4 patients/1000 admissions (95% CI, 0.3-0.5 patients/1000 admissions). In contrast, for patients with OHCA, each year was associated with an additional 0.2 patients/1000 admissions (95% CI, 0.1-0.4 patients/1000 admissions). This increase occurred in tertiary ICUs and declined in non-tertiary ICUs. Survival to hospital discharge for both groups improved, increasing annually by 1.2% (95% CI, 0.8%-1.6%) for patients with IHCA, and by 1.1% (95% CI, 0.7%-1.4%) for patients with OHCA. CONCLUSIONS: Use of routinely collected registry data uncovered important trends in adult ICU admission and survival rates for patients with IHCA and OHCA. The improved survival rates and increased number of admissions to tertiary centres requires further study to understand mechanisms and related factors.

Aim: This study investigated temporal trends in the incidence of out-of-hospital cardiac arrests (OHCA) in metropolitan Perth (Western Australia) between 1997 and 2010. Methods: We calculated crude and age-and-sex-standardised incidence rates (ASIRs) using the 2011 Australian population as the standard population. Incidence rates are reported per 100,000 population, and for eight age categories (0-14, 15-34, 35-64, 65-69, 70-74, 75-79, 80-84, =85). Temporal trends were analysed with linear regression. Results: Over the 14-years, 12,421 OHCAs of presumed cardiac aetiology were attended by St John Ambulance Western Australia paramedics. The overall ASIR per 100,000 population decreased significantly over this time (75.7-70.6, p < 0.001), but predominantly between 1997 and 2002 (75.7-65.9) and in those aged =65 years (410.2-336.7, p < 0.001). This trend was observed for both males and females and across all five-year age-groups between 65 and 84 years, but not in those =85 years - whom by 2010 represented 30% of the older adult (65+ years) OHCAs attended, up from 16% in 1997 (p < 0.001). Conclusions: Over the study period, a decline in the ASIR for OHCAs of presumed cardiac aetiology in Perth was observed. This is largely attributed to a decreasing incidence in the population aged 65-84 years between 1997 and 2002, and is likely the result of improvements in cardiovascular risk profiles that have previously been reported among Western Australian adults. Future studies of the impact of the ageing population are required.

Background: Out-of-hospital cardiac arrest (OHCA) remains a major public health issue. Several studies have found that an increased level of ambient particulate matter (PM) smaller than 2.5 microns (PM2.5) is associated with an increased risk of OHCA. We investigated the relationship between air pollution levels and the incidence of OHCA in Perth, Western Australia.Methods: We linked St John Ambulance OHCA data of presumed cardiac aetiology with Perth air pollution data from seven monitors which recorded hourly levels of PM smaller than 2.5 and 10 microns (PM2.5/PM10), carbon monoxide (CO), sulfur dioxide (SO2), nitrogen dioxide (NO2) and ozone (O3). We used a case-crossover design to estimate the strength of association between ambient air pollution levels and risk of OHCA.Methods: We linked St John Ambulance OHCA data of presumed cardiac aetiology with Perth air pollution data from seven monitors which recorded hourly levels of PM smaller than 2.5 and 10 microns (PM2.5/PM10), carbon monoxide (CO), sulfur dioxide (SO2), nitrogen dioxide (NO2) and ozone (O3). We used a case-crossover design to estimate the strength of association between ambient air pollution levels and risk of OHCA.Conclusions: Elevated ambient PM2.5 and CO are associated with an increased risk of OHCA.