2025+AHA心肺复苏与心血管急救指南-第4部分：护理系统

PREAMBLE

Cardiac arrest SOC represent a comprehensive frame-work of personnel, resources, and policies and procedures designed to provide a coordinated, efficient, and highly ef-fective response(Figure 1). The primary goal of cardiac arrest SOC is to resuscitate patients back to the function and quality of life that they enjoyed before the cardiac arrest. Important secondary goals include effective team function, optimizing the long-term survivor experience for the patient and those involved in the resuscitation, and improving the SOC through ongoing quality management and research. The objective of a cardiac arrest SOC is to quickly, efficiently, and effectively perform each step within the Chain of Survival (Figure 2). The SOC needed to execute the early links of the Chain of Survival differs between in-hospital cardiac arrest (IHCA) and OHCA, but assuming ROSC, these converge within the intensive care unit and continue through hospitalization and following discharge. These SOC guidelines are broadly applicable to persons of all ages, though are not geared toward neo-natal resuscitation. These guidelines provide recommen-dations on how to create, maintain, and optimize systems intended to produce the best outcomes possible follow-ing cardiac arrest. Patient outcomes ultimately depend on some factors beyond the scope of this Part, such as the patient's comorbidities, yet a well-functioning cardiac

 Figure 1. Systems of care.

Graphical representation of the components of cardiac arrest systems of care.

arrest SOC can produce the best outcome achievable for any given patient by optimizing the execution of each link in the Chain of Survival.

The cardiac arrest Chain of Survival provides a pro-gression of events beginning with the recognition that an individual is having a cardiac arrest and ideally results in the survival and recovery of that individual. There are opportunities to optimize each link in this chain with the ultimate goal of maximizing survival and function follow-ing cardiac arrest. The Chain of Survival is intended to be applied to both adult and pediatric in- and out-of-hospital cardiac arrest, though the details vary in each application. The recommendations in this Part follow the links of the Chain of Survival, beginning with preven-tion and preparedness, which precede the cardiac arrest event.

INTRODUCTION

Scope of the Guidelines

These guidelines are designed primarily for North Ameri-can lay rescuers and health care professionals looking for up-to-date guidance to optimize clinical care through the design and operation of resuscitation systems. The emphasis in this Part of the 2025 American Heart As-sociation(AHA) Guidelines for CPR and Emergency Car-diovascular Care(ECC) is on elements of care involving coordination between different contributors to the Chain of Survival(eg, emergency telecommunications and un-trained lay rescuers), those elements common to the resuscitation of different populations (eg, community CPR training and public access to defibrillation, early

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 Figure 2. Updated 2025 Chain of Survival.

interventions to prevent IHCA), and means to improve the performance of resuscitation teams and systems.

Our recommendations are directly relevant to lay res-cuers, health care professionals, emergency telecom-municators, and those determining policy or legislation.These individuals operate within varied settings with dif-fering levels of training and access to resuscitation equip-ment, which influences what is reasonable to recommend within that SOC. Our recommendations cover a broad temporal range from before cardiac arrest occurs until after resuscitation is successful or terminated, with guid-ance on assessing and improving the quality of each step.

Organization of the SOC Writing Group

The SOC Writing Group included a diverse group of vol-unteers from the AHA with expertise in emergency medi-cine, emergency medical services(EMS) pediatric and adult critical care, cardiology, education, research, epi-demiology, and public health. A call for candidates was distributed to the AHA ECC committee, and members with recognized expertise in pediatric and adult resus-citation were nominated by the writing group co-chairs.Writing group members were selected by the AHA Emer-gency Cardiovascular Care Science Subcommittee then approved by the AHA Manuscript Oversight Committee.

The AHA has rigorous conflict of interest policies and procedures to minimize the risk of bias or improper influence during the development of guidelines. Prior to appointment, writing group members disclosed all com-mercial relationships and other potential(including intel-lectual) conflicts. These procedures are described more fully in“Part 2: Evidence Evaluation and Guidelines Devel-opment." Appendix 1 of this document lists the writing group members' relevant relationships with industry.

METHODOLOGY AND EVIDENCE REVIEW

These SOC guidelines are based on extensive evidence evaluation. Most of the evidence evaluation was performed in conjunction with the International Liaison Committee

<EndOfPara>on Resuscitation(ILCOR) and affiliated ILCOR member councils. Three different types of ILCOR evidence reviews (systematic reviews, scoping reviews, and evidence updates) were used in the 2025 process. In most cases,the SOC writing group supplemented the evidence update reviews completed by ILCOR through a literature search of additional databases (Pubmed, EMBASE, CINAHL).For knowledge chunks lacking ILCOR reviews, the writ-ing group worked with AHA librarians to create a relevant search strategy and conducted evidence update reviews.Each of these resulted in a summary of the literature that facilitated guideline development. A more comprehen-sive description of these methods is provided in "Part 2:Evidence Evaluation and Guidelines Development"

Class of Recommendation and Level of Evidence

The writing group reviewed all relevant and current AHA Guidelines for CPR and Emergency Cardiovascular Care and all relevant International Liaison Committee on Re-suscitation Consensus on CPR and Emergency Cardio-vascular Care Science With Treatment Recommendations statements from 2020, 2021, 2022, 2023, and 2024.2-7 Evidence and recommendations were reviewed to deter-mine if current guidelines should be reaffirmed, revised or retired or if new recommendations were needed. The writing group then drafted, reviewed, and approved rec-ommendations, assigning to each a Class of Recommen-dation(COR; ie, strength) and Level of Evidence (LOE;ie, quality, certainty). Criteria for each COR and LOE are described in the Table.

Guideline Structure

The 2025 guidelines are organized into “knowledge chunks," grouped into discrete modules of information on specific topics of management issues.8 Each modular knowledge chunk includes a table of recommendations that uses standard AHA nomenclature of COR and LOE.Recommendations are presented in order of COR: most potential benefit(Class 1), followed by lesser certainty

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Table. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care(Updated December 2024)*

CLASS(STRENGTH) OF RECOMMENDATION

Class 1(STRONG)

Benefit >>> Risk

Suggested phrases for writing recommendations:

•Is recommended

● Is indicated/useful/effective/beneficial

● Should be performed/administered/other

Comparative-Effectiveness Phrases+

- Treatment/strategy A is recommended/indicated in preference to treatment B

- Treatment A should be chosen over treatment B

Class 2a (MODERATE)

Benefit >> Risk

Suggested phrases for writing recommendations:

• Is reasonable

• Can be useful/effective/beneficial

•Comparative-Effectiveness Phrases$\dagger$

_ Treatment/strategy A is probably recommended/indicated in preference to treatment B

It is reasonable to choose treatment A over treatment B

Class 2b (WEAK)

Benefit ≥ Risk

Suggested phrases for writing recommendations:

● May/might be reasonable

● May/might be considered

• Usefulness/effectiveness is unknown/unclear/uncertain or not well-established

Class 3: No Benefit(MODERATE)Benefit= Risk(Generally, LOE A or B use only)

Suggested phrases for writing recommendations:

•Is not recommended

● Is not indicated/useful/effective/beneficial

● Should not be performed/administered/other

Class 3: HARM(STRONG)

Risk> Benefit

Suggested phrases for writing recommendations:

• Potentially harmful

· Causes harm

● Associated with excess morbidity/mortality

$\checkmark$ Should not be performed/administered/other

LEVEL(QUALITY) OF EVIDENCE#

Level A

•High-quality evidence\# from more than 1 RCT

Meta-analyses of high-quality RCTs

•One or more RCTs corroborated by high-quality registry studies

Level B-R

(Randomized)

•Moderate-quality evidence\# from 1 or more RCTs

•Meta-analyses of moderate-quality RCTs

Level B-NR

(Nonrandomized)

• Moderate-quality evidence $\neq$ from 1 or more well-designed, well-executed nonrandomized studies,observational studies, or registry studies

Meta-analyses of such studies

(Limited Data)

Level C-LD

Randomized or nonrandomized observational or registry studies with limitations of design or execution

• Meta-analyses of such studies

•Physiological or mechanistic studies in human subjects

Level C-EO

(Expert Opinion)

• Consensus of expert opinion based on clinical experience

COR and LOE are determined independently (any COR may be paired with any LOE).

A recommendation with LOE C does not imply that the recommendation is weak. Many important clinical questions addressed in guidelines do not lend themselves to clinical trials. Although RCTs are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.

*The outcome or result of the intervention should be specified (an improved clinical outcome or increased diagnostic accuracy or incremental prognostic information).

+ For comparative-effectiveness recommendations (COR 1 and 2a; LOE A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.

\# The method of assessing quality is evolving, including the application of standardized, widely-used, and preferably validated evidence grading tools; and for systematic reviews, the incorporation of an Evidence Review Committee.

COR indicates Class of Recommendation; EO, expert opinion;LD,limited data; LOE, Level of Evidence; NR,nonrandomized;R,randomized; and RCT,randomized controlled trial.

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of benefit (Class 2), and finally, potential for harm or no benefit (Class 3). Following the COR, recommendations are ordered by the certainty of supporting LOE: Level A(high-quality randomized controlled trials) to Level C-EO(expert opinion). This order does not reflect the order in which care should be provided.

A brief synopsis is provided to put the recommenda-tions into context with important background information and overarching management or treatment concepts.Recommendation-specific text clarifies the rationale and key study data supporting the recommendations. When appropriate, flow diagrams or additional tables are included.

Document Review and Approval

The guideline was submitted for blinded peer review to 5 subject matter experts nominated by the AHA. Before appointment, all peer reviewers were required to disclose relationships with industry and any other potential con-flicts of interest, and all disclosures were reviewed by AHA staff. All guidelines were reviewed and approved for publication by the AHA Science Advisory and Coor-dinating Committee and the AHA Executive Committee.Comprehensive disclosure information for peer review-ers is listed in Appendix 2.

These recommendations supersede the last full set of AHA recommendations for SOC, made in 2020.9 The writing group members voted on and approved all guide line recommendations.

REFERENCES

1. Panchal AR, Bartos JA, Wyckoff MH, Drennan IR, Mahgoub M, Schexnayder SM, Rodriguez AJ, Asson C, Wright J. BIrooks SC, et al. Part 2: evi-dence evaluation and guidelines development: 2025 American Heart As-sociation Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2025;152(suppl 2):313-s322. doi: 10.1161/CIR.00000000000000000000000000000000000000000000000000000000000

2. Olasveengen TM, Mancini ME, Perkins GD, Avis S, Brooks S, Castrén M. Chung SP. Considine J. Cooper K, Escalante R, et al: Adult Basic Life Support Collaborators. Adult basic life support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardio-vascular Care Science With Treatment Recommendations. Circulation 2020;142(suppl2):S41-S91. doi: 10.1161/CIR.0000000000000892

3.Wyckoff MH,Singlelet EM, Soar J, Olsovengen TM, Gref R, Liley HG,Dizeman D B, Dhanji F, Andersen L W, Avis SR, et al; Collaborators.2021 In-ternational Consensus on Cardioplumonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: summary from the Basic Life Support; Advanced Life Support; Neonatal Life Sup-port; Education, Implementation, and Teams; First Aid Task Forces; and the COVID-19 Working Group. Circulation. 2022;145:e645-e721: doi: 10.1161/CIR00000000000001017

4.Wyckoff MH, Greif R, Morley PT, Ng KC, Oslevaengen TM, Singlety EMon, Soar J, Chang E, Drennan IR, Liley HG, et al; Collaborators.2022 International Consensus on Cardiopulmonary Resuscitation and Emerg.ency Cardiovascular Care Science With Treatment Recommendations: summary summary summary summary summary summary summary summary summary summary summary summary summary summary summary summary summary summary summary summary summary summary summary summary summary summary summary summary summary

5.Greif R, Bray JE, Djarr T, Drennan IR, Liley HG, Ng KC, Cheng A, Douma MJ,Solechfield, BR Smyth M, et al. 2024 International Consensus on Car-diopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: summary from the Basic Life Support; Advanced Life Support;

Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Edu-cation, Implementation, and Teams; and First Aid Task Forces. Circulation.2024;150:e580-e687. doi: 10.1161/CIR.00000000000001288

6.Greif R, Bhanji F, Bigham BL, Bray J, Breckwoldt J, Cheng A, Duff JP,Gilfoyle E, Hsieh M-J, Wami T, et al. Education, implementation, and teams: 2020 International Consensus on Cardiopulmonary Resusci-tation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2020;142(suppl 2):S222-S283. doi: 10.1161/cir.00000000000000896

7. Berg KM, Bray JE, Ng KC, Liley HG, Greif R, Carlson JN, Morley PT,Drennan IR, Smyth M, Scholefield BR, et al; and Collaborators. 2023 In-ternational Consensus on Cardiopulmonary Resuscitation and Emer-gency Cardiovascular Care Science With Treatment Recommendations summary from the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Resuscitation. 2024;195:109992. doi:10.1016/j.resuscitation.2023.109992

8.Levine GN, O'Gara PT,Beckman JA, Al-Khatib SM, Bircher KK, Cigarroa JE,de Las Fuentes L, Deswaval A, Fleisher LA, Gentile F, et al. Recent innovations,modifications, and evolution of ACC/AHA clinical practice guidelines: an up-date for our constituencies: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Cir-culation.2019;139:e879-e886.doi:10.1161/CIR.0000000000000651

9. Berg KM, Cheng A, Pandhral AR, Topjian AA, Aziz K, Bhanji F, Bigham BL, Hirsch KG, Hoover AV, Kurz MC, et al; on behalf of the Adult Basic and Ad-vanced Life Support, Pediatric Basic and Advanced Life Support, Neonatal Life Support, and Resuscitation Education Science Writing Groups. Part 7:systems of care: 2020 American Heart Association Guidelines for Cardio- pulmonary Resuscitation and Emergency Cardiovascular Care. Circulation.2020;142(suppl 2):S580-S604. doi: 10.1161/CIR.0000000000000899

MAJOR CONCEPTS

The Components of SOC

Any SOC (Figure 1) is shaped by the environment in which it is based. The guidelines provided in this Part ap-ply best to the United States and Canada, which have societal values and structures distinct from other coun-tries. Out-of-hospital cardiac arrest SOC involve person-nel including laypersons who may recognize OHCA and ideally participate as rescuers in the resuscitation, prop-erty owners who maintain automated external defibrilla-tors(AEDs),emergency service telecommunications(also known as dispatchers or call-takers), and basic life sup-port (BLS) and advanced life support (ALS) profession-als working within EMS. In-hospital cardiac arrest SOC personnel often include physicians; nurses; respiratory therapists; pharmacists; occupational, physical, speech/language, and mental health therapists; and other profes-sionals who participate in resuscitation and postresusci-tation care. Following discharge, survivorship and recovery may require physicians, social workers, family, and friends.A major part of cardiac arrest SOC involves education and training for these individuals. Policies and procedures within cardiac arrest SOC include local and national laws as well as protocols and workflows within numerous health care organizations spanning EMS and telecommu-nicators, hospitals, and rehabilitation centers. The estab-lishment and optimization of these SOC often require a local champion. The resources that are essential to car-diac arrest SOC include equipment, medications, physi-cal facilities, and ongoing innovation within these areas.

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Finally, quality management is crucial to optimizing any SOC. This includes ongoing review of data from cardiac arrest resuscitation resulting in system modifications and,ideally, research communication of generalizable findings to permit improvement across systems.

The History of the AHA Chain of Survival

In 1991, the AHA introduced the cardiac arrest Chain of Survival, which depicted a series of sequential steps crucial to resuscitations.1 The initial Chain of Survival de-picted early access to resuscitation, CPR, defibrillation,and advanced care. In 2010, the AHA elaborated on the Chain of Survival to include early recognition of cardiac arrest and activation of the emergency response system,early high-quality CPR, rapid defibrillation, advanced life support, and post-cardiac arrest care.2 The 2020 AHA Guidelines for CPR and ECC depicted 4 distinct but re-lated chains of survival for adults and infants/children experiencing IHCA and OHCA.3 In all but the 2020 adult OHCA chains, the concept of prevention was also insert-ed into the initial link of the Chain of Survival. In 2020, an additional link was added to represent recovery. Recov-ery is unique in that it could be temporally quite distant from the earlier links, all of which occur in rapid succes-sion in the process of resuscitation.

The neonatal chain of care concept("Part 5: Neo-natal Resuscitation") differs from the Chain of Survival presented here. Neonatal resuscitation often involves dif-ferent emphasis on breathing and ventilation than pediatric and adult cardiac arrest do. The timing of transition from neonatal to pediatric guidelines and chains of survival is not strictly defined and depends on the setting, resources,team preferences, and the nature of the clinical deteriora-tion.4 The SOC guidelines cover pediatric and adult resus-citation, not neonatal, and likewise, the 2025 Chain of Survival is specific to pediatric and adult guidelines.

The 2025 AHA Chain of Survival

For 2025, we have elected to revert to a single Chain of Survival (Figure 2) for all forms of cardiac arrest, whether adult or pediatric, in- or out-of-hospital. This was for sim-plicity and because the writing groups felt each link of the chain could be applied to the different forms of cardiac ar-rest, although the details of this application may vary. The symbol for high-quality CPR has changed to demonstrate compressions and breaths, represented by the lungs, in recognition of the importance of breathing in resuscita-tion of pediatric cardiac arrest and a substantial minority of adult cardiac arrests such as those caused by drowning or opioid poisoning. The missing link from the 2025 Chain of Survival is prevention and preparedness. These actions are crucial both to avoid cardiac arrest and to equip sys-tems to rapidly respond to it when it occurs, both of which are important steps in improving survival. The importance

of prevention and preparedness is not lost on the 2025 Guidelines writing groups, but we have elected to defer the addition of this link until the concepts can be better defined and clarified in a dedicated scientific statement.

Organization of This Part Around the Chain of Survival

The SOC chapter provides recommendations across the entire Chain of Survival, and indeed the links of the Chain of Survival have been used to organize the contents of the knowledge chunks. In the following text, we review each link in further detail and discuss some of the con-tents of this Part, which relate to that link.

● Prevention and preparedness: The best out-come from a cardiac arrest is obtained by avoiding having the arrest and thus sparing the body from global ischemia and reperfusion injury. Predictive analytics using patient vital signs and other data offer the promise of providing early warning to avoid a cardiac arrest. Public access to naloxone permits reversal of opioid-induced respiratory arrest prior to progression to cardiac arrest. Preparedness for cardiac arrest includes having appropriate teams for high-acuity conditions(rapid response, shock, high-risk obstetric deliveries) and in- and out-of-hospital resuscitation, with corresponding training and qual-ity improvement protocols in place. Individual and team training is addressed in "Part 12:Resuscitation Education Science"5 and predelivery preparedness is the subject of "Part 5: Neonatal Resuscitation."- Relevant knowledge chunks: Prevention of IHCA, Public Access Naloxone

- Relevant knowledge chunks: Prevention of IHCA, Public Access Naloxone

• Recognition and emergency activation:Detecting the onset of cardiac arrest is increasingly possible through in-hospital monitoring and out-of-hospital wearable devices. Community initiatives to increase layperson recognition of OHCA and activa-tion of EMS and layperson rescue are crucial first steps in resuscitation, which may be aided by tele-communicator recognition and instruction. The use of video technologies to supplement telephone com-munications may assist in recognition and activation.

- Relevant knowledge chunks: Community Initiatives to Improve Layperson Response to OHCA,Telecommunicator Recognition of Cardiac Arrest, Telecommunicator-CPR(T-CPR) Instruc-tions, T-CPR Quality Management, Video-Based Dispatch Systems

● High-quality CPR involves appropriate rate and depth of chest compressions with minimal interrupt-tions. ${ }^{7}$ In many cases, such as pediatric cardiac arrest or opioid-associated cardiac arrest, respiratory sup-port through breaths or ventilation are also critical for successful resuscitation. Appropriate team com-position, with defined roles and clinical debriefing

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and quality improvement, are crucial to optimize CPR efforts. Determining when to terminate OHCA resuscitation efforts or to transport patients still in cardiac arrest to the hospital is another important system question.

- Relevant knowledge chunks: Clinical Debrief-ing, OHCA Team Composition, In-Hospital Code Team Composition, On-Scene OHCA Resuscita-tion

● Defibrillation should be provided promptly, aided by public access to AEDs whose location and delivery may be facilitated using mobile technologies or drones,all of which require appropriately designed SOC.

- Relevant knowledge chunks: Community Initiatives to Improve Rayson Response to OHCA, Public Access Defibrillation

•Advanced resuscitation interventions includ-ing medications, advanced airway interventions,and extracorporeal CPR(ECPR) often necessitate system-level planning.

- Relevant knowledge chunks: Extracorporeal CPR SOC

·Post-cardiac arrest care, including critical care interventions (eg, coronary angiography), targeted temperature management, and neuroprognostica-tion, require expertise and systems that may be regionalized to centers of excellence.

- Relevant knowledge chunks: Recommenda-tion for Cardiac Arrest Centers, Extracorporeal CPR SOC

● Recovery, including effective support for physical,cognitive, emotional, and family needs, continues far beyond discharge from the hospital. Systems are needed to identify these needs and deliver support and, in the case of nonsurvival, to support organ donation, which may permit survival for others.

- Relevant knowledge chunks: Organ Dona-tion, Improving Cardiac Arrest Recovery

Use of Data for Continuous Improvement

Although the Chain of Survival emphasizes key elements in the care of an individual patient, it does not sufficiently emphasize steps that are necessary for improving future performance. Data collected through registries, such as AHA's Get With The Guidelines(for IHCA) and the Cardi-ac arrest Registry to Enhance Survival(for OHCA) initia-tives, have been critical to amassing the data needed to improve each link within the Chain of Survival. The goal is to become a learning health care system8 that uses data to continually improve preparedness and resuscita-tion outcomes. Application of this concept to resuscita-tion SOC has been previously supported and is ongoing in many resuscitation organizations.9,10

● Relevant knowledge chunks: Data Registries to Improve System Performance

REFERENCES

1.Cummins RO,Ornato JP,Thies WH,Pepe PE.Improving survival from sud-den cardiac arrest: the "chain of survival" concept: a statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Association. Cir-citation 1991;83:1832-1847. doi: 10.1161/01.cir83.5.1832

2.Travers AH,Rea TD,Brohow BJ,Edelson DP,Berg RA,Sayre MR,Berg MD,Chameides L,O'Connor RE,Swor RA part:4 CPR Overview. Circulation.2010;122:S676-S684.doi:10.1161/CIRCULATIONAHA.110.970913

3. Berg KM,Cheng A,Panchal AR,Topjian AA,Aziz K,Bhanji F,Bigham BL,Hirsch KG, Hoover AV,Kurz MC,et al; Adult Basic and Advanced Life Sup-port, Pediatric Basic and Advanced Life Support, Neonatal Life Support, and Resuscitation Education Science Writing Groups. Part 7: Systems of Care:2020 American Heart Association Guidelines for Cardioluonary Resus-Cardiovascular Care. Circulation.2020;142(suppl 2)S580-S604. doi: 10.1161/CIR.00000000000000899

4.Sawyer T, McBride ME, Ades A, Kapadia VS, Leone TA, Lakshminusrimaha S,Ali N, Marshall S, Schmolzer GM, Kadlec KD, et al. Considerations on the Use of Neonatal and Pediatric Resuscitation Guidelines for Hospitalized Neo-nates and infants: on behalf of the American Heart Association Emergency Cardiovascular Care Committee and the American Academy of Pediatrics. Pediatrics.2023;153:e2023064681. doi: 10.1542/peds.2023-064681

5.Cheng A, Magid DJ, Auerbach M, Bhanji F, Bigham BL, Blewer AL, Dainty KN, Diederibeh E, Lin Y, Leary M, et al. Part 6: Resus-citation Education Science: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cario-divascular Care. Circulation. 2020;142(suppl 2):S551-S579. doi:10.1161/CIR.000000000000000000000

6.Aziz K, Lee CHC, Escobedo MB, Hoover AV, Kamath-Rayne BD, Kapadia VS, Magid DJ, Niermeyer S, Schmölzer GM, Szyld E, et al. Part 5: Neo-natal Resuscitation: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pe-diatrics. 2021;147:e2020038505E. doi: 10.1542/peds.2020-038505E

7. High-Quality CPR. Accessed May 4, 2025. https://cprheart.org/en/resus-citation-science/high-quality-cpr#

8.Institute of Medicine (US) Roundtable on Evidence-Based Medicine. Washing-ton, DC: National Academies Press; 2007.

9.Committee on the Treatment of Cardiac Arrest: Current Status and Future Directions; Board on Health Sciences Policy; Institute of Medicine. Strategies to Improve Cardiac Arrest Survival: A Time to Act In: Graham R, McCoy MA,Schultz AM,eds.Washington,DC;2015.

10.Neumar RW E,igel B,Callaway CW,Estes NA III,Jollis JG,Jklein ME,Morrison LJ, Peberdy MA, Rabstein A, Rea TD,et al; American Heart As-sociation. American Heart Association response to the 2015 Institute of Medicine report on strategies to improve cardiac arrest survival. Circulation 2015;132:1049-1070.doi:10.1161/CIR.0000000000000233

PREVENTION OF IHCA

|Recommendations for Prevention of IHCA||| |---|---|---| |COR|LOE|Recommendations| |2a|B-R|1. Early warning score (EWS) systems can be beneficial to detect clinical deterioration, prompt an assessment, and facilitate intervention or transfer to a higher level of care.| |2a|B-NR|2. Rapid response teams (RRTs) or medical emergency teams (METs) can be effective in reducing the incidence of cardiac arrest, particularly in general care wards.| |2a|B-NR|3. Implementation of safety huddles to improve situations national awareness of high-risk hospitalized patients and mitigate deterioration can be effective in reducing cardiac arrest rates.|

Synopsis

Survival to hospital discharge after IHCA is approxi-mately 19% for adults and 40% for children. ${}^{1}$ Survival

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is improved when IHCA occurs in a monitored setting,such as an intensive care unit.2,3 Expert panels adjudi-cating adult IHCA and prevention initiatives in pediatric IHCA have suggested that a proportion of IHCAs are indeed preventable by recognizing and dedic re-sources to the deteriorating patient.4-6 Teams such as RRTs and METs are intended to evaluate and provide therapies to rescue and triage patients experiencing clinical decline to a higher level of care(eg, from the general hospital ward to the intensive care unit). Addi-tionally, EWS systems incorporate patient characteris-tics, vital signs, and other physiologic parameters in an effort to identify patients at risk for clinical deterioration prior to IHCA; EWSs may trigger RRT/MET automated responses. The RRT, EWS, and cardiac arrest preven-tion quality improvement initiatives(eg, safety hurdles for high-risk patients) have been adopted by hospitals in an effort to prevent IHCA. Variability in the structure and function of these systems has likely contributed to the inconsistency in reported outcomes regarding ef-ficacy of these interventions. The potential benefits of RRTs, EWSs, or prevention bundles are unlikely to be impacted by patient age; therefore, these recommenda-tions are intended to apply across the pediatric and adult age spectrum.

Recommendation-Specific Supportive Text

1.In a multicenter, international cluster randomized trial, implementation of the bedside pediatric EWS was associated with a decrease in clinically impor-tant deteriorations on the wards of nonterary care hospitals but not with all-cause mortality.7 A recent systematic review identified a statistically signifi-cant increase in unplanned code events when a pediatric EWS was not utilized. This analysis also noted trends demonstrating decreased cardiac arrest events and mortality associated with EWS use.8 Additionally, a recent prospective multicenter cohort study in Latin America demonstrated that pediatric EWS implementation was associated with reduced rates of cardiac arrest and clinical deterioration-related mortality in pediatric patients with cancer.9 In adults, 2 recent observational stud-ies reported contrasting findings about the abil-ity of EWSs to reduce IHCA, ${ }^{10,11}$ which parallels earlier inconsistencies in adult studies. ${ }^{12}$ Artificial intelligence and machine learning algorithms are currently being developed to predict clinical dete-rioration in hospitalized patients. These technolo-gies may improve detection and prevent clinical deterioration better than current systems; however,additional validation and mitigation of bias from the algorithms is warranted. ${ }^{13-16}$

2. The evidence supporting the efficacy of RRT/MET systems in reducing IHCAs or hospital mortality

remains mixed, but their use is widespread and recommended by multiple organizations, which lim-its the prospect of future randomized studies.17-21 The RRT/MET systems have been associated with reductions in hospital mortality and cardiac arrest rates in both pediatric and adult popula-tions.22-24 However, 1 observational registry study of 38 pediatric hospitals found no difference in risk-adjusted mortality rates associated with RRT/MET implementation.25 Variation in RRT structure and function may drive these observed differences in outcomes, and a better understanding of best practices is needed.26

3. A prospective, observational, multicenter quality improvement project demonstrated a 30% reduc-tion in risk-adjusted IHCA rates in pediatric cardiac intensive care units of hospitals that implemented a cardiac arrest prevention bundle.4 A similar single-center quality improvement initiative aimed at improving situational awareness and mitigating deterioration of high-risk patients admitted to the pediatric intensive care unit reduced IHCA rates by 52%.27 Both studies incorporated care team safety huddles on high-risk patients to discuss monitor-ing and preparedness for deterioration to pre-vent progression to cardiac arrest. Neither study observed a reduction in mortality. A similar initiative in hospitalized adult patients in the intensive care unit did not reduce cardiac arrests, but the suc-cesses observed in pediatrics are likely to general-ize to adults with proper intervention design and utilization.28

REFERENCES

1. Tsao CW, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, Baker-Smith CM, Beaton AZ, Boehme AK, Buxton AE, et al;American Heart Association Council on Epidemiology and Preven-tion Statistics Committee and Stroke Statistics Subcommittee. Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association. Circulation. 2023;147:e93-e621. doi:10.1161/CIR.000000000000001123

2. Holmberg MJ, Wiberg S, Ross CE, Kleinman M, Hoeyer-Nielsen AK,Donnino MW, Andersen LW. Trends in Survival After Pediatric In-Hospital Cardiac Arrest in the United States. Circulation.2019;140:1398-1408. doi: 10.1161/CIRCULATIONAHA.119.041667

3.Perman SM, Stanton E, Soar J, Berg RA, Donnino MW, Mikkelsen ME,Edelson DP,Churpek MM,Yang L,Merchant RM;American Heart Associa-tion's Get With the Guidelines®-Resuscitation(formerly the National Regis-ity of Cardiopulmonary Resuscitation) Investigators. Location of In-Hospital Cardiac Arrest in the United States-Variability in Event Rate and Outcomes.J Am Heart Assoc.2016;5:e003638. doi: 10.1161/JAHA.116.003638

4.Alten J, Cooper DS, Kuglman D, Raymond TT, Wooton S, Garza J,Clarke-Myers K, Anderson J, Pasquali SK, Absi M, et al; PC4 CAP Col-laborators. Preventing Cardiac Arrest in the Pediatric Cardiac Intensive Care Unit Through Multicenter Collaboration. JAMA Pediatr. 2022;176:1027-1036. doi: 10.1001/jamapedietrics.2022.2238

5. Lyons PG, Reid J, Richardville S, Edelson DP. A novel structured debriefing program for consensus determinations of in-hospital cardiac arrest predictability and preventability. Resuscitation. 2024;197:110161. doi: 10.1016/j.resuscitation.2024.110161

6. Moskowitz A, Berg KM, Cocchi MN, Chase M, Yang JX, Sarge J,Grossestrueav AY, Sarge T, O'Donoghue S, Donnino MW. Cardiac arrest

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Systems of Care: 2025 AHA Guidelines for CPR and ECC

in the intensive care unit: An assessment of preventability. Resuscitation.2019;145:15-20. doi:10.1016/j.resuscitation.2019.09.003

7. Parshuram CS, Dryden-Palmer K, Farrell C, Gottesman R, Gray M, Hutchinson JS, Heifar M, Hunt EA, Jeffar R, Acollar R, Jacoli J, et al; Canadian Critical Care Trials Group and the EPOCH Investigators. Effect of a Pediatric Early Warn-ing System on All-Cause Mortality in Hospitalized Pediatric Patients: The EPOCH Randomized Clinical Trial. JamIA 2018;319:1002-1012. doi:10.1001/jama.2018.0948

8. Wyckoff MH, Greif R, Morley PT, Ng KC, Olasveeneng TM, Singletary EM, Esar J, Cheng A, Drenner R, ILiyer HG, et al. Collaborations. 2022 International Consensus on Cardiopulmonary Resuscitation and Emer-gency Cardiovascular Care Science with Treatment Recommendations:Summary From the Basic Life Support; Advanced Life Support; Pediat-ric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Circulation 2022: 146e483-857: doi: 10.1011/681(CIRIC)000000000001095

9.Augulnik A, Muniz-Talavera H, Pham LTD, Chen Y, Carrillo AK,Cardenas-Aguire A, Gonzalez Ruiz R, Agarza M, Condeo Morels Zarago TM, Soberanis Vasquez DJ,et al.Effect of paediatric early warning systems(PEWS) implementation on clinical deterioration event mortality among children with cancer in resource-limited hospitals in Latin America: a pro-spective, multicentre cohort study. Lancet Oncol. 2023;24:978-988. doi: 10.1016/S1470-2045(2023)2855-2

10.Creutzburg A, Isbye D, Rasmussen LS. Incidence of in-hospital cardiac arrest at general wards before and after implementa-tion of an early warning score. BMC Emerg Med. 2021;21:79. doi:10.1186/s12873-021-0469-50

11. Hogan H, Hutchings A, Wulff, J Carver C, Holdsworth E, Nolan J, Welch J,Harrison D, Black N. Type of Track and Trigger system and Indence of in-hospital cardiac arrest: an observational registry-based study. BMC Health Serv Res 2020;208:885. doi:10.1186/271912-030-02761-572.

128:Rif Ghan B, Rhifman B, Bray B, Bruckwolt J, Cheng D, Cheng A, Duff JP, Gilfoey L,Ehsie M.-J, Iwami T, et al. Education, Implementation, and Teams: 2020 International Consensus on Dopiandopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2020;142(suppl 2):S222-S283. doi:10.1161/cir.0000000000000896

13. Cho KJ, Kim KH, Choi Y, D. Kim J. External Validation of Deep Learning-Based Cardiac Arrest Risk Management System for Predict-ing In-Hospital Cardiac Arrest in Patients Admitted to General Wards Based on Rapid Response System Operating and Nonoperating Peri-ods: A Single-Center Study. Crit Care Med. 2024;52:e110-e120. doi: 10.1097/CCM000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000

42 L.49LO H.Jamb, Bachstam, D.Bode RS, Maa T, Hoffman JM, Rust SW.The Deterioration Risk Index: Developing and Pilating a Machine Learning Algorithm to Reduce Pediatic Inpatient Deterioration. Pediat Crit Care Med.2023;24:322-333. doi:10.1097/PCC.000000000003186

15.Salehinejad H, Meehan AM, Rahman PA, Core MA, Borah BJ, Caraballo RJ. Novel machine learning model to improve performance of an early warning system in hospitalized patients: a retrospective multi-site cross-validation study. EclincicalMedicine. 2023;66:102312. doi:10.1016/j.jeclm.2023.102312.

16. Winsml OJ, Edelson DP, Churpek MM, Taneja M, Shah NS, Datta A,Wang CH. Ravichandran U, McNlyc P. Kharrisc M, et al. The impact of a Machine Learning Early Warning Score on Hospital Mortality: A Multi-center Clinical Intervention Trial. Crit Care Med. 2022;50:1339-1347. doi:10.1097/CC0000000000004692

17. Bhongir D,Lander H,Green M,Straney L,Jones D,Pilcher D,Reduction of in-hospital cardiac arrest rates in intensive care-equipped New South Wales hospitals in association with implementation of Between the Flags rapid re-sponse system. Intern Med J.2021;51:375-384. doi:10.1111/imj.14812

18. Chan PS, Graf R, Anderson R, Biumhott Circout to S. Considine J.-De Caen AR, Djarar T, Doll A, Daouma MJ, et al; International Liaison Commit-tee on Resuscitation. Ten Steps Toward Improving In-Hospital Acar-rest Quality of Care and Outcomes. Resuscitation 2023;193:109996: doi:10.1016/j.resuscitation.2023.109996

19. Girotra S, Jones PG, Peberdy MA, Vaughan-Sarrazin MS, Chan PS;American Heart Association GWTG-Resuscitation Investigators. As-sociation of Rapid Response Teams with Hospital Mortality in Medi-care Care patients. Circ Cardiovasc Dual Outcomes. 2022:15e008901. doi:10.1161/CIRCOUTCOMES122.2008901

20. Honarmand K, Wax RS, Penyer D, Lighthall G, Danesh V, Rocherg B,Cheacham L, Davis DP-Deva M, Downi et J. Society of Critical Care Medicine Guidelines on Recognizing and Respondining to Clinical De-terior Outside the ICU: 2023: Crit Care Med. 2024:52:314-330. doi:10.1097/CCM/000000000000006072

21. McGaughey J, Fergusson DA, Van Bogaert P, Rose L. Early warning systems and rapid response systems for the prevention of patient dete-rioration on acute adult hospital wards. Cochrane Database Syst Rev.2021:11:CD005529 doi:10.1002/14651858.CD005529.pub3

22. Bonafide CP, Localio AR, Roberts KE, Nadkarni VM, Weirich CM, Keren R. Impact of rapid response system implementation on critical de-terioration events in children. JAMA Pediatr. 2014;168:25-33. doi: 10.1001/jamapediac.2023.3266

23. Kolovos NS,Gill J,Michelson PH,Doctor A,Hartman ME.Reduction in Mor-tality Following Pediatric Radiative System Implementation. Pediatr Crit Care Med.2018;19:477-482. doi:10.1097/PCC.00000000000001519

24. Maharaj R, Raffaele L, Wendon J. Rapid response systems: a sys-tematic review and meta-analysis. Crit Care. 2015;19:254. doi: 10.1186/s13054-015-0973-y

25.Kutty S. Jones PG,Karels Q,Joseph N, Spertus JA, Chan PS. Association of Pediatric Medical Emergency Teams With Hospital Mortality. Circulation.2018;137:38-46. doi:10.1161/CIRCULATIONAHA.117.029535

26. Dukes K, Bunch JL, Chan PS, Guettingan TC, Lehrich JL, Trumpower B, Harrod M, Krein SL, Kellenberg JE, Reisinger HS, et al. Assess-ment of Rapid Response Teams at Top-Performing Hospitals for In-Hospital Cardiac Arrest. JAMA Intem Med. 2019;179:1398-1405. doi: 10.1001/jamainternmed.2019.2420

27. Dewan M, Soberano B, Sosa T, Zackoff M, Hagedorn P, Brady PW,Chima RS, Stalets EL, Moore L, Britto M, et al. Assessment of a Situa-tion Awareness Quality Improvement Intervention to Reduce Car-diac Atrests in the PICU. Pediatr Crit Care Med. 2022;23:4-12. doi:10.1097/PCC.0000000000000002816

28. Moskowitz A, Berg KM, Cocchi MN, GrossestreuerAV, Issa M, Balaji L, Chase M, Yang JX, Sarge J, O'Donoghue S, et al. A Trigger and Re-sponse System for Preventing Cardiac Arrest in the ICU. Crit Care Explor.2021;3e0557. doi: 10.1097/CEC.0000000000005557

PUBLIC ACCESS NALOXONE

|Recommendations for Public Access Naloxone|| |---|---| |COR|LOE| |BOR|1. Public policies should allow for possession, use, and immunity from civil and criminal liability for good faith administration of naloxone by lay rescucers.| |2a|B-NR| |2a|2. Naloxone distribution programs can be beneficial to increase naloxone availability among lay rescucers and decrease mortality from opioid- related overdose.|

Synopsis

Opioid-related overdoses continue to represent a ma-jor public health concern in the United States.1 An estimated 1 in 6 to 1 in 3 OHCAs are related to an overdose, most commonly involving opioids.2-4 One com-mon public health harm reduction strategy to decrease opioid-related overdose mortality is increasing access to naloxone in the community, also known as public access naloxone(PAN). Naloxone is an opioid antagonist that is used to reverse respiratory depression due to opioid overdose.5 In March 2023, the first over-the-counter naloxone product was approved for use in the United States.6 Presently,naloxone nasal spray is the only over-the-counter formula available for public distribution in the United States. While the dosage is intended for adults, pediatric postmarketing data have not revealed adverse events when it is used in children.7 Despite the availability of naloxone over the counter, cost remains a barrier to access and not all states have legislation

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to support and protect its use by lay rescuers,89 though all states and Washington, DC, have laws increasing ac-cess to naloxone.10 Legislation case may permit coprescribing of naloxone with opioid prescriptions or decriminaliza-tion of distribution, possession, and administration of naloxone. Beyond legislation, specific PAN strategies include naloxone distribution programs, naloxone vend-ing machines, and stationing of naloxone in public set-tings(similar to AED cabinets).11-14 No evidence has been found to suggest that PAN increases opioid use or opioid-related overdoses in the community.15,16 Second-ary prevention measures include provision of naloxone by emergency departments and EMS after a nonfatal opioid-related overdose.17

Recommendation-Specific Supportive Text

1. Four observational studies18-21 were found that examine the effect of naloxone access laws on opioid-related overdose mortality. Two18,19 demon-strated that legislative changes making naloxone available without a prescription were associated with decreased opioid-related overdose mortal-ity on a population level. One study identified an increase in opioid-related overdose deaths follow-ing implementation of naloxone access laws.21 One study found differing changes in opioid-related overdose mortality based on US region(Northeast versus West) with the implementation of laws allowing lay rescuer distribution; however, posses-sion laws(ie, allowing lay rescuers to carry nalox-one without a prescription) were associated with decreased mortality.20 The ecological design of these studies poses challenges in assessing cau-sality, as the increase in deaths may reflect general increases in opioid-related overdoses and deaths in a community rather than an effect attributable to naloxone access legislation. The potential benefit at a population level of increasing access to this effective, lifsaving medication was deemed by the writing group to greatly outweigh the risks.

2. There has been inconsistent evidence of the effect of PAN on opioid-related overdose mortal,depending on mode of naloxone access (ie,law versus distribution program), region stud-ied, and time frame. Most studies have examined individual opioid education and naloxone distri-bution programs or used an ecological design to estimate the population-level effect. Six observa-tional studies22-27 were found that examine the effect of community-based naloxone distribution programs, where naloxone was provided without a patient-specific prescription, on opioid-related overdose mortality. Four studies22-25 found a decrease in opioid-related overdose mortality fol-lowing program implementation, with evidence of

a dose-dependent effect. However, 2 additional studies26,27 found either no significant difference after program implementation or an increase in the number of opioid-related deaths per month. As these studies were ecological, causality cannot be inferred.The increase in deaths may, again, reflect secular trends of opioid-related overdose burden in the community. There also remains a lack of direct evidence regarding the effect of PAN on survival after opioid-associated OHCA.

REFERENCES

1. National Center for Health Statistics, Centers for Disease Control and Pre-vention.U.S.Overdose Deaths Decrease in 2023,First Time Since 2018.In;2024.

2. Wang RC,Montoy JCC,Rodriguez RM,Menegazzi JJ,Lacocque J, Dillon DG. Trends in presumed drug overdose out-of-hospital cardiac arrests in San Francisco, 2015-2023. Resuscitation. 2024;198:110159. doi:10.1016/j.resuscitation.2024.110159

3. Shekhar AC, Nathanson BH, Mader TJ, Coute RA. Cardiac Arrest Follow-ing Drug Overdose in the United States: An Analysis of the Cardiac Arrest Registry to Enhance Survival. J Am Heart Assoc.2024;13:e031245. doi: 10.1161/JAHA.123.031245

4. Yogeswaran V, Drucker C, Kume K, Poel A, Yarid N, Leyde S, Rea TD,Chatterjee NA. Presentation and Outcomes of Adults With Overdose-Related Out-of-Hospital Cardiac Arrest. JAMA Netw Open.2023;6:e2341921. doi:10.1001/jamanetworkopen.2023.4.1921

5. Office of the Surgeon General. US Surgeon General's advisory on naloxone and opioid overdose.Accessed August 28,2024.https://www.hhs.gov/sur/geongeneral/reports-and-publications/addiction-and-substance-misuse/adversory-on-naloxone/index.html#ftn3.2018.

6.Office of the Commissioner. FDA Approves First Over-the-Counter Nal-oxone Nasal Spray. U.S. Food and Drug Administration. Accessed 1049.gov/news-events/press-announcements/fda-approves-first-over-counter-naloxone-nasal-spray.2023.

7.Saely S. Narcan Pediatric Postmarketing Pharmacovilance Review. Food and Drug Administration. Accessed May 2,2025.https://www.fda.gov/me-hedron/123725/download.2019.

8. Davis C, Chang S, Carr D, Hernandez-Delgado H, Breen S, Lieberman AJ, Razavi S, Dennis A. Legal interventions to reduce overdose mortality: Nalox-one access laws. Accessed August 28,2024. https://www.networkforphyl.org/wp-content/uploads/2023/11/Naloxone-Access-Laws-50-State-Survey-2023.pdf.2023.

9.Marley GT, Annis IE, Egan KL, Delamater P, Carpenter DM. Nal-oxone availability and Cost After Transition to an Over-the-Counter Product. JAMA Health Forum. 2024;5:e241920. doi:10.1001/jamahealthforum.2024.1920

10. Prescription Drug Abuse Policy System. Naloxone Overdose Prevention Laws. Accessed August 28,2024. https://pdaps.org/datasets/laws-reg-ulating-administration-of-naloxone-1501695139.2022.

11. Wheeler E, Jones TS,Gilbert MK, Davidson PJ; Centers for Disease Con-trol and Prevention(CDC). Opioid Overdose Prevention Programs Providing Naloxone to Laypersons - United States, 2014. MMWR Morb Mortal Wkly Rep.2015;64:631-635.

12.Weiner J., Murphy SM, Behrends C. Expanding access to naloxone: a review of distribution strategies. Issue Brief. 2019;23:132.

13.Goldberg SA,Dworkis DA,Liao VT,Eyre AJ,Albert J,Fawcett MM,Narovec CM,DiClemente J, Weinmer SG. Feasibility of Bystander Administration of Public-Access Naloxone for Opioid Overdose. Prehosp Emerg Care.2018;22:788-794. doi:10.1080/10903127:2018.1461284

14. Kohli S, Garg J, Velasquez DE, Weiner SG. Designing a public access naloxone program for public transportation stations. Healthc(Amst).2023;11:100694.doi:10.1016/j.hjdsi.2023.100694

15. Tse WC, Djordjevic F, Boraja V, Picco L, Lam T, Olsen A, Larney S, Dietze P,Nielsen S. Does naloxone provision lead to increased substance use?A systematic review to assess if there is evidence of a'moral hazard' as-sociated with naloxone supply. Int J Drug Policy. 2022;100:103513. doi:10.1016/j.drugpo.2021.103513

16.$\text{Colledge-Fisby S, Rathayake K, Nielsen S, Stoove M, Maher L, Agius}$PA, Higgs P, Dietze P. Injection Drug Use Frequency Before and After

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Take-Home Naloxone Training. JAMA Netw Open.2023;6:e2327319. doi:10.1001/janametworkopen.20237319.

17. Sindhwani MK,Friedman A,O'Donnell M,Stader D,Weiner SG.Naloxone distribution programs in the emergency department: A scoping review of the literature. J Am Coll Emerg Physicians Open. 2024;5:e13180. doi:10.1002/emp2.13180

18. McClellan C, Lambmelan BH, Ai AMM, Mutter R, Davis CS, Wheeler E,Pemberton M, Kalh AN. Alpo-oxidoverse laws association with opi-oid use and overdose mortality. Addict Behav. 2018;86:90-95. doi:10.1016/j.jaddbeh.2018.03.014

19. Tabatabai M, Cooper RL, Wlius DM, Edgerton RD, Ramesh A, MacMaster SA, Patel PN, Singh KP. The Effect of Naloxone Access laws on Fatal Synthetic OpidO Overdose Fatalty Rates. J Prim Care Community Health.2023;14:21501319221147246. doi: 10.1177/21501319221147246

20. You HS, Ha J, Kang CY, Kim L, Kim J, Shen JJ, Park SM, Chun Sy, Hwang J, Yamashita, T. et al. Regional variation in states' naloxone acces-sibility laws in association with opioid overdose death rates-Observational study(STROBE compliant). Medicine(Baltim). 2020:99e20033. doi:10.1097/MD.0000000000020033

21. Lee B, Zhao W, Yang KC, Ahn YY, Perry BL. Systematic Evaluation of State Policy Interventions Targeting the US. OpiE pidi demic, 2007-2018. JAMA Netw Open. 2021;4:e2036687. doi: 10.1001/jamanetworkopen.2020:366877.

22. Frermeth CE, Ancona RM, Brown JL, Punches BE, Ryan SA, Ingram T,Lyons MS.Evaluation of a large-scale health department naloxone distribu-tion program: Per capita naloxone distribution and overdose morality. PLoS One.2013;8:e18928959. doi:10.1371/journal.pone.0289959

23. Hakansson A, Alkano Blomé M, Insendah P, Landgren M, Malmqvist U,Troberg K. Distribution of intralanal naxo potential to potential opioid overdose bystanders in Sweden: effects on overdose mortality in a full region-wide study. BMJ open.2024;14:e074152.doi:10.1136/bmppen-2023-074152

24.Nesoff ED,Meisel ZF,Saeed H.,Martins SS.Mesons-Headirectional Dis-parities in Community-Based Naloxone Access for Opioid Overdose Preven-tion J.Lutan Health.2024;10:0164-74. doi:10.1007/s1152-0042-003821-2

25.Walley AY,Xuan Z,Hackman HH,Quinn E,DoE-Simkins M,Sorensen-Alawad A, Ruiz S,Ozonoff A. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMI.2013;346:f174. doi:10.1136/bmj.f174

26. Yeung MEM, Lee CH, Hartmann R, Lang E. Opioid-related emergen-cy department visits and deaths after a harm-reduction intervention:a retrospective observational cohort time series analysis. CMAJ Open.2023;11:E537-E545.doi:10.9787/cmajo.20220104

27. Naumann RB, Durrance CP, RanupwalSlia, Austin AE, Proescholdbell S,Childs R, Marshall SW, Kansagra S, Shanahan ME. Impact of a community-based naloxone distribution program on opioid overdose death rates. Drug Al-chool Depend.2019;204:107536. doi:10.1016/j.drugaldec.2019.06.038

COMMUNITY INITIATIVES TO IMPROVE LAY RESCUER RESPONSE TO OHCA

|Recommendations for Community Initiatives to Improve Lay Resuer Response to OHCA||| |---|---|---| |COR|LOE|Recommendations| |2a|B-NR|1. Implementing a bundle of community initiatives is a reasonable strategy to improve lay rescuer response to OHCA.| |2a|B-NR|2. Increasing the availability of instructor-led training in communities can be effective to improve lay rescuer response to OHCA.| |2a|B-NR|3. Mobile technologies to summon responders to nearby OHCA events is a reasonable strategy to increase timely relay rescuer CPR and AED use.| |2b|C-LD|4. Mass media campaigns may be considered to promote learning of CPR skills in all populations.| |2b|C-LD|5. It may be reasonable for communities to implement policies that require CPR certification in the general public.|

Synopsis

Early CPR and debiflation are staples of the Chain of Survival. Despite the recognized role of lay rescuers in improving OHC AO outcomes, most communities still ex-perience low rates of lay rescuer CPR and AED use.Community awareness of cardiac arrest and response by providing CPR play key roles in shaping survival. Interven-tions at the community level to improve awareness and responsiveness by lay rescuers include initiatives such as instructor-led training(eg,classes),mobile technology to summon the public, mass media campaigns(eg, social media and television advertisements), and legislative pol-icies for CPR training. Community interventions exist at the local, state, regional, or national level and may involve collaboration between government and organizations. In-terventions are most likely to be successful when taking into context the patient population, geography, and other cultural factors and when implemented with other inter-ventions to optimize resuscitation.

Recommendation-Specific Supportive Text

1. Ten observational studies evaluated the impact of bundled interventions on lay rescuer CPR rates and survival outcomes.1-9 Lay rescuer CPR rates were improved in 7 of these studies.1-3,5-8 Interventions included classes taught in person in schools, work-places, and the community; videos watched asyn-chronously; and public messaging through various forms of media.

2. Nine observational studies assessed the impact of instructor-led training.10-18 Three of 5 stud-ies found improvement in survival with good neurological outcomes after implementation of instructor-led training.11,12,15,17,18 Two of 3 stud-ies reported improvements in survival to hospital discharge,11,13,18 and 1 study demonstrated an improvement in ROSC after instructor-led train-ing.13 Instructor-led training improved lay rescuer CPR rates by 10% to 19% in 5 studies.10-14

3. The 2020 AHA guidelines reviewed 6 observa-tional studies and 1 randomized controlled trial(RCT) and found uniformly positive data supporting the use of mobile technologies to summon lay res-cuers for CPR.19 Thirteen new observational stud-ies20-32 and 1 new RCT33 were identified. Twelve studies examined a period when mobile technol-ogy was in place without a comparison period.One study compared the implementation of mobile technology with a retrospective cohort. There was universal improvement in rates of bystander CPR when a mobile technology alert was accepted by a lay rescuer but inconsistent data on the incidence of ROSC and survival. Studies with improved sur-vival(4/13) were associated with higher population

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density and high acceptance of the alert by lay rescuers.23 The SAMBA trial randomized mobile technology to test implementation of deployment strategies for directing lay rescuers to the patient location versus nearest available AED first. The primary outcome of AED attachment was not sig-nificantly higher in the group directed to AEDs first(13.2% versus 9.5%, P=0.08); there were also no significant differences in rates of lay rescuer CPR or defibrillation.30

4.One observational study reported a 12% abso-lute increase in lay rescuer CPR rates during a campaign of television advertisements promoting lay rescuer CPR34 The durability of this improve-ment was not assessed. However, mass distribu-tion (via mail) of a 10-minute CPR instructional video to 8659 households resulted in no signifi-cant improvement in lay rescuer CPR rates when compared with a community with households that did not receive a video (47\% in intervention house-holds, 53\% in controls).35

5. Two studies looked at the effectiveness of laws requiring CPR certification either to graduate high school or to receive a driver's license. Both studies showed increases in lay rescuer CPR and survival to hospital discharge.36,37

REFERENCES

1. Bergamo C, Bui QM, Gonzales L, Hinchery P, Sassan C, Cabasan JG. TEAKE: A 10. community approach to teaching compression-only CPR to high-risk zip codes. Resuscitation. 2016;102:75-79. doi: 10.1016/j.resuscitation.2016;02.019.20

2. Hwang WS, Park JS, Kim SJ, Hong YS, Moon SW, Lee SW. A system-wide approach from the community to the hospital for improving neuro-logic outcomes in out-of-hospital cardiac arrest patients. Eur J Emerg Med 2017;24:87-95. doi: 10.1016/MEJ.0000000000000313

3. Møller Nielsen A, Loub Isye Dk, Knudsen Lpert F, Rasmussen LS. Engaging a whole community in resuscitation. Resuscitation. 2012;83:1067-1071.doi:10.1016/j.resuscitation.2012.04.012

4.Nielsen AM, Isbye DL, PERT Fk, Rasmussen LS. Persisting effect of com-munity approaches to resuscitation. Resuscitation. 2014;85:1450-1454.doi:10.1016/j.resuscitation.2014.08.019

5.Ro YS,Shin SD,Song K.Hong,SQ Jr,NYt Lee,Shu CD,Sho YI Public aware-ness and self-efficacy of cardiopulmonary resuscitation in communities and outcomes of out-of-hospital cardiac arrest: A multi-level analysis. Resuscita-tion,2016;102:17-24, doi:10.1016/j.resuscitation.2016.02.004

6.Ro YS,Song KJ,Shin SD,Hong KJ,Park JH,Song KJ,ShO. Asso-ciation between county-level cardiopulmonary resuscitation training and changes in Survival Outcomes after out-of-hospital cardiac arrest over 5 years: A multilevel analysis. Resuscitation. 2019;139:291-298. doi: 10.1016/j.resuscitation.2019.01.012

7. Wissenberg M, Lippert FK, Feweke P, Hansen CM, Christensen EF,Jans H, Hansen PA, Lang-Jensen T, Olesen JB, et al. Association of national initiatives to improve cardiac arrest management with rates of bystander intervention and patient survival after out-of-hospital cardiac arrest. JAMA 2013;310:1377-1384. doi:10.1001/jama.2013.278483

8.Del Rios M, Han J, Cano A, Ramirez M, Gorales C, Campbell T, Hoek TP Pay It Forward: High School Video-based Instruction Can Disseminate CPR Knowledge in Priority neighborhoods. West J Emerg Med 2018;19:423-429.429:10.58,1011:579.10.35108

9. Isbyde RL, Smussen LS, Ringsted C, Lippert FK. Disseminating cardio, pulmonary resuscitation training by distributing 35,000 personal mani-kins among school children. Circulation. 2007;116:1380-1385. doi:10.1161/CIRCULATIONAHA.107:10617

10. Boland LL, Formanek MB, Harkins KK, Frazee CL, Kamrud JW, Stevens AC, Lick CJ, Yannopoulos D. Minnesota Heart Safe Communities: Are community-based initiatives increasing pre-ambulance CPR and AED use?Resuscitation.2017;119:33-36. doi:10.1016/j.resuscitation.2017.07.031

11. Fordyce CB, Hansen C, Kragholm K, Dupre ME, Jollis JG, Roettig ML,Becker LB, Hansen SM, Hinohara TT, Corbett CC, et al. Association of Public Health Initiatives With Outcomes for Out-of-Hospital Cardiac Arrest at Home and in Public Locations. JAMA Cardiol. 2017;2:1226-1235. doi: 10.1001/jamacardio.2017.3471

12. Malta Hansen C, Kragholm K, Pearson DA, Tyson C, Monk L, Myers B,Nelson D, Dupre ME, Fosbol EL, Jollis JG, et al. Association of Bystander and First-Responder Intervention With Survival After Out-of-Hospital Car-diac Arrest in North Carolina, 2010-2013. JAMA 2015;314:255-264. doi:10.1001/jama.2015.7938

13. Tay PJm, Pek PP, Fan Q, Ng YY, Leong BS, Gan HN, Mao DR,Chia MYC, Cheah SO, Doctor N, et al. Effectiveness of a commu-nity based out-of-hospital cardiac arrest(OHCA) interventional bun-die: Results of a pilot study. Resuscitation. 2020;146:220-228. doi:10.1016/j.resuscitation.2019.10.015

14. Baldi E, Contri E, Savastano S, Canevari F, Mosca C, Molinari S, Raimondi M.Teaching CPR in secondary schools improves the rate of bystander CPR in a city and its neighbourhoods: Results of #SCUOLESICURE project. Re-suscitation.2016;106:e11. doi:10.1016/j.resuscitation.2016.07.025

15.Jensen TW,Ersoll AK,Folke F,Wolthers SA,Andersen MP,Blomberg SN, Andersen LB, Lippert F, Torp-Pedersen C, Christensen HC. Train-ing in Basic Life Support and Bystander-Performed Cardiopulmo-nary Resuscitation and Survival in Out-of-Hospital Cardiac Arrests in Denmark, 2005 to 2019. JAMA Netw Open. 2023;6:e233338. doi:10.1001/jamanetworkopen.2023.3338

16.Soar J, Bottiger BW, Carlri P, Couper K, Deakin CD, Djär V, Tott L, Oasveenchen T, Paal P, Pellis T, et al. European Resuscitation Council guide-lines 2021: Adult advanced life support. Resuscitation.2021;161:115-151.doi:10.1016/j.resuscitation.2021.02.010

17.Nishiyama C,Kitamura T,Sakai T, Murakami Y, Shimamoto T, Kawamura T,Yonezawa T, Nakai S, Marukawa S, Sakamoto T, et al. Community-Wide Dissemination of Bystander Cardiopulmonary Resuscitation and Automated External Defibrillator Use Using a 45-Minute Chest Compression-Only Car-diopulmonary Resuscitation Training. J Am Heart Assoc. 2019;8:e009436.

18. Uber A, Sadler RC, Chasseee T, Reynolds JC. Does Non-Targeted Communi-ty CPR Training Increase Bystander CPR Frequency? Prehosp Emerg Care.2018:22:785-781: doi:10.1080/10903127.2018.1459978

19. Berg KM, Cheng A, Panchal AR, Topjian AA, Aziz K, Bhanji F, Bigham BL,Hirsch KG, Hoover AV, KURz MC, et al; Adult Basic and Advanced Life Sup-port, Pediatric Basic and Advanced Life Support, Neonatal Life Support, and Resuscitation Education Science Writing Groups. Part 7: Systems of Care:2020 American Heart Association Guidelines for Cardiopulmonary Resus-citation and Emergency Cardiovascular Care. Circulation. 2020;142(suppl 2):S580-S604. doi: 10.1016/CIR.000000000000899

20.Andelius L, Malta Hansen C, Lippert FK, Karlsson L, Torp-Pedersen C,KjaerBersoll A, Kober L, Collatz Christensen H, Blomberg SN, Gislason GH,et al. Smartphone Activation of Citizen Responders to Facilitate Defibrilla-tion in Out-of-Hospital Cardiac Arrest. J Am Coll Cardiol. 2020;76:43-53. doi: 10.1016/j.jacc.2020.004.073

21. Andelius L, Malta Hansen C, Jonsson M, Gerds TA, Rajan S, Torp-Pedersen C,Cliesson A, Lippert F, Tofte Gregers MC, Berglund E, et al. Smartphone-activated volunteer responders and bystander configuration for out-of-hospital cardiac arrest in private homes and public locations. Eur Heart J Acute Cardiovasc Care.2023;12:87-95. doi: 10.1093/ehaccu/zuac165

22.Blewer AL, Ho AFW, Shahidah N, White AE, Pek PP, Ng YY, Mao DR,Tah,Chia,New. Los,ong BS, et al. Impact of bystander-focused pub-lic health interventions on cardiopulmonary resuscitation and sur-vival: a cohort study. Lancet Public Health. 2020;5:e428-e436. doi:10.1016/S2468-2667(20)30140-7

20. Derkennie C, Jost D, Roquet F, Dardel P, Kedzierewicz R, Mignon A, Travers S, Frattini B, Prieux L, Rozenberg E, et al. Mobile Smartphone Technology is Associated With Outf-of-hospital Cardiac Arrest Survival Improvement:The First Year“Greater Paris Fire Brigade” Experience. Acad Emerg Med.2020;27:951-962. doi:10.1111/acem.13987

24.Gamberini L, Deli-Guidence D, Saltalamacchia S, Taylor B, Sala I, Allegri D,Pastori A, Coniglio C, Gondini G, Semeraro F; Collaborators. Factors associ-ated with the arrival of smartphone-activated first responders before the emergency medical services in Out-of-Hospital cardiac arrest dispatch. Re-suscitation.2023;185:109746. doi:10.1016/j.resuscitation.2023.109746

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25.Gregers MCT, Andelius L, Kjoelby JSu, Julabrange My, Jakobsen LK,Bo Christensen N, Kragh AR, Hansen CM, Lyngby RM, Vaegmose U,et al.Association Between Number of Volunteer Responders and Inter-ventions Before Ambulance Arrival for Cardiac Arrest. J Am Coll Cardiol 2023;81:668-680. doi: 10.1016/j.jacc.2022.11.047

26. Nielsen CG,Folke F,Andelius L,Hansen CM,Vaeggemose U,Christensen EF,Torp-Pedersen C,Erisell AK, Greggers MCT. Increased bystander interven-tion when volunteer responders attend out-of-hospital cardiac arrest. Front Cardiovasc Med.2022;9:1030843. doi:10.3389/fcmv.2022.1030843

27. Oosterveon DM, de Visser M, Heringhaus C. Improved ROSC rates in out-of-hospital cardiac arrest patients after introduction of a text message alert system for trained volunteers. Neth Heart J. 2023;31:36-41. doi:10.1007/s12471-021-01656-6.

28. Pjils RWM, Nelemans PJ, Rahel BM, Gorgels APM. Characteristics of a novel citizen rescue system for out-of-hospital cardiac arrest in the Dutch province of Limburg: relation to incidence and survival. Neth Heart J.2019;27:100-107. doi:10.1007/s12471-018-1215-0

29. Pijs RWM, Nelemans RI, Rahel BM, Gorgels APM. Circumstances and causes of sudden circulatory arrests in the Dutch province of Limburg and the involvement of citizen rescuers. Neth Heart J. 2018;26:41-48. doi:10.1007/s12471-018-1057-1-10

30. Smida T, Salerno J, Weiss L, Martin-Gill C, Salcido DD. PulsePoint dis-patch associated patient characteristics and prehospital outcomes in a mid-sized metropolitan area. Resuscitation. 2022;170:36-43. doi:10.1016/j.resuscitation.2021.11.007

31.Smith CM Lall, Rofhergil RT, Spairg R, Perkins GD, The effect of the GoodSAM volunteer first-pricer response app on survival to hospital discharge following out-of-hospital cardiac arrest. Ear Heart J Acute Cardiovasc Care.2022;11:20-31.dol.101093/ehjacc/uzabu 103

32. Wong XY,Fan Q, Shahid N, De Souza CR, Arulanandam S, Ng YY, Ng WM, Leong BSH, Chia MV, Cong MEH. Impact of dispatcher-assisted cardiopulmonary resuscitation and myResponder self appon by on-stander resuscitation. Ann Acad Med Singap. 2021;50:212-221. doi:10.4102/annals-acadmedg.2020458

33. Berglund E, Hollenberg J, Jonsson M, Svensson L, Claesson A, Nord A, Nordberg P, Forsberg S, Rosenqvist M, Lundgren P, et al. Effect of Smartphone Dispatch of Volunteer Responders on Automated Ex-ternal Defibrillators and Out-of-Hospital Cardiac Arrests: The SAM-BA Randomized Clinical Trial. JAMA Cardiol. 2023;8:81-88. doi: 10.1001/jacomardi.2022.4362

34. Becker L, Vath J, Eisenberg M, Meischke H. The impact of television public service announcements on the rate of by bystander CPR. Phesorp Emerg Care.1999;3:353-356. doi:10.1080/10903129908958968

35.Eisenberg M, Damon S, Mandel L, Tewodros A, Meischke H, Beaupied E,Bennett J, Guildner C, Ewell C, Gordon M, CPR instruction by videotape:results of a community project. Ann Emerg Med. 1995;25:198-202. doi:10.1016/s0196-0644(95)70324-1

36. Li S, Qin C, Zhang H, Maimaitiming, M Shi J, Feng Y, Huang K, Bi Y, Wang M, Zhou Q, et al. Survival After Out-of-Hospital Cardiac Arrest Before and After Legislation for Bystander CPR. JAMA Netw Open.2024;7:e247909. doi: 10.1001/jamanetworkopen.2024.7909

37.Vetter VL,Griffis H, Daldorf KF, Naim MY, Rossano J, Vellano K, McNally B, Glatz AC; CARES Surveillance Group. Impact of State Laws: CPR Education in High Schools. J Am Coll Cardiol. 2022;79:2140-2143. doi:10.1016/j.ijacc.2022.03.359

TELECOMMICATOR RECOGNITION OF CARDIAC ARREST

|Recommendations for Telecommunicator Recognition of Cardiac Arrest|||| |---|---|---|---| |COR|LOE|Recommendations|| |1|C-LD|1|1. If the patient is unresponsive with abnormal, argonal, or absent breathing, the telecommunicator should assume that the patient is in cardiac arrest.| |2|C-EO|2|Telecommunications should determine the location of the event before questioning to identify OHCA, to allow for simultaneous dispatching of EMS response.|

Synopsis

Emergency telecommunications serve as a critical link in the OHCA Chain of Survival, improving early cardiac ar-rest recognition and provision of lay rescuer CPR while sending EMS resources to the scene. Telecommunica-tors must quickly diagnose OHCA using verbal descrip-tions from callers and other auditory cues, which may be vague, incomplete, and even contradictory.1 Rates of telecommunicator cardiac arrest recognition vary sub-stantially across systems, ranging from 46% to 98%.1 Recognition of cardiac arrest has been linked to multiple factors related to patients, callers, and telecommunica-tors.2 The most consistent challenges to telecommunica-tor cardiac arrest recognition are the misinterpretation of agonal breathing.23 and, to a lesser extent, misclassifica-tion of OHCA and seizures.2 Cardiac arrest is unrecog-nized more often in children and adolescents.4 Various algorithms have been implemented to optimize telecom-municator recognition of cardiac arrest.

Recommendation-Specific Supportive Text

1.When a caller describes an individual as unre-responsive with a absent or abnormal breathing, con-cluding that the person is experiencing OHCA maximizes sensitivity of detection and permits immediate provision of T-CPR instructions.5.6 To address the variation in OHCA presentations,telecommunicators require training to identify OHCA across a broad range of circumstances,including agonal gasping and brief myoclo-nus.7 Asking the 2 scripted questions from the No-No-Go process(Figure 3) to determine if an

 Figure 3. The No-No-Go Mnemonic for Initiation of Bystander CPR.

Image reproduced from The Road to Recognition and Resuscitation:The Role of Telecommunications and Telephone-CPR QI in Cardiac Arrest Survival with permission from the Resuscitation Academy,Seattle, WA.

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individual is unresponsive with abnormal breath-ing positively identifies 92% of people suffering OHCA.7 Time to first compression is strongly associated with survival from OHCA.8 The writing group believes that the benefit of early recogni-tion of OHCA and provision of timely chest com-pressions outweighs the risk of providing CPR to a person not in cardiac arrest.

2. It is critical to first obtain location information when receiving an emergency call (ie, a 911 call) to per-mit the dispatch of appropriate emergency medi-cal response while additional information is being obtained and CPR instructions are being provided. 9 This permits a response to be mobilized even if the call is disconnected prematurely.

REFERENCES

1. Schwarzkoph M, Yin L, Hergert L, Drucker C, Counts CR, Eisenberg M. Seizure-like presentation in OHCA creates barriers to dispatch rec-ognition of cardiac arrest. Resuscitation. 2020;156:230-236. doi:10.1016/j.resuscitation.2020;06.0366.

2. Juol Grabmay A, Dicker B, Dassanayake V, Bray J, Vaillancourt C, Dainty KN, Olasveengen T, Malta Hansen C; International Liaison Committee on Resuscitation Basic Life Support Task Force. Optimising telecommunicator recognition of out-of-hospital cardiac arrest: A scoping review. Resusc Plus.2024;20:100754. doi: 10.1016/j.respuhi.2024.100754.

3.Fukushima H, Imanishi M, Iwami T, Seki T, Kawai Y, Norimoto K,Urisono Y, Hata M, Nishio K, Saeki K, et al. Abnormal breathing of sud-den cardiac arrest victims described by layerspersons and its association with emergency medical service dispatcher-assisted cardiopulino-nary resuscitation instruction. Emerg Med J. 2015;32:314-317. doi:10.1136/emmed-2013-203112

4. Kirby K, Voss S, Bird E, Benger J. Features of Emergency Medical Sys-tem calls that facilitate or inhibit Emergency Medical Dispatcher recec-ognition that a patient is in, or at imminent risk of cardiac arrest: A systematic mixed studies review. Resusc Plus. 2021;8:100173. doi:10.1016/j.respuod.2021.100173

5.Panchal AR, Berg KM, Cabanas JG, Kurz MC, Link MS, Del Rios M, Hirsch KG, Chan PS, Hazinsky MF, Morley PT, et al. 2019 American Heart As-sociation Focused Update on Systems of Care: Dispatcher-Assisted Car-diopulmonary Resuscitation and Cardiac Arrest Centers: An Update to the American Heart Association Guidelines for Cardioplumary Resuscitation and Emergency Cardiovascular Care. Circulation: 2019:140:e895-e903.doi: 10.1161/CIR.0000000000000733

6. Kurz MC, Bobrow BJ, Buckingham J, Cabanas JG, Eisenberg M,Fromp P, Panczyk MJ, Rea T, Seaman K, Vaillancourt C; American Heart Association Advocacy Coordinating Committee. Telecommuni-cator Cardiopluminary Resuscitation: A Policy Statement from the American Heart Association. Circulation. 2020;141:e686-e700. doi: 10.1161/CIR.00000000000000744

7. Lewis M, Stubbs BA, Eisenberg MS. Dispatcher-assisted cardiopul-ary resuscitation: time to identify cardiac arrest and shelter chest compression instructions. Circulation. 2013;128:1522-1530. doi:10.1161/CIRCULATIONHAA.113.002627

8.Nguyen DD, Spertus JA, Kennedy KF, Gupta K, Uzendu Al, McNally BF, Chan PS. Association Between Delays in Time to Bystand-er CPR and Survival for Unvested Cardiac Arest's in the United States. Circ Cardiovasc Qual Outcomes. 2024;17:e010116. doi: 10.1161/CIRCOUTCOMES 123:010116.

9. Lerner EB, Rea TD, Bobrow BJ, Acker JE 3rd, Berg RA, Brooks SC,Cone DC, Gay M, Gent LM, Mears G, et al; American Heart Association Emergency Cardiovascular Care Committee. Emergency medical service dispatch cardiopulmonary resuscitation prearrival instructions to improve survival from out-of-hospital cardiac arrest: a scientific statement from the American Heart Association. Circulation. 2012;125:648-655. doi:10.1161/CIR.0b013e31823ee5fc

T-CPR INSTRUCTIONS FOR PERSONS WITH SUSPECTED CARDIAC ARREST

|Recommendations for T-CPR Instructions for Persons With Suspected Cardiac Arrest||| |---|---|---| |COR|LOE|Recommendations| |1|A|1.T-CPR instructions for adult OHCA should advise compression-only CPR consistent with adult BLS guidelines.| |2|C-LD|2. Telecommunications should instruct callers to initiate CPR for individuals with suspected OHCA.| |1|C-LD|3.T-CPR instructions for infants and children experiencing OHCA should advise conventional CPR with breaths consistent with pediatric BLS guidelines.|

Synopsis

Rates of lay rescuer CPR remain low for adults and children.1 T-CPR instructions are verbal guidance given by emergency telecommunications to callers that guide CPR. After identifying cardiac arrest by asking the caller whether the patient is responsive and breathing normally,telecommunicators can provide step-by-step instruc-tions for initiating CPR, including how to position the pa-tient, where to place hands for chest compressions, and coaching to maintain the correct rhythm and depth of compressions. Common types of T-CPR instructions in-clude conventional CPR, which includes chest compres-sions and breathing,or compression-only CPR.T-CPR instructions are vital to increase rates of lay rescuer CPR and bridge the gap between the onset of cardiac arrest and the arrival of EMS.

Recommendation-Specific Supportive Text

1.While recent observational studies have reported improved neurologically intact survival outcomes with conventional CPR in adults,2 these studies are vul-nerable to selection bias and confounding. Three ran-domized trials comparing T-CPR compression-only CPR with conventional CPR instruction in adults trended toward better survival with compression-only CPR instructions.3-5 In a pooled analysis of these data, the improvement in survival was sig-nificant(risk ratio, 1.22; 95% CI, 1.01-1.46) with a number needed to treat of 41(95% CI, 20-1250).6 In one of these RCTs, compression-only instructions were delivered 1.4 min faster and more likely to be delivered completely by the telecommunicator.3 It is noteworthy that the adult OHCA RCTs largely pre-date the rise in overdose-associated OHCA seen in the past decade.

2. In 3 adjusted observational studies, T-CPR instruc-tions were associated with a greater than 5 times likelihood of provision of lay rescuer CPR7-9 and

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CPR was initiated 7 minutes sooner8 compared with no T-CPR instructions. The delivery of lay res-cuer CPR before the arrival of EMS was associated with survival and favorable neurological outcome in 6 observational studies. 78,10-13 In 2 studies, offer-ing T-CPR was associated with improved favorable neurological survival 1 month after discharge, even after adjustment for multiple variables. 8,11 Based on these data, the AHA has recommended T-CPR instructions and provided resources to help imple-ment these systems. ${}^{14}$

3. Pediatric OHcAs are mostly of asphyxi etol-ogy.15 Large observational studies comparing compression-only CPR to CPR with breaths have consistently shown improved outcomes associated with CPR that includes breaths. 16-19 In some cases,conventional CPR was provided despite T-CPR instructions to provide compression-only CPR,which calls into question the possibility of signifi-cant selection bias.

REFERENCES

1. Ok Ahn K, McNally B, Al-Arai R, Cisneros C, Chan PS. Sex differ-ences in the association between bystander CPR and survival for Out-of-Hospital cardiac arrest. Resuscitation. 2023;182:109603. doi:10.1016/j.resuscitation.2022.09.016

2. Goto Y,Funada A, Maeda T, Goto Y. Dispatcher instructions for bystander cardiopulmonary resuscitation and neurologically intact survival after bystander's withdrawal-out of-1018/01-3900-2016: A nationwide and will study: Crit. Crit. Care. 2021;25:408. doi:10.1186/s13054-01-03285-w

3.Hallstrom A, Cobb L, Johnson E, Compass M. Cardiopulmonary rescustation by chest compression alone or with mouth-to-mouth ventilation. N Engl J Med.2000;342:1546-1553.dol.10105/NEJMO20000525432101

4.Svensson L, Bohm K, Castren M, Pettersson H, Engerstrom L, Herlitz J, Rosenvist M, Compressor-only CPR or standard CPR in out-of-hospital cardiac arrest. N Engl J Med. 2010;363:434-442. doi:10.1056/NEJMoA0908991

5.Rea TD, Fahrenchub C, Culley L, Donhoe RT, Hambly, C. Innes J, Bloomingdale M, Subido, Cromines S, Eisenberg MS. CPR with chest com-pression alone or with rescue breathing. Neng J, Med.2010;363:423-433.dol.1056/NEJMoA0908993

6.Hupf M, Selig HF, Nagale P. Chest-compression-only versus standard cardiopulmonary resuscitation: a meta-analysis. Lancet (London, England).2010;3765:1557-1557: doi:10.1016/S1040-6736(10)16454-7

7. Song KJ, Shin SD, Park CB, Kim JY, Kim DK, Kim CH, Ha SY,Eng Hock Ong M, Bobrow BJ, McNally B. Dispatcher-assisted bystander cardiopulmonary resuscitation in a metropolitan city: a before-after population-based study. Resuscitation. 2014;85:34-41. doi: 10.1016/j.resuscitation.2013.06.004

8. Goto Y, Maeda T, Goto Y. Impact of dispatcher-assisted bystando cardiopulmonary resuscitation on neurological outcomes in chil-dren with out-of-hospital cardiac arrests: a prospective, nationwide-population-based cohort study.J Am Heart Assoc.2014;3:e000499. doi:10.1161/JAHA.113.000499

9.Fukushima H, Panczyk M, Hu C, Dameff C, Chikani V, Vadebonceurour,Taspite DW, Bobrow BJ. Description of Abnormal Breathing Is Associ-ated With Improved Outcomes and Delayed Telephone Cardiopulmonary Resuscitation Instructions. J Am Heart Assoc. 2017;6:e005058. doi:10.1161/JAHA.116.005058

10.Besner E, Damm C, Jardel B, Veber B, Compere V, Dureil B, Dispatch assisted cardiopulmonary resuscitation protocol improves diagnosis and re-suscitation recommendations for out-of-hospital cardiac arrest. Emerg Med Australas.2015;27:590-596.doi:10.1111/1742-6723.12493

11. Harjanto S, Ma XH, Yao Ng, YY; Doctor N, Goh ES, Leong BS, Gan HN,Chia MY, Tham LP et al: PAROS study group. A before-after interventional

trial of dispatcher-assisted cardio-pulmonary resuscitation for out-of-hospital cardiac arrests in Singapore. Resuscitation. 2016;102:85-93. doi:10.1016/j.resuscitation.2016.02.014

12.Hiltenu PV, Silvast TO, Jantth TH, Kuisma MJ, Kurola JO; FINNE-SUSCI Prehospital Study Group. Emergency dispatch process and pa-tient outcome in bystander-witnessed out-of-hospital cardiac arrest with a shockable rhythm. Eur J Emerg Med. 2015;22:266-272. doi: 10.10197/MEJ.O0000000000151

13. Takahashi H, Sagisaka R, Natsume Y, Tanaka S, Takyu H, Tanaka H. Does dispatcher-assisted CPR generate the same outcomes as spontaneously delivered bystander CPR in Japan? Am J Emerg Med.2018;36:384-391.doi:10.1016/j.ajem.201708.034

14.Kurz MC,Bobrow BJ,Buckingham J,Cabanas JG,Eisenberg M,Fromm P,Canczyk MJ, Rea T, Seaman K, Vaillancourt C; American Heart Association Advacy Coordinating Committee.Telecommunicator Cardiopulmonary Re-suscitation: A Policy State Form. From the American Heart Association. Cir-culation.2020;141:e686-e700.doi:10.1161/CIR.000000000000744

15. Molor FW, Silversten FS, Holubkov R, Slomine BS, Christensen JR,Nadkarni VM, Meert KL, Clark AE, Browning B, Pemberton VL, et al;THAPCA Trial Investigators. Therapeutic hypothermia after out-of-hospital cardiac arrest in children. N Engl J Med.2015;372:1898-1908. doi: 10.1056/NEJmoA1411480

16. Kitamura T, Iwami T, Kawamura T, Nagao K, Tanaka H, Nadkarni VM, Berg RA, Hiraide A; implementation working group for All-Japan Utstein Regis-try of the Fire and Disaster Management Agency, Disaster Management A.Conventional and chest-compression-only cardiopulmonary resuscitation by bystanders that children who have out-of-hospital cardiac arrests: a prospec-tive,nandwide, population-based cohort study. Lancet 2010;375:1347-1354. doi:10.1016/S0140-6736(10)60064-5

17. Naim MY, Burke RV, McNally BF, Song L, Griffiths HM, Berg RA, Vellano K, Markenson D, Bradley RN, Rossano JW. Association of Bystander Cardiopulmonary Resuscitation with Overall and Neurologically Fa-vorable Survival After Pediatric Out-of-Hospital Cardiac Arrest in the United States; A Report From the Cardiac Arrest Registry to Enhance Survival Surveillance Registry. JAMA Pediatr. 2017;171:133-141. doi: 10.1001/jamapediatrics.2016.3643

18. Zhang X,Zhang W,Wang C,Tao W,Dou Q,Yang Y.Chest-compression-only versus conventional cardiac arrest: A systematic review and meta-analysis.Resuscitation.2019;134:81-90.doi:10.1016/j.resuscitation.2018.10.03219.189.2020.1166666688.2020.116666688.2020.11666688.2020.11666688.2020.11666688.2020.11666688.2020.11666688.2020.11666688.2020.11666688.2020.11666688.2020.11666688.2020.11666688.2020.11666688.2020.11666688.2020.11666688.2020.11666688.2020.11666688.2020.11666688.2020.11666688.2020.11666688

19.Ogawa T,Akahane M,Koike S,Tanabe S,Mizoguchi T,Imamura T.Outcomes of chest compression only CPR versus conventional CPR conducted by lay people in patients with out of hospital cardiopulmonary arrest witnessed by bystanders: nationwide, nationwide, Thermary PAC and Rokov, Bembert, Baryy, Baryy, Baryy, Baryy, Baryy, Baryy, Baryy, Baryy, Baryy, Baryy, Baryy, Baryy, Baryy, Baryy, Baryy, Baryy, Baryy, Baryy, Baryy, Baryy, Baryy, Baryy, Baryy, Baryy, Baryy, Baryy, Baryy, Baryy, Baryy, Baryy, Baryy

T-CPR QUALITY MANAGEMENT

|Recommendation for T-CPR Quality Management|| |---|---| |COR|LOE| |1|1. Telecommunicator recognition of cardiac arrest| |8|B-NR| |1|1. and Ecommunicator recognition of cardiac arrest and evaluation process. A detailed evaluated as part of an EMS system quality management process.|

Synopsis

Quality management programs are essential for ensur-ing that telecommunications considers consistently identify cardiac arrest and deliver effective CPR instructions. Quality management encompasses both quality assurance ac-tivities where cases are retrospectively reviewed and quality improvement activities where proactive changes are made to the system to achieve meaningful improve-ments. Key metrics include assessing how quickly and accurately cardiac arrest is recognized, time to first in-structed compression, the clarity and completeness of

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CPR instructions, appropriate coaching on compression depth, chest recoil and patient positioning, and adher-ence to established protocols. ${}^{1}$ A complete list of resus-citation variables desirable to review in OHCA quality management ${}^{2}$ and in evaluating CPR quality ${}^{3}$ is provided elsewhere. Quality management programs seek to op-timize telecommunicator metrics by identifying gaps in performance and providing targeted coaching, with the ultimate goal of increasing survival rates from cardiac arrest.

Recommendation-Specific Supportive Text

1. Successful T-CPR programs incorporate a robust quality management process, including review of OHCA calls, to ensure that T-CPR is being provided as broadly, rapidly, and appropriately as possible.4,5 Applied quality improvement initiatives have been shown to increase rates of telecommunicator car-diac arrest recognition.6,7

REFERENCES

1. Dowker SR,Smith G,O'Leary M,Missel AL,Trumpower B,Hunt N,Herbert L,Sams W,Kamdar N,Coulter-Thompson El,et al;Emergent Health Part-ners Collaborators. Assessment of telecommunicator cardiopulmonary resuscitation performance during out-of-hospital cardiac arrest using a standardized tool for audio review. Resuscitation. 2022;178:102-108. doi:10.1016/j.resuscitation.2022.04.015

2.Grasner J-T,Bray JE, Nolan JP, Iwami T, Ong MEH, Finn J, McNally B,Nehme Z, Sasson C, Tjssen J, et al; International Liaison Commit-tee on Resuscitation. Cardiac arrest and cardiopulmonary resuscitation to future reports: 2024 update of the Ustein Out-of-Hospital Cardiac Arrest Registry template. Resuscitation. 2024;2011:10288. doi: 10.1016/j.resuscitation.2024.2011:10288. doi: 10.1016/j.resuscitation.2024.2011:10288.

3.High-Quality CPRy.Accessed May 4,2025.https://cpr.hear.org/en/resus-citation-science/high-quality-cpr#

4. Tanaka Y, Taniguchi J, Wato Y, Yoshida Y, Inaba H. The continuous quality improvement project for telephone-assisted instruction of cardiopulmonary resuscitation increased the incidence of bystander CPR and improved the outcomes of out-of-hospital cardiac arrests. Resuscitation. 2012;83:1235-1241. doi: 10.1016/j.resuscitation.2012.02.013

5. Bobrow BJ,Spaite DW,Vadebonceour TF, Hu C,Mullins T, Tormala W,Dameff C, Gallagher J, Smith G, Panczyk M. Implementation of a Regional Telephone Cardiopulmonary Resuscitation Program and Outcomes Af-ter Out of-Hospital Cardiac Arrest. JAMA Cardiol. 2016:1;294-302. doi: 10.1001/jamarcdic.2016.02519.

6. Huang CH, Fan HJ, Chien CY, Seak CJ, Kuo CW, Ng CJ, Li WC,Weng YM. Validation of a Dispatch Protocol with Continuous Qual-ity Control for Cardiac Arrest: A Before-and-After Study at a City Fire Department-Based Dispatch Center J. Emerg Med 2017;53:697-707. doi:10.1016/j.jresusmer.2017.06.02015

7. Gram KH, Praest M, Laulund O, Mikkelsen S. Assessment of a quality im-provement programme to improve telephone dispatchers' accuracy in id-tifying of-out-hospital cardiac arrest. Resusc Plus. 2021:61:00096. doi:10.1016/j.resplu.2021.100096

VIDEO-BASED DISPATCH SYSTEMS

|Recommendation for Video-Based Dispatch Systems||| |---|---|---| |COR|LOE|Recommendation| |2b|B-NR|1. Video-based dispatch systems for OHCA response may be reasonable in systems with such capabilities.|

Synopsis

T-CPR is currently provided in many communities through a standard telephone audio call. Mobile tech-nology has become ubiquitous, and the use of video calling technology has become more generalized.Video-based T-CPR may allow the telecommunicator to see the caller in real time, to better assess the scene and patient's condition, to coach the caller through the response, and to provide feedback on CPR per-formance. Video calls are more invasive, may require more cooperation from the caller, and may need mul-tiple rescuers on scene to be effective. Video-based dispatch systems have additional costs for implemen-tation, which may be prohibitive in some countries, and the cost-benefit of these systems has not been fully described.

Recommendation-Specific Supportive Text

1. Simulation studies have consistently shown improved CPR quality using video-based T-CPR compared with traditional audio instruction,1 but RCTs are lacking.1,2 Three observational studies,3-519 randomized simulation studies,6-24 and 4 sys-tematic or scoping reviews25-28 compared a video-based dispatch system for OHCA with an audio-based system or no assistance. Two observa-tional studies reporting patient outcomes4,5 favored video-based T-CPR over conventional T-CPR for prehospital ROSC(pooled odds ratio OR, 2.33;95% CI, 1.87-2.88), survival to hospital discharge(pooled OR 2.33, 95% CI, 1.87-2.91), and good neurological outcome(pooled OR, 2.77; 95% CI,2.14-3.59).2 However, because a video-capable smartphone and at least 2 bystanders were needed,less than 20% of participants received video-based T-CPR in these studies. Among simulation studies,video-based T-CPR consistently improved CPR quality compared with audio-only T-CPR,25 includ-ing for untrained rescuers and simulated pediatric patients. One observational study reporting on CPR quality before and after video instruction found improved hand position, rate, and depth.3 Some studies reported delays to first compression with video calls; however, the more recent observational studies have not reproduced this concern,4,5 poten-tially due to improved telecommunicator protocols and technology. Generalizability of protocols and dispatcher training to US-based systems and bar-riers to implementation are unclear.

REFERENCES

1.Wyckoff MH,Singleletary EM,Soar J, Olasveeneng TM,Greif R,Liley HG,Zideman D,Bhanji F,Andersen LW,Avis SR,et al; Collaborators.2021 In-ternational Consensus on Cardiopulmonary Resuscitation and Emergency

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Cardiovascular Care Science With Treatment Recommendation: Summary: From the Basic Life Support; Advanced Life Support; Neonatal Life Sup-port; Education, Implementation, and Teams: First Aid Task Forces; and the COVID-19 Working Group. Circulation 2022;145:e645-e721: doi:10.1016/CIR.00000000000001010000000000010

2.Wyckoff MH,Greif R, Morley PT, NG K, Olcasevengen, Tom Singley EM, Soar J, Cheng A, Drenran IR, Liley GH, et al. 2022 International Consensus on cardiopulmonary Resuscitation and Emergency Cardio-vascular Care Science with Treatment Recommendations: Summary From the Basic Life Support: Advanced Life Support: Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams;and First Ad Task Forces. Pediatrics. 2023;151:e2022060463. doi:10.1542/peds-2022-060436.

3. Linderoth G, Rosenkrantz O, Lippert F, Ostergaard D, Ersboll AK, Meyhoff CS, FoF; Christensen HC. Live video from bystanders' smartphones to improve cardiopulmonary resuscitation. Resuscitation. 2021;168:35-43. doi: 10.1016/j.resuscitation.2021.08.048

4. Lee HS, You K, Jeon JP, Kim C, Kim S. The effect of video-instructed ver-sus audio-instructed dispatcher-assisted cardiopulmonary resuscitation on patient outcomes following out of hospital cardiac arrest in Seoul. Sci Rep.2021;11:115555. doi:10.1038/s41598-021-95077-5

5. Lee SY, Song KJ,Shin SD, Hong KJ, Kim TH. Comparison of the effects of audio-instructed and video-instructed dispatcher-assisted cardiopulmonary resuscitation on resuscitation outcomes after out-of-hospital cardiac arrest.Resuscitation.2020;147:12-20. doi:10.1016/j.resuscitation.2019.12.004

6. Aranda-Garcia S, Bario-Cortes J, Fernandez-Mendez F, Otero-Agra M,Darne M, Herrera-Pedrovie E, Barca-Furalie R, Rodriguez-Nunez A,Dispatcher-assisted BLS for lay bystanders: A pilot study comparing video streaming via smart glasses and telephone instructions. Am J Emerg Med 2023;71:163-168. doi:10.1016/j.jaem.2023.06.035

7.Atkinson PR,Bingham J,NichBoil PLeane MA,Wocton T. Reelementage and cardiopulmonary resuscitation: the value of video-link and telephone instruction to a mock bystander. J Teledem Telecare. 1999;5:242-245. doi:10.1268/135763991393783

8. Bang YJ,ChO,Cho GC,Lee J,Kim Y.I.Can Mobile Vodecall Assist Layer-sons' Use of Automated External Defibrillators? A Randomized Simulation Study and Qualitative Analysis. Biomed Res Int 2020;2020/A069749,091.10.1155/2020/4069749

9.Bolle SR, Scholl J, Gilbert M. Can video mobile phones improve CPR quality when used for dispatcher assistance during simulat-ed cardiac arrest? Acta Anaesthesiol Scand. 2009;53:116-120. doi: 10.1117/j.1399-6576.2008.01779x

Dong X, Zhang L, Mylebust H, Birkenes T, Zheng Z. Effect of a real-time feedback smartphone application(TCPRLink) on the qual-ity of telephone-assisted CPR performed by trained lapeypan in China: a manikin-based randomised controlled study. BMJ Open.2020;10:e038813.doi:10.1136/bmjopen-2020-038813

11. Ecker H, Lindfer F, Adams N, Hamacher S, Wingen S, Schier R,Bottiger BW, Wetsch WA. Video-assisted cardiopulmonary resuscita-tion via smartphone improves quality of resuscitation: A randomised controlled simulation trial. Eur J Anaesthesiol. 2020;37:294-302. doi:10.1097/EJA.0000000000001177

12.Ecker H. Wingen, S. Hamacher S. Lindner B. Fütherbeta W. Wetchwa S.Nexud:OPC Quality Y4nitorle with Phone A Livelivest-A Study In A Metropolitan Area. Prehosp Emerg Care.2021;25:76-81. doi:10.1080/1090312720200173412

13. Hunt EA, Heine M, Shilkofski NS, Bradshaw JH, Nelson-McMillan K,Duval-Anould J, Efeinbein R. Exploration of the impact of a voice activated decision support system(VADSS) with video on resuscitation performance by lay rescuers during simulated cardiopulmonary arrest. Emerg Med J.2015;32:189-14. doi: 10.1136/emnerted-2013-202867

14. Kim H, Kim JH, Park D. Comparing audio- and video-delivered instructions in dispatcher-assisted cardiopulmonary resuscitation with drone-delivered automatic external defibrating: a mixed methods simulation study. Reple J.2021;9:11761 doi:10.7717/peerj.11761

15. Marquez-Hernandez VV, Gutierrez-Puertas L, Garrido-Molina JM,Garcia-Viola A, Granados-Ganyos G., Aquaglian-Mreusing G. Using a Mo-bile Phone Application Versus Telephone Assistance During Cardiopul-monary Resuscitation: A Randomized Comparative Study. J. Emerg Nurs 4020;28:460-467e2.doi:10.1016/j.jen2020.03.015

16.Perry O,Wacht O,Jaffe E,Sinuny-Stern Z,Bitan Y. Using a filming protocol to improve video-instructed cardiopulmonary resuscitation. Technology Health Care.2020;28:213-220. doi:10.3233/THC-192024

17. Peters M, Stipulante S, Cloes V, Mulder A, Lebrun F, Donneau AF, Guyhsen A.Can Video Assistance improve the Quality of Pediatric Dispatcher-Assisted

Cardiopulmonary Resuscitation? Pediatr Emerg Care.2022;38:e451-e457. doi:10.1097/PEG.000000000002392

18. Plata C, Stolz M, Warncke T, Steinhauser S, Hinkelbein J, Wetsch WA,Bottiger BW Epseten O. Using a smartphone application(PocketCPR) to determine CPR quality in a bystander CPR scenario- A manikin trial. Re-suscitation.2019;137:87-93. doi:10.1016/j.resuscitation.2019.01.039

19. Stipurtei S, Delfosse AS, Donneau AF, Hartsein G, Haus S, D'Orio V,Phuynsen A. Interactive videoconferencing versus audio telephone calls for dispatcher-assisted cardiopulmonary resuscitation using the ALERT algorithm: a randomized trial. Eur J Emerg Med.2016;23:418-424. doi: 10.1097/MEJ.0000000000000338

20. Solzosi V,Hovath B,Nemeth D,Banfai-Sonka H,Betlehem J,Banfai B.A randomized controlled simulation trial comparing video-assisted with telephone-assisted and unassisted cardiopulmonary resuscitation per-formed by non-healthcare university students. Sci Rep.2023;13:14925.

21. Yang, CW Wang HC, Chiang WC, Chang WT, Yen ZS, Chen SY, Ko PC, Ma MH,Chen SC,Chang SC,et al.Impact of adding video communication to dispatch instructions on the quality of rescue breathing in simulated cardiac arrests-a randomized controlled study. Resuscitation. 2008;78:327-332.doi:10.1016/j.resuscitation.2008.03.232

22. Yang CW, Wang HC, Chiang WC, Hsaw CW, Chang WT, Yen ZS, Ko PC, Ma MH,Chen SC,Chang SC,Interactive video instruction improves the quality of dispatcher-assisted chest compression-only cardiopulmonary resuscita-tion in simulated cardiac arrests. Crit Care Med. 2009;37:490-495. doi:10.1097/CCM.018e31831819573a5

23. Lee JS, Jeon WC, Ahm J, Cho YJ, Jung YS, Kim GW. The effect of a cellular phone video demonstration to improve the quality of dispatcher-assisted chest compression-only cardiopulmonary resuscita-tion as compared with audio coaching. Resuscitation.2011;82:64-68. doi:10.1016/j.resuscitation.2010.09.467

24. Lee SGW, Kim TH, Lee HS, Shin SD, Song KJ, Hong KJ, Kim JH, Park YJ.Efficacy of a new dispatcher-assisted cardiopulmonary resuscitation proto-col with audio call-to-video call transition. Am J Emerg Med. 2021;44:26-32. doi:10.1016/j.ajem.2021.01.049

25.Bielski K, Bottiger BW, Pruc M, Gasecka A, Sieminski M, Jaguszewski MJ, Smereka J, Giles-Mainowska N, Peacock FW, Szarpak L. Outcomes of audio-instructed and video-instructed dispatcher-assisted cardiopul-monary resuscitation: a systematic review and meta-analysis. Ann Med 2022;54:464-471. doi:10.1080/07853890.2022.2032314

26. Lin YY,Chiang WC,Hsieh MJ,N, Sun JT,Chang YC,Ma MH.Quality of audio-assisted versus video-assisted dispatcher-instructed bystander cardiopul-10.1016/j.resuscitation.2017.12.010

27. Pan DF, Li ZJ, Ji XZ, Yang LT, Liang PF. Video-assisted bystander cardiopulmonary resuscitation improves the quality of chest com-pressions during simulated cardiac arrests: A systemic review and meta-analysis. World J Clin Cases. 2022;10:11442-11453. doi:10.12998/jwcc.j.10.311.11442

28. Sykora R, Peran D, Renza M, Bradna J, Smetana J, Duska F. Video Emer-gency Calls in Medical Dispatching: A Scoping Review. Prehosp Disaster Med.2022;37:819-826. doi: 10.1017/S1049023X22001297

CLINICAL DEBRIEFING

|Recommendations for Clinical Debriefing||| |---|---|---| |COR|LOE|Recommendations for Clinical Debriefing| |2a|B-NR|1. Performance-focused debriefing of rescuers after cardiac arrest can be effective for resuscitation improvement programs.| |2a|B-NR|2. Review of objective and quantitative resuscitation data can be effective in improving the quality of postevent debriefing for adults and children.| |2a|C-LD|3. It is reasonable for debriefings to be facilitated by health care professionals familiar with established debriefing processes.| |2a|C-EO|4. Incorporating immediate and delayed debriefing is reasonable and may identify different opportunities for system improvement.|

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Synopsis

Postevent clinical debriefing is defined as“a reflective con-versation about performance and may include processed select performance data" with the goal of improving fu-ture clinical practice.1 Feedback is defined as“informa-tion about the performance compared with a standard"delivered in real time. During debriefing, resuscitation team members may identify systems issues that include process and quality of care(eg, algorithm adherence);review quantitative data collected during the event(eg,CPR metrics); reflect on teamwork, communication, and performance of specific roles; and address emotional re-sponses to the event.2-6 A facilitator, typically a health care professional, leads a discussion focused on identifying opportunities and strategies for improving performance.2.7 Debriefings may occur either immediately after a resusci-tation event(hot debriefing) or at a later time, at least a day to weeks later(cold debriefing).3,8,9 Some debriefings take the form of personalized reflective conversations, while others involve group discussion among a larger, multidis-ciplinary resuscitation team.5,7 We focused on postevent clinical debriefing excluding critical incident stress de-briefing (ie, psychological debriefing). Data-informed de-briefing of professionals after cardiac arrest has potential benefits for both IHCA and OHCA SOC.6,10,11 Structured debriefing and continuous feedback play complementary roles in enhancing CPR performance and outcomes in both prehospital and hospital settings. 12,13

Recommendation-Specific Supportive Text

1. Debriefing following cardiac arrest is a critical practice that enhances team performance, sup-ports rescuers, and ultimately leads to improved patient outcomes. ${ }^{14}$ A systematic review and meta-analysis compared real-time or postevent feedback with no real-time or postevent debriefing for adults with OHCA and found that feedback and postevent debriefing, when combined, improve CPR quality(compression depth, rate and fraction) and out-comes (ROSC and survival). ${ }^{12}$ Four prospective observational studies of post-IHCA debriefing among multidisciplinary resuscitation team mem-bers showed mixed results ${ }^{6,9,10,15}$ A systematic review of these studies demonstrated improved ROSC and mean chest compression depth in the period after implementation of a bundle of care that included evaluation of CPR quality, feedback, and debriefing. ${ }^{15,16}$ In a survey of hospital resuscitation practices linked to data and outcomes from hospi-tals within the Get With the Guidelines national reg-istry, there was no association between debriefing frequency and adherence to CPR measures such as defibrillation and epinephrine administration. ${ }^{17}$

2.Because health care professional's recall of events and self-assessment of performance are often

poor, the objectivity and quality of debriefings improve when supplemented with quantitative data on CPR performance. Data elements associated with improved clinical debriefing quality include chest compression rate, depth, and fraction; telem-etry and defibrillator tracings; end-tidal CO ${}_{2}$ trac-ings; and resuscitation record review. ${ }^{6,10,18,19}$

3.In all studies reviewed, debriefings were facilitated by health care professionals familiar with the rec-ommended debriefing process or structure, who in some cases were supported by use of a cognitive aid5 or checklist.5,16,20 Discussions were tailored to participant type and group size and were individual-ized to the nature of performance during the event.Interdisciplinary by debriefing in intensive care units may improve survival outcomes and foster better teamwork. ${}^{8,13}$

4.Studies have not directly compared hot versus cold debriefing. Both are recommended because each may bring out different information. Hot debriefings benefit from closer temporal proximity of the event and may foster effective teamwork. Cold debriefing provides the opportunity to review the data system-atically and incorporate additional perspectives.

REFERENCES

1.Cheng A, Nadkarni VM, Mancini MB, Hunt EA, Sinz EH, Merchant RM.Donoghue A, Duff JP, Epichow W, Auerbach M, et al; American Heart As-sociation Education Science Investigators and or behalf of the American Heart Association Science and Programs Committee, Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; Council on Cardiovascular and Stroke Nursing; and Council on Quality of Care and Outcomes Research. Resuscitation Education Science: Educational Strat-gegies to Improve Outcomes From Cardiac Arrest: A Scientific Statement From the American Heart Association. Circulation. 2018;138:e82-e122.doi: 10.1161/CIR.000000000000000583

2.Hale SJ, Parker MJ,Cupido C, Kam AJ. Applications of Postresuscitation Debriefing Frameworks in Emergency Settings: A Systematic Review. AEM Educ Train.2020;4:223-230. doi: 10.1002/aet2.10444

3. Berg KM, Cheng A, Panchal AR, Topjian AA, Aziz K, Bhanji F, Bigham BL, Hirsch KG, Hoover AV, Kurz MC, et al; Adult Basic and Advanced Life Sup-port, Pediatric Basic and Advanced Life Support, and Resuscitation Education Science Writing Groups. Part 7: Systems of Care:2020 American Heart Association Guidelines for Cardiopulmonary Resus-citation and Emergency Cardiovascular Care. Circulation. 2020;142:S580-604. doi: 10.1161/CIR/00000000000000899

4. Greif R, Bhanji F, Bgham BL, Bray J, Breckwoldt J, Cheng A, Duff JP, Giloffoy E, Hsieh MJ, lwami T, et al. Education, Implementation,and Teams: 2020 International Consensus on cardiopulmonary Re-suscitation and Emergency Cardiovascular Care Science With Treat-ment Recommendations. Resuscitation. 2020;156:A188-A239. doi:10.1016/j.resuscitation.2020.09.014

5.Hunt EA,Jeffers J,McNamara L,Newton H,Ford K,Bernier M,Tucker EW,Jones K,O'Brien C,Codge P,et al.Improved Cardiopulmonary Resuscitation Performance With CODE ACES(2): A Resuscitation Quality Bundle. J Am Heart Assoc.2018;7:e009860. doi: 10.1161/JAHA.118.009860

6.Couper K,Kimani PK, Davies RP, Baker A, Davies M, Hussebee N,Melody T, Griffiths F, Perkins GD. An evaluation of three methods of in-hospital cardiac arrest educational debriefing: The cardiopulmonary re-suscitation debriefing: Resuscitation.2016;105:130-137. doi:10.1016/j.resuscitation.2016.05.005

7.Eppich WJ, Mullan PC, Brett-Fegler M, Cheng A."Let's Talk About It":Translating Lessons From Health Care Simulation to Clinical Event Debrief-ings and Coaching Conversations. Clin Pediatr Emerg Med. 2016;17:200-211.doi: 10.1016/j.cpm.2016.07.001

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8. Wolfe HA, Wenger J, Sutton R, Seshadri R, Niles DE, Nadkarni V,Dual-Arnould J, Sen Al, Cheng A. Cold Debriefings after In-hospital Cardiac Arrest in an International Pediatric Resuscitation Qual-ity Improvement Collaborative. Pediatr Qual Saf Qual: Soc2020:5e319. doi:10.1097/pq9.00000000000000319

9.Wolfe H, Zebruch C, Topjian AA, Nishisaki A, Niles DE, Meaney PA, Boyle L, Giordano RT, Davis D, Priestley M, et al. Interdisciplinary ICU cardiac ar-rest debriefing improves survival outcomes'. Crit Care Med. 2014;42:1688-1695. doi: 10.1097/CCM.0000000000000327

10.Edelson DP, Litzinger B, Arora W, Walsh D, Kim S, Lauderdale DS,Vanden Hoek TL, Becker LB, Abella BS. Improving in-hospital cardiac ar-rest process and outcomes with performance debriefing. Arch Intern Med 2008;168:1063-1069. doi:10.1001/ar.1368.10.1063

11. Couper K,Salman B,Soar J,Finn J,Perkins GD.Debriefing to improve out-comes from critical illness: a systematic review and meta-analysis. Intensive Care Med.2013;39:1513-1523. doi:10.1007/s00143-013-2951-7

12. Lyngby RM, Handel MN,Christensen AM,Nikoleot D,Folke F,Christensen HC,Barfod C, Quin T. Effect of real-time and post-event feedback in out-of-hospital cardiac arrest attended by EMS- A systematic review and meta-analysis.ResuscPlus 2021;6:100101.10:10.1016/j.resplu.2021;100101

13. Sweberg T, Sen Al, Milan PC, Cheng A, Knight L, Del Castillo J, Ikeyama T, Seshadri R, Hazinski MF, Raymond T, et al; pediatric resuscitation qual-ily(pedRES-C) collaborative investigators. Description of hot debrief-ings after in-hospital cardiac arrests in an international pediatric quality improvement collaborative Resuscitation. 2018;128:181-187. doi:10.1016/j.resuscitation.2018;05.015

14. Bleijenberg E, Koster R, WU de Vries, Bees SGs. The im-pact of post-resuscitation feedback for paramedics on the qual-ity of cardiopulmonary resuscitation. Resuscitation. 2017;110:1-5. doi: 10.1016/j.resuscitation.2016.08.034

15. Couper K, Mason A, Gould D, Nolan JP, Soar Y, Jueng Y, Harrison D,Perkins GD. The impact of resuscitation system factors on in-spatial car-diac arrest outcomes across UK hospitals: An observational study. Resuscifi-tation 2020;151:166-172. doi: 10.1016/3861-1886.2020;2020;157:156-166. doi: 10.1016/j.resuscitation.2020.10.024

16. Ko YC, Hsieh MJ, Ma MH, Bhamid B, Bhanji F, Greif R. The effect of system performance improvement on patients with cardiac ar-rest: A systematic review. Resuscitation: 2020;157:156-165. doi: 10.1016/jiresuscitation.2020.10.024

17. Malik ACO, Nallamothu BK, Trumpower B, Kennedy M, Krein SL,Channinkopadelli KM, Hejjavi,G Chan PS. Association Between Hospital Debriefing Practices With Adherence to Resuscitation Process Measures and Outcomes for In-Hospital Cardiac Amrest. Circ Cardiovasc Qual Out-comes.2020;13:e006695. doi: 10.1161/CIRCOUTCOMES.120006695

18.Mullan PC,Cochrane NH,Chamberlain JM,Burd RS,Brown FD,Zinns LE,Cardall KM,O'Connell KM,J.Accuracy of Postresuscitation Team Debriefings in a Pediatric Emergency Department. Ann Emerg Med. 2017;70:311-319.doi:10.1016/j.annemergmed.2017.01.034

19.Cheng A,Overly F,Kessler D,Nadkami VM,Lin Y,Daan O,Duff JP,�tilf NM, Bhanji F, Adler M, et al; International Network for Simulation-based Pediatric Innovation, Research, Education (INSPIRE) CPR Investiva-tors. Perception of CPR quality: Influence of CPR feedback, J-inTime CPR training and provider role. Resuscitation. 2015;87:44-50. doi:10.1016/j.resuscitation.2014;11.015

20.Rolston DM,Li T,Owens C,Haddad G,Palmieri TJ,Blinder V,Wolff JL,Cassara M, Zhou Q, Becker LB. Mechanical, Team-Focused, Video-Reviewed Cardiopulmonary Resuscitation Improves Return of Spontaneous Circulation After Emergency Department Implementation. J Am Heart As-soc.2020;9:e014420.doi:10.1161/JAHA.119.014420

OUT-OF-HOSPITAL CARDIC ARREST TEAM COMPOSITION

|Recommendations for OHCA Team Composition||| |---|---|---| |COR|LOE|Recommendations| |2a|B-NR|1. It can be beneficial to have an advanced life support-level clinician present during the resuscitation of a person with suspected OHCA.| |2a|B-NR|2. It is reasonable to ensure that EMS systems have a size team sufficient to achieve discretely assigned roles within the team.|

Synopsis

Resuscitation in the prehospital environment is a unique and complex undertaking that requires a cross-functional, highly trained team of professionals.1-3 The makeup of this team, from education level to experi-ence, plays a significant role in how the team performs and the outcomes of the cardiac arrest patient.3-5 Most studies on prehospital team composition focus on team dynamics and guideline adherence. Increasingly, there is interest in adoption of a“pit crew” model, in which team members fill defined roles in parallel to achieve an efficient and meticulous resuscitation.6 While guideline adherence is a commonly used outcome, achieving fa-vorable patient outcomes such as neurologically intact survival is more important and was prioritized in craft-ing our recommendations. First responders to OHCA may be police or fire fighters trained in BLS and AED use a supplemented by BLS or advanced cardiac life sup-port(ACLS)-trained EMS professionals. The number of responders available may be dependent on resources within the community as well as population density(urban versus rural). In systems with limited human resources, the use of mechanical chest compression devices and ventilators may assist prehospital profes-sionals, but no data support superiority over an ade-quately staffed team.

Recommendation-Specific Supportive Text

1. Eighteen studies examined the effect of having an ALS-level clinician at the scene of an OHCA.2,5-21 While there remains no consensus regarding the number of ALS clinicians (ie, paramedics or advanced emergency medical technicians) on scene that is beneficial or the specific interventions ALS clinicians performed that increased survival,the presence of an ALS clinicians was consistently associated with favorable neurologically intact sur-vival to hospital discharge.2,5-21

2. Five retrospective 5,7,12,20,21 and 2 prospective obser-vational studies6,14 specifically examined the num-ber and roles of prehospital professionals present at OHCA events and their correlation to neurologi-cally intact hospital survival. These studies observed a consistent pattern of improved outcomes corre-lated to the inclusion of additional ALS clinicians;however, team size in general appeared most important because it permitted specific roles to be assigned like in a pit crew model. Much of the cor-relation with favorable outcomes was associated with better provision of BLS, such as high-quality CPR and shorter time to defibrillation. Various cli-nician configurations were explored within these studies and found to be successful; thus, sys-tems have the opportunity to develop creative and

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innovative ways to obtain adequate team size using resources such as fire departments, community ini-tiatives, and law enforcement.

REFERENCES

1.Kuzovlev A, Monsieurs KG, Gilfoyle E, Finn J, Greif R, Education I; Teams Task Force of the International Liaison Committee on R. The effect of team and leadership training of advanced life support providers on patient outcomes: A systematic review. Resuscitation. 2021;160:126-139. doi:10.1016/j.resuscitation.2021.01:0200

2. Fang PH, Lin YY, Lu CH, Lee CC, Lin CH. Impacts of Emergency Medi-cal Technician Configurations on Outcomes of Patients with Out-of-Hospital Cardiac Arrest. Int J Environ Res Public Health. 2020;17:1930. doi: 10.3390/jerph17061930

3. Rainer TH, Marshall R, Cusack S. Paramedics, technicians, and survival from out of hospital cardiac arrest. J Accid Emerg Med. 1997;14:278-282. doi:10.1136/emj.14.5.278

4. Freire-Tellado M, Navarro-Paton R, Mateor-Lorenzo, J. Perez-Pingo C.Pavon-Prieto MDP, Mecias-Calvo M. Influence of the Type of Physi-cian on Survival from Emerglyc-Medical-Service-Witnessed Cardiac Arrest: An Observational study. Healthcare(Basel). 2022;10:1841. doi: 10.3390/healthcare10101841

5. Kim Y,Kim KH, Song KJ, Shin SD, Park JH. The number and level of first-contact emergency medical services crew and clinical outcomes in out-of-hospital cardiac arrest with dual dispatch response. Clin Exp Emerg Med.20229:314-322. doi 10.15441/ceem.22.205

6. Hopkins CL, Burk C, Moser S, Meersman J, Baldwin C, Youngquist St. Implementation of Pit Crew Approach and Cardiopulmonary Resuscita-Tion Metrics for Out-of-Hospital Cardiac Arrest Improves Patient Survival and Neurological Outcome. J Am Heart Assoc. 2016;5:e002892. doi: 10.1161/JAHA.115.002892.

7. Netherton SJ, Leach A, Bryce R, Hiller T, Cheskes S, Woods R. Im-pact of Pit-Crew Cardiopulmonary Resuscitation on Out-of-Hospital Cardiac Arest in Sakatoon. J Emerg Med 2020;59:384-391. doi:10.1016/j.jemmered.2020.05.010

8. Woodall J, McCarthy M, Johnston T, Tippett V, Bonham R. Impact of ad-vanced cardiac life support-skilled paramedics on survival from out-of-hospital cardiac arrest in a stateguide emergency medical service. Emerg Med.J.2007;24:134-138. doi:10.1136/emj.2005.033365

9. Mann CJ, Guly H. Paramedic Intentions increase the rate of return of spontaneous circulation in out of hospital cardiac arrests. J. Accid Emerg Med.1997;14:149-150. doi:10.1136/emj.14.3149

10. Han K, Jo YH, Jin Kim Y, Park Med S, Keon Lee D, Kim DW, Ja Lee K,Ju Choi H, Jang DH. Association between Paramedic Workforce and Survival Rate in Prehatal Advanced Life Support in Out-of-Hospital Cardiac Arrest Patients. Emerg Med Int 2022;2022:9991944. doi: 10.1155/2022/9991944

11. Sun JT,Chiang WC,Hsieh MJ,Huang EP,Yang WS,Wen JC,YC,Wang RC,El BC,Sim SS,Tsai KC,et al.The effect of the number and level of emergency medical technicians on patient outcomes following out of hospital cardiac arrest in Taipei. Resuscitation. 2018;182:48-53. doi:10.1016/j.resuscitation.2017.11.048

12. Hagiwara S, Oshima K, Aoki M, Miyazak D, Sakurai A, Tahara Y,Nagawa K,Yonemato N, Yaguchi A, Morimura N, SOS-KANTAO 2012 Study Group.Does the number of emergency medical technicians affect the neurological outcome of patients with out-of-hospital cardiac arrest? Am J Emerg Med.2017;35:391-396. doi:10.1016/j.jaem.2016.11.020

13.Nguyen-Van-Tam JS, Dove A, BFrad, MPeyson LC, Durston P,Madeley RJ. Effectiveness of ambulance paramedics versus ambulance technicians in managing out of hospital cardiac arrest. J Accid Emerg Med.1997;14:142-148.doi:101136/emj.14.3.142

14. Dicker B, Govender K, Howie G, Swain A, Todd VF. Positive asso-ciation between ambulance double-crewing and OHCA outcomes: A New Zealand observational study. Resuscus 2021:100187: doi:10.1016/j.resplu.2021.100187

15.Dyson K, Bray JE, Smith K, Bernard S, Straney L, Finn J. Paramedic Ex-pposure to Outof-Hospital Cardiac Arrestz Usem is Associated With Patient Survival. Circ. Circavak Qual Outcomes.2016;9:154-160. doi: 10.1161/CIRCOUTCOMES.115.002317

00-Lhoo, Gray D, Young, T. Huff, Nshle S, Hampton JR. Resuscitation from out-of-hospital cardiac arrest: is survival dependent on who is available at the scene? Heart 1999;81:47-52. doi:10.1016/j.781.147

17. Soo LH, Gray D, Young T, Skene A, Hampton JR. Influence of ambulance crew's length of experience on the outcome of out-of-hospital cardiac ar-rest. Eur Heart J.1999;20:535-540. doi: 10.1053/oeuhj.1998.1334

18. Pilbery R, Teare MD, Lavton D. Do RATs save lives? A service evaluation of an out-of-hospital cardiac arrest team in an English ambulance service. Br Paramed J.2019;3:32-39. doi: 10.29045/14784726.2019.03.3.4.32

19.Kim KH,Ro YS,Park JH,Kim TH,Jeong J,Hong KJ,Song KJ,Shin SD.Association between case volume of ambulance stations and clinical out-comes of out-of-hospital cardiac arrest: A nationwide multilevel analysis.Resuscitation.2021;16371-77. doi:10.1016/j.resuscitation.2021.04.014

20. Gold LS, Eisenberg MS. The effect of paramedic experience on sur-vival from cardiac arrest: Prehosp Emerg Care. 2009;13:341-344. doi:10.1080/10903120902935389

21. Eschmann NM, Pirrallo RG, Aufderheide TP, Lerner EB. The associa-tion between emergency medical services staffing patterns and out-of-fospital cardiac arrest: survival. Prehosp Emerg Care. 2010;14:71-77. doi:10.3109/10903120903349820

IN-HOSPITAL CODE TEAM COMPOSITION AND TRAINING

|Recommendations for In-Hospital Code Team Composition and Training|||| |---|---|---|---| |COR|LOE|Recommendations|| |1|B-NR|1. In-hospital code teams should comprise members with ALS training.|| |2a|B-NR|2. Designated or dedicated code teams with clearly defined roles, diverse expertise, and adequate training incorporating simulation can be beneficial in improving patient outcomes following IHCA.||

Synopsis

For patients with IHCA, prompt initiation of CPR and early defibrillation is lifeshaving.1 Accordingly, hospitals throughout the world devote considerable resources for deploying resuscitation or code teams that can promptly initiate resuscitation efforts for patients in cardiac ar-rest.2.3 Clinicians have the option to obtain ACLS training through courses like ACLS and pediatric ALS. Hospitals must determine the roles to be filled by members of the code team with recent articles comparing this model to the efficient and highly choreographed actions of a race car pit crew. There is considerable variation in IHCA sur-vival between hospitals5 with variable adherence to ACLS and pediatric ALS. The structure, composition, training,and practices of code teams vary markedly across hos-pitals, including differences in how communication and leadership are incorporated.

Recommendation-Specific Supportive Text

1. Teamwork and leadership training have been incor-porated in many aspects of patient care and resus-citation skills. Training in ACLS or pediatric ALS has been shown to be associated with higher-quality CPR and patient outcomes.6.7 Advanced life sup-port training focuses both on technical and non-technical skills, however, there remains a lack of data on patient-specific outcomes that may reflect

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the different methods applied to behaviors and leadership skills. ${}^{6}$ A systematic review of 7 studies involving patient outcomes after participants took structured ALS courses that focused on leader-ship training found a low certainty of evidence that teamwork and leadership training improved IHCA outcomes. ${}^{8}$ Effective leadership is critical in resus-citation contexts, with various studies identifying specific leadership behaviors and skills that corre-late with improved patient outcomes. ${}^{9,10}$ However,a survey of hospitals participating in a US regis-try found no association between adult resuscita-tion team leadership(physician, physician trainee,or nonphysician) with hospital's risk-standardized survival. ${}^{9,11}$

2.Resuscitation teams at hospitals with high IHCA survival tend to include hospital staff with either lim-ited(designated team) or no other clinical respon-sibilities(dedicated team), ensuring consistency of clinical expertise and teamwork during resuscita-tion events.11 Moreover, including team members from diverse disciplines (eg, pharmacists) during resuscitation efforts can enhance compliance with ACLs guidelines, suggesting that interdisciplin-ary collaboration may improve resuscitation care quality.12,13] implementing structured simulation and training with specific role assignments (ie, the pit crew model) significantly improves CPR quality and is associated with improved survival. 4,13,14

REFERENCES

1. Nallamothu BK, Greif R, Anderson T, Atiq H, Couto TB, Considine J, De Caen AR,Djarv T,Doll A,Douma MJ,et al; International Liaison Committee on Re-suscitation. Ten Steps Toward Improving In-Hospital Cardiac Arrest Quality of Care and Outcomes. Circ Cardiovasc Qual Outcomes.2023;16:e010491.doi:10.1161/CIRCOUTCOMES 123.010491

2. Berg KM,Cheng A,Panchal AR,Topjian AA,Aziz K,Bhanji F,Bigham BL,Hirsch KG,Hover AV,Kurz MC,et al; Adult Basic and Advanced Life Sup-port,Pediatric Basic and Advanced Life Support, Neonatal Life Support,and Resuscitation Education Science Writing Groups. Part 7: Systems of Care:2020 American Heart Association Guidelines for Cardiovascular Resus-citation and Emergency Cardiovascular Care. Circulation. 2020;142:S580-S604. doi:10.1161/CIR.0000000000000899

3.Greif R, Bhanji F, Bhanji B, Bruckewt J, Cheng A, Duff JP, Gibleoy E, Hsieh MJ, Wiwari T, et al. Education, Implementation,and Teams: 2020 International Consensus on Cardiopulmonary Re-suscitation and Emergency Cardiovascular Care Science With Treat-ment Recommendations. Resuscitation. 2020;156:A188-A239. doi:10.1016/j.resuscitation.2020.09.014

4.Spitzer Cr, Evans K, Buehler, J AI, NaBEscher BY Code. Code pt blue plir model:A novel approach to in-hospital cardiac arrest resuscitation.Resuscitation.tand.2019;143:158-164.doi:10.1016/j.resuscitation.2019.06.290

5. Chan PS, Kennedy KF, Girotra S; American Heart Association's Get With The Guidelines®-Resuscitation Investigators. Updating the mod-el for Risk-Standarding survival for In-Hospital cardiac arrest to fa-cilitate hospital comparisons. Resuscitation. 2023;183:109686. doi:10.1016/j.resuscitation.2022.109686

6.Cheng A, Nadkami VM, Cramini MB, Hunt E, Simein H, Merchant RM,Donoghue A, Duff JP, Eppich W, Auerbach M, et al; American Heart As-sociation Education Science Investigators; and on behalf of the American Heart Association Education Science and Programs Committee, Council on cardiopulmonary, Critical Care, Perioperative and Resuscitation; Council on

Cardiovascular and Stroke Nursing; and Council on Quality of Care and Outcomes Research. Resuscitation Education Science: Educational Strat-giees to Improve Outcomes From Cardiac Arrest: A Scientific Statement From the American Heart Association. Circulation. 2018;138:e82-e122. doi: 10.1161/CIR.00000000000583

7. Lockey A,Lin Y,Cheng A.Limpact of adult advanced cardiac life support course participation on patient outcomes-A systematic review and meta-analysis.Resuscitation.2018;129:48-54. doi:10.1016/j.resuscitation.2018.05.034

8.Kuzovlev A, MonsieKG, Gilfoyle E, Finn J, Greif R; Education Implemen-tation and Teams Task Force of the International Liaison Committee on Resuscitation. The effect of team and leadership training of advanced life support providers on patient outcomes: A systematic review. Resuscitation.2021;160:126-139.doi:10.1016/j.resuscitation.2021.01.020

9.Hejaji V,Chakrabarti AK,Larnamothu BK,Iwashyna TJ,Krein SL,Trumpower B, Kennedy M, Chinnakopendi L, Makik AQ, Chan PS. Association Be-tween Hospital Resuscitation Team Leader Credentials and Survival Out-comes for In-hospital Cardiac Arrest. Mayo Clin Proc Innov Qual Outcomes.2021;5:1021-1028.doi:10.1016/j.mayocpiq.2021.06.002

10.Jurd C,Barr J. Leadership factors for cardiopulmonary resuscitation for cli-nicians in-hospital; behaviours, skills and strategies: A systematic review and synthesis without meta-analysis. J Clin Nurs.2024;33:3844-3853.doi:10.1111/jocn.17215

11. Nallamothu BK, Guetterman TC, Harrod M, Kellenberg JE, Lehrich JL,Kronick SL, Krein SL, Iwashyna TJ, Saint S, Chan PS. How Do resci-tation Teams at Top-Performing Hospitals for In-Hospital Cardiac Ar-test Succeed? A Qualitative Study. Circulation. 2018;138:154-163. doi:10.10161/CIRCULATIONAHA.118.033674

12. Draper HM, Eppert JA. Association of pharmacist presence on compliance with advanced cardiac life support guidelines during in-hospital cardiac ar-rest. Ann Pharmacother.2008;42:469-474. doi: 10.1345/aph.1K475

13.Anderson TM, Secrest K, Krein SL, Schildhouse R, Guetterman TC,Harrod M, Trumpower B, Kronick SL, Pribble J, Chan PS, et al. Best Pract-tices for Education and Training of Resuscitation Teams for In-Hospital Cardiac Arrest. Circ Cardiovasc Qual Outcomes. 2021;14:e008587. doi: 10.1161/CIRCOUTCOMES.121.008587

14. Weidman EK,Bell G,Walsh D,Small S,Edelson DP.Assessing the impact of immersive simulation on clinical performance during actual-in-hospital cardiac arrest with CPR-sensing technology: A randomized feasibility study. Resus-citation.2010;81:1556-1561. doi:10.1016/j.resuscitation.2010.05.021

ON-SCENE OHCA RESUSCITATION

|Recommendations for On-Scene OHCA Resuscitation||| |---|---|---| |COR|LOE|Recommendations| |1|B-NR|1. EMS systems should be prepared to perform termination of resuscitation(TOR) on scene, including death notification training for EMS professionals.| |2a|B-NR|2. Prioritizing on-scene resuscitation focused on achieving sustained ROSC prior to initiation of transport for most adults and children experiencing OHCA can be beneficial in the absence of special circumstances.|

Synopsis

EMS systems play a central role in OHCA SOC and em-phasize delivery of high-quality resuscitation in the field.However, practices for managing OHCA vary across com-munities, particularly regarding decisions about when to transport patients to a medical center-whether during ongoing resuscitation efforts or after achieving sustained ROSC. Transporting patients during active resuscitation can compromise the quality of CPR provided1,2 and intro-duce safety risks for both patients and EMS clinicians.3,4

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It is also known that EMS transport under emergency settings (ie, lights and sirens) is associated with an in-creased risk of motor vehicle collisions. ${ }^{5}$ On-scene re-suscitation often ends with field TOR, requiring that EMS clinicians perform death notifications. Death notification training, which teaches skills for communication and pro-viding families with resources, improves the confidence and competence of EMS personnel. 6 The ethics of TOR in adults is discussed elsewhere (refer to “Part 3: Eth-ics")."Emerging evidence indicates that select patients with OHCA might benefit from early transport to a facility capable of providing ECMO. Specific recommendations regarding ECMO are detailed in a separate section of the guidelines. Additional examples may be found where remaining on scene is less beneficial, such as the exam-ple of circulatory arrest due to trauma. These exceptions should be made on a case-by-case basis.

Recommendation-Specific Supportive Text

1. Field TOR provides an ethical framework for resource triage, enhances clinician and community safety by reducing unnecessary lights-and-siren transports, and alleviates additional distress for governing survivors.8 Both pediatric and adult TOR clinical decision rules have demonstrated reliability in determining when continued resuscitation efforts are unlikely to suc-ceed.89 EMS systems implementing TOR protocols,particularly for pediatric patients, should collaborate with local government and community stakeholders to address and mitigate concerns regarding pub-lic perception. Proper training for EMS clinicians in TOR and death notification has been associated with reduced burnout and improved emotional resilience in navigating these challenging situations. ${ }^{10}$

2.In secondary analyses of the Resuscitation Outcomes Consortium, intra-arrest transport was not linked to improved survival in adults or chil-dren.11-13 Survival to discharge was twice as high without intra-arrest transport in adults12 and infants aged under 1 year old.13 Higher agency rates of intra-arrest transport were associated with a step-wise decrease in survival. ${ }^{11}$

REFERENCES

1. Ong M, Mackey KE,Zhang Z,Tanaka H,Ma M,Swor R,Shin S.Mechanical CPR devices compared to manual CPR during out-of-hospital cardiac ar-rest and ambulance transport: a systematic review. Scand J Trauma Resusc Emerg Med.2012;20:39.doi:10.1186/1757-7241-20-39

2.Choi S, Kim TH, Hong KJ, Lee SGW, Park JH, Ro YS, Song KJ, Shin SD. Comparison of prehospital resuscitation quality during scene evacuation and early ambulance transport in out-of-hospital cardiac arrest be-tween residential location and non-residential location. Resuscitation 2023;182:109680. doi: 10.1016/j.resuscitation.2022.109680.

3.Maguire BJ, Al Amir Ay', O'Neill BJ. Occupational Injuries and Ilnesses among Paramedicine Clinicians: Analyses of US Department of Labor Data(2010- 2020). Prehosp Disaster Med.2023;38:581-588. doi:10.1017/S1049023X23006118

4. Brice JH, Studek Jr, Bigham BL, Martin-Gill C, Custalow CB, Hawkins E,Morrison LJ. EMS provider and patient safety during response and trans-port: Proceedings of an ambulance safety conference. Prehosp Emerg Care.2012;16:3-19. doi:10.3109/10903127.2011.626106

5.Watanabe BL, Patterson GS, Kempema JM, Magallanes O, Brown LH.Is Use of Warning Lights and Sirens Associated With Increased Risk of Ambulance Crashes? A Contemporary Analysis Using National EMS Infor-mation System (NEMSIS) Data Ann Emerg Med.2019;74:101-109. doi:10.1016/j.jannemerg.2018.09.032

6.Hobgood C, Mathew D, Woodyard DJ, Shofer FS, Brice JH. Death in the Field: Teaching Paramedics to Deliver Effective Death Notifications Us-ing the Educational Intervention "GRIEV_ING". Shrefo EMPer Emerg Care.2013;17:501-510.doi: 10.3109/10903127.2013.804135

7. Elmer J, Atkins DL, Dana MR, Del Rios M, Fry JT, Henderson CM,Lewis Newby M, Madrigal VN, Marco CA, Ornato JP, et al. Part 3: ethics:2025 American Heart Association Guidelines for Cardiopulmonary Resus-citation and Emergency Cardiovascular Care. Circulation. 2025;152(suppl 2):S323-S352.doi:10.11161/CIR.0000000000001371

8.Morrison LJ,Verbeek PR,Vermeulen MJ, Kiss A, Allan KS, Nesbitt L, Stiell I.Derivation and evaluation of a termination of resuscitation clinical prediction rule for advanced life support providers. Resuscitation.2007;74:266-275.doi:10.1016/j.resuscitation.2007.01.009

9. Harris MI, Crowe RF, Anders J. D'Acuto S, Adelgais KM, Fishe J. Ap-plying a set of termination of resuscitation criteria to paediatric out-of-hospital cardiac arrest. Resuscitation. 2021;169:175-181. doi:10.1016/j.resuscitation.2021.09.015

10. Campos A, ErnestV, Cash RE, Rivard MK, Panchal AR, Clemency BM, Swor RA, Crowe RP. The Association of Death Notification and Related Training with burnout among Emergency Medical Services Professionals. Preshop Emerg Care. 2021;25:539-548. doi: 10.1080/109031272020.1785599

11.Grunau B, Kawano T, Rea TD, Okubo M, Scheuermeyer FX, Reynolds JC,Heidet M, Drennan IR, Cheskes S, Fordyce CB, et al. Emergency medical services employing intra-arrest transport less frequently for out-of-hospital cardiac arrest have higher survival and favorable neurological outcomes.Resuscitation.2021;168:27-34. doi: 10.1016/j.resuscitation.2021.09.004

12.Grunau B, Kime N, Leroux B, Rea T, Van Belle G, Menegazzi JJ, Kudenchuk PJ, Vallancourt C, Morrison LJ, Elmer J, et al. Association of Intra-rest Transport vs Continued On-Scene Resuscitation With Survival to Hospital Discharge Among Patients With Out-of-Hospital Cardiac Arrest. JAMA 2020;324:1058-1067 doi:10.1001/jama.2020.14185

13. Okubo M, Komukai S, Izawa J, Chung S, Drennan IR, Grunau BE, Lupton JR, Ramgopal S, Rea TD, Callaway CW. Survival After Intra-Arrest Transport vs On-Scene Cardiopulmonary Resuscitation in Children. JAMA Net Open. 2024;7:e2411641-e2411641. doi:10.1001/jamanetworkopen.2024.11641

PUBLIC ACCESS DEFIBRILLATION

|Recommendation for Public Access Exfibrillation|| |---|---| |COR|LOE| |1|1. We recommend that public access defibrillation (PAD) programs be implemented in communities at high risk of OHCA.|

Synopsis

Early defibrillation significantly increases survival rates from OHCA.1-4 Studies have found that lay rescuer ap-plication of an AED is associated with improved survival to hospital discharge and 30-day and 1-year survival after OHCA,including studies in children.5-18 Public access de-fibrillation(PAD) programs are designed to reduce time to defibration by placing AEDs in public places and training community members in how to use them. Prior literature on PAD includes studies that(1) examined the effective-ness of a public AED program(ie, PAD program) in com-munities to improve OHCA outcomes and(2) examined

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the association of lay rescuer AED application with OHCA survival compared with defibrillation performed by EMS. The writing committee focused the current re-view on studies that examined the effectiveness of a PAD program in improving OHCA survival. Despite widespread implementation of AEDs in public spaces, use of public access defibrillations by lay rescurs remains low.12,19

Recommendation-Specific Supportive Text

1. In the PAD Trial implementation of a structured emergency response system that included train-ing of lay volunteers in CPR and AED use led to a doubling of OHCA survival compared with CPR training alone(30 survivors in 107 arrests versus 15 survivors in 128 arrests, respectively; risk ratio,2.0;95% CI, 1.07-3.77; P=0.03).20 These findings are also supported by multiple observational stid-ies and systematic reviews.212. Although the qual-ity of evidence from observational studies remains low, these studies have found improved rates of survival to discharge,5,7,10 days,6,8,9,11,13,14 and 1 year,7 including studies in children.11,15-17 The 2022 ILCOR scientific statement on PAD addresses key interventions(early detection, optimizing availability,signage, novel delivery methods, public awareness,device registration, mobile apps for AED retrieval,and personal access defibrillation).293 The incremen-tal cost-effectiveness ratio of PAD has ranged from US $37200$ to $1152400$ per quality-adjusted life-year, ${}^{22}$ whereas a recent study found a high probability that public AEDs are cost effective at traditional willingness to pay thresholds of up to$15000 per quality-adjusted life year. ${}^{24}$

REFERENCES

1. Larsen MP, Eisenberg MS, Cummins RO, Hallstrom AP. Predicting surviv-eral from out-of-hospital cardiac arrest: graphic. Ann Emerg Med 1993;22:1652-1658. doi: 10.1016/s0196-0644(05)81302-2

2.Sasson C, Rogers MA. Dahl J. Kelmermann AL. Predictors of sur-vival from out-of-hospital cardiac arrest: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes. 2010;3:63-81. doi:10.1161/CIRCOUTCOMES.109.8895676

3.Soar J, Bottiger BW, Carl P, Couper K, Deakin CD, Djarr V, Tott L,Colausveng T, Paal P,Pellis T,et al. European Resuscitation Council Guide-lines 2021: Adult advanced life support. Resuscitation. 2021:161:115-151.doi: 10.1016/j.resuscitation.2021.02.010

4.Wissenberg M, Iippert FK,Folke F, Sweke R, Hansen CM, Christensen F,Jans H, Hansen PA, Lang-Jensen T,Olesen JB,et al. Association of nation-al initiatives to improve cardiac arrest management with rates of bystander intervention and patient survival after out-of-hospital cardiac arrest, JAMA 2013;310:1377-1384. doi:10.1001/jama.2013.278483

5. Berdowski J, Blom MT, Bardai A, Tan HL, Tijssen JG, Koster RW. Impact of onsite or dispatched automated external defibrator use on survival after ut-ort of hospital cardiac arrest. Circulation. 2011;24:1225-2232. doi: 10.1161/CIRCULATIONHA.110.015545

6aless Aner, Hlitz J., Svensson L, Ottosson L, Bergfeldl L, Engdahl J,Ericson C, Sanden P, Axelsson C, Bremer A. Defibrillation before EMS arrival in western Sweden. Am J Emerg Med. 2017;35:1043-1048. doi: 10.1016/j.jemar.20170.0203

7. Gianotto-Oliveira R, Gonzalez MM, Vianna CB, Monteiro Alves M, Timerman S, Kali Filho R, Kern KB. Survival After Ventricular Fibrillation Cardiac Arrest

in the Sao Paulo Metropolitan Subway System: First Successful Targeted Automated External Defibrillator(AED) Program in Latin America. J Am Heart Assoc.2015;4:e002185. doi: 10.1161/JAHA.115.002185

8. Kiguchi T, Kiyohara K, Kitamura T, Nishiyama C, Kobayashi D, Okabayashi S,Shimamoto T, Matsuyama T, Iwami T.Public-Access Defibrillation and Survival of Out-of-Hospital Cardiac Arrest in Public vs. Residential Loca-tions in Japan. Circ.J.2019;83:1682-1688. doi: 10.1253/circj.CJ-19-0065

9.Kitamura T,Kiyohara K,Sakai T,Matsuyama T,Hatakeyama T,Shimamoto T,Izawa J,Fuji T,Nishiyama C,Kawamura T, et al. Public-Access De-fibrillation and Out-of-Hospital Cardiac Arrest in Japan. N Engl J Med.2016;375:1649-1659. doi: 10.1056/NEJMsa1600011

10. Kuisma C, Castenst M, Nurnimen K. Public access defibrillation in Helsinki-costs and potential benefits from a community-based pilot study. Resuscit-a-tation.2003;56:149-152. doi:10.1016/s0300-9572(02)00344-1

11. Matsui S,Kitamura T,Sado J,Kiyohara K,Kobayashi D,Kiguchi T,Nishiyama C,Okabayashi S,Shimamoto T,Matsuyama T,et al. Location of arrest and survival from out-of-hospital cardiac arrest among children in the public-access defibrillation era in Japan. Resuscitation.2019;140:150-158. doi:10.1016/j.resuscitation.2019.04.045

12. Myat A, Baumbach A. Public-access defibrillation: a call to shock. Lancet. 2019;394:2204-2206. doi: 10.1016/S0140-6736(19)32560-7

13. Nakahar S, Tomio J, Ichikawa M, Nakamura F, Nishida M, Takahashi H,Morimura N, Sakamoto T. Association of Bystander Interventions With Neurologically Intact Survival Among Patients With Bystander-Witnessed Out-of-Hospital Cardiac Arrest in Japan. JAMA 2015;314:247-254. doi:10.1017/jama.2015.8068

14. Ringh M, Jonsson M, Norberg D, Fredman D, Hasselqvist-Ax, I, Hakansson F,Claesson A,Riva G,Hollenberg J. Survival after Public Access Defibrilla-tion in Stockholm, Sweden-A striking success. Resuscitation. 2015;91:1-7.doi: 10.1016/j.resuscitation.2015;20.032.03

15.Fukuda T, Ohashi-Fukuda N, Kobayashi H, Gunshin M, Sera T, Kondo Y, Yahagi N. Public access defibrillation and outcomes after pediat-ric out-of-hospital cardiac arrest. Resuscitation. 2017;111:1-7. doi:10.1016/j.resuscitation.2016.11.010

16. Kiyohara K, Nitta M, Sato Y, Kojimahara N, Yamaguchi N, Iwami T,Kitamura T. Ten-Year Trends of Public-Access Defibrillation in Japanese School-Aged Patients Having Neurologically Favorable Survival After Out-of-Hospital Cardiac Arrest. Am J Cardiol. 2018;122:890-897. doi:10.1016/j.jamcardi.2018.05.021

17. Naim MY, Burke RV, McNally BF, Song L, Griffiths HM, Berg RA, Vellano K, Markenson D, Bradley RN, Rossano JW. Association of Bystander Cardiopulmonary Resuscitation With Overall and Neurologically Fa-vorable Survival After Pediatric Out-of-Hospital Cardiac Arrest in the United States: A Report from the Cardiac Arrest Registry to Enhance Survival Surveillance Registry. JAMA Pediatr. 2017;171:133-141. doi 10.1001/jamapediatrics.2016.3643

18. Naim MY,Griffis HM, Burke RV, McNally BF, Song L, Berg RA, Nadkarni VM,Vellano K, Markenson D, Bradley RN, et al. Race/Ethnicity and Neigh-borhood Characteristics Are Associated With Bystander Cardiopulmonary Resuscitation in Pediatr of Bystander Incut-of-Hospital Cardiac Arresti and In the United States: A Study from CARE. J. Am Heart Assoc. 2019;8:e012637. doi:10.1161/JAHA.119.012637

19. Ringh M, Hollenberg J, Palsgaard-Moeller T, Svensson L, Rosenqvig M, Lippert FK, Wissenberg M, Malta Hansen C, Claesson A, Viereck S,et al; COSTA study group(research collaboration between Copenha-gen, Olsio, Stockholm, and Amsterdam). The challenges and possibili-ties of public defibrillation. J Intern Med. 2018;283:238-256. doi:10.1111/joim.12730

20. Hallstrom AP Ornato JP, Weisfeldt M, Travers A, Christenson J, McBurnie MA,Zalenski R, Becker LB, Schron EB, Proschan M; Public Access De-fibrillation Trial Investigators. Public-access defibrillation and survival after out-of-hospital cardiac arrest. N Engl J Med.2004;351:637-646. doi:10.1056/NEJMoau04056

21.Baekgaard J S, Vereck S, Moller TP,Ersoll b AK, Lippert F, Folke F. Response by Baekgaard et al. Letters regarding Article,"The Effects of Public Ac-cess Defibrillation in Survival After Out-of-Hospital Cardiac Arrest: A Systematic Review of Observational Studies," Circulation.2018;137:1650-1651. doi:10.1161/CIRCULATIONAHA.117.032513

22. Holmberg M.J., Vognsen M., Andersen MS, Donnino MW, Andersen LW. By-stander automated external defibrillator use and clinical outcomes after out-of-hospital cardiac arrest: A systematic review and meta-analysis. Re-suscitation 2017;120:77-87. doi: 10.1016/j.resuscitation.2017.09.003

23. Brooks SC, Clegg GR, Bray J, Deakin CD, Perkins GD, Ringh M,Smith CM, Link MS, Merchant RM, Pezo-Morales J, et al; Interna-tional Laision Committee on Resuscitation. Optimizing Outcomes After

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Out-of-Hospital Cardiac Arrest With Innovative Approaches to Public-Access Defibrillation: A Scientific Statement From the International Liai-son Committee on Resuscitation. Circulation. 2022;145:e776-e801.doi:10.1161/CIR.00000000000001013

24. Andersen LW, Holmberg MJ, Granfeld A, James LP, Caulley L. Cost-effectiveness of public automated external defibrillators. Resuscitation.2019;138:250-258. doi:10.1016/j.resuscitation.2019.03.029

RECOMMENDATION FOR CARDIAC ARREST CENTERS

|Cardiac Arrest Centers||| |---|---|---| |COR|LOE|Recommendation| |2b|B-R|1. Transport of resuscitated patients to specialized cardiac arrest centers when comprehensive postrestare care is not available at local facilities may be reasonable.|

Synopsis

Regionalized coordination of care improves outcomes for acute critical conditions, such as ST-segment eleva-tion myocardial infarction1 and cerebrovascular ischemic events.2 Expited transfer to a center capable of provid-ing specialized interventions, such as primary percutate-ous coronary intervention, provides incremental benefit over care at the nearest hospital that cannot provide such care.3 Analogous pathways for cardiac arrest pa-tients have been proposed in the form of cardiac arrest centers(CACs). These CACs lack universal definitions but most commonly have been defined as those with around-the-clock temperature control and percutane-ous coronary intervention capability and less consistently as centers with access to formal neuroprognostication protocols, mechanical circulatory support, and hemody-namic targeted protocols. Alternatively, CACs have been defined based on the volume of cardiac arrest cases.Studies of CACs also vary on setting(rural versus urban)and whether transport to the CAC occurs at the time of arrest or by subsequent interfacility transport. Transport of acutely resuscitated persons to a CAC must weigh the potential benefit of a higher level of care against risk of decompensation during transport and subsequent dis-tance from loved ones.

Recommendation-Specific Supportive Text

1.We identified 1 new RCT that demonstrated no dif-ference in 30-day all-cause mortality when patients were transported to designated CACs-defined as centers that had around-the-clock availability of interventional cardiology,cardiac surgery, and spe-cialist intensive-care facilities-compared with the geographically closest emergency department.4 This trial was conducted in a metropolitan area, and control hospitals were high-functioning, providing temperature control, delayed neuroprognostication,

<EndOfPara>and protocolized hemodynamic management. The findings of this RCT contrast with observational studies that have demonstrated benefit associ-ated with regionalized CACs. ${ }^{5,6}$ Three new system-atic reviews of observational studies demonstrated improved neurologically favorable survival with care provided at CACs of varying definitions. ${ }^{7-9}$ No studies have identified specific components of a CAC associated with clinical benefit, and sev-eral components used to define CACs have not demonstrated benefit when studied in isolation.These interventions include temperature control ${ }^{10}$ or immediate coronary angiography in patients without ST-segment elevation myocardial infarc-tion. ${ }^{11-15}$ The association between CAC volume and outcomes also varies. ${ }^{16-18}$ Additional observational studies found greater benefit of direct ${ }^{19}$ or inter-facility transport ${ }^{17}$ to CACs when the patient was coming from a smaller population center or lower-volume emergency room.

REFERENCES

1.Henry TD,Sharkey SW,Burke MN,Chavez IJ,Graham KJ,Henry CR,Lips DL, Madison JD, Menssen KM, Mooney MR, et al. A regional sys-tem to provide timely access to percutaneous coronary intervention for ST-elevation myocardial infarction. Circulation. 2007;116:721-728. doi: 10.1161/CIRCULATIONAHA.107.694141

2.Jauch EC, Schwamm LH, Panagos PD, Barbazzeni J, Dickson R, Dunne R, Foley J, Fraser Jr, Lassers G, Martin-Gill C, et al; Prenspital Stroke System of Care Consensus Conference. Recommendations for Regional Stroke Destination Plans in Rural, Suburban, and Urban Communities From the Prehospital Stroke System of Care Consensus Conference: A Consen-sus Statement From the American Academy of Neurology, American Heart Association/American Stroke Association, American Society of Neurora-diology, National Association of EMS Physicians, National Association of State EMS Officials, Society of Neurolinterventional Surgery, and Society of Vascular and Interventional Neurology. Stroke.2021;52:e133-e152. doi:10.1161/STROKEAHA.20.033228

3.Huynh T, Perron S, O.Loughlin J, Joseph L, Labrecque M, Tu JV,Theroux P. Comparison of primary percutaneous coronary interven-tion and fibrinolytic therapy in ST-segment-elevation myocardial infarc-tion: bayesian hierarchical meta-analyses of randomized controlled trials and observational studies. Circulation. 2009;119:3101-3109. doi: 10.1161/CIRCULATION.AHA.108.793745

4.Patterson T, Perkins GD, Perkins A, Clayton T, Evans R, Dodd M, Robertson S, Wilson K, Mellett-Smith A, Fothergill RT, et al; ARREST trial collabora-tors. Expeded transfer to a cardiac arrest centre for non-ST-elevation out-of-hospital cardiac arrest (ARREST): a UK prospective, multicen-tre, parallel, randomised clinical trial. Lancet. 2023;402:1329-1337. doi:10.1016/S0140-6736(23)01351-X

5.Emler J, Callaway CW, Chang CH, Madaras J, Martin-Gill C, Nawrocki P,Seaman KAC, Sequeira D, Traynor OT, Venkat A, et al. Long-Term Outcomes of Out-of-Hospital Cardiac Arrest Care at Regionalized Centers. Ann Emerg Med.2019;73:29-39. doi:10.1016/j.annemergmed.2018.05.018

6.Elmer J,Rittenberger JC,Coppler PJ,Guyette FX,Doshi AA,Callaway CW:Pittsburgh Post-Cardiac Arrest Z. Long-term survival benefit from treatment at a specialty center after cardiac arrest. Resuscitation.2016;108:48-53.doi:10.1016/j.resuscitation.2016.09.008

7. Lipe D, Giwa A, Caputo ND, Gupta N, Addison J, Courmoyer A. Do Out-of-Hospital Cardiac Arrest patients Have Increased Chances of Survival When Transported to a Cardiac Resuscitation Center? J Am Heart Assoc 2018;7e011079. doi:10.1161/JAHA.118.011079

8. Storm C, Leithner C, Krannich A, Suarez JI, Stevens RD. Impact of Structured Pathways for Postcardiac Arrest Care: A Systematic Re-view and Meta-Analysis. Crit Care Med.2019;47:e710-e716. doi:10.1097/CCM.0000000000003827

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9.Yeo JW,Ng ZHC,Goh AXC,Gao JF,Liu N,Lam SWS,Chia YW,Perkins CD, Ong MEH, Ho AFW; National Targeted Temperature Management Workgroup. Impact of Cardiac Arrest Centers on the Survival of Pa-tients With Nontraumatic Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis. J Am Heart Assoc.2022;11:e023806. doi: 10.1161/JAHA.121.023806

10. Dankiewicz J,Conberg T,Lijga J, Jakobsen J, Levin H, Ullen S, Rylander C, Wise MP,Odd M, Caroi A,et: TTM2 Trial Investigators. Hypothermia versus Normothermia after Out-of-Hospital Cardiac Arrest. N Engl J Med.2021;3842289-2994.d.10:1056/NEJmoA2100591

11. Desch S, Freund A, Akin I, Behnes M, Preusch MR, Zelniker TA, Skurk C,Landmesser G, Uraf T, Eletil et al; TOMAHK WIVJK investigators. Angiography after Out-of-Hospital Cardiac Arrest without ST-Segment Elevation. N Engl J Med.2021;385:2544-2553. doi: 10.1056/NEJMoA2101909

12. Elwren L, Lagedal R, Norberg P, James S, Oldgren J, Bohrm F, Lundgren R, Pylander van der Linden J, Hollenberg J, et al. Direct or subacute coronary angiography in out-of-hospital cardiac arrest(DISCO)-An initial pilot-study of a randomized clinical trial. Resuscitation: 2019;19:253-261.doi: 10.1016/j.resuscitation.2019.04.027

13. Hauw-Berlemont C, Lamhaut L, Diehl JL, Andreotti C, Varenne O,Leroux P, Larcashou JB, Guerin P, Loube T, Roupie E, et al: EMERGE Investigators. Emergency vs Delayed Coronary Angiogram in Sur-viors of Out-of-Hospital Cardiac Arrest: Results of the Random-ized, Multicentric EMERGE Trial. JAMA Cardiol. 2022:7:700-707. doi: 10.1001/jamacardio.2022.1416

14. Kem KB, Radsel P, Jenter JC, Serced DB, Lee KS, Dortun K, Janahanran R,Stub D, Hsu CH,Noc. Randomized Pilot Clinical Trial of Early Coro-nary Angiography Versus No Early Coronary Angiography After Car-diac Arrest Without ST-Segment Elevation: The PEARL Study. Circulation 2020;142:2002-2012.doi:10.1161/CIRCULATIONAHA.120.045969

15. Lemkes JS, Janssens GN, van der Haven NWillah LSD, Dubois EA,Weuzmann M, Rjostra B, Boska H, Blans MJ, Bleker GB,et al. Coro-nary Angiography after Cardiac Arrest without ST-Segment Elevation. N Engl J Med.2019;380:1397-1407. doi 10.1056/NEmOla 1816897

16. Goh AXC, SeoJ L, Cai MYH, Liu N, Man Goh Y, Ong MEH, Lim SL, Ho JSY, Yeo JW, Ho AFW. Association of High-Volume Centers With Sur-vial Outcomes Among Patients With Nontraumatic Oxult-Off-Hospital Car-Adiac Arrest: A Systematic Review and Meta-Analysis. JAMA Netw Open.2022;5:e2214639. doi: 10.1001/jamanetworkopen.2022.14639

17. Park JH, Lee SC, Shin SD, Song KJ, Hong KJ, Ro YS. Interhospital transfer in low-volume and high-volume emergency departments and survival out-comes after out-of-hospital cardiac arrest: A nationwide observational study and propensity score-matched analysis. Resuscitation. 2019;139:41-48.doi:10.1016/j.resuscitation.2019.03.044

18. Tsuchida T, Ono K, Maekawa K, Hayamizu M, Hayakawa M. Effect of an-nual hospital admissions of out-of-hospital cardiac arrest patients on prognosis following cardiac arrest. BMC Emerg Med. 2022;22:121. doi:10.1186/s12873-022-00685-7

19. Jung E, Ryu HH, Ro YS, Shin SD. Association between scene time in-terval and clinical outcomes according to key Utstein factors in out-of-hospital cardiac arrest. Medicine(Baltim). 2021;101:e32351. doi:10.1097/MD.0000000000032351

EXTRACORPOREAL CPR SOC

|Recommendations for ECPR SOC||| |---|---|---| |COR|LOE|Recommendations| |2a|C-LD|1. It is reasonable that centers with ECPR programs develop and frequently reassess patient selection criteria to maximize cardiac arrest survival, ensure equitable access, and limit futility.| |2a|C-LD|2. It is reasonable that clinicians performing adult peripheral ECPR cannulation be experienced in percutaneous technique.| |2a|C-LD|3. A regionalized approach to ECPR is reasonable to optimize outcomes and resource utilization.| |2b|B-R|4. Rapid intra-assert transport for the purposes of ECPR may be considered for limited, highly selected adult OHCA patients.|

Synopsis

The use of ECMO for refractory cardiac arrest, or ECPR,has grown substantially1 and may benefit selected pa-tients with IHCA or OHCA.2 Many of the SOC needed to support ECPR are similar regardless of whether cases result from IHCA or OHCA. Present guidelines recom-mend the use of ECPR“in select patients when provided within an appropriately trained and equipped system of care.”3 However, RCTs of ECPR, recruiting exclusively adult OHCA patients, have shown mixed results.4-7 This heterogeneity in outcomes may be related to differences in the SOC, patient selection, center experience, and trial design across studies. Extracorporeal CPR is a highly resource-intensive intervention that requires significant experience and expertise in both the cannulation pro-cess and specialized intensive care management and is associated with a high rate of morbidity and mortality.2.8-11 The ethics of patient selection, equitable distribution, and resource allocation are discussed elsewhere(refer to the Advanced Therapies section in“Part 3: Ethics”).12

Recommendation-Specific Supportive Text

1. Patient selection for ECPR affects survival and program success. Prudent patient selection with defined inclusion criteria is necessary so that all individuals with potential benefit from the ther-apy are considered while clear exclusion criteria ensure mindful resource utilization and avoidance of aggressive and costly therapy in futile circum-stances.13 Considerations for patient selection may differ between IHCA and OHCA. No specific cri-teria can be recommended with the current state of evidence, but patient characteristics that have been associated with survival include lay rescuer CPR receipt, intermittent ROSC, shockable rhythm,intermittent signs of life during CPR, and short low-flow times.14-18 Age cutoffs and metabolic criteria suggesting futility, such as high lactate, low end-tidal carbon dioxide, and low pH, have been identi-fied in retrospective analyses and used as selection criteria in RCTS.6,19,20 System protocols that con-sider a consistent set of predefined variables in determining which patients to select for ECPR,along with routine reevaluation of these variables as additional local and external data evolve, are important components of an ECPR SOC.

2. Adult peripheral ECP Rannulation carries a risk of significant complications, including bleeding vascular injury, limb ischemia, and cannulation fail-ure, especially in the emergent setting with ongo-ing CPR,4.5,21 Retrospective observational data suggest that percutaneous cannulation under ultrasound guidance, compared with vascular cut-down, may result in faster time to cannulation

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without significant differences in cannulation-related complications.22-24 One of these studies,an Extracorporeal Life Support Organization registry review, also reported less brain death or diffuse cerebral ischemia with percutaneous cannulation.24 The optimal training path to master ECR cannula-tion has not been established.

3.There are no prospective randomized trials that have assessed regionalization or specialty ECR cen-ters. Multiple observational studies demonstrate an association between increasing ECR volume and improved patient outcomes, although RCTs,ings are limited by confounding.25-27 Among RCTs,the positive Advanced Reperfusion Strategies for Patients With Out-of-Hospital Cardiac Arrest and Refractory Ventricular Fibrillation(ARREST) trial was conducted at a single high-volume ECR center,which contrasts with the neutral results from the Early Initiation of Extracorporeal Life Support in Refractory OHCA (INCEPTION) trial, which spanned 10 Dutch cardiosurgical centers, 5 of which cannulated 2 or fewer patients.5 Variation across these studies pre-cludes a specific definition of a specialized ECR center. However, given the relatively low frequency of ECR events(<1% of all cardiac arrests)28 as well as the nuanced complexities of cannulating and car-ing for these patients, it may be reasonable to match patients to specialized, experienced centers.

4.One single-center RCT randomized OHCA patients to rapid intra-arest transport coupled with in-hospital ECPR compared with ongoing CPR at the scene.4 This study did not show a statistically improved survival with good neurologic outcome at 180 days post-OHCA; however, it was stopped prematurely with a trend favoring ECP(differ-ence, 9.5%; 95% CI, -1.3% to 20.1%; P=0.09),which raises the question of whether the study was sufficiently powered. Two other OHCA ECPR RCTs randomized patients following intra-arest transport.One was stopped early for benefit,6 whereas the other found no difference between ECPR and stan-dard ACLS.5 Intra-arest transport poses significant risks, including delays in BLS and ACLS interven-tions, ineffective compressions, and safety risks to EMS professionals and the public with high-speed emergency vehicle operations. Monitoring out-comes at the level of the entire community is impor-tant to account for changes in resuscitation quality that may occur with rapid transport during ongoing resuscitation. Moreover, there is no direct evidence assessing the allowable diversion distance or time past a non-ECPR-capable receiving facility.4-7

REFERENCES

1. Richardson AS, Schmidt M, Bailey M, Pellegrino VA, Rycus PT, Pilcher DV.ECMO Cardio-Pulmonary Resuscitation (ECPR), trends in survival from

<EndOfPara>an international multicentre cohort study over 12-years. Resuscitation.2017;112:34-40.doi:10.1016/j.resuscitation.2016.12.009

2. Low CJW, Ramanathan K, Ling RR, Ho MJC, Chen Y, Lorusso R, MacLaren G, Shekar K, Brodie D. Extracorporeal cardiopulmonary resuscitation versus conventional cardiopulmonary resuscitation in adults with cardiac arrest: a comparative meta-analysis and trial sequential analysis. Lancet Respir Med.2023;11:883-893.doi:10.1016/S2213-2600(23)00137-6

3.Perman SM,Elmer J, Maciel CB, Uzendu A, May T, Mumbe BE, Bartos JA, Rodriguez AJ, Kurz MC, Panchal AR, et al; American Heart Asso-ciation.2023 American Heart Association Focused Update on Adult Ad-vanced Cardiovascular Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emer-gency Cardiovascular Care. Circulation. 2024;149:e254-e273. doi: 10.1161/CIR:000000000000001194

4. Belohlavek J, Smalcova J, Rob D, Franek o, Smid O, Pokorna M, Horak J,Mrazek V, Kovarnik T, Zemanek D et, al; Prague OHCA Study Group. Effect of Intra-arrest Transport, Extracorporeal Cardiopulmonary Resuscitation,and Immediate invasive Assessment and Treatment on Functional Neuro-logic Outcome in Refractory Out-of-Hospital Cardiac Arrest. A Randomized Clinical Trial. JAMA.2022;327:7377-747. doi: 10.1001/jama.2022.1025

5.Suverein MM,Delnoij TSR, Lorusso R,Brandon Bravo Bruinsma GJ,Otterspo R,Elzo Kraemer CV, Vaaral APJ, van der Heijden JJ, Scholten E, den Uil C,et al.Early Extracorporeal CPR for Refractory Out-of-Hospital Cardiac Arrest. N Engl J Med.2023;388:299-309. doi: 10.1056/NEJMaoo240511

6. Yannopoulos D, Bartos J, Raveendran G, Walser E, Connett J, Murray TA, Collins G, Zhang L, Kalra R, Kosumopoulos M, et al. Advanced reper-fusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation(ARREST): a phase 2, single centre, open-ibel, randomised controlled trial. Lancet 2020;396:1807-1816. doi: 10.1016/S0140-6736(20)32338-2

7. Hsu CH, Meuer WJ, Domanier R, Fowler J, Whitmore SP, Bassin BS,Gunnerson KJ, Haft JW, Lynch WR, Nallamothu BK, et al. Extracorporeal Cardiopulmonary Resuscitation for Refractory Out-of-Hospital Cardiac Arrest(EROCA): Results of a Randomized Feasibility Trial of Expe-dited Out-of-Hospital Traport. Ann Emerg Med.2021;78:92-101. doi:10.1016/jannemergmed.2020.11.011

8. Tonna JE, Boonstra PS, MacLaren G, Paden M, Brodie D, Anders M, Hoskote A,Ramanathan K, Hyslopac R, Fanning JJ, et al.; Extracorporeal Life Support Organization(ELSO) Member Centers Group. Extracorporeal Life Support Organization Registry International Report 2022; 100,000 Survivors. ASAIO J.2024;70:131-143. doi: 10.1097/MAT.0000000000002128

9.Debaty G,Babaz V,Durand M,Gaide-Chevronnay L,Nourfe E,Blancher M, Bouvaist H, Chavanon O,Maignan M,Bouzat P,et al. Prognostic factors for extracorporeal cardiopulmonary resuscitation recipients following out-of-hospital refractory cardiac arrest. A systematic review and meta-analysis.Resuscitation.2017;112:1-10. doi: 10.1016/j.resuscitation.2016.12.011

10. Tonna JE, Selzman CH, Girotra S, Presson AP, Thiagarajan RR, Becker LB,Zhang C, Rycus P, Keenanan HT; American Heart Association Get With the Guidelines-Resuscitation. Investigators. Resuscitation Using ECPR Dur-ing In-Hospital Cardiac Arresti(RSUEC-IHCA) Mortality Prediction Score and External Validation. JACC Cardiovasc Intervan. 2022;15:237-247. doi: 10.1016/j.jcin.2021.09.032

11. Wengemayer T, Tigges E, Staudacher DL. Extracorporeal cardiopul-monary resuscitation in 2023. Intensive Care Med Exp. 2023;11:74. doi:10.1186/s40635-023-00558-8

12.Eimer J, Atkins DL, Daya MR, Del Rios M, Fry JT, Henderson CM,Lewis-Newby M, Madrigal VN, Marco CA, Ornato JP,et al. Part 3: Ethics:2025 American Heart Association Guidelines for Cardiopulmonary Resus-citation and Emergency Cardiovascular Care. Circulation. 2025;152(Suppl 2):S323-S352. doi: 10.1161/CIR.00000000000001371

13. Assoublé B,Mentha N,Wozniak H,Donner V,Looyens C,Suppanp L,Larribau R,Banfi C,Bendjelid K,Giraud R.Improved Extracorporeal Cardiopulmonary Resuscitation(ECPR) Outcomes Is Associated with a Restrictive Patient Selection Algorithm. J Clin Med 2024;13:497. doi:10.3390/jcm13020497

14. Bunya N,Ohnishi H, Kasai T, Katayama Y, Kakizaki R, Nara S, Ijuin S, Inoue A,Hifumi T, Sakamoto T, et al; Study of Advanced life support for Ventricular fi-brillation with Extracorporeal circulation in Japan II(SAVE-J II) Study Group.Prognostic Significance of Signs of Life in Out-of-Hospital Cardiac Arresti Patients Undergoing Extracorporeal Cardiopulmonary Resuscitation. Crit Care Med.2024;52:542-550. doi:10.1097/CCM.00000000006116

15. Havranek S, Fingrova Z, Rob D, Smalcova J, Kavalkova P, Franke O,Smid O, Huptych M, Dusik M, Linhart A, et al. Initial rhythm and sur-vival in refractory out-of-hospital cardiac arrest. Post-hoc analysis of the Prague OHCA randomized trial. Resuscitation. 2022;181:289-296. doi:10.1016/j.resuscitation.2022.10.006

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Systems of Care: 2025 AHA Guidelines for CPR and ECC

16. Otani T, Hifumi T, Inoue A, Abe T, Sakamoto T, Kuroda Y; SAVE-J II study Group. Transient return of spontaneous circulation related to favourable out-comes in out-of-hospital cardiac arrest patients resustigated with extracor-poral cardiopulmonary resuscitation: A secondary analysis of the SAVE-J II study.Resusc Plus.2022;12:100300. doi:10.1016/j.respuil.2022.100300

17. Scquizzato T, Calabro MG, Franco A, Fominskiy E, Pieri M, Nardelli P, Delrio S,Altor S, Altya Medislo, G et al. ECPR-CARE Collaborators. Extracor-poral cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest: 10-year experience in a metropolitan cardiac arrest centre in Milan, Italy. Resus Plus; 2024;17:100521; doi: 10.1016/j.respuol.2023.100521

18. Tominaga N, Takiguchi T, Seki T, Hamaguchi T, Nakata J, Yamamoto T, Tagami T, Inoue A, Hifumi T, Sakamoto T; et al; SAVE-J II study group Investigation Supervision. Factors associated with favourable neurological outcomes fol-lowing cardiopulmonary resuscitation for out-of-hospital cardiac arrest: A retrospective multi-centre cohort study. Resusc Plus.2024;17:10057.44.

19. Dusik M, Rob D, Smalcova J, Havranek S, Karasek J, Smid O, Brodska HL,Kavalov P, Hupychun M, Bakker J, et al. Serum lact in refractory out-of-hospital cardiac arrest: Post-hoc analysis of the Prague OHCA study. Re-suscitation.2023;192:109935. doi:10.1016/j.resuscitation.2023.109935

20. Tran A, Rochergav B, Fan E, Belohlakev J, Severein MM, Poll M, Lonusro, Price S, Yannopoulos D, MacLaren G, et al. Prognostic factors associated with favourable functional outcome among adult patients requiring extra-corporeal cardiopoleal resuscitation for out-of-hospital cardiac arrest: A systematic review and meta-analysis. Resuscitation. 2023;193:110004.doi:10.1016/j.resuscitation.2023;110004

21. Nguyen ML, Gauge E, Mills B, Tonna JE, Alvley H, Saczkowski R, Grunau B,Becker LB, Gaieski DF, Younggist S, et: Extracorporeal Resuscitation Consortium.Traumatic and hemorrhagic complications after extracorporal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: Resuscita-tion.2020;157:225-229.doi:10.1016/j.resuscitation.2020.09.035

22. Lee HS, Lee CH, Jang JS, Cho JE, JON YH. Differences in Treatment Outcomes According to the Insertion Method Used in Extracorporeal Car-diopulmonary Resuscitation: A Single-Center Experience. J Chest Surg 2024;57:281-288.doi:10.5090/jc.23.118

23. Nakatsutumi K,Endo A, Costantini TW, Takayama W, Morishita K, Otomo Y, Inoue A, Hifumi T, Sakamoto T, Kuroda Y; SAVE J. I study group. Time-saving effect of real-time ultrasound-guided cannulation for extracorporeal cardiopulmonary resuscitation: A multicenter retrospective cohort study. Re-suscitation.2023;191:109927. doi: 10.1016/j.resuscitation.2023.109927

24. Wang L, Li C, Hao X, Rycus P, Tonna JE, Alexander P, Fan E, Wang H,Yang F, Hou X. Percutaneous cannulation is associated with lower rate of severe neurological complication in femorof LECR: results from the Extracorporeal Life Support Organization Registry. Ann Intensive Care.2023;13:77. doi:10.1186/s13613-023-01174-1

25. Choi S,Hong KJ,Lee SGW,Kim TH,Shin SD,Song KJ,Ro YS,Jeong J,Park JH, Lee GM. Association between Case Volumes of Extracorporeal Life Support and Clinical Outcome in Out-of-Hospital Cardiac Arrest. Preshop Emerg Care.2024;28:139-146. doi: 10.1080/10903127.2023.2216786

26.Misumi K, Hagiwara Y, Kimura T, Hifumi T, Inume O, Sakamoto T, Kuroda Y,Ogura T; group S-JJs. Impact of center volume on in-hospital mortality in adult patients with out-of-hospital cardiac arrest resuscitation using extra-corporeal cardiopulmonary resuscitation: a secondary analysis of the SAVE-J II study. Sci Rep.2024;14:8309. doi: 10.1038/s41598-024-58808-y

27. Tonna JE, Selzman CH, Bartos JA, Presson AP, Ou Z, Jo Y, Becker L,Youngquist ST, Thiagarajan R, Johnson MA, et al. The Association of Medi-fiable Postresuscitation Management and Annual Case Volume With Sur-vival After Extracorporeal Cardioiulmonary Resuscitation. Crit Care Explor.2022;4:e0733. doi:10.1097/CCE.000000000000733

28. Extracorporeal Life Support Organization.The ECLS Registry Report.2024.

ORGAN DONATION AFTER CARDIAC ARREST

|Recommendations for Organ Donation After Cardiac Arest||| |---|---|---| |COR|LOE|Recommendations| |1|B-NR|1. We recommend that all patients who are resuscitated from cardiac arrest but who subsequently meet neurologic criteria for death or have planned withdrawal of life-sustaining therapies be evaluated for organ donation.|

|Recommendations for Organ Donation After Cardiac Arrest (Continued)|||| |---|---|---|---| |COR|LOE|Recommendations|| |1|C-EO|2. Institutions should develop SOC focused on facilitating and evaluating organ donation after cardiac arrest consistent with local legal and regulatory requirements.|| |2b|B-NR|3. Patients who do not have ROSC after resuscitation efforts and who would otherwise have termination of resuscitation efforts may be considered candidates for donation in settings where such programs exist.||

Synopsis

There are over 100 000 people awaiting a transplant in the United States, with dozens dying each day due to a donor shortage.1 Nonsurvivors of cardiac arrest could represent an underrecognized source of lifesav-ing organs. As in other settings, donation after cardiac arrest occurs after confirmation of circulatory or brain death. Donation after circulatory death(DCD) is fur-ther divided into controlled and uncontrolled donation.Controlled DCD typically occurs following planned with-drawal of life-sustaining therapies. Uncontrolled DCD occurs immediately after cessation of resuscitative ef-forts. Although ethical considerations(refer to“Part 3:Ethics")2 and local regulations dictate the circumstances and settings in which organ donation is appropriate, mul-tiple studies across the globe reinforce that cardiac ar-rest nonsurvivors represent an effective donor allograft source.

Recommendation-Specific Supportive Text

1. Numerous observational studies have docu-mented comparable allograft function and recipci- ent outcomes when transplanted organs are recovered from donors who have suffered cardiac arrest's-3.7 includes donation after brain death and controlled DCD, including among donors resuscitated via ECPR or otherwise supported on ECMO.8.9

2. A 2023 ILCOR R scientific statement focused on the importance of increasing organ availability after cardiac arrest.10 Specific interventions and SOC targeting organ donation may help facilitate its acceptance and performance following cardiac arrest, potentially expanding the donor pool.11,12 It is vital that such programs adhere to local laws and regulations governing determination of death and organ donation.13,14 Metrics of interest for such sys-tems may include organ referrals and donor con-version rates on the percentage of eligible donors who go on to successful organ donation.

3. Uncontrolled DCD is less commonly performed;however, several studies have demonstrated

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acceptable kidney and liver allograft function and recipient outcomes following uncontrolled DCD among centers with established uncontrolled DCD programs. 6,15-17

REFERENCES

1. Organ Donation Statistics. Health Resources Service Administration. Ac-cessed 10/28/2024. https://www.organdonor.gov/learn/organ-donation-statistics

2. Elmer J, Aktins DL, Daya MR, Del Rios M, Fry JT, Henderson CM,Lewis-Newby M, Madrigal VN, Marco CA, Ornato JP, et al. Part 3: ethics:2025 American Heart Association Guidelines for Cardioplumive Resources and Emergency Cardiovascular Care. Circulation. 2025;152(suppl 2):S323-S352. doi: 10.1161/CR/0000000000001371

3Rovth S, M.Pemberele V, Narcuroa St, Arota T, Benge T, B6 S, Lix Stu,Westenfeld R, Rellecke P, Tudorache I, et al. Impact of Cardiopulo-nary Resuscitation of Donors on Days Alive and Out of Hospital at-ter Orthotopic Heart transplantation. J Clin Med. 2022;11:3853. doi:10.3390/jcm11133853

4.Mohite PN, Zych B, Sabashnikov A, Povop AF, Garcia-Saez D, Patini NP Koch A, Zeroh M, Rahmanian PB, Dhar D, et al. Effect of donor cardiac arrest and arrest duration on outcomes of lung transplantation. Clin Transplant.2016;30:421-428. doi: 10.1111/ctr:12704

5. Hoyer DP, Paul A, Saner F, Gallinat A, Mathe Z, Treckmann JW, Schulze M, Kaiser, G. Manby C, Ganay M, Molenti E, et al. Safely expanding the donor pool: brain dead donors with history of temporary cardiac arrest. Liver Int 2015;35:1756-1763. doi: 10.1111/l/12766

6. West S, Soar J, Callaway GW. The viability of transplantings from do-nors who underwent cardiopulmonary resuscitation: A systematic review.Resuscitation.2016;108:27-33. doi: 10.1016/j.resuscitation.2016.07.229

7. Renaudier M, Binois Y, Dumas L, Lamhaut L, Begaton F, Jostov, Charperen J, Lesieur O, Marijon E, Jouven X et, al: Paris sudden Death Expertise Cen-ter group. Organ donation after out-of-hospital cardiac arrest: a population-based study of data from the Pais Sudden Death Expertise Center. Ann Intensive Care. 2022;12:48. doi:10.1186/s13613-022-01023-7

8.Raphenal JH,Soumagnac T,Blanot S,Bougoun W,Bourault A,Vimpere D,Ammar H,Gardon C,An K,Mungur A,et al.Kidren recovered from brain dead cardiac arrest patients resuscitation with ECRP show similar one-year graft survival compared to other donors. Resuscitation.2023;1901-109883 doi:10.1016/j.resuscitation.2023.109883

9.Smalcova J, Havranek S, Pokorna E, Franeek O, Huyptych M, Kavalkova P, Pudil J, Pod J, Dussik M, Belohlavek J. Extracorporeal cardiopulo-nary resuscitation-based approach to refractory out-of-hospital car-diac arrest: A focus on organ donation, a secondary analysis of a Prague OHCy randomized study. Resuscitation. 2023;193:109993. doi: 10.1016/j.resuscitation.2023.109993

10.Morrison L, Sandioni C, Grunau B, Parr, M. Macneil F, Perkins GD,Aibib M, Censullo E, Lin S, Neuram RW, et al; International Liaison Committee on Resuscitation. Organ Donation After Out-of-Hospital Cardiac Arrest A. Scientific Statement From the International Liaison Committee on Resuscitation. Resuscitation. 2023;190:109864. doi:10.1016/j.resuscitation.2023.109864

11. Gibson JE, Campbell B, Gibson K, Kotlemann K, Krause MA, Pack L. Col-laborative Approach to Organ Donation in a Level II Trauma Center. AACN Axt-Crit Dev C.2023;34:88-94. doi:10.4037/haaccnac2023552

12D'Aragon, Fach lasso, Lefurte A, Ortegaoff D, Almasse MH, Trepanier G, Lamarche D, Battista MC. Program of Uncontrolled Donation Air-circulatory Death as Potential Solution to the Shortology of Organs: A cana-dian Single-Center Retrospective Cohort Study. Open Access Emerg Med.2022;14:413-420.doi:10.2147/OAEM.S361930

13. Etheredge HR: Assessing Global Organization Policies: Opt-h vs Opt-Out. Risk Manag Health Policy. 2021;14:1985-1998. doi: 10.2147/RMHSPS270234

14.Greur D, Shemire SD, Lewis A, Sortrance S, Varelas P, Goldenberg F,Bernat JL, Souter M, Topcuoglu MA, Alexandrov AW,et al.Determination of Brain Death/Dather of Neurologic Certierra: The World Brain Death Project.JAMA 2020;324:1078-1097. doi:10.1001/jama.2020.11586

15.Cohen JD, Kaplan T, Fink T, Grozovsky S, Krugo R, Kagan I, Ashkenazi T. Outcome of Kidney Transplantation in Israel Following Uncontrolled Donation after Cardiculatory Determination of Death. Sir Med Assoc J.2023;25:434-437.

16.Fondevila C, Hessheimer AJ, Flores E, Ruiz A, Mestres N, Calatayud D,Paredes D, Rodriguez C, Fuster J, Navasa M, et al. Applicability and results of Maaststricht type 2 donation after cardiac death liver transplantation. Am J Transplant.2012;12:162-170. doi: 10.1111/j.1600-6143.2011.03834.x

17. Alonso a, Fernandez-Rivea C, Villaverde P, Oliver J, Cillero S, Lorenzo D,Valdes F. Renal transplantation from non-heart-beating donors: a single-center 10-year experience. Transplant Proc.2005;37:3658-3660. doi: 10.1016/j.transproceed.2005.09.104

DATA REGISTRIES TO IMPROVE SYSTEM PERFORMANCE

|Recommendation for Data Registries to Improve System Performance||| |---|---|---| |COR|LOE|Recommendation| |1|B-NR|1. Organizations that treat cardiac arrest patients should collect processes-of-care data and outcomes to guide system improvement.|

Synopsis

Measurement is the cornerstone of evaluating perfor-mance and identifying opportunities for improvement. For cardiac arrest, measurement may be at the local, region-al, or national level through participation in data registries that collect information on processes (CPR performance data, defibrillation times, adherence to guidelines) and outcomes (ROSC, survival) of care. Ideally, data registries are based on the Ustein template, which standardizes core and supplemental elements across participating sites. ${ }^{1-3}$ In the United States, the AHA's Get With The Guidelines-Resuscitation registry and the Cardiac Arrest Registry to Enhance Survival are examples of initiatives that capture data related to processes and outcomes for IHCA and OHCA, respectively. More recently, an expert panel convened by ILCOR and the AHA for IHCA and the Global Resuscitation Alliance for OHCA identified participation in a registry as a key step for improving car-diac arrest survival. ${ }^{4-6}$ Systematic collection of cardiac arrest data within registries is used to identify gaps in care quality that inform quality improvement interven-tions. They are also used to determine whether quality improvement initiatives are successful in improving care and outcomes.

Recommendation-Specific Supportive Text

1. Consistent with prior studies, recent observational studies demonstrate improved survival and adher-ence to key performance indicators (CPR process measures, defibrillator application, adherence to guidelines) over time.7-10 In the population-based OHCA registries from Japan and Korea, survival to discharge and favorable neurological survival for OHCA patients have steadily increased since the inception of these registries, with improvements attributable to structured interventions guided by systematic data collection.8,10 These findings are

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consistent with prior studies from established regis-tries in other countries, highlighting the importance of registries in improving survival.11-13 For IHCA,an observational study found notable improvement in ROSC from 61% to 73.5%($P=0.03) following the implementation of a quarterly CPR training program.9 In a separate study from Singapore, the initiation of a multiproonged quality improvement program that focused on CPR training and commu-nication, improved staffing, audit and feedback was also associated with a significant improvement in ROSC(OR,20.5; 95% CI,1.04-4.05; P=0.04) but not survival to discharge.7

REFERENCES

1.Cummings R,Chamberlain DA, Hazinski MF, Nadkarni V, Kloeck W, Kramer E,Becker L, Robertson C, Koster R, Zaritsky A, et al. Recommended guidelines for reviewing, reporting, and conducting research on in-hospital resuscita-tion: the in-hospital'Utstein style': a statement for healthcare professionals from the American Heart Association. Circulation. 1997;95:2213-2239. doi: 10.1161/01/cir.95.8.2213

2.Cummins RO, Chamberlain DA, Abramson NS, Allen M, Baskett PJ,Becker L, Bousart L, DelooH, Dick HF, Eck Fisenberg MS. Rec-mended guidelines for uniform reporting of data from out-of-hospital cardiac arrest; the Usthe style: a statement for health professionals from a task force of the American Heart Association, the European Re-suscitation Council, the Heart and Stroke Foundation of Canada, and the Australian Resuscitation Council. Circuits 1991;84:96-970. doi: 10.1161/01.cir.84.2.960

3. Bray JE,Grasner JT,Nolan JP,Iwami T,Ong MEH,Finn J,McNally B,Nnehze Z, Sasson C, Tissen J,et al: International Laisison Committee on Resuscitation. Cardiac Arrest and Cardiopulmonary Resuscitation Outcome: Reports:2024 Update of the Ustain Outf-Hospital Car-diac Arrest Registry Template. Circulation: 2024;150:e203-e223. doi: 10.1161/CIR0000000000001243

4. The Resuscitation Academy. Resuscitation Academy. 10 Steps for Improving Survival from Sudden Cardiac Arrest. 2nd ed. Global Resuscitation Alliance.2019. Accessed July 17, 2024.https://globalresuscitationalliance.org/downloads/ebock/10_steps_2019.pdf

5. Chan PS, Greif R, Anderson T, Atiq H, Bittencourt Couto T, Considine J,De Caen AR,Djar T, Doll A,Douma MJ,et al; International Liaison Commitmi-tee on Resuscitation. Ten Steps Toward Improving In-Hospital Cardiac Arrest-est Quality of Care and Outcomes. Resuscitation. 2023;193:109996.doi:10.1016/j.resuscitation.2023;109:09996.doi:10.1016/j.resuscitation.2023;109:09996.doi:

6. Nallouthu BK, Greif R, Anderson T, Atiq H, Couto TB, Considine J, De CaAR, Dijar T, Doll A, Douma MJ, et al; International Liaison Committee on Resuscitation. Ten Steps Toward Improving In-Hospital Cardiac Arset of Care and Circuits. Circocardial Quasual Outcomes. 2023;16:e010491.doi:10.1161/CIRCOUTCOMES.123:010491.

17. LeCK Pan, Zhan HL,Cheng Y/TJ, K.Incproving response time and survival in ward based in-hospital cardiac arrest: A quality improvement initiative. Re-suscitation:2024;197:1110134.doi:10.1016/j.resuscitation:2024;110134

8. Nakahara S, Nagao T, Nishi R, Sakamoto T. Task-shift Model in Pre-hospital Care and Standardized Nationwide Data Collection in Japan: Improved Out-comes for Out-of-hospital Cardiac Arrest patients. JMA J 2021;4:8-16.doi:10.31662/jm.2020j.00-2074

9.O'Leary A, Butler P, Fine JR. Dedicated chest compressor team: A qual-ily improvement to improve chest compression performance at in-hospital cardiac arrest events through quarterly training. Resusc Plus.2023;13:100361:doi 10.1016/j.respu23.200310361

[10 Park,CHJoi,OR Ro,YoS,Gunk Shi,OR 235D.Establishing the Korean Out-of-Hospital cardiac arrest registry(KOHCAR).Resuscus 2024;17:100529.dol.10.1016/j.resplu2023.100529

11. Chan PS, McNally B, Tang F, Kerrmann A; Group S. Recent trends of survival from out-of-hospital cardiac arrest in the United States. Circulation.2014;130:1876-1882. doi:10.1161/CIRCULATIONAHA-114.094711

12.Girostra N, Samollathu BH, Spertus JA, Li Y, Krumhol HM, Chan PS;American Heart Association Get with the Guidelines-Resuscitation lives

$\underline{t}}{t)}$ 2012;367:1912-1920.doi: 10.1056/NEJmoa1109148

13. Wissenberg M, Lippert F, Folke F, Weeke P, Hansen CM, Christensen EF,Jans H, Hansen PA, Lang-Jensen T, Olesen JB, et al. Association of nation-al initiatives to improve cardiac arrest management with rates of bystander intervention and patient survival after out-of-hospital cardiac arrest. JAMA 2013;310:1377-1384.doi: 10.1001/jama.2013.278483

IMPROVING CARDIAC ARREST RECOVERY

|Recommendation for Improving Cardiac Arrest Recovery||| |---|---|---| |COR|LOE|Recommendation| |2a|B-R|1. The recovery and long-term functional outcomes of cardiac arrest survivors are likely to benefit from the use of integrated systems that assess patients prior to discharge, reassess their needs after discharge, and address these needs on an ongoing basis during recovery.|

Synopsis

Recovery after cardiac arrest encompasses many facets beyond the acute event and resuscitation, affects many individuals beyond the survivor, and spans long after the initial hospitalization. ${ }^{1}$ Patients are often laden with new diagnoses and treatments for the underlying cause of their cardiac arrest. They may also deal with new neuro-logic, physical, or psychosocial impairments that present challenges to reintegration to work, leisure, and society. ${ }^{2}$Finally, friends, family, lay rescuers, and emergency per-sonnel, appropriately recognized as cosvivors, suffer a critical toll after experiencing a resuscitation-whether successful or not-which is increasingly being appreci-ated ${ }^{3}$ Previous guidelines and scientific statements have shed light on the importance of building SOC and sci-ence to optimize the recovery, survivorship, and cosur-vivorship process. ${ }^{1,3}$ Indeed, the creation of such SOC is considered an ethical responsibility for organizations that provide care for cardiac arrest survivors (refer to the Im-pact on Survivors section in "Part 3: Ethics"). ${ }^{4}$

Recommendation-Specific Supportive Text

1.In an RCT where semistructured cognitive, medical,and psychosocial support offered to adult OHCA and IHCA survivors for 6 months after discharge was compared with no intervention, survivors had significant improvement in multiple domains of qual-ity of life at 12 months.5 This intervention was found to be potentially cost effective at the 1-year follow-up.6 Other RCTs have evaluated the effectiveness of biofeedback and cognitive behavioral therapy ${}^{7}$ and a structured telephone follow-up ${}^{8}$ in cardiac arrest survivors, surviving improvements in long-term survival and quality of life, respectively. However, a recent systematic review of RCTs and observa-tional studies of rehabilitation following cardiac arrest found significant heterogeneity of treatment

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effects. ${ }^{9}$ Provision of integrated recovery services,and prevention of loss to follow-up, requires the presence of a multidisciplinary system that spans the inpatient and outpatient domains. ${ }^{10-12}$

REFERENCES

1. Sawyer KM, Camp-Rogers TR, Kotini-Shah P, Del Rios M, Gossip MR,Moirto VK, Haywood KL, Dougherty CM, Lubitz SA, Rabstein AA, et al;American Heart Association Emergency Cardiovascular Care Committee;Council and Cardiovascular and Stroke Nursing; Council on Genomic and Precision Medicine; Council on Quality of Care and Outcomes Research;and Stroke Council. Sudden Cardiac Arrest Survivorship: A Scientific State-ment From the American Heart Association. Circulation.2020;141:e654-e6858. doi: 10.1161/C178.Circumodulation 0000000000000747

2. Perkins GD,Callaway CW, Haywood K, Nephwer MW, Lijga R, Rowland M, Sawyer KN, Skrifvaris MB, Nolan JP. Brain injury after cardiac arrest. Lancet.2021;398:1269-1278. doi: 10.1016/50140-6736(21)00953-3

3. Dainty KN, Colquitt B, Bhanji F, Hunt EA, Ejfsark T, Leary M, Ornato JP,Swor RA, Panchal A. Understanding the Importance of the Lay Responder Experience in Out-of-Hospital Cardiac Arrest: A Scientific Statement from the American Heart Association. Circulation. 2022;145:e852-e867. doi: 10.1161/C.R.00000000000001054

4. Elmer J, Akits DL, Daya MR, Del Rios M, Fry Jt, Henderson C,Lewis-Newby M, Madrigal VN, Marco CA, Ornato JP,et al. Part 3: ethics:2025 American Heart Association Guidelines for Cardoproduction Programy Resus-citation and Emergency Cardiovascular Care. Circulation. 2025;152(suppl 2):S323-S352. doi: 10.1161/CIR.000000000000001371

5. Moulaert VR, van Heugent M, Winkens B, Bakx W, de Krom MC, Gorgels TP, Wade QTb, Verbunt JA. Early neurologically focused follow-up after car-diac arrest improves quality of life at one year: A randomised controlled trial.Int J Cardiol.2015;1938-16-18.doi:10.1016/j.ijcard.2015.04/2299

6. Moulaert VR, Goossens M, Heijnders IL, Verbunt JA, Heugsten CM. Early neurologically focused follow-up after cardiac arrest is cost-effective: A trial-based economic evaluation. Resuscitation. 2016:106:30-36. doi:101016/j.resuscitation.2016.06.015

7. Cowan MJ, Pike K, Budzynski HK. Psychosocial nursing surgery following sudden cardiac arrest impact: on two-year survival. Nurs. Res.2001;50:68-76. doi: 10.1097/00060199-200103000-00002

8. Dougherty CM, Thompson EA, Lewis FM. Long-term outcomes of a tele-phone intervention after an ICD. Pacing Clin Electrophysiol 2005;28:1157-1167. doi: 10.1111/j.1540-8159.2005.09500.x

9.Joshi VL,Christensen J, Lejsgadd E, Taylor RS, Swirley AD, Tang LH.Ef-fectiveness of rehabilitation interventions on the secondary consequences of surviving a cardiac arrest: a systematic review and meta-analysis. BMJ open.2021;11:e047251.10:1136/bmjopen-2020-047251

10. Wagner MK, Christensen J, Christensen KA, Dichman C, Gottlieb R, Kolster I, Hansen CM, Hoff H, Hassager C, Folke F, et al. Multidisciplinary guideline-based approach to improving the sudden cardiac arrest care pathway: The Copenhagen framework. Resusc Plus.2024;17:100546. doi:10.1016/j.resplu.2023.100546

11. Mion M,Al-Janabi F,Islam S,Magee N,Balasubramanian R,Watson N,Potter M, Karamasis GV,Harding J,Seligman H,et al.Care After ReSuscitation:Implementation of the United Kingdom's First Dedicated Multidisciplinary Follow-Up Program for Survivors of Out-of-Hospital Cardiac Arrest. Ther Hypothermia Temp Manag 2020;10:53-59. doc.10.1089/theri.2018.0048

12. Mion, Simpson R, Johnson T, Oriolo V, Gudec Re, Ees P, Quinn T,Vopelius-Feldt VJ, Gallagher S, Mozid A, et al. British Cardiovascular Inter-vention Society Consensus Position Statement on Out-of-Hospital Cardiac Arrest 2: Post-discharge Rehabilitation. Interv. Cardiol. 2022;17:e19. doi:10.15420/icr.2022.08

KNOWLEDGE GAPS AND PRIORITIES FOR RESEARCH

Resuscitation science continues to evolve, with a grow-ing understanding of how integrated SOC impact clinici-cal outcomes as new literature emerges. Although many areas still require further study, the writing group felt

that the following items represented the most important knowledge gaps in SOC, therefore deserving the highest priority for future research:

1.Although the clinical effectiveness of community CPR and AED programs is well established, defin-ing the cost effectiveness of implementation in spe-cific populations and settings requires further study.

2. Mobile technologies hold considerable promise as a means to engage lay rescuers in CPR and AED use, however, the optimal implementation of these technologies requires further research.

3. As mobile technologies are implemented, potential risks to privacy, liability, and personal safety during lay rescuer CPR in an unknown location need to be understood.

4. Preliminary studies on drone delivery of AEDs are promising. However, the use of a drone net-work as part of a community cardiac arrest SOC requires cost-effectiveness analysis and research to define its application in real-world situations and its impact on patient outcomes.

5.Further research is needed to better comprehend the barriers, challenges, and benefits of integrating out-of-hospital and in-hospital datasets as part of quality improvement programs within SOC.

6. While growing evidence supports the benefits of regionalized SOC for time-sensitive emergen-cies (eg, stroke, ST-segment elevation myocardial infarction), CAs require better definition, includ-ing research to identify which components confer benefit and to determine whether delivery of these components justifies the requisite transport time.

7. Further studies are needed to understand how telecommunications can better recognize cardiac arrest, particularly in pediatric patients, and how their instructions can be delivered to optimize lay rescuer participation and delivery of high-quality CPR. Research to identify age cutoffs and etiolo-gies for which individuals in cardiac arrest ben-efit from full CPR with breaths, as opposed to compression-only CPR, is needed.

8.The timing, methods, and specific components of feedback or debriefing after attempted cardiac arrest resuscitation require further study.

9. Research is needed to identify which patients war-rant transport to a hospital with ongoing CPR and to define the fest means to do so while maintain-ing high-quality CPR.

10.Further research is needed to identify the patient characteristics wherein RRT/MET programs pro-vide the greatest outcome benefits, which interven-tions are most efficacious, and whether RRT/MET programs should be linked to an automated EWS.

11.Research is needed on how to apply behavior and leadership skill training to code teams and EMS systems to optimize resuscitation.

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12. Compression-only CPR is easier to implement because of its simplicity and reduced contact but may be less efficacious than CPR with breaths in some etiologies of OHCA(eg, opioid-associated OHCA). Research is needed to define whether specific etiologies of OHCA warrant distinct tele-communicator instructions.

Disclosures

Appendix 1. Writing Group Disclosures

|Writing group member|Employment|Research grant|Other research support|Speakers' bureau/ honoraria|Expert witness|Ownership interest|Consultant/ advisory board|Other| |---|---|---|---|---|---|---|---|---| |Cameron Dezfulian|Baylor College of Medicine|None|None|None|None|None|None|None| |José G.Cabanas|Wake County EMS|None|None|None|None|None|None|None| |Jason R. Buckley|Medical University of South Carolina|None|None|None|None|None|None|None| |Rebecca E. Cash|Massachusetts General Hospital; Harvard Medical School|Emergencying Medicine Foundation'; NIHT; NIHt; Society for Academic Emergency Medicine Foundationt|None|None|None|None|American College of Emergency Physicians*; Prehospital Guidelines Consortium*; Air Methods Corpt|None| |Remle P. Crowe|ESO|None|None|None|None|None|None|None| |lan R. Drennan|University of Toronto(Canada)|ZOLLt|None|Speakers' Bureau: ZOLLt|None|None|None|None| |Saketi Girotra|The University of Texas Southwestern Medical Center|NHLBIt|None|None|None|None|None|None| |Melissa Mahgoub|American Heart Association|None|None|None|None|None|None|None| |Candace N. Mannarino|Ann& Robert H. Lurie Children's Hospital of Chicago|None|None|None|None|None|None|None| |Teresa May|Maine Medical Center|NINDS -1R01NS119825*|None|None|None|None|None|None| |David D. Salcido|University of Pittsburgh School of Medicine|Hillman Family Foundationt|None|None|None|None|None|None| |Anezi I. Uzendu|UT Southwestern Medical Center and VA North Texas Health Care System|None|None|None|None|None|None|None| |Melissa A. Vogelsong|Stanford University|Zoll Foundation Young Investigator Grant*; Stanford Cardiovascular Health Clinical Research Innovation Grant*|None|None|None|None|None|None| |Joshua A. Worth|AmeriPro Health|None|None|None|None|None|None|None|

This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be"significant" if(a) the person receives$5000 or more during any 12-month period, or 5% or more of the person's gross income; or(b) the person owns 5% or more of the voting stock or share of the entity, or owns$5000 or more of the fair market value of the entity. A relationship is considered to be"modest" if it is less than"significant" under the preceding definition.*Modest.

*Modest.

tSignificant.

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Appendix 2. Reviewer Disclosures

|Reviewer|Employment|Research grant|Other research support|Speakers bureau/ honoraria|Expert witness|Ownership interest|Ownership advisory board|Other| |---|---|---|---|---|---|---|---|---| |Joseph Grover|The University of North Carolina at Chapel Hill|None|None|None|None|None|None|None| |Lia Lowrie|St. Louis University School of Medicine|None|None|None|None|None|None|None| |Christian Martin-Gill|University of Pittsburgh Medical Center|None|None|None|None|None|None|None| |Michael R. Sayre|University of Washington|NIH(Collaborator)+|None|None|City of Bulletin, WA*|None|Stryker Emergency Caret|None| |Scott T. Youngquist|University of Utah|NINDS(PediDOSE Trial EMS Investigator)*; DoD(PAIN Clinical Trial Site Pl)*; NHLI(ICECAP Trial Site Investigator)*;HARQ(FEED-PT Trial Site Investigator)*|None|None|None|None|Emergency Scientific*|None|

This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Ques-tionnaire, which all reviewers are required to complete and submit. A relationship is considered to be“significant" if(a) the person receives$5000 or more during any 12-month period, or 5% or more of the person's gross income; or(b) the person owns 5% or more of the voting stock or share of the entity, or owns$5000 or more of the fair market value of the entity. A relationship is considered to be“modest” if it is less than“significant” under the preceding definition.

*Modest.

tSignificant.