Effect of bystander cardiopulmonary resuscitation in out-of-hospital cardiac arrest patients in Sweden☆
Introduction
After its introduction in 1960, the present method of cardiopulmonary resuscitation (CPR) remained, in the most part, a technique for medical professionals but with a number of notable exceptions, for more than a decade.
The American Heart Association's decision in 1973 [1] to endorse CPR training of the lay public give support to the concept of large-scale training in many regions. During the ensuing years, a number of studies reported the positive effect on survival of bystander CPR (B-CPR) enthusiastically in out-of-hospital cardiac arrests [2], [3], [4], [5], [6].
However, various aspects of bystander CPR have been criticised. The training programs have been criticised for being ineffective with too little time for practical training [7]. Many studies of the retention of knowledge and skills have demonstrated a rapid deterioration over a period of only few months [8], [9], [10]. It has also been stated that, even if lay people do learn CPR, they hesitate to intervene in a cardiac arrest situation [11].
One other major problem remains. If significant proportions of cardiac arrest victims are to benefit from B-CPR, it will be necessary to train a large proportion of the population. In spite of this, the effect of the strategies and techniques used for such large-scale training have been given little attention. With some exceptions, reports of successful CPR training of the general public have come from certain smaller regions, where it has been relatively simple to organise large-scale CPR training. There are fewer reports of the effect of CPR training from larger regions or nations [12], [13].
In Sweden, large-scale CPR training for the general public started in 1983 and has been ongoing since then. This gives an opportunity to study the effect of public CPR training at a national level. The aim of this study was to investigate: (a) the proportion of patients suffering out-of-hospital cardiac arrest who were given B-CPR; (b) where and by whom B-CPR was given; and (c) the effect of B-CPR on survival.
Section snippets
Ambulance registry
This study was based on material collected within the Swedish ambulance cardiac arrest registry. The registry started in 1990 when it comprised a few ambulance systems. It has been joined successively by more and the registry now is based on reports from some 60% of the Swedish ambulance systems. These systems cover 5 million of the total of 8 million inhabitants in Sweden.
Most of the ambulance organisations in the registry serve small communities with fewer than 100 000 inhabitants and only
Results
By May 1995, 14 065 reports of cardiac arrest were collected. Resuscitation was attempted in 10 966 cases. In 3099 cases CPR was not started by ambulance crews. Among these 3099 cases bystanders had started CPR in 3.6%. Furthermore 1089 ambulance-crew-witnessed cases were excluded as the rescuers were by definition not bystanders. The following analyses are based on the remaining 9877 patients.
In 67%, bystanders witnessed the cardiac arrest. In 45% of the cases, the first recorded ECG-rhythm
Discussion
For B-CPR to have a major impact on mortality in out-of-hospital cardiac arrest patients, two conditions must be met. Firstly, a large proportion of the population must be trained. Secondly, the persons who are trained must be willing to use their skills and remember enough of what they have learned to perform effectively.
Our report shows how these conditions have been approached in Sweden using a standardised and simplified training programme and an effective training organisation. The data
Limitations of the study
There was no assessment of the quality of performed B-CPR.
There was no information on the kind of CPR training in which the bystander had participated or how long ago the training took place so no conclusions about the quality of different CPR educational systems could therefore be drawn.
This is a prospective observational study with all the data on the patients based on reports from the ambulance crew on a standard report form. For most variables there are patients with missing data. For
Conclusion
Our data strongly suggest that in Sweden where we have long median delay from collapse to arrival of the first ambulance and a standardised, simplified B-CPR training system, B-CPR increase survival by two to three times.
Acknowledgements
This study was supported by grants from the Swedish Heart and Lung Foundation, Stockholm, and by the Gothenburg Medical Society, Göteborg.
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For the Swedish Cardiac Arrest Registry (see Appendix A)