Abstract
The standard level of care provided to medical cardiac arrest patients took a drastic turn when the first closed chest defibrillator was introduced in the mid 1950’s by Paul Zoll (Nelson, 2013). Official training on the regulated EMT use of Automated External Defibrillators (AED) began in 1980 following the release of the first readily available AED (Dyck, 2014). Thus, paving the way for AED’s becoming a standard piece of equipment for EMS providers and the ever-evolving standard of care for cardiac arrest patients. In 1979 a discussion was held at the 3rd national conference on CPR where Advanced Cardiac Life Support (ACLS) was developed (American Heart Association, 2018). With the recent development of Ontario’s steps toward increasing the standard level of paramedic care from primary to advanced in pre-hospital setting, we have chosen to research ACLS and Basic Cardiac Life Support (BCLS) effects on cardiac arrest resuscitation survival rates in pre-hospital care in Ontario. Our goal is to determine whether advanced life support, as opposed to basic life support, would provide a better standard of care to victims of cardiac arrest. To further this goal, we will analyze and contrast the research available on this topic, not limited to: statistics on resuscitation survival rates, ALS and BLS cardiac arrest protocols and response times in the province of Ontario.
RATIONALE
Consistently Paramedics are called upon to respond to medical cardiac arrests. Primary Care Paramedics (PCP) are trained to provide BCLS capabilities while Advanced Care Paramedics (ACP) are trained to ACLS level of care (Ontario Paramedics Association, 2018). This distinct difference leads to patients with similar cardiac emergencies receiving different levels of care and pre-hospital management. PCP care makes up a large portion of first response
ACLS AND BCLS EFFECTS ON PREHOSPITAL CARDIAC ARREST CARE 3
to medical emergencies and ACP is considered a specialty qualification and requires substantial additional training and cost. Our intention is to compare the rate of survival when different levels of care are provided within a similar criterion of patient.
STUDY CRITERIA
To ensure accurate results of the study, our population must be in cardiac arrest (no detectable pulse, unresponsive or apneic), the arrest must be of cardiac origin and must be out of hospital. In addition, emergency responders must have attempted resuscitation [i.e., return of spontaneous circulation (ROSC) must be achieved through BLS or ALS intervention] and the subject must be within age majority as outlined by protocols. Response time must also be within eight to ten minutes as eight minutes is standard target response time for larger cities within Ontario (Ministry of Health and Long Term Care, 2017) and after ten minutes, the success rate of ROSC is dramatically decreased.
Exclusions include: trauma, high-risk groups (e.g., morbidly obese), underlying pathologies (e.g., known pre-existing cardiac disease) and samples with a response time of over 10 minutes.
DATA COLLECTION
Our primary source of data would be Base Hospitals due to a requirement for access to Ambulance Call Reports (ACR). We need these to gather information regarding dispatch records, patient history, paramedic interventions, etc. We would also require a specific record of how many Primary Care Paramedics and Advances Care Paramedics are employed by each hospital, allowing us to take survival rates of cardiac arrest into account based off the availability of Advanced Cardiac Life Support. Examples of base hospitals include:
ACLS AND BCLS EFFECTS ON PREHOSPITAL CARDIAC ARREST CARE 4
• Lakeridge Health
• Hamilton Health Sciences Centre for Paramedic Education and Research
• Centre for Prehospital Care – Health Sciences North
• Regional Paramedic Program for Eastern Ontario
• Sunnybrook Centre for Prehospital Medicine
• London Health Sciences Centre
• Thunder Bay Regional Health Sciences Center
Secondary sources of data include Statistics Canada to gather the data regarding survival rates outside of hospital after cardiac arrest following above criteria. We also need to access medical records from receiving hospitals to compile patient statistics following successful resuscitation without significant deficit and reasonable quality of life.
CONSIDERATIONS
• Witnessed arrest versus found VSA
• CPR initiated by bystander/quality of CPR given by bystander
• Defibrillator initiated by bystander
• Defibrillator administered by Advanced Care Paramedic or Primary Care Paramedic –
ACP have been trained to perform manual shocks upon interpretation of
electrocardiogram (ECG) where as PCPs can only apply automatic external defibrillator.
• Medications given prior to shocks
ACLS AND BCLS EFFECTS ON PREHOSPITAL CARDIAC ARREST CARE 5
STUDY HYPOTHESES
As ACP personnel provide ACLS levels of care which is closer to care that would be received in hospital; there is reason to hypothesise that ACP cardiac care will show higher survivability rates than PCP cardiac arrest management.
OBJECTIVE
This study aims to expand on the previously done OPALS (Ontario Prehospital Advanced Life Support) with a narrower scope on cardiac care (Stiell, 1997). OPALS looked critically at prehospital advanced care in the late 1990’s, since then much has changed in the treatment of patients. Our intent is to take inspiration from the OPALS study and discover the best course of action for the survivability of cardiac patients in a prehospital setting.
DISCUSSION
As a growing number of cities are electing to move towards increasing their standard levels of care by employing only Advanced Care Paramedics, it is imperative to research the risks and benefits of doing so. While it seems that being able to provide advanced medical support would be favourable, we need to consider factors such as cost to employ Advanced Care Paramedics, including additional equipment and increased time on scene versus Advanced Care Paramedics having increased medical knowledge and being able to perform earlier interventions in contrast with Primary Care Paramedics. We intend to eliminate as many variables as possible but understand that this is not possible. As mentioned above, the preferred design of a controlled group is not ethical, and it will take several years to acquire accurate results regarding long-term survival rates for patients who were discharge from hospital following their cardiac arrest and
ACLS AND BCLS EFFECTS ON PREHOSPITAL CARDIAC ARREST CARE 6
what life changes did they make to increase survival time. We will take all variables into consideration when compiling results.
References
American Heart Association. (2018). History of CPR. Retrieved March 2018, from heart.org: http://cpr.heart.org/AHAECC/CPRAndECC/AboutCPRFirstAid/HistoryofCPR/UCM_475751_H istory-of-CPR.jsp
Dyck, D. (2014). AED History and Use. Retrieved March 2018, from Safety Services Manitoba.
Ministry of Health and Long Term Care. (2017). Land Ambulance Response Time Standard. Retrieved March 2018, from health.gov:
http://www.health.gov.on.ca/en/pro/programs/emergency_health/land/responsetime.aspx/respons etime.html
Nelson, C. (2013, May 29). A Little Defibrillator History and Its Potential Future. Retrieved March 2018, from http://www.aed.com/blog/a-little-defibrillator-history-and-its-potential-future/
Ontario Paramedics Association. (2018). Advanced Care Paramedics. Retrieved March 2018, from Ontario Paramdics: https://www.ontarioparamedic.ca/curriculum/advanced-care-paramedics/
Stiell, I. G. (1997, August). The Ontario Prehospital Advanced Life Support (OPALS) Study: Rationale and Methodology for Cardiac Arrest Patients . Annal Of Emergency Medicine, 32(2), pp. 180- 190. doi:https://doi.org/10.1016/S0196-0644(98)70135-0