Cardiopulmonary Resuscitation and Termination of Resuscitation on Out-of-Hospital Cardiac Arrest in China
Out-of-hospital cardiac arrest (OHCA) remains a significant public health challenge globally, and China is no exception. Early initiation of cardiopulmonary resuscitation (CPR), high-quality CPR, and the use of automated external defibrillators (AEDs) have been shown to significantly improve survival rates and long-term outcomes for OHCA patients. In China, pre-hospital emergency personnel are often the first to provide professional CPR to OHCA patients, and their on-site availability and decision-making often determine patient outcomes. CPR for OHCA patients typically ends with one of three outcomes: death, return of spontaneous circulation (ROSC), or referral to a hospital emergency department for continued resuscitation until ROSC or death is achieved.
The American Heart Association (AHA) published guidelines for the termination of resuscitation (TOR) in 2010, followed by the European CPR Guidelines in 2015. These guidelines recommend that CPR should be terminated when specific criteria are met: the cardiac arrest was unwitnessed, no bystander CPR occurred, no shock was delivered, and resuscitation efforts did not result in ROSC. However, China currently lacks its own guidelines or consensus for terminating CPR. As a result, pre-hospital emergency personnel must rely on their knowledge, skills, and understanding of international CPR guidelines to make decisions about when to terminate resuscitation efforts.
This study aimed to assess the current knowledge level of pre-hospital emergency personnel in China regarding basic CPR and TOR standards. The goal was to improve the efficiency of the pre-hospital emergency service system and standardize the role of TOR in China. To achieve this, a survey was conducted among emergency medical services (EMS) personnel across 23 provinces, five autonomous regions, and four municipalities in China in February 2021. The survey was completed within four weeks, and the data were analyzed to identify key factors influencing the decision-making process of pre-hospital emergency personnel.
The survey questionnaire collected demographic information about the respondents, including gender, age, ethnicity, employment status, years of experience, and educational background. It also included questions about pre-hospital CPR treatment options and TOR decisions. The questionnaire was designed by an expert group from the Beijing Emergency Medical Center, with input from emergency clinical experts. The study was approved by the Ethics Committee of the Beijing Emergency Medical Center, and written informed consent was waived due to the nature of the study.
A total of 4,318 valid questionnaires were collected. The respondents were nearly evenly split between males (47.27%) and females (52.73%), with the majority aged between 30 and 40 years (47.27%). Most respondents were of Han ethnicity, and the largest group held a bachelor’s degree (44.51%). In terms of professional titles, 46.80% held a junior professional title, and 35.66% had formal training in emergency medicine. The majority of respondents worked in municipal (41.08%) or county (30.96%) emergency centers, and 45.39% had been in their positions for less than five years.
The survey revealed that 94.40% of respondents had participated in adult basic life support training, 66.33% in adult advanced life support (ALS) training, 39.07% in child life support training, and 21.31% in pregnant women’s life support training. In terms of their exposure to OHCA cases, 74.02% of respondents reported encountering fewer than five cases per month, while 2.25% reported encountering more than 20 cases per month. The majority (72.86%) encountered fewer than three resuscitation cases per month, and 81.80% terminated one or fewer resuscitation cases per month due to ROSC. This is consistent with the current success rate of out-of-hospital CPR in China. Additionally, 91.43% of respondents terminated 0–5 cases per month due to do-not-resuscitate (DNR) orders from family members, and 68.06% terminated 0–1 cases per month due to the need for hospital referral for further treatment. Only 2.96% of respondents reported continuing resuscitation efforts until arrival at the emergency department without termination, regardless of the patient’s condition.
The survey also explored the factors influencing the decision to terminate CPR. Only 32.98% of respondents reported considering the patient’s age when deciding whether to perform resuscitation. The majority (69.66%) believed that the decision to terminate resuscitation should be made by the emergency doctor, while 29.74% thought that a family member should make such decisions. Respondents indicated that they typically limit the length of CPR to 20 minutes (2.73%), 30 minutes (72.58%), 40 minutes (9.29%), 60 minutes (4.26%), or more than 60 minutes (11.14%). The reasons for terminating pre-hospital CPR included lengthy CPR (>30 minutes) without ROSC, DNR orders from family members, long-term low end-tidal carbon dioxide (ETCO2) partial pressure (<10 mmHg), posterior sternum or rib fractures due to compressions, serious effects on the quality of life after resuscitation, and organ donation.
ETCO2 monitoring was used by 25.22% of pre-hospital emergency personnel to assess the quality of CPR. ETCO2 levels below 10 mmHg after 10 minutes (15.79%), 20 minutes (9.46%), 30 minutes (62.99%), 40 minutes (3.86%), or 60 minutes (7.90%) were used as indicators for terminating chest compressions. The reasons provided for failure to achieve ROSC included long emergency response times, lack of bystander CPR, underlying patient conditions, prolonged CPR duration, multiple failed electrical defibrillations, decreased quality of chest compressions, lack of CPR guidance over the phone, failure to use an AED, insufficient on-site emergency personnel, and poor team cooperation.
The survey also analyzed the factors influencing the use of ETCO2 and patient age as indicators for TOR. Multivariate analysis revealed that educational background, professional title, the major of the highest degree attained, adult ALS training, and maternal life support training were independent factors predictive of ETCO2 use as an indicator for terminating CPR. Gender, age, employer level, unit operation mode, and the major of the highest degree were independent factors predictive of using patient age as an indicator for TOR.
The study highlighted several challenges in China’s pre-hospital emergency system. Unlike in Europe and the United States, China’s pre-hospital emergency personnel require systematic and multi-year medical education and training. The high professional training demands and the large number of pre-hospital first aid professionals needed create significant pressure, which negatively affects the stability and professionalism of pre-hospital emergency teams in China. The current outcomes of OHCA in China are concerning, and a detailed analysis of the reasons for lagging behind other countries is necessary. Factors such as a lack of social impetus to improve CPR, inadequate pre-hospital CPR skills, different underlying conditions of enrolled cases, and uneven distribution of emergency resources contribute to the low success rate of CPR in China.
Pre-hospital emergency response times are greatly affected by the local economic environment, as seen in studies from the Republic of Korea. Choosing the right modes for pre-hospital emergency treatment and improving response times in a country with a large land area and significant regional economic differences, such as China, are enormous challenges. Although different modes of cardiac arrest responses have varying success rates due to China’s vast land area, uneven population distribution, and socioeconomic disparities, pre-hospital emergency centers adapted to local situations should be capable of meeting the population’s first aid needs. The proportion of personnel with related training is high, but the educational background of the personnel is less satisfactory, and the majority of emergency personnel are young and relatively inexperienced. Team quality and stability still need improvement.
The study also compared dispatcher-assisted CPR (DA-CPR), no CPR, and spontaneous initiation of CPR. It found that the 30-day survival rate of OHCA patients who underwent DA-CPR was higher than that of patients who received no CPR but lower than that of patients who received spontaneous initiation of CPR. Studies in North Carolina and Washington State found that the application of CPR by bystanders increased in both urban and non-urban areas. Strengthening the ability of pre-hospital emergency teams and increasing first aid training among the public could improve the emergency medical services in China.
The study found that pre-hospital emergency personnel in China can perform standardized CPR for cardiac arrest patients, and the recovery effect is consistent with the success rate of CPR in the literature in China. However, there is still a gap compared to international counterparts. The Non-shockable initial rhythm, Unwitnessed arrest, Eighty years or older (NUE) rule, which identifies OHCA patients unlikely to survive hospital discharge, could be used in EMS protocols and policies to identify patients who are very unlikely to benefit from aggressive resuscitation. However, China’s pre-hospital emergency personnel appear to make subjective and inconsistent decisions about the timing, indications, and indicators of TOR. Some personnel lack the correct concept of ineffective CPR and CPR termination. While pre-hospital emergency personnel can master CPR rescue skills, their understanding of life support training is not comprehensive, and evidence-based and effective implementation of CPR is not always fully accomplished, especially in the termination of CPR.
A protocol for terminating CPR using longer resuscitation times and ETCO2 monitoring criteria was implemented for EMS providers in an urban pre-hospital system in 2017. This led to a significant decrease in the rate of arrivals to the emergency department with ROSC, particularly for bystander-witnessed OHCA. The hierarchical analysis in this study exposed problems in the pre-hospital first aid field disposal process. Further multivariate analysis regarding ETCO2 as a factor in considering TOR found that education background, professional title, the major of the highest degree attained, adult ALS training, and maternal life support training are independent factors. Multivariate analysis regarding age as a factor for the termination of CPR found that gender, age, employer level, unit operation mode, and the major of the highest degree are independent factors. These problems are related to medical responsibility rather than CPR skills. Unnecessary continuation of CPR not only wastes the hospital’s precious rescue resources but also transfers potential medical disputes to the hospital emergency department, which may require significant time and resources to resolve.
In conclusion, the existing emergency systems and personnel in China are capable of meeting the basic requirements for pre-hospital emergency services. However, the survey of emergency personnel found that neither ETCO2 nor patient age was consistently considered as an indicator for TOR. Addressing these issues is crucial for improving the efficiency and effectiveness of pre-hospital emergency services in China.
doi.org/10.1097/CM9.0000000000001718
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