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(Circulation. 2009;119:728-734.)
© 2009 American Heart Association, Inc.

Resuscitation Science

Continuous Improvements in "Chain of Survival" Increased Survival After Out-of-Hospital Cardiac Arrests

A Large-Scale Population-Based Study

Taku Iwami, MD, PhD; Graham Nichol, MD, MPH; Atsushi Hiraide, MD, PhD; Yasuyuki Hayashi, MD, PhD; Tatsuya Nishiuchi, MD; Kentaro Kajino, MD, PhD; Hiroshi Morita, MD, PhD; Hidekazu Yukioka, MD, PhD; Hisashi Ikeuchi, MD, PhD; Hisashi Sugimoto, MD, PhD; Hiroshi Nonogi, MD, PhD; Takashi Kawamura, MD, PhD

From Kyoto University Health Service (T.I.,T.K.), Kyoto, Japan; University of Washington–Harborview Center for Prehospital Emergency Care (G.N.), Seattle, Wash; Center for Medical Education (A.H.), Kyoto University Graduate School of Medicine, Kyoto, Japan; Senri Critical Care Medical Center (Y.H.), Osaka Saiseikai Senri Hospital, Suita, Japan; Osaka Prefectural Senshu Critical Care Medical Center (T.N.), Izumisano, Japan; Emergency and Critical Care Medical Center (K.K.), Osaka Police Hospital, Osaka, Japan; Department of Emergency Medicine (H.M.), Osaka Medical College, Takatsuki, Japan; Yukioka Hospital (H.Y.), Osaka, Japan; Osaka General Medical Center (H.I.), Osaka, Japan; Department of Traumatology and Acute Critical Medicine (H.S.), Osaka University Graduate School of Medicine, Suita, Japan; and Division of Cardiology (H.N.), National Cardiovascular Center, Suita, Japan.

Correspondence to Taku Iwami, MD, PhD, Kyoto University Health Service, Yoshida Honmachi, Sakyo-Ku, Kyoto 606-8501, Japan. E-mail iwamit2000{at}yahoo.co.jp

Received June 24, 2008; accepted November 28, 2008.

Background— The impact of ongoing efforts to improve the "chain of survival" for out-of-hospital cardiac arrest (OHCA) is unclear. The objective of this study was to evaluate the incremental effect of changes in prehospital emergency care on survival after OHCA.

Methods and Results— This prospective, population-based observational study involved consecutive patients with OHCA from May 1998 through December 2006. The primary outcome measure was 1-month survival with favorable neurological outcome. Multiple logistic regression analysis was used to assess factors that were potentially associated with better neurological outcome. Among 42 873 resuscitation-attempted adult OHCAs, 8782 bystander-witnessed arrests of presumed cardiac origin were analyzed. The median time interval from collapse to call for medical help, first cardiopulmonary resuscitation, and first shock shortened from 4 (interquartile range [IQR] 2 to 11) to 2 (IQR 1 to 5) minutes, from 9 (IQR 5 to 13) to 7 (IQR 3 to 11) minutes, and from 19 (IQR 13 to 22) to 9 (IQR 7 to 12) minutes, respectively. Neurologically intact 1-month survival after witnessed ventricular fibrillation increased from 6% (6/96) to 16% (49/297; P<0.001). Among all witnessed OHCAs, earlier cardiopulmonary resuscitation (odds ratio per minute 0.89, 95% confidence interval 0.85 to 0.93) and earlier intubation (odds ratio per minute 0.96, 95% confidence interval 0.94 to 0.99) were associated with better neurological outcome. For ventricular fibrillation, only earlier shock was associated with better outcome (odds ratio 0.84, 95% confidence interval 0.80 to 0.88).

Conclusions— Data from a large, population-based cohort demonstrate a continuous increase in OHCA survival with improvement in the chain of survival. The incremental benefit of early advanced care on OHCA survival is also suggested.

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