EuReCa ONE-27 Nations, ONE Europe, ONE Registry : a prospective one month analysis of out-of-hospital cardiac arrest outcomes in 27 countries in Europe

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ContentslistsavailableatScienceDirect

Resuscitation

j o ur na l h o me p a g e:ww w . e l s e v i er . c o m / l o c a t e / r e s u s c i t a t i o n

Clinical paper

EuReCa ONE—27 Nations, ONE Europe, ONE Registry

A prospective one month analysis of out-of-hospital cardiac arrest outcomes in 27 countries in Europe

^夽

Jan-Thorsten Gräsner

^a^,^b^,∗

, Rolf Lefering

^c

, Rudolph W. Koster

^d

, Siobhán Masterson

^e

, Bernd W. Böttiger

^f

, Johan Herlitz

^g

, Jan Wnent

^a,b

, Ingvild B.M. Tjelmeland

^h

,

Fernando Rosell Ortiz

ⁱ

, Holger Maurer

^j

, Michael Baubin

^k

, Pierre Mols

^l

,

Irzal Hadˇzibegovi ´c

^m

, Marios Ioannides

ⁿ

, Roman ˇSkulec

^o

, Mads Wissenberg

^p

, Ari Salo

^q

, Hervé Hubert

^r

, Nikolaos I. Nikolaou

^s

, Gerda Lóczi

^t

, Hildigunnur Svavarsdóttir

^u

,

Federico Semeraro

^v

, Peter J. Wright

^w

, Carlo Clarens

^x

, Ruud Pijls

^y

, Grzegorz Cebula

^z

, Vitor Gouveia Correia

^aa

, Diana Cimpoesu

^ab

, Violetta Raffay

^ac

, Stefan Trenkler

^ad

, Andrej Markota

^ae

, Anneli Strömsöe

^af

, Roman Burkart

^ag

, Gavin D. Perkins

^ah

, Leo L. Bossaert

^ai

, on behalf of EuReCa ONE Collaborators

¹

aUniversityHospitalSchleswig-Holstein,Dep.AnaesthesiologyandIntensiveCareMedicine,Kiel,Germany

bUniversityHospitalSchleswig-Holstein,InstituteforEmergencyMedicine,Kiel,Germany

cUniversityWitten/Herdecke,Cologne,Germany

dAcademicMedicalCenter,Amsterdam,TheNetherlands

eNationalUniversityofIrelandGalway,Ireland

fUniversityHospitalofCologne,Germany

gUniversityofBorås,SahlgrenskaUniversityHospital,Sweden

hNorwegianNationalAdvisoryUnitonPrehospitalEmergencyMedicine(NAKOS),Oslo,Norway

iEmpresaPúblicadeEmergenciasSanitarias,Almería,Spain

jUniversityHospitalSchleswig-Holstein,Dep.AnaesthesiologyandIntensiveCareMedicine,CampusLübeck,Germany

kUniversityHospitalInnsbruck,Austria

lCentreHospitalierUniversitaireSaint-Pierre,UniversitéLibredeBruxelles,Belgium

mMedicalFacultyOsijek,JosipJurajStrossmayerUniversity,Osijek,Croatia

nNicosiaGeneralHospital,Cyprus

oEmergencyMedicalServiceoftheCentralBohemianRegion,Kladno,andJ.E.PurkinjeUniversity,MasarykHospitalUstinadLabem,CzechRepublic

pEmergencyMedicalServicesCopenhagen,UniversityofCopenhagen,Denmark

qEmergencyMedicalServices,DepartmentofEmergencyMedicine,UniversityofHelsinkiandHelsinkiUniversityHospital,Helsinki,Finland

rUniversityofLille,France

sKonstantopouleioGeneralHospital,Athens,Greece

tHealthCareCentersofCsongradCountyHódmez ˝ovásárhely-Makó,Hungary

uAkureyriHospital/UniversityofAkureyri,Iceland

vOspedaleMaggiore“CarloAlbertoPizzardi”AUSLBologna,Italy

wHealthServiceExecutiveBallyshannon,Ireland

xLuxembourgResuscitationCouncil,Luxembourg

yMaastrichtUniversity,TheNetherlands

zJagiellonianUniversity,Kraków,Poland

aaServic¸odeEmergênciaMédicaRegional-SEMER/EMIR,Portugal

abUniversityofMedicineandPharmacyGr.T.PopaandUniversityCountyHospitalSf.Spiridon,Ias¸i,Romania

acMunicipalInstituteforEmergencyMedicineNoviSad,Serbia

adP.J.SafarikUniversity,Kosice,Slovakia

aeUniversityMedicalCentreMaribor,Maribor,Slovenia

afMälardalensUniversity,Västerås,Sweden

agFondazioneTicinoCuore,Breganzona,Switzerland

ahUniversityofWarwickandHeartofEnglandNHSFoundationTrust,Coventry,UnitedKingdom

aiUniversityofAntwerp,DepartmentofMedicineandHealthSciences,Antwerp,Belgium

夽 ASpanishtranslatedversionofthesummaryofthisarticleappearsasAppendixintheﬁnalonlineversionathttp://dx.doi.org/10.1016/j.resuscitation.2016.06.004.

∗ Correspondingauthorat:UniversityHospitalSchleswig-Holstein,InstituteforEmergencyMedicine,Germany.

E-mailaddress:jan-thorsten.graesner@uksh.de(J.-T.Gräsner).

1 Nameslistedattheendofthemanuscript.

http://dx.doi.org/10.1016/j.resuscitation.2016.06.004

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a r t i c l e i n f o

Articlehistory:

Received19May2016

Receivedinrevisedform31May2016 Accepted8June2016

Keywords:

Cardiacarrest Resuscitation Epidemiology Resuscitationregistry Emergencymedicine,Europe

a b s t r a c t

Introduction:TheaimoftheEuReCaONEstudywastodeterminetheincidence,process,andoutcomefor outofhospitalcardiacarrest(OHCA)throughoutEurope.

Methods:Thiswasaninternational,prospective,multi-centreone-monthstudy.Patientswhosufferedan OHCAduringOctober2014whowereattendedand/ortreatedbyanEmergencyMedicalService(EMS) wereeligibleforinclusioninthestudy.Datawereextractedfromnational,regionalorlocalregistries.

Results:Dataon10,682conﬁrmedOHCAsfrom248regionsin27countries,coveringanestimatedpop- ulationof174million.In7146(66%)cases,CPRwasstartedbyabystanderorbytheEMS.Theincidence ofCPRattemptsrangedfrom19.0to104.0per100,000populationperyear.1735hadROSConarrivalat hospital(25.2%),Overall,662/6414(10.3%)inallcaseswithCPRattemptedsurvivedforatleast30days ortohospitaldischarge.

Conclusion:TheresultsofEuReCaONEhighlightthatOHCAisstillamajorpublichealthproblemaccount- ingforasubstantialnumberofdeathsinEurope.

EuReCaONEveryclearlydemonstratesmarkeddifferencesintheprocessesfordatacollectionand reportedoutcomesfollowingOHCAalloverEurope.Usingthesedataandanalyses,differentcountries, regions,systems,andconceptscanbenchmarkthemselvesandmaylearnfromeachothertofurther improvesurvivalfollowingoneofourmajorhealthcareevents.

Introduction

Out-of-hospitalcardiacarrest(OHCA)isamajorhealthproblem inEuropeandintheUnitedStates.Thenumbersofpatientswho haveOHCAannuallyinthesetwopartsoftheworldhavetradition- allybeenreportedtobe275,000and420,000respectively.^1,2This correspondswithan incidencerateof approximately38.0–55.0 all-rhythm OHCAs per 100,000 person-years withresuscitation attemptedbyEmergencyMedicalServices(EMS).

Thebestwaytodescribetheepidemiologyofadiseaseistocre- atearegistrytowhichthediseaseisreported.WithregardtoOHCA, suchregistriescaninvolveanEMSservice,aregion,ora whole country.Aregistrycandescribechangesovertimeinincidence, survival,andvariousmodesoftreatment.Animportantmodiﬁable factortomeasureinOHCAisbystandercardiopulmonaryresuscita- tion(CPR)whichreﬂectsthecommunityinvolvementintreatment ofthisemergencycondition.IntermsofOHCA,anumberofreg- istrieshavebeenbuiltupoutsideEurope.Ofparticularnotearethe CardiacArrestRegistrytoEnhanceSurvival(CARES),theResusci- tationOutcomesConsortiumEpistry(ROC)inNorthAmerica,the All-JapanUtsteinRegistry,andthePan-AsianResuscitationOut- comesRegistry(PAROS).^3–6

DuringthelastdecadesanumberofregistriesforOHCAhave been implemented in Europe.^7–17 These registries cover varied parts ofthe participatingcountries. The greaterpart of Europe howeverisnotincludedinaregistrywiththeaimofcontinuous reportingofOHCA.AregistrycoveringlargerareasofEuropeshould createtheopportunitytobuildanoverallpictureoftheepidemi- ologyofOHCAintheseareas.

Thelackofapan-Europeanregistrymeansthereisstillagap inactualknowledgeregardingthecurrentincidenceofOHCAand furthermore,thesurvivalafterOHCA.Theaimofthisprojectofthe EuropeanRegistryofCardiacArrest(EuReCaONE)wastodetermine theincidence,process,andoutcomeforOHCAinalargenumber ofcountriesinEurope.Majoroutcomesthat wereaddressedin thisprospectiveanalysiswerereturnofspontaneouscirculation (ROSC),admissiontohospital,and/or30-daysurvival.

Methods

EuReCaONE was an international,prospective, multi-centre one-monthstudy,designedasinitialﬁrststeptoestablishaEuro- peanRegistryofCardiacArrest(EuReCa).¹⁸Patientswhohadan OHCAduringOctober2014whichoccurredinanyparticipating regionandwho wereattendedand/ortreatedbyanEmergency

Medical Service (EMS) were eligible for inclusion in the study.

Patients were eligible for inclusion regardless of performance ornon-performanceofa resuscitationattempt,arrest aetiology, initialarrestrhythm,age,orgender.Thestudydatasetwasdevel- opedbytheSteeringCommittee(SC)inaccordancewithUtstein deﬁnitions.¹⁹ArevisedUtsteindatasetwasintroducedclosetothe timeofstudyinception,whichincludedanewcategoryofaeti- ology i.e.‘medical’. Aswellas‘presumed cardiac’,the‘medical’

categoryincludesallothermedicalcausesinwhichthereisnoobvi- ouscauseofcardiacarrest.¹⁴Inordertofacilitatedatacollection fromexistingsystems,dataonaetiologywascollectedforboththe

‘presumedcardiac’and‘medical’categories.TheEuReCaONEstudy isregisteredwithClinicalTrials.gov(T02236819).Thestudyproto- colhasbeenpublishedpreviouslyanddescribesallquestionstobe addressedintheEuReCaONEStudy(seeSupplementS1).²⁰

CountrieswererecruitedtoparticipateinEuReCaONEthrough an open invitation meeting during the European Resuscitation Council(ERC)Congressin2013.Therecruitmentprocessresulted in27countriescommittingtoparticipateinEuReCaONE.

Each participating country was requested to identify one National Coordinator (NC). All NCs signed a Memorandum of Understandingagreeingthattheywereresponsibleforobtaining ethical approval/waiver for participation in EuReCa ONE, coor- dinatingnational data collection,assuring dataquality, and for submittingde-identifieddataforanalysis.NationalCoordinators weresuppliedwithelectroniccopiesofthedataset,coding,and definitionsandgivenacontactfortheStudyManagementTeam (SMT)sothatanyspecificqueriescouldbedealtwithbytheSMT orescalatedtotheSCasrequired.EachSMTmemberactedasa liaisonpersonforagroupofcountriesandkeptincontactwithNCs incaseofissuesarising.

Datawereextractedfromnational,regionalorlocalOHCAreg- istriesanddatabases,orbyuseofapaperversionoftheEuReCaONE datasheetfordatacollection.Datawereobtainedfrom:existing registrieswithnationalcoverage(fivecountries);existingregistries withpartialcountrycoverage(eightcountries);registriesprovided bythelocalResuscitationCouncil(threecountries);patientambu- lancerecords(threecountries).Eightcountriesusedpaper-based datacollection andreportedcases directlytotheNC.Dataele- mentswerede-identified anddata wastranscribed byeach NC ontoaEuReCaONEDataExportTemplateandsubmittedviapass- wordencryptedsecureelectronictransfertothespeciallydesigned EuReCawebsite.Priortotranscription,NCswereexpectedtoassure thequalityofthedatabeingsentintermsofcomprehensiveness andadherencetodatadefinitionsandcoding.

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Afterexploratoryanalysisonsubmitteddataandclariﬁcationof outstandingissuesinrelationtodataqualitywereaddressedwith NCs,theﬁnaldatasubmissionwascompletedinAugust2015.

Statisticalanalysis

Incidenceratesforonemonthwereextrapolatedtoincidence ratesper100,000populationperyear.Incountrieswithpartialcov- eragethecoveredpopulationwascalculatedbyaddingregional populations.Descriptiveanalysesof patientdemographics,case characteristics,andtreatmentand outcomevariables wereper- formedforthewholegroupaswellasforeachparticipatingcountry in orderto investigatethedegree of variability betweencoun- triesandregions.Survivalwasderivedfromstatusat30days,and replacedbyhospitaldischargestatusincaseofmissing30dayssta- tus.StatisticalanalysisisbasedoncaseswhereCPRwasstartedby abystanderorbytheEMS.

Inordertolimitstatisticaluncertainty,forsomeanalysesonly countrieswithtenormorecaseswereincluded.Forselectedcate- goricalvariables,e.g.ROSCorsurvival,95%conﬁdenceintervals(CI 95)werecalculatedbasedonthePoissondistribution.

Roleofthefundingsource

ThestudywasfundedbytheEuropeanResuscitationCouncil (ERC)andbytheindividualregistrieswithinparticipatingcoun- tries. Co-fundingwasprovided by theGermanAnaesthesiology Association(BDA).TheLaerdalFoundationforAcuteMedicineco- fundedameeting oftheNCs,theSMT,andtheSC.Thefunding organisationshadnoinﬂuenceonthedataanalysisorpreparation ofthemanuscript.

TheERC appointed a SC that was responsiblefor the study design,conduct,anddataanalyses.Technicalandadministrative supportwasgivenbytheSMT.MembersoftheSChadfullaccess

tothestudydataandallNCswereresponsibleforcriticalrevision ofthesubmittedversionofthemanuscript.

Results

Patientandprocesscharacteristics

Dataon10,682conﬁrmedOHCAswerecollectedfrom248dif- ferentregionsin27countries,coveringanestimatedpopulationof 174million(34%)of514millionpeoplelivingintheseEuropean countries(Table1).Sevencountriesprovidednationaldata,other countriesreporteddatafromselectedregionswithinthecountry (range1–51regions).Thepopulationcoveredvariedfrom3%to 100%ofthetotalpopulationofthecountry.Threecountriespro- videdonly caseswhen CPRwas started.The lowestnumber of reportedpatientsforonecountrywasfour(Cyprus)andthehighest numberwas1536(UnitedKingdom).In7146cases,CPRwasstarted byabystanderorbytheEMS.WefoundanOHCAincidencerateof 84.0per100,000populationforpatientsconsideredforresuscita- tionbytheEMS.TheincidenceofCPRattemptsrangedfrom19.0 to104.0per100,000populationperyear(Table1).

ThefollowingcalculationsarebasedonallcaseswhereCPRwas startedbyEMSorbystander.Meanpatientagewas66.5(SD18.6) years,andthemedianagewas70.0years,(range0–104)(Table2).

Themajorityofpatientsweremale(66.3%).ThemajorityofOHCAs (69.4%)occurredinaprivateresidence.In54.3%ofcasesthecol- lapsewaswitnessedbybystandersandin11.9% bytheEMS.In 47.4%ofcasesCPRwasinitiatedbyabystander.ThecauseofOHCA waspresumedtobemedicalin91.4%ofcases.Thisincludedcases wherethepresumedcausewasreportedasunknownorwheredata wasmissing(24.0%),asthesearealsoconsideredmedical(includ- ingcardiac)followingtheUtsteinrecommendations.¹⁹Atraumatic causewasreportedin4.1%ofcases(range0–16.0%).Thepropor- tionoftelephoneassistedCPRwasreportedfrom21countries.The

Table1

Summarydataforallparticipatingcountries.

Code Country Total

population (inthousands)

Population covered (inthousands)

Percentage covered

Regions Cases withCA

CAper100,000 peryear

CPR attempted

CPRper 100,000per year

A Austria 8474 1538 18% 7 71 55 54 42

B Belgium 11,200 1530 14% 6 105 ^a 105 82

CRO Croatia 4285 1893 44% 6 98 62 66 42

CYP Cyprus 0.800 0.200 25% 1 6 36 4 24

CZ CzechRep. 10,520 4359 41% 7 886 244 379 104

DK Denmark 5614 1726 31% 1 116 81 101 70

SF Finland 5439 4445 82% 20 467 126 216 58

F France 66,318 17,166 26% 44 855 60 743 52

D Germany 80,620 13,416 17% 51 1369 122 738 66

GR Greece 11,030 6144 56% 7 253 49 165 32

H Hungary 9909 1288 13% 3 127 118 85 79

ICE Iceland 0.328 0.328 100% 6 13 58 10 44

IRL Ireland 4588 4588 100% 1 209 76 155 41

I Italy 59,830 8015 13% 4 773 116 428 64

LUX Luxemburg 0.549 0.549 100% 3 46 102 28 62

NL Netherlands 16,800 4870 29% 3 250 62 190 47

N Norway 5048 3931 78% 11 188 57 167 51

PL Poland 38,530 2265 6% 1 275 146 133 70

P Portugal 10,460 0.262 3% 1 35 160 16 73

RO Romania 19,960 5344 27% 3 378 85 229 51

SRB Serbia 7164 3200 45% 7 488 183 159 60

SK Slovakia 5421 5421 100% 1 670 148 343 76

SLO Slovenia 2050 0.660 32% 4 38 69 25 45

E Spain 47,270 47,270 100% 17 1107 28 756 19

S Sweden 9593 7482 78% 20 301 ^a 301 48

CH Switzerland 8081 0.346 4% 1 22 76 14 48

UK UnitedKingdom 64,597 26,346 41% 12 1536 ^a 1536 70

Total 514,478 174,582 34% 248 10,682 – 7146 –

aB,S,UK:onlycaseswithcardiopulmonaryresuscitation(CPR)attempted.

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Table2

Selectedsummaryﬁndingsfromallcountries.Resultsarepresentedasoverallmeanvalueorpercentageofallcases,andmedianwithrangeoftheindividualcountryvalues.

CalculationsarebasedonallcaseswhereCPRwasstartedbyEMSorbystander.

No.ofcountries No.ofcases Overallaverage Medianofcountryvalues Rangeofcountryvalues

CaseswithCPRattempted 27 7146 264.7 159 4–1536

Meanage(years) 27 6826 66.5 66.0 58.4–75.6

Malegender(%) 27 7004 66.3 65.7 50.0–90.0

Medical/cardiaccause^a(%) 27 7146^a 91.4 90.1 78.1–100

Traumaticcause(%) 27 7146^a 4.1 3.7 0–16.5

Location:residence(%) 27 7052 69.4 67.1 46.4–79.9

TelephoneCPR(%) 21 3439 29.9 30.4 0–100

Collapsewitnessed(%) 27 6815 66.1 67.5 37.4–93.5

BystanderCPR(%) 27 6619 47.4 50.0 6.3–78.0

Shockablerhythm(%) 26 6533 22.2 23.6 4.4–50.0

ROSC(%) 27 6963 28.6 30.6 9.1–50.0

aMissingorunknownvalueswereconsideredasmedical/cardiac.

averagepercentage was30.0%. A shockable initialrhythm was reportedin22.2%ofpatients,rangingbetween4.4%and50.0%.

Outcomes

Dataonreturnofspontaneouscirculationatanystage(ROSC) wasavailablefor6963of7146patients(97.4%)(Fig.1).Percentage ROSCforallcountrieswas28.6%(n=1994)(Fig.2).Therewasawide rangeof percentageROSCreported(9.0–50.0%).Somecountries

Confirmed cases of OHCA N=10,682

Cases with CPR attempted

N=7,146

CPR not attempted N=3,536

ROSC status available

N=6,963

ROSC sta tus missing N=183

Admission sta tus missing N=79

Survival status missin g N=646 Survival to 30 days /

hospital discharge 569 of 1,829 (31.1%) Hospital treatment

N=2,475

Survival in all cases with hospital outcome

662 of 2,005 (33.0%)

Survival in all cases with CPR attempted 662 of 6,414 (10.3%) Hospital admission status available

N=6884

ROSC 1,735 / ongoing CPR 740 / dead 4,409

OHCA= out of hospital cardiac arrest,

ROSC= Return of spontaneous circulation, CPR= cardiopulmonary resuscitation

Fig.1. Flowchartwithnumberofcases.OHCA=outofhospitalcardiacarrest, ROSC=returnofspontaneouscirculation,CPR=cardiopulmonaryresuscitation.

withasmallnumberofcasesreportedhighproportionsofROSC withwideconﬁdenceintervals,but therange ofreportedROSC fromcountrieswithlargernumbersofcasesandnarrowconﬁdence intervalsalsovariedfromlessthan10.0%tomorethan40.0%.The incidencerateofROSCrangedbetween6.0and32.0per100,000 populationperyear.

Thestatus onarrivalathospital wasknownfor6884of the 7146patients(96.3%)forwhomaresuscitationattemptwasstarted (Fig.3).Ofthesepatients,4409diedonsceneorenroutetothehos- pital(64.0%).Onefourthofpatients(n=1735)hadsustainedROSC onarrivalatED(ROSCathospital)(25.2%),and740patients(10.7%) arrivedwithongoingCPR.OfthepatientswithROSCathospitalfor whomsurvivaldatawasavailable,543/1291(42.0%)survivedfor 30daysortohospitaldischarge.OfthepatientswithongoingCPR forwhomdatawasavailable,26/538(4.8%)survivedforatleast30 daysortohospitaldischarge(Fig.4).

Dataonsurvivalto30daysortohospitaldischargewasavail- ablefor2005ofpatientsadmittedtohospital,includingthosewith ongoingCPRandmissingROSCathospitaldata.Ofthesepatients, 662(33.0%,) survived. The values ofthe participatingcountries rangedfrom6.4%to66.7%.InallpatientswhereCPRwasstarted, andhospitaloutcomewasavailable(n=6414),10.3%survivedfor atleast30daysafterOHCAortohospitaldischarge(Fig.5).This percentagerangedfrom1.1%and30.8%amongtheparticipating countries.Theextrapolatedincidencerateofsurvivalforadmitted patientsrangedbetween0.2and17.3per100,000populationper year(SupplementaryTableS3).

Fig.2. ROSCrateinpatientswithCPRattempted.Theverticallinesrepresentthe95%

conﬁdenceintervals(CI).Thegraphincludes6963patientsfrom27countries(range percountry4–1475).Theoverallresultis28.6%.Abbreviations:ROSC=returnof spontaneouscirculation.AbbreviationsforCountriesnamesareexplainedinTable1.

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Fig.3.Statusonhospitaladmission(n=6884)*.Abbreviations:ROSC=Returnof spontaneouscirculation;CPR=cardiopulmonaryresuscitation;Abbreviationsfor countriesnamesareexplainedinTable1.*Patientsincludedinthe‘Dead’category eitherdiedatsceneorwerepronounceddeadonarrivalathospital.Numberstothe rightofeachbarrepresentthetotalnumberofcasespercountry.

OutcomesfortheUtsteincomparatorgroup

The Utstein comparator group included patients with a bystanderwitnessedarrestofsuspectedcardiaccauseandanini- tialrecordedshockablerhythm.In12.5%ofpatients(890/7146), allcriteriafortheUtsteincomparatorwereavailable(Supplement S2). Sevencountries withless than ten patientsin theUtstein comparatorgroupwereexcluded(25cases).InformationonROSC wasavailablefor845(98%)ofthesecases.Theoverallproportion ofROSCwas56.8%,rangingfrom25.0%to84.6%betweencountries.Dataonsurvivalwasavailablefor733patients(85%)(Fig.5).

Ofthesepatients,218(29.7%)survivedforatleast30daysorto hospitaldischarge.Survivalrangedbetween5.3%and57.9%.The incidencerateofsurvivalrangedfrom0.1survivorsto6.3survivors per100,000population(SupplementS3).

Fig.4. PercentagesurvivalincaseswithCPRattempted(dischargedfromhospital aliveoraliveatleast30daysafterevent).Theverticallinesrepresentthe95%con- ﬁdenceintervals.Thegraphincludes6414patientsfrom27countries(range4– 1218).Theoverallrateis10.3%.Abbreviationsforcountriesnamesareexplainedin Table1.

Fig.5. HospitalsurvivalrateintheUtsteinComparatorGroup(cardiaccause,shockablerhythm,andcollapsebystanderwitnessed).Hospitalsurvivaldatawasavailable for733patients(sevencountrieswithlessthan10caseswereexcluded:Austria, Cyprus,Iceland,Luxembourg,Portugal,Slovenia,Switzerland;n=25).Thevertical linesrepresentthe95%conﬁdenceintervals.Thepercentageofpatientspercountry whobelongtotheUtsteinComparatorGroupismarkedwith‘x’.

AbbreviationsforCountriesnamesareexplainedinTable1.

Discussion

Thisistheﬁrststudyreportingincidence,communityinvolve- ment (asbystander CPR), and outcomes following OHCA in 27 Europeancountries. Assumingthat therateofOHCA wassimi- lar duringthe remainingeleven monthsof theyear, we found anincidencerateof84per100,000population.Apreviousstudy reported87.4OHCAsper100,000person-yearsforEurope.²¹Thus, ourresultssuggestthattheincidenceofOHCAinEuropeisinthe rangeofwhathaspreviouslybeenreported.

WefoundtheoverallincidenceofOHCAwhereCPRwasstarted tobe49patientsper100,000population.ThisFig.includesEMS andbystandertreatedcardiacarrests.Itisclearlyhigherthanpre- viouslyreportedfromEuropetenyearsago(38.0per100,000).¹ Ontheotherhand,ourﬁndingsareingoodagreementwithmore recentdatafromnationalsurveysinDenmarkandSweden.^9,10In ourstudy,forboththeseestimates,therewassubstantialvariability betweencountrieswhichmayreﬂectavariationindisease,report- ingbiasoranaturalvariabilitywhichwillbecommenteduponin theLimitationsSection.

TheproportionofpatientswithCPRattemptedwhowerefound inventricularfibrillationwas22.2%.Thisisarelativelylowfigure ascomparedwiththereportedincidence10yearsagoinEurope (42.9%).¹ However,thesefindingsareingoodagreementwitha reporteddeclineintheincidenceofVFbothfromEuropeandfrom USA.²²Ourfindingsalsoconcurwithmorerecentstudiesoftheinci- denceofVFamongpatientswithOHCAwhereCPRwasattempted.⁹ However,therearecountriesinEuropewhereahigherincidence ofVFhasrecentlybeenreported.²³

Three previousstudies have reported on the incidence and survival ofOHCAfroma Europeanperspective. Thefirstsurvey waspublishedin1999andreportedthatmanyEMSsystemsin Europeshowedgood resultsinterms of survival afterOHCA.²⁴ Thesecondsurveywaspublishedin2005andreportedanover- allincidenceof38EMS-treatedOHCAper100,000personyears inEurope.¹ThecorrespondingFig.forventricularfibrillation(VF) was17.Theoverallpercentagesurvivaltohospitaldischargewas 10.7%forallrhythmsand21.2%forVF.Itwasextrapolatedthat 29,000personsweresuccessfullyresuscitatedeachyearafterOHCA inEurope.Thethirdsurveywaspublishedin2011andincludedfive regional/nationalregistries.²⁵Theincidenceofattemptedresusci- tationsafterOHCAwasreportedtovarybetween17.0 and53.0

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per100,000person-years.Therewasawidevariabilityintermsof bystanderCPRandearlysurvival.

OurstudyreportsvariabilityofROSCfromlessthan10.0%upto 50.0%,andhospitalsurvivalrangingfromlessthan5.0%to30.0%.

Differencesin EMSstructures and CPR practicesmay bea rea- sonforthisanditshouldberememberedthatreporteddataare averagevaluesfromeverycountry.Nevertheless,wefoundasim- ilardifferencewithinthesystemsandvariabilityintheoutcome parameters.²⁶

The“Utsteincomparatorgroup”isonewayofdeﬁningauni- form population of victims of OHCA with the best chance of survival. Within this groupwe alsofounda wide variability of incidence,ROSC,admissiontohospital,dischargeand/or30-day survival.Itmayseemreasonabletoassumethatthereshouldbe similarnumbers ofsurvivors in this group.However we found hospitalsurvival ratesrangingfromless than6.0%upto55.0%.

Recentpublications describea 30-daysurvival rangingfrom20 to31% in victimswith witnessedcardiac arrest and VF.^11,27 In a longitudinal study from North America, an increasing num- berofsurvivorswerefoundbutalsowithvariabilitywithinthe participatingsystems.²⁸Inrelationtotheseoutcomedifferences, we might assume differences in bystander-CPR, quality of CPR andpost-ROSCtreatmentinourstudygroupwithinthedifferent countriesandsystems.RecommendationsforuniqueCPRmetrics havebeenpublishedandshouldbeusedfordescribingquality.²⁹ Also,ariskadjustmentwithmoredetailsaboutthevictimsand the setting might be helpful to understand the variability in outcome.³⁰

Europeisa continent withdifferent nations,cultures, medi- caltreatmentstandardsandOHCAoutcomes.DifferencesinEMS systemsandcommunityfactorsincludingbystanderCPRmayalso inﬂuencetheoutcomeaftercardiacarrest.

Limitations

First, the methods of data collection were not standardised betweencontributingcountriesand regionsand qualitycontrol waslimitedtoqueriestotheNCs.Thismayexplainsomeofthe variationofincidenceratesofinitiatedresuscitationbetweencoun- trieswithrangesbetween24and104per100,000patientsperyear.

Consideringthatsomevariableshadmissingdata,itispossiblethat dataweredifﬁculttoobtainincertainsubgroups,suchaspatients attended by the EMS for whom resuscitation was considered futile.

Second,theresultsofourstudyshowlargedifferencesinthe processesfordatacollectionandoutcomesbetweencountries.Per- centageROSCfollowing aresuscitationattemptvaried between 9.0% and 50.0%, survival todischarge varied between6.4% and 66.7%. This wide variation may be due to genuine differences betweencountries, similartothelargevariation in outcomeas reportedfortheResuscitationOutcomeConsortiumcentres.⁴That studyemployedrigidandstandardisedmethodsofdatacollection withinonenation,toensuredatacompletenessanddataquality.

Theyreportedaﬁve-foldrange,muchlessthanthe20-foldrange insurvivalratethatisreportedinourstudy.Severalexplanations thereforemayplayaroleinthewidevariabilityinoutcomesin ourstudy.First,ourstudyisasnapshotofOHCAinonemonth.

Giventheinherentvariabilityofoutcomesofcardiacarrest,espe- ciallyinsmallsamplesinpartofthecontributingcountries,the comparisonbetweencountriesoversuchashorttimeperiodhas limitations.However,thecombineddataofallcountriesmayadd totherobustnessoftheoveralloutcomeasreported.

Third,variationinincidenceratemaybeduetoseasonalvari- ationsorindicate,legal,cultural,andreligiousdifferencesinthe willingnesstoactivateEMSandtoinitiateresuscitationwhenalow

probabilityofsuccessisexpected,ortoterminateeffortsintheﬁeld, whichmayaffectadmissionrates.Threecountriesonlyreported caseswhereresuscitationwasstartedorcontinuedbyEMSstaff.

Anotherissuethatcaninﬂuenceoutcomeistheactualavailabil- ityofEMSresourcestothepopulationserved.Higheravailability maypromotethedecisiontostartresuscitation,especiallycoun- trieswherebystanderCPRislower.Thesefactorsarenotrecorded anditisnotknownhowtheymayhaveaffectedindividualcases.

Thislimitsourinterpretationofthedataandattributionofthese differencestobiologicalpatientfactorsortosystemparamatersof healthcareforOHCA.

Conclusions

TheresultsofEuReCaONEhighlightthatOHCAisstillamajor public health problem accounting for a substantial number of deathsinEurope.

EuReCaONEveryclearlydemonstratesmarkeddifferencesin theprocessesfordatacollectionandreportedoutcomesfollow- ingOHCAalloverEurope.Usingthesedataandanalyses,different countries,regions, systems,andconceptscanbenchmarkthem- selvesandmaylearnfromeachothertofurtherimprovesurvival followingoneofourmajorhealthcareevents.

Funding

ThestudywasfundedbytheEuropeanResuscitationCouncil (ERC)andbytheindividualregistrieswithinparticipatingcoun- tries. Co-funding wasprovided bytheGerman Anaesthesiology Association(BDA).TheLaerdalFoundationforAcuteMedicineco- fundedameetingoftheNCs,theSMTandtheSC.Theopen-Access Option wasfunded by the German Resuscitation Registry.The fundingorganisations had noinﬂuence onthedata analysisor preparationofthemanuscript.

EuReCaONE-LocalContributorGroup:

Austria:MarcKaufmann,MarkusThaler,MartinMaier,Gerhard Prause,HelmutTrimmel,Belgium:DianedeLongueville,Thierry Preseau, Dominique Biarent, Christian Melot, Nicolas Mpotos, KoenMonsieurs,PatrickVandeVoorde,MarieVanhove,Pascale Lievens, Mathias Faniel, Croatia: Slobodanka Keleuva, Milan Lazarevic, RadmilaMajhen Ujevic, MatoDevcic,Branka Bardak, FabijanBarisic,SilvijaHunyadiAnticevic,Cyprus:MariosGeorgiou, CzechRepublic:AnatolijTruhláˇr,JiˇríKnor,EvaSmrˇzová,Roman Sviták,Robin ˇSín,PetrMokrejˇs,OndrejFranek,Denmark:Freddy K.Lippert,Finland:JuhanaHallikainen,MarkoHoikka,TimoIirola, TimoJama,HelenaJäntti,RaimoJokisalo,MillaJousi,HettiKirves, MarkkuKuisma,JukkaLaine, SamiLänkimäki,PetriLoikas,Vesa Lund,TeuvoMäättä,HeiniNal,HeimoNiemelä,PetraPortaankorva, MarkoPylkkänen,MarkoSainio,PirittaSetälä,JerryTervo,Taneli Väyrynen,Timo Jama,France: DavyMurgue,AnneChampenois, Marc Fournier,DanielMeyran, RomainTabary, Aurélie Avondo, GelinGelin,BrunoSimonnet,MarcJoly,IsabelleMegy-Michoux, XavierParingaux,YvesDuffait,MichaelVial,JulienSegard,Sophie Narcisse, David Hamban, Jonathan Hennache, Sylvain Thiriez, Mathieu Doukhan, Carine Vanderstraeten, Jean-Charles Morel, GillesMajour,CorinneMichenet,LaurentTritsch,MarcDubesset, OlivierPeguet,DavidPinero,FrédericGuillaumee,PatrickFuster, Jean-Franc¸oisCiacala,BenoîtJardel,Jean-YvesLetarnec,FrankGoes, Pierre Gosset, Muriel Vergne, Christian Bar, Fabienne Branche, Stevens Prineau,StevenLagadec,Carole Cornaglia,Cécile Ursat, PhilippeBertrand,Jean-MarcAgostinucci,PierreNadiras,Géraldine GonzalesdeLinares,LineJacob,Franc¸oisRevaux,ThomasPernot, Nathalie Roudiak, Agnès Ricard-Hibon, Laurent Villain-Coquet,

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Germany:StefanBeckers,ThomasHanff,BerndStrickmann,Nicolai Wiegand, Petra Wilke, Harald Sues, Stefan Bogatzki, Wolfgang Baumeier,KaiPohl,BertWerner,HansFischer,TorstenZeng,Erik Popp, Andreas Günther, Andreas Hochberg, Alex Lechleuthner, Jens-Christian Schewe, Hans Lemke, Erich Wranze-Bielefeld, Andreas Bohn, Markus Roessler, Frank Naujoks, Frank Sensen, Torben Esser, Matthias Fischer, Martin Messelken, Christopher Rose, Gabriele Schlüter, Wolfgang Lotz, Michael Corzilius, Claus-Martin Muth, Christian Diepenseifen, Björn Tauchmann, Torsten Birkholz, Andreas Flemming, Stefanie Herrmann, Uwe Kreimeier,ClemensKill, Frank Marx, RalphSchröder, Wolfgang Lenz, Greece: Glykeria Botini, Barakos Grigorios, Nikolaos Giannakoudakis, Michail Zervopoulos, Dimitrios Papangelis, SoﬁaPetropoulou-Papanastasiou, ThemistoklisLiaskos,Spyridon Papanikolaou,AndreasKarabinis,Hungary:AttilaZentay,Iceland:

HólmgeirÞorsteinsson,AnnaGilsdóttir,SvavarA.Birgisson,Fjölnir FreyrGuð^mundsson,^Hallgrímur^Hreið^arsson,^Björgvin ^Árnason,

HermannHermannsson,GísliBjörnsson,BrynjarÞórFrið^riksson,

GunnarBaldursson,ÁrmannHöskuldsson,JórunnValgarð^sdottir,

MatthildurÁsmundardóttir,Guð^mundur ^Guð^mundsson,^Hjörtur

Kristjánsson,EyþórRúnarÞórarinsson,JónGuð^laugsson,^Sigurð^ur

Skarphéðînsson, Îreland: ^National Âmbulance ^Service ôf ^the

HealthServiceExecutiveDublinFireBrigade,Dublin,Italy:Alberto Peratoner, Andrea Santarelli, Cesare Sabetta, Giovanni Gordini, GiovanniSesana, RiccardoGiudici,SimoneSavastano, Tommaso Pellis,Luxembourg:JeanBeissel,JeanUhrig,TomManderscheid, MarcoKlop,PascalStammet,MarcKoch,PhilippeWelter,Robert Schuman,TheNetherlands:WendyBruins,HesamAmin,Norway:

Nina Braa, Staale Bratland, Eirik AlnesBuanes, Tomas Draegni, KnutRoarJohnsen,WencheTorunnMathisen,TerjeOedegaarden, MarieOppedal,AlfStolt-NielsenReksten,MatsEirikRoedsand,Jon ErikSteen-Hansen,Poland:MartaDyrda,AnnaFrejlich,Sławomir Maci ˛ag, Sonia Osadnik, Ireneusz Weryk, Portugal: Eugénio Mendonça,CarlosFreitas,PintoCruz,CarmoCaldeira,JoséBarros, LuisVale,AntónioBrazão,NunoJardim,FernandaRocha,Ricardo Duarte, NicodemosFernandes, Pedro Ramos, Margarida Jardim, MiguelReis,RomuloRibeiro,SérgioZenha,JorgeFernandes,Juan Francisco,DavidAssis,FernandaAbreu,DinarteFreitas,Leonardo Ribeiro, Paulo Azevedo, Débora Calafatinho, Rui Jardim, Aleixo Pestana, Rui Faria, Romania: Bogdan Oprita, Alis Grasu, Paul Nedelea,SorinaSovar,FlorinAgapi,Serbia:AleksandarKliˇckovi ć, Aleksandra Lazi ć, Bogdan Nikoli ć, Bogdan Zivanovic, Branislav Martinovi ć, Duˇsan Milenkovi ć, Huseinovi ć Damir, Jovanka Koprivica, Kornelija Horvat Jakˇsi ć, Margit Pajor, Saˇsa Mili ć, Mirko Vidovi ć, Radojka Petrovic Glamoclija, Sladjana Andjelic, Vlajovic Sladjana, Zlatko Babi ć, Zlatko Fiˇser, Slovakia: Peter Androvic, Lubica Bajerovska, Miroslav Chabron, Viliam Dobias, Eva Havlikova, Bozena Horanova, Renata Kratochvilova, Dana Kubova,JanMurgas,JurajPatras,LadislavSimak,VladimirSnarskij, Zuzana Zaviaticova, Marcela Zuffova, Spain: Francesc Escalada Roig,LuisSánchezSantos,AlfredoEcharriSucunza,JuanA.Cordero Torres,GuadalupeInzaMu ñoz,MartaMartínezdelValle,Isabel CenicerosRozalen, EnriqueMartínSánchez,MaríaVictoria Raúl CanabalBerlanga, KarlosIbarguren Olalde,JoséI. RuizAzpiazu, María José García-Ochoa, Rafael Zoyo López-Navarro, José M.

AdsuarQuesada,JoséA.CortésRamas,FranciscoJ.MelladoVergel, Juan B. López Messa, PatriciaFernández delValle, Nuria López Cabeza,JoséM.NavalpotroPascual,Sweden:TheSwedishAsso- ciation of Local Authorities and Regions, Switzerland: Luciano Anselmi, Federazione Cantonale Ticinese Servizi Ambulanze, Breganzona Claudio Benvenuti, United Kingdom: Nigel Batey, Yorkshire Ambulance, Scott Booth, Patricia Bucher, Charles D. Deakin, Jay Duckett, Chen Ji, Nancy Loughlin, Jenny Lumley-Holmes, Jessica Lynde, Frank Mersom, Carly Ramsey, Clare Robinson, Robert Spaight, Sukhdeep Dosanjh, Gurkamal Virdi,AndrewWhittington.

Conﬂictofintereststatement

Therearenoﬁnancialandpersonalrelationshipswithotherpeo- pleororganisationsthatcouldinﬂuencethispaper.COIstatements areavailableforallauthors.

AppendixA. Supplementarydata

Supplementarydataassociatedwiththisarticlecanbefound, intheonlineversion,athttp://dx.doi.org/10.1016/j.resuscitation.

2016.06.004.

References

1.AtwoodC,EisenbergMS,HerlitzJ,ReaTD.IncidenceofEMS-treatedout-of- hospitalcardiacarrestinEurope.Resuscitation2005;67:75–80.

2.ReaTD,EisenbergMS,SinibaldiG,WhiteRD.IncidenceofEMS-treatedout-of- hospitalcardiacarrestintheUnitedStates.Resuscitation2004;63:17–24.

3.ChanPS,McNallyB,TangF,KellermannA.Recenttrendsinsurvivalfrom out-of-hospital cardiac arrest in the United States. Circulation 2014;130:

1876–82.

4.NicholG,ThomasE,CallawayCW,etal.Regionalvariationinout-of-hospital cardiacarrestincidenceandoutcome.JAMA-JournaloftheAmericanMedical Association2008;300:1423–31.

5.OngME,ShinSD,DeSouzaNN,etal.Outcomesforout-of-hospitalcardiacarrests across7countriesinAsia:ThePanAsianResuscitationOutcomesStudy(PAROS).

Resuscitation2015;96:100–8.

6.HasegawaK,TsugawaY,CamargoJrCA,HiraideA,BrownDF.Regionalvariabil- ityinsurvivaloutcomesofout-of-hospitalcardiacarrest:theAll-JapanUtstein Registry.Resuscitation2013;84:1099–107.

7.GräsnerJT,MeybohmP,FischerM,etal.Anationalresuscitationregistry of out-of-hospital cardiac arrest in Germany-a pilot study. Resuscitation 2009;80:199–203.

8.SedgwickML,DalzielK,WatsonJ,CarringtonDJ,CobbeSM.Performanceofan establishedsystemofﬁrstresponderout-of-hospitaldeﬁbrillation.Theresults ofthesecondyearoftheHeartstartScotlandProjectinthe‘UtsteinStyle’.Resus- citation1993;26:75–88.

9.StromsoeA,SvenssonL,AxelssonAB,etal.ImprovedoutcomeinSweden afterout-of-hospital cardiacarrestandpossibleassociationwith improve- mentsineverylinkinthechainofsurvival.Europeanheartjournal2015;36:

863–71.

10.WissenbergM,LippertFK,FolkeF,etal.Associationofnationalinitiativesto improvecardiacarrestmanagementwithratesofbystanderinterventionand patientsurvivalafterout-of-hospitalcardiacarrest.Jama2013;310:1377–84.

11.MastersonS,WrightP,O’DonnellC,etal.Urbanandruraldifferencesinout-of- hospitalcardiacarrestinIreland.Resuscitation2015;91:42–7.

12.BlomMT, BeesemsSG,HommaPC,etal. Improvedsurvival after out-of- hospitalcardiacarrestanduseofautomatedexternaldeﬁbrillators.Circulation 2014;130:1868–75.

13.CebulaGM,OsadnikS,WysockiM,etal.Comparisonoftheearlyeffectsofout-of- hospitalresuscitationinselectedurbanandruralareasinPoland.Apreliminary reportfromthePolishCardiacArrestRegistrybythePolishResuscitationCoun- cil.PolishHeartJournal2016;74:143–8.

14.VanHoeyweghenRJ,BossaertLL,Mullie A,etal.Quality andefﬁciencyof bystander CPR. BelgianCerebral Resuscitation Study Group. Resuscitation 1993;26:47–52.

15.HubertH,TazarourteK,WielE,etal.Rationale,methodology,implementation, andﬁrstresultsoftheFrenchout-of-hospitalcardiacarrestregistry.Prehospital EmergencyCare:OfﬁcialJournaloftheNationalAssociationofEMSPhysicians andtheNationalAssociationofStateEMSDirectors2014;18:511–9.

16.RistagnoG, SemeraroF, RadeschiG, etal. The“ItalianRegistryofCardiac Arrest-RIAC”,aNationalachievementtoportraittheItalianrealityandto contributetothewiderEuropeanvisionby“EuReCa”.Resuscitation2014;85:

e193–4.

17.RosellOrtizF,MelladoVergelF,LopezMessaJB,etal.Survivalandneurologic outcomeafterout-of-hospitalcardiacarrest.Resultsoftheandalusianout-of- hospitalcardiopulmonaryarrestregistry.In:Revistaespanoladecardiologia;

2016[Englished].

18.GräsnerJT,BottigerBW,BossaertL.EuropeanRegistryofCardiacArrestONESC, EuReCaONESMT.EuReCaONE–ONEmonth–ONEEurope–ONEgoal.Resus- citation2014;85:1307–8.

19.PerkinsGD,JacobsIG,NadkarniVM,etal.Cardiacarrestandcardiopulmonary resuscitationoutcomereports:updateoftheutsteinresuscitationregistrytem- platesforout-of-hospitalcardiacarrest:astatementforhealthcareprofessionals fromaTaskForceoftheInternationalLiaisonCommitteeonResuscitation (AmericanHeartAssociation,EuropeanResuscitationCouncil,Australianand NewZealandCouncilonResuscitation,HeartandStrokeFoundationofCanada, InterAmericanHeartFoundation, Resuscitation Councilof SouthernAfrica, ResuscitationCouncilofAsia);andtheAmericanHeartAssociationEmergency CardiovascularCareCommitteeandtheCouncilonCardiopulmonary,Critical Care,PerioperativeandResuscitation.Resuscitation2015;96:328–40.

20.Wnent J, Masterson S,GräsnerJT, et al. EuReCaONE - 27Nations,ONE Europe,ONERegistry:aprospectiveobservationalanalysisoveronemonthin

(8)

27resuscitationregistriesinEurope–theEuReCaONEstudyprotocol.Scandi- navianJournalofTrauma,ResuscitationandEmergencyMedicine2015;23:7.

21.BerdowskiJ,BergRA,TijssenJG,KosterRW.Globalincidencesofout-of-hospital cardiacarrestandsurvivalrates:Systematicreviewof67prospectivestudies.

Resuscitation2010;81:1479–87.

22.KellerSP,HalperinHR.Cardiacarrest:thechangingincidenceofventricularﬁb- rillation.CurrentTreatmentOptionsinCardiovascularMedicine2015;17:392.

23.HullemanM,ZijlstraJA,BeesemsSG,etal.Causesforthedecliningpropor- tionofventricularﬁbrillationinout-of-hospitalcardiacarrest.Resuscitation 2015;96:23–9.

24.HerlitzJ,BahrJ,FischerM,KuismaM,LexowK,ThorgeirssonG.Resuscitationin Europe:ataleofﬁveEuropeanregions.Resuscitation1999;41:121–31.

25.GräsnerJT,HerlitzJ,KosterRW,Rosell-OrtizF,StamatakisL,BossaertL.Qual- itymanagementinresuscitation—towardsaEuropeancardiacarrestregistry (EuReCa).Resuscitation2011;82:989–94.

26.NeukammJ,GräsnerJT,ScheweJC,etal.Theimpactofresponsetimereliability onCPRincidenceandresuscitationsuccess:abenchmarkstudyfromtheGerman ResuscitationRegistry.CriticalCare2011;15:R282.

27.RinghM,JonssonM,NordbergP,etal.Survivalafterpublicaccessdeﬁbrillation inStockholm,Sweden—astrikingsuccess.Resuscitation2015;91:1–7.

28.DayaMR,SchmickerRH,ZiveDM,etal.Out-of-hospitalcardiacarrestsur- vivalimprovingovertime:resultsfromtheResuscitationOutcomesConsortium (ROC).Resuscitation2015;91:108–15.

29.Meaney PA, BobrowBJ,Mancini ME, etal. Cardiopulmonaryresuscitation quality:[corrected]improvingcardiacresuscitationoutcomesbothinsideand outsidethehospital:aconsensusstatementfromtheAmericanHeartAssocia- tion.Circulation2013;128:417–35.

30.GräsnerJT,MeybohmP,LeferingR,etal.ROSCaftercardiacarrest—theRACA scoretopredictoutcomeafterout-of-hospitalcardiacarrest.EuropeanHeart Journal2011;32:1649–56.