International initiation and termination of resuscitation practices: Protocol of a cross-sectional survey.

BACKGROUND: Substantial variation in survival following out-of-hospital cardiac arrest (OHCA) is described both internationally and nationally. The Utstein factors account for half of the variation, but the remaining is not fully understood. Local regulations or guidelines concerning the withholding and termination of resuscitation may influence the reporting of cardiac arrests when comparing outcomes between different Emergency Medical Service systems.
METHOD: We have developed an online cross-sectional mixed-methods explanatory design survey aimed at describing the international and national variations in the initiation, the termination of resuscitation, and the refraining from resuscitation of adult patients (>18 years of age) suffering from non-traumatic OHCA. The respondents will be national experts and the questionnaire will be distributed among members of European Prehospital Research Alliance, the International Liaison Committee of Resuscitation, the European Resuscitation Council, and the Resuscitation Academy. Each invited country will have to identify at least two national experts with special expertise in prehospital resuscitation practices. We exclude countries with less than two respondents.
RESULTS: The survey will provide both quantitative and qualitative data. Quantitative data will be presented as frequencies and proportions. Qualitative data will be analyzed using content analysis.
CONCLUSION: This survey could be of importance in understanding the multiple factors leading to the substantial variation in survival found following OHCA. Furthermore, the interpretation of future studies on OHCA from different settings may be improved to further increase survival following OHCA.

BACKGROUND

Out‐of‐hospital cardiac arrest (OHCA) is a leading cause of death in the world. , , , Substantial international differences in survival to hospital discharge have been reported , ; ranging from 0% to 18% in Europe, , 0.5% to 8.5% in Asia, 9% to 17% in Australia and New Zealand, and from 1.1% to 8.4% in North America. Regional differences of up to a fivefold increase in survival have also been reported in multiple settings and geographic locations. , , , ,

Neither the international nor the national variation is fully understood but may be attributed to multiple factors such as organization of the Emergency Medical Service (EMS) system, , the response time of the EMS, bystander cardiopulmonary resuscitation (CPR), , and the use of Automatic External Defibrillators. , , , However, Dyson et al. found that the Utstein core factors accounted for only 51% of the global variation in survival to hospital discharge. Supplemental factors accounting for the global variation in survival following OHCA may be variations in the population that are sought resuscitated in each emergency medical system. Transportation rates may vary and the number of patients with OHCA that have their treatment terminated prehospitally may influence the survival. If an EMS initiates resuscitation in all patients with cardiac arrest—even patients with obvious signs of death, different considerations of who to include in the calculations may skew the survival rate. Similarly, local regulations or guidelines concerning the withholding and termination of resuscitation may influence the survival rate when comparing outcomes between different EMS systems. ,

The European Resuscitation Council (ERC) stated in their 2021 guidelines that the EMS systems should define and implement criteria for the withholding and termination of CPR in OHCA, taking into consideration the specific local legal, organizational, and cultural context.

Validating Termination‐of‐Resuscitation guidelines locally could be challenging both ethically and epidemiologically. This would ultimately require a prospective study with a transportation rate of 100%, which would put an immense amount of pressure on the limited sources of the EMS systems.

In this survey, we want to describe the international and national variations in the initiation, the termination of resuscitation, and the refraining from resuscitation of adult patients (>18 years of age) suffering from non‐traumatic OHCA. Specifically, we want to describe differences in initiation‐, termination‐, and practices of refraining from resuscitation in OHCA and the guidance documents or legislation that govern these practices.

METHOD

Study design

We have developed an online cross‐sectional mixed‐methods explanatory design survey through feedback from members of the European Prehospital Research Alliance (EUPHOREA), a review of published literature, and following consensus among the authors. The survey is designed in accordance with the CROSS checklist and will be conducted from May 2022 until June 2022.

Population

Members of the EUPHOREA, the International Liaison Committee of Resuscitation (ILCOR), the ERC, and the Resuscitation Academy are invited to participate. In total, more than 35 countries will be invited. Each invited country will have to identify at least two national experts with special expertise in prehospital resuscitation practices. We exclude countries with less than two respondents.

Survey

We plan to perform a pilot test of the questionnaire in five countries with divergent EMS systems. This pilot study will enable us to improve the questionnaire. The questionnaire will be modulated following feedback received during the pilot test. If there are major changes, the questionnaire will be tested again in all settings. To maximize data quality, participants will be contacted in case of missing data or major discrepancies in the answers from the same country.

Data

The database will consist of both qualitative and quantitative data. REDCap, an online questionnaire tool, will be used to share the questionnaire with the participants and to record the data. The survey is conducted using an approved server provided by Odense Patient data Explorative Network, at Odense University Hospital and the University of Southern Denmark. Analyses will be conducted using STATA (StataCorp, 2021, Stata Statistical Software: Release 17, StataCorp LLC, College Station, TX) and NVivo (qualitative data analysis software; QSR International Pty Ltd., Version 12, 2018). The answers will be anonymized when eligible for analysis.

Analysis

Prior to the initiation of the study, the questionnaire will be tested among experts, and an agreement regarding the content of the questionnaire is made. If none or only one participant responds on behalf of a country or region, that particular country/region will be ineligible for analysis. Quantitative data will be presented as frequencies and proportions. Qualitative data will be analyzed using content analysis.

This study is registered with ClinicalTrials.gov (NCT05029180).

Perspective

This survey could be of importance in understanding the multiple factors leading to the substantial variation in survival found following OHCA. Understanding both international and regional differences in resuscitation practices and the outcome will help improve EMS system characteristics. , , Using these data and analyses, different countries, regions, and systems may be able to benchmark themselves. Furthermore, the interpretation of future studies on OHCA from different settings may be improved to further increase survival following OHCA.

Strengths and limitations

The objectiveness in the questions, a reflective stage, and the need for providing evidence when answering, decreases the possibility of perception bias and recall bias. We further consider that it will reduce the risk of any Hawthorne effect and availability bias. Since the questionnaire is only available in English and the provided evidence from respondents may be in their native language, there is a risk of language bias. As the number of respondents is limited, not all the regional differences may be described.

Ethics

The Danish Health and Medicines Authority has approved the study (Ref. No. 3‐3013‐3088/1). All regulations of data security will be complied with and are approved by the Region of Southern Denmark (Ref. No. 21/23002). Since this survey regards organizational differences, no formal contact with patients is established.

Publication

This study will be part of a PhD thesis “Termination of Resuscitation in a physician‐manned Emergency Medical System” and published in a peer‐reviewed journal with the PhD student as the first author and other authors included according to the Vancouver rules for authorship. The participants of the questionnaire are listed as collaborators in any publications related to this study.

FUNDING INFORMATION

This study is part of a PhD program supported with grants from the Laerdal Foundation and The Danish Helicopter Emergency Medical Service Research Foundation

CONFLICT OF INTEREST

The authors declare no conflicts of interest.