CPR in Australia: A case for national action
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CPR in Australia: A case for national action Gerard FitzGerald Commissioner Queensland Ambulance Service Perhaps no single area of the emergency medical system has received such attention in the international literature as out-of-hospital cardiac arrest. These studies concern sudden unexpected death in which an attempt at resuscitation is made, and exclude patients in whom death is expected or in whom attempts at resuscitation would be futile. Out-of-hospital cardiac arrest will occur in an estimated one individual per 2,000 population per annum. That is 9,000 incidents per year throughout Australia. Further, particular focus has been on those cases of primary cardiac origin in whom known counter measures are more likely to be effective. Untreated, out-of-hospital cardiac arrest has a very poor prognosis. However, with the devel- opment of transportable defibrillators and the implementation of advanced life support in the field by medical retrieval teams and paramedics, the outcome has improved considerably in most communities. Best outcome can be achieved by application of the principles of the 'chain of survival'. The chain involves early recognition, early access, early CPR and early defibrillation. Recent studies have confirmed the significant associa- tion with improved sur\'ival of time to defibrillation, age and effective bystander CPR'. All ambulance ser\'ices in Australia have now implemented early defibrillation programs with variable success. The most recent report from Auckland demonstrated 13% sur\'ival to leave hospital-, however, the success of defibrillation programs in Australia has been limited by the relah\ely slow response times associated with our dispersed populations. It is now time to address the other significant factor known to be associated with improved survival. It is estimated that about 8% of the popula- Hon of Australia is trained tn CPR. Fewer than 2% have a current first aid certificate and the remainder include health professionals who ha\'e been trained through their own profes- sional educational programs and others who have received some training although not formal certification. This lack of knowledge is supported by the fact that only one in three patients receive effective bystander resuscitation attempts^. There is strong evidence that effective bystander CPR significantly improves survival from out-of-hospital cardiac arrest. Crone- demonstrated in Auckland a survival rate of 19% amongst those who received effec- tive CPR compared with 4% in those who had not received CPR. Herlitz' demonstrated 25% survival with CPR compared with 8% amongst remaining patients and Wik' has shown 23% survival for those who received effective CPR compared with 6% for those who do not. So if CPR improves outcome, is it only a temporary survival anyway? Herlitz"' has demonstrated 80% one year sur\ival and up to 20% 10 year survival while Kimman' has shown a five year survival of 61% and 10 year survival of 20%. Both rates are little different to that which would apply if the patient had not suffered a cardiac arrest. Weston'' has estimated from studies in Cardiff that a minimum of six lives per 100,000 popula- tion could be saved by early CPR. That rate translates into over 100 lives per year in Australia. Initiatives must be directed at improving the likelihood that individuals who suffer an out-of- hospital cardiac arrest will have their condition recognised immediately and receive immediate CPR. There is value in taking a 'whole of Emer^encv Medicine 199fc • Vol 8
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Transcript of CPR in Australia: A case for national action
CPR in Australia: A case for national action
Gerard FitzGerald Commissioner Queensland Ambulance Service
Perhaps no single area of the emergency medical system has received such attention in the international literature as out-of-hospital cardiac arrest.
These studies concern sudden unexpected death in which an attempt at resuscitation is made, and exclude patients in whom death is expected or in whom attempts at resuscitation would be futile.
Out-of-hospital cardiac arrest will occur in an estimated one individual per 2,000 population per annum. That is 9,000 incidents per year throughout Australia. Further, particular focus has been on those cases of primary cardiac origin in whom known counter measures are more likely to be effective.
Untreated, out-of-hospital cardiac arrest has a very poor prognosis. However, with the development of transportable defibrillators and the implementation of advanced life support in the field by medical retrieval teams and paramedics, the outcome has improved considerably in most communities.
Best outcome can be achieved by application of the principles of the 'chain of survival'. The chain involves early recognition, early access, early CPR and early defibrillation. Recent studies have confirmed the significant association with improved sur\'ival of time to defibrillation, age and effective bystander CPR'.
All ambulance ser\'ices in Australia have now implemented early defibrillation programs with variable success. The most recent report from Auckland demonstrated 13% sur\'ival to leave hospital-, however, the success of defibrillation programs in Australia has been limited by the relah\ely slow response times associated with our dispersed populations.
It is now time to address the other significant factor known to be associated with improved survival.
It is estimated that about 8% of the popula-Hon of Australia is trained tn CPR. Fewer than 2% have a current first aid certificate and the remainder include health professionals who ha\'e been trained through their own professional educational programs and others who have received some training although not formal certification. This lack of knowledge is supported by the fact that only one in three patients receive effective bystander resuscitation attempts^. There is strong evidence that effective bystander CPR significantly improves survival from out-of-hospital cardiac arrest.
Crone- demonstrated in Auckland a survival rate of 19% amongst those who received effective CPR compared with 4% in those who had not received CPR. Herlitz' demonstrated 25% survival with CPR compared with 8% amongst remaining patients and Wik' has shown 23% survival for those who received effective CPR compared with 6% for those who do not.
So if CPR improves outcome, is it only a temporary survival anyway?
Herlitz"' has demonstrated 80% one year sur\ival and up to 20% 10 year survival while Kimman' has shown a five year survival of 61% and 10 year survival of 20%. Both rates are little different to that which would apply if the patient had not suffered a cardiac arrest. Weston'' has estimated from studies in Cardiff that a minimum of six lives per 100,000 population could be saved by early CPR. That rate translates into over 100 lives per year in Australia.
Initiatives must be directed at improving the likelihood that individuals who suffer an out-of-hospital cardiac arrest will have their condition recognised immediately and receive immediate CPR. There is value in taking a 'whole of
Emer^encv Medicine 199fc • Vol 8
Crrarii FttzCcratd
community' approach to tlris issue, and to encourage early recognition, early inter\'ention and early CPR.
Why don't people intervene? Perhaps it is because they do not recognise
the incident as a cardiac arrest, or they lack the information or confidence to act. Wik'' also demonstrated a shorter time to initiation of CPR amongst those patents who received effechve bystander CPR. It would seem that those who had the skills to perform effective CPR had the confidence to recognise the condition early and immediately intervene.
Monitored arrests have the greatest potenhal for success with up to 60% survival to leave hospital-. Early recognition, not only of cardiac arrest, but also of prodromal conditions such as myocardial infarction may also significantly improve outcome. CPR instruction campaigns are an ideal foriAm for instruction on health promohon and early inter\'ention issues.
What stops people undertaking CPR training? Is it cost, a fear of failure or inconvenience?
Programs need to be flexible in their structure with less focus on the processes than on the development of a state of awareness and preparedness to intervene. Any means of familiarity may be useful. Peer training has been shown to be a cost effective means of spreading the message^.
We need to target 25% of the population of Australia to be trained in effective CPR in order to significantly improve the outcome from out-of-hospital cardiac arrest. The achievement of
such a goal will require policy changes as well as leadership and effort.
Changes in public policy may ensure that any immediate program will ha\'e long lasting effect. All public workers, particularly health care workers, should be required to be current in resuscitation competency and resuscitation should be included in school curricula and all tertiary courses. Community support must be developed through leadership by health professionals and be translated into both political and financial support for the program.
Emergency physicians should be at the forefront of professional action required to develop programs and exact the required communit}' changes in attitude.
References 1 HerliU J, Ekstrom L, Wennerblom B. Axelsson A. Bang A,
Holmderg S. Effect of bystander initiated cardiopulmonary resuscitation on ventricular fibrillation and survival after witnessed cardiac arrest outside fiospital. Br Heart J 1994.72:408-412.
2 Crone PD Auckland Ambulance Service cardiac arrest data 1991-3. NZ Med J 1995.108:297-299
3. Wik L. Sten PA, Birctner NG, Quality of bystander cardiopulmonary resuscitation influences outcome after prehospital cardiac arrest. Resuscitation 1994,28 195-203
4, Herlitz J, Ekstrom L, Wennerblom B, Axelsson A, Bang A, Holmberg S Prognosis of survivors of prefiospital cardiac arrest Ann Emerg Med 1995:25:58-63
5 Kimman GP, Ivens EM, Hartman JA, Hart HN, Simoons ML Long term survival after successful out-of-fiospital resuscitation Resuscitation 1994:28,227-232
6 Weston CF. Hughes DW. Donnelly MD, Potential impact upon community m.ortality rates of training citizens in cardiopulmonary resuscitation J Roy Coll Physicians 1994:28:402-406
7. Wik L, Brennan RT. Braslow A A peer training model for instruction of basic cardiac life support. Resuscitation 1995:29 119-128
Emergency Medicine 1996 • Vol H
