Conflict of Interest Declaration
The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy.
Task Force members and other authors declared no conflict of interest; we recognize that most of the authors are involved in writing resuscitation guidelines and that this should be considered a potential intellectual conflict of interest. This was acknowledged by the Task Force Chairs and Conflict of Interest committees.
Task Force Scoping Review Citation
Scapigliati A, Zace D, Pisapia L, Bray J, Bhanji F, Bigham BL, Bray JE, Breckwoldt J, Cheng A, Duff JP, Glerup Lauridsen KG, Gilfoyle E, Hsieh MJ, Iwami T, Lockey AS, Ma M, Monsieurs KG, Okamoto D, Pellegrino JL, Yeung J, Finn J, Greif R - on behalf of the International Liaison Committee on Resuscitation Education Implementation and Team Task Force.
Community initiatives to promote BLS implementation Scoping Review and Task Force Insights [Internet]: International Liaison Committee on Resuscitation (ILCOR) EIT Task Force, 2020, January 3. Available from: http://ilcor.org
Methodological Preamble
The continuous evidence evaluation process to achieve a Consensus on Science with Treatment Recommendations (CoSTR) is an update from 2010.
We searched for studies investigating interventions associated with improved and actual implementation of BLS in communities intended as group of populations with no duty to respond in case of a cardiac arrest. We excluded simulation studies or studies overlapping with other PICO.
We identified three major groups of intervention: training, mass media and bundle initiatives.
Scoping Review
PICOST
The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)
- Population: Within the general population of children and adults suffering an out-of-hospital cardiac arrest (OHCA)
- Intervention: Does the community initiatives to promote Basic Life Support (BLS) implementation
- Comparison: In comparison to current practice
- Outcomes: impact on
- 1) the survival to hospital discharge with good neurological outcome,
- 2) survival to hospital discharge,
- 3) return of spontaneous circulation
- 4) time to first compressions
- 5) bystander CPR rate
- 6) proportions of population trained
- Setting: in community settings
- Time: no limit, search ended 10.November 2019
- Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) are eligible for inclusion.
Search Strategies
PubMed
- (((("Heart Arrest"[Mesh] OR "heart arrest*"[TIAB] OR "cardiac arrest*"[TIAB] OR "cardiovascular arrest*"[TIAB] OR "cardiopulmonary arrest*"[TIAB] OR "cardio-pulmonary arrest*"[TIAB] OR "Out-of-Hospital Cardiac Arrest*"[Mesh] OR OHCA OR "Out of Hospital Cardiac Arrest*"[TIAB] OR "out-of-hospital cardiac arrest*" [TIAB] OR "Outside-of-Hospital Cardiac Arrest"[TIAB]) OR (resuscitation [Mesh] OR resuscitation* [TIAB] OR "cardiopulmonary resuscitation"[Mesh] OR "cardiopulmonary resuscitation"[TIAB] OR "Cardio-Pulmonary Resuscitation" OR "Cardio Pulmonary Resuscitation" OR CPR [TIAB] OR "Life Support Care"[Mesh] OR "Basic Cardiac Life Support" OR "basic life support" OR "Cardiac Life Support" [TIAB] OR "cardiorespiratory resuscitation"[TIAB] OR "Heart Massage*"[Mesh] OR “heart massage*”[TIAB] OR “cardiac massage*” [TIAB] OR “chest compression*”[TIAB] OR “cardiac compression*”[TIAB]) OR (defibrillators [Mesh] OR defibrillator* [TIAB] OR “automated external defibrillator*” OR AED OR “External Defibrillator*” OR “Electric Shock Cardiac Stimulator*” OR “Electric Defibrillation” OR Electric Countershock [Mesh] OR “Electrical Cardioversion*” [TIAB] OR “Cardiac Electroversion*”))AND (bystander*[TIAB] OR "first responder*"[TIAB] OR "first-responder*"[TIAB] OR Layperson*[TIAB] OR “lay people”[TIAB] OR “lay rescuer*”[TIAB] OR “lay public” OR witness*[TIAB] OR “non-healthcare professional” [TIAB] )) AND (((community OR public OR local OR social OR population* OR citizen*) AND (initiative* OR intervention* OR action* OR participation OR involvement* OR engagement OR preparation* OR implement* OR project* OR strategy* OR program OR programs OR network* OR training* OR campaign* OR education OR coaching OR information* OR learning OR instruction* OR guidance* OR response* OR responsiveness OR reply OR reaction OR awareness OR alertness OR realization OR sensibility OR sensitivity OR consciousness) OR “community-based initiative*” OR “community-driven initiative*”))
- Search performed on 10/11/2019
- Filters: Only humans
EMBASE
- ((('heart arrest' OR 'cardiac arrest*' OR 'cardiovascular arrest*' OR 'cardiopulmonary arrest*' OR 'cardio-pulmonary arrest' OR 'out of hospital cardiac arrest' OR ohca OR 'out-of-hospital cardiac arrest*' OR 'outside-of-hospital cardiac arrest') OR ('heart massage OR 'cardiopulmonary resuscitation' OR 'cardio-pulmonary resuscitation' OR 'cardio pulmonary resuscitation' OR cpr OR 'basic life support' OR 'cardiorespiratory resuscitation' OR 'heart massage*' OR 'cardiac massage*' OR 'chest compression*' OR 'cardiac compression*' OR defibrillator* OR “automated external defibrillator*” OR AED OR “External Defibrillator*” OR “Electric Shock Cardiac Stimulator*” OR “Electric Defibrillation” OR Electric Countershock OR “Electrical Cardioversion*” OR “Cardiac Electroversion*”)) AND ('layperson' OR bystander* OR 'first responder*' OR 'first-responder*' OR layperson* OR 'lay people' OR 'lay rescuer*' OR 'lay public' OR witness* OR 'non-healthcare professional')) AND ((community OR public OR population* OR citizen*) AND (initiative* OR intervention* OR action* OR participation OR involvement* OR engagement OR implement* OR program OR programs OR network* OR training* OR campaign* OR guidance* OR response* OR responsiveness OR reply OR awareness OR alertness OR sensibility OR sensitivity OR consciousness OR 'community-based initiative*' OR 'community-driven initiative*’)))
- Search performed on 10/11/2019
- No filters
COCHRANE
- (MeSH descriptor: [Heart Arrest] OR ("cardiac arrest" OR "cardiovascular arrest*" OR "cardiopulmonary arrest*" OR "cardio-pulmonary arrest*"):ti,ab,kw OR MeSH descriptor: [Out-of-Hospital Cardiac Arrest] OR ("cardiopulmonary resuscitation" OR "Cardio Pulmonary Resuscitation" OR CPR OR "Life Support Care" OR "Basic Cardiac Life Support" OR "basic life support" OR "Cardiac Life Support" OR "cardiorespiratory resuscitation"):ti,ab,kw OR MeSH descriptor: [Heart Massage] OR ("cardiac massage*" OR "chest compression*" OR "cardiac compression"):ti,ab,kw OR defibrillator* OR “automated external defibrillator*” OR AED OR “External Defibrillator*” OR “Electric Shock Cardiac Stimulator*” OR “Electric Defibrillation” OR Electric Countershock OR “Electrical Cardioversion*” OR “Cardiac Electroversion*”):ti,ab,kw) AND ((bystander* OR "first responder*" OR "first-responder*" OR Layperson* OR “lay people” OR “lay rescuer*” OR “lay public” OR witness* OR “non-healthcare professional”):ti,ab,kw) AND (community OR public OR local OR social OR population* OR citizen* OR person OR people):ti,ab,kw AND (initiative* OR intervention* OR action* OR participation OR involvement* OR engagement OR preparation* OR implement* OR project* OR strategy* OR program OR programs OR network* OR training* OR campaign* OR education OR coaching OR information* OR learning OR instruction* OR guidance* OR response* OR responsiveness OR reply OR reaction OR awareness OR alertness OR realization OR sensibility OR sensitivity OR consciousness OR “community-based initiative*” OR “community-driven initiative*”):ti,ab,kw
- Search performed on 10/11/2019
- No filters
Inclusion and Exclusion Criteria
- Inclusion Criteria:
1) Studies were eligible if they addressed the research question, reporting the impact of community initiatives (i.e. training, video-based CPR courses, media broadcasts, etc.) involving laypersons on OHCAs outcomes,
2) Peer reviewed journal papers,
3) Written in English
4) Involving human participants and
5) All study designs
- Exclusion Criteria:
1) Studies not addressing the research question
2) Abstract only studies,
To avoid overlapping with other PICOs:
3) PAD programs or other AED dissemination and deployment programs including use of drones,
4) Dispatched and/or Telephone CPR including use of Apps for FR dispatch and/or AED localization,
5) Impact of social or economic factors in bystander’s engagement, including geographical areas, neighborhoods differences, ethnic background,
6) Effect of different CPR Techniques or protocols including changes in resuscitation guidelines
Data tables
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STUDY: AUTHOR, YEAR, 1st PAGE |
DESIGN COUNTRY |
POPULATION1 |
INTERVENTION |
MAIN FINDINGS |
NOTES |
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1. Bergamo, 2016, 75 |
Cross-sectional Texas, USA |
Total population of Travis County 1,024,301 people. 50 zip codes: 12 high risk for OHCAs and 38 general risk for OHCAs. 11,242 community members completed compression-only CPR training. 2474 OHCAs eligible for the analysis. |
Peer-to-peer training of compression-only CPR. TAKE10 trainers received 1 h of interactive lecture-based training. Then they trained CC-only CPR to learners through a 10 min program (through training manikins and 1 DVD). The program was marketed through newspaper and television, telephone calls to community organizations; word of mouth |
Proportion of population trained. During the study period 1.09% of the total population was trained. The number trained per zip code (n± sd) was 263 ± 235 in the high-risk zip codes and 212 ± 193 in the general zip codes. Bystander CPR rate. Mean bystander CPR incidence of all zip codes increased over the study period (2008: 0.42 ± 0.34 vs. 2013: 0.47 ± 0.30; p < 0.05). In the high-risk zip codes, there was an upward trend in bystander CPR from 0.28 in 2008 to 0.39 in 2013 (p-value = 0.34) |
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2. Becker, 1999, 353 |
Non-randomized controlled study Seattle, USA |
Snohomish County, population 551,000, Kitsap County, population 230,000, and Whatcom County, population 156,000. Comparison: Spokane County, population 410,000, and Yakima County, population 209,000. During the study period: 2,075 OHCAs, 1,786 in the ”before” period and 289 in the ”during” period. 1,099 in the intervention communities and 976 in the comparison communities. |
Two 30-second Public Service Announcements (PSA) demonstrating CPR for 8 months. Each featured an older couple with the husband experiencing a witnessed cardiac arrest at home and the wife calling 911 and initiating CPR. The PSAs concluded with the phone number 1-888-CPR-KING more information |
Bystander CPR rate: In the intervention community there was a significant increase from 43% to 55% (p<.05). The rate remained at 33% in the comparison community (p=.967) |
The results may simply reflect a secular trend toward an increase in bystander CPR. It should be noted that the rates of bystander CPR in the intervention community are high compared with those in most other scales. |
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3. Ro, 2016, 17 |
Cross-sectional study Korea |
Survey database of 228,921 responders sampled representatively from 253 counties. 29,052 OHCAs. Result were grouped in quartile from Q1 (lower level of capacity) to Q4 (highest) according to answers to the five domains questions: awareness of CPR (CPR-Awareness), any training experience of CPR (CPR-Any-Training), recent CPR training within the last 2 years (CPR-Recent-Training), CPR training with a manikin (CPR-Manikin-Training), and CPR self-efficacy (CPR-Self-Efficacy). |
Bundle intervention. CPR training programs were developed in the early 2000s. The recent guideline for layperson CPR was released in 2011, which outlines 1-h layperson training on hands-only compression CPR, 1. 5 to 2 h of first responder training on chest compression with rescue ventilation CPR, and advanced cardiovascular life support training for professional providers. Enforcement of the EMS Act requires mandatory training of all first responders such as firefighters, police officers, nursing teachers, safeguarding officers, and transportation employees. |
Bystander CPR. Of 29,052 OHCA patients with presumed cardiac origin, 11,079 (38.1%) received bystander CPR. Bystander CPR in Q1(lower level of CPR capacity) = 33.9% vs Q4 (higher level of CPR capacity) 39.4% (p < 0.01) |
The study also reported survival outcomes (Prehospital ROSC, Survival to admission, Survival to discharge, Good neurological recovery). However, here, clinical endpoints could be affected by other interventions implemented in the study period (i.e. FR and EMS protocols), so we did not report results regarding these clinical outcomes. |
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4. Eisenberg, 1995, 198 |
RCT Washington, USA |
A commercial mailing list was used to identify 17,318 households, One half of the households (8,659) were considered the intervention group, and one half (8,659) served as the control. 65 cardiac arrests occurred in the study households: 31 in households that received the videotape and 34 in households that did not review the videotape. |
Free 10-minutes videotape with CPR instructions mailed to the 8,659 intervention households. The box also contained a small brochure illustrating CPR steps and a small pocket card with the same steps. |
The overall incidence of bystander CPR in the videotape and no-videotape groups was 47% and 53%, respectively (P = NS). There was no statistical difference between the incidence of bystander CPR in the videotape and no-videotape. No impact of the intervention on the outcomes groups |
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5. Hwanga, 2017, 87 |
Before-after study Korea |
The selected 581 OHCA patients were divided into three period groups: before group (2009–2010 period: before the system CPR program) (n = 182), transition group (2011 period: during the CPR program) (n = 117), and after group (2012–2013 period: after the CPR program) (n = 282). |
Bundle interventions: The university hospital developed the system-wide CPR program for OHCA patients which included interventions at both prehospital and hospital levels. CPR education sessions were conducted at public sites to indicate the importance of early EMS activation, bystander CPR, early use of AED if available. CO-CPR, in addition to standard basic life support techniques, was taught to citizens in schools and workplaces, and by volunteer organizations. |
The number of citizens who received CPR education was 1760 in 2009, 3394 in 2010, 682 in 2011, 3659 in 2012, and 5994 in 2013. Bystander CPR rate (without dispatcher assistance) increased from 13.2% in the before period to 27.7% in the after period (p value not reported). |
1. CPR program used a hospital-based OHCA registry. This registry was not identical to the cohort of OHCA patients confirmed by the regional EMS. Not representative. 2.Concomitant interventions: The dispatcher centre operated by the Seoul metropolitan fire department instituted a standard dispatcher assisted CPR (DA-CPR) protocol in January 2011. We did not consider any other outcome, except bystander CPR rate because other outcomes could be affected by the other initiatives. |
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6. Nielsen 2014, 1450 |
Prospective observational study Denmark |
124 patients with OHCA in the follow up period and 90 in the intervention period. |
1. 24-min DVD-based-self-instruction BLS courses. 2. 4-h BLS/AED courses. 3. the local television station had approximately 50 broadcasts about resuscitation |
The bystander BLS rate was significantly higher in the follow-up period (70% [95% CI 61–77] vs. 47% [95% CI 37–57], p = 0.001). There was no significant difference in the 30-day survival (6.7% [95% CI 3–13] in the follow-up period; vs. 4.6% [95% CI 1–12], p = 0.76). |
Different study period (2010-2013) from Nielsen et al, 2012 (September 28th 2008 to September 27th 2010) |
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7. Del Rios 2018, 423 |
Cross sectional Chicago USA |
71 Ninth and tenth graders and 347 friends and family members of theirs. |
1. Two in-class training sessions of 45 minutes each. 2. AHA CPR Anytime video self-instruction kit. This previously validated kit includes an instructional DVD (in English and Spanish) and inflatable mannequins with a built-in feedback mechanism that clicks with adequate compression depth |
Proportion of population trained: 71 students were trained for CPR, who later trained other 347 friends and family members for a total of 418 people trained. On average, each student trained an additional 4.9 people |
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8.Nishiyama 2019, e009436 |
Prospective observational study Japan |
57 173 residents (14.7%) completed the chest compression–only CPR training and 32 423 (8.3%) completed conventional CPR training. 722 patients with OHCA were eligible for the analysis |
Bundle intervention: 1. The Toyonaka City Fire Department has provided a conventional 3-hour CPR training consisting of chest compressions, rescue breathing, and AED use and an instructor training course to the residents at companies, governmental offices, and nursing homes. 2. A video-based CPR training program. 3. The participants used a Mr. PUSH CPR training kit to practice chest compressions and AED use. 4. Especially for schools, the Toyonaka City Fire Department introduced systematic CPR training programs with CCCPR-collaborating municipal board of education. |
23% of the residents were trained. The trend in the proportion of bystander CPR did not change from 43.3% (26/60) in 2010 to 42.0% (78/188) in 2015 (P for trend=0.915), but the trend in the proportion of high-quality CPR increased from 11.7% (7/60) in 2010 to 20.7% (39/188) in 2015 (P for trend=0.015). There were not statistically significant improvements in both proportion of 1-month survival (AOR, 0.949; 95% CI, 0.802– 1.124) and 1-month survival with favourable neurological outcome (AOR, 0.947; 95% CI, 0.751–1.194) |
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9. Fordyce 2017, 1226 |
Retrospective observational study North Carolina |
8269 patients with OHCAs (5602 [67.7%] at home and 2667 [32.3%] in public). No data on number of population trained. |
Training: The Heart Rescue project. For community members, chest compression-only training was offered at major civic events as well as to patients with cardiovascular disease and their family members before hospital discharge. School staff were trained in the use of AEDs, and community grants were provided to groups to implement CPR training programs |
From 2010 through 2014, rates of bystander-initiated CPR significantly increased at home (from 28.3%to 41.3%, P < .01) and in public (from 61.0% to 70.5%, P = .01). From 2010 through 2014, survival to hospital discharge significantly increased both at home (from 5.7% [60 of 1057] to 8.1% [100 of 1238], P = .047) and in public locations (from10.8% [50 of 464] to 16.2% [98 of 604], P = .04). Favourable neurological survival (CPC 1 or 2) significantly increased in public (from 9.5% [44 of 464] to 14.7% [89 of 604], P = .02) but not among patients with at-home OHCA (from 4.9% [52 of 1057] to 6.1% [76 of 1238], P = .06). |
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10. Hansen 2015, 255 |
Retrospective observational study North Carolina |
4961 out-of-hospital cardiac arrest patients. No data on trained population. |
Training: The Heart Rescue project. For community members, chest compression-only training was offered at major civic events as well as to patients with cardiovascular disease and their family members before hospital discharge. School staff were trained in the use of AEDs, and community grants were provided to groups to implement CPR training programs. |
In the period 2010–2013 significant increase in the proportion of patients receiving bystander initiated CPR was observed from 39.3% (95% CI, 36.5%- 42.1%) in 2010 to 49.4% (95%CI,46.7%-52.0%) in 2013 (P < .01). Survival with favourable neurological outcome increased from 7.1% (82 of 1149; 95% CI, 5.8%-8.8%) in 2010 to 9.7% (129 of 1334; 95% CI,8.2%-11.4%) in 2013 (P = .02) and was associated with bystander-initiated CPR. |
Similar to Fordyce 2017 But no less cases and years and no distinction between public and home |
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11. Boland 2017, 33 |
Before-after study Minnesota USA |
120 OHCA occurred before Hear Safe Program designation and 174 occurred after 46 communities in Minnesota |
Community-specific action plans typically include educating citizens about the warning signs and symptoms of cardiac arrest, conducting training sessions on how to perform CPR and use AEDs, registering and mapping existing AEDs, and procuring and placing additional AEDs in strategic public locations or first responder vehicles. |
Bystander CPR rate: Prior to HS designation, 83% of victims received CPR before ambulance arrival, but this figure rose to 95% after HS designation (OR=4.23 [1.80-9.98]). Overall unadjusted survival to hospital discharge was slightly higher after HS designation, but this difference was not statistically significant (17% vs 20%, p = 0.32). |
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12.Nielsen 2012, 1067 |
Cohort study Denmark |
Population of 42,000, and about 600,000 tourists visiting per year. 11679 people trained. 35 witnessed by bystander OHCAs |
Short 24-min DVD-based-self-instruction BLS courses were offered to laypersons. Information about the enrolment was provided through television announcements. Laypersons could also participate in 4-h BLS/AED courses. |
Proportion of population trained: For 2 years 9226 people (22% of the population) completed the short course and 2453 (6% of the population) completed the 4-h course. For the witnessed OHCAs (N = 35) the bystander BLS rate increased significantly from 22% (2004) to 74% [95% CI 58–86]. The association between the intervention and survival to hospital discharge was not significant (11%) [95% CI 4–27] |
Different study period (September 28th 2008 to September 27th 2010) from Nielsen et al, 2014 (2010-2013) |
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13.Tay, 2019, 9 |
Before-after study Singapore |
1241 OHCA, 880 before, 361 after. Close to 30,000 individuals were trained in CPR |
The Save-A-life (SAL) initiative offered free training in chest-compression only cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use, with signups conducted through the local community centres and schools by different agencies, with standardized teaching material |
The intervention group had higher survival (3.3% [12/361] vs. 2.2% [19/880] p-value 0.23), pre-hospital return of spontaneous circulation (ROSC) (9.1% [33/361] vs 5.1% [45/880] p-value = 0.01), bystander CPR (63.7% [230/361] vs 44.8% [394/880] p-value <0.001). After adjusting, the intervention was associated with increased odds ratio (OR) for survival (OR 2.39 [1.02 -5.62]), pre-hospital ROSC (OR 1.94 [1.15 -3.25]) and bystander CPR (OR 2.29 [1.77 -2.96]). |
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14.Uber, 2018, 1 |
Before-after study Michigan, USA |
A total of 1,486 cardiac arrest patients were included (899 P1 and 587 P2). 2,253 passersby at 7 public locations in Grand Rapids, Michigan were trained. |
CPR Training. On a single day in May 2014, prehospital providers trained a convenience sample of 2,253 passers-by in compression-only CPR at 7 different public locations. |
In adjusted modelling, the bystander CPR training intervention was not associated with bystander CPR frequency (β −0.002; 95% CI −0.16, 0.15), compression- only CPR (β −0.06; 95% CI−0.15, 0.02), ROSC (β −0.06; 95% CI −0.21, 0.25), survival (β −0.02; 95% CI −0.11, 0.06), or favourable neurologic outcome (β −0.01; 95% CI −0.07, 0.09). No impact of the intervention on the outcomes groups |
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15.Wissenberg, 2013, 1377 |
Cross-sectional Denmark |
A study population of 19 468 OHCA patients. |
Bundle intervention 1. Mandatory education in resuscitation in elementary schools (Jan 2005) 2. New guidelines for resuscitation (Nov 2005) 3.Mandatory resuscitation course when acquiring a driver’s license (Oct 2006) |
Bystander CPR: From 21.1% in 2001 to 40.9% in 2009 (p value<0.001) |
At the same period other interventions took place like Introduction of therapeutic hypothermia (starting 2004) and Introduction of health care professionals at dispatch centres (starting 2009). That is why we considered only data from the period 2001-2009, since Introduction of health care professionals at dispatch centers could impact on bystander CPR rate. We did not consider any other outcome, except bystander CPR rate because other outcomes could be affected by the other initiatives. Because of the co-occurrence of other related initiatives, a causal relationship remains uncertain. |
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16.Ro, 2019, 291 |
Cross-sectional Korea |
81,250 OHCAs in 254 counties were analysed. 228,452 participants responded to the survey of 247 items (0.6% of approximately 42 million populations of aged 19), reporting the proportions of residents having received on-site group CPR training for 40 minutes or longer in the county. The number of population trained per county was then classified by quartiles based on the number of counties: the highest (Q1), higher (Q2), lower (Q3), and lowest (Q4) counties. |
Bundle intervention. Public CPR campaigns and training for laypersons |
Bystander CPR in relation to CPR training rate in the four quartiles: Q1 3,453/5,412 (63.8%) vs Q4 1,272/2,117 (60.1) OR 1.16 (1.04–1.29) AOR 1.29 (1.13–1.48). Bystander CPR in relation to CPR training rate in time 2012-2016: Q1 2012: 36.8 (34.6 to 39.1) 2016: 66.9 (64.8 to 69.0) adj difference rate 30.1 (28.2 to 32.0). Q4 2012: 30.0 (27.1 to 32.9) 2016: 64.4 (61.6 to 67.1) adj diff rate: 34.3 (31.4 to 37.3) |
Concomitant interventions: mandatory training of first responders, including firefighters, police officers, sports facility managers, safety guards, lifeguards, school health teachers, workplace safety employees, managers of nursing homes and public transportation vehicle drivers. 2.The National Fire Agency implemented a nationwide dispatcher-assisted bystander CPR programme in 2012. No other outcomes (clinical) were reported since could be affected by other interventions implemented during the study period. |
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17. Isbye, 2007, 1380 |
Prospective observational |
OHCA 1877 (one month after the intervention) Population trained: 35 002 resuscitation manikins to pupils (12 to 14 years of age) at 806 primary Schools. Training: one hour of lesson in the week following manikin dissemination. |
Training: instructor-led (School: first tier) + peer to peer (Family: second tier) |
Population trained: mean, 2.5 persons per pupil; 95% confidence interval, 2.4 to 2.5) Bystander CPR: not improved. (25.0% versus 27.9%; P=0.16) |
Low response rate to questionnaire (19.8% of the distributed manikins). The teachers had used a mean of 64 minutes (95% confidence interval, 60 to 68) for preparation and a mean of 13 minutes (95% confidence interval, 11 to 15) to tidy up. CPR training can be disseminated in a population using personal resuscitation manikins distributed to children in primary schools and that the teachers felt confident in facilitating this initiative. The incidence of bystander CPR did not increase significantly but the observation time was only one month. |
Task Force Insights
1. Why this topic was reviewed
The first 3 links of the Chain of Survival (i.e. recognition of CA, call to local emergency number, chest compressions with or without rescue ventilations and early defibrillation with AED) have shown to largely affect survival and good neurological outcomes of patients suffering cardiac arrest. The role of community as a whole is crucial in providing this response through “bystander CPR” but this is far from optimal.
In the 2015 Guidelines process, a systematic review titled “Implementation of Guidelines in Communities” addressed these aspects in general terms. Nevertheless, researchers have investigated several interventions that are worthy to be evaluated specifically rather than included in the wide category of “implementation of guidelines”. Therefore, the EIT TF decided broaden the scope of the previous 2015 641 PICO “Implementation of Guidelines in Communities”, changing its title into the new 2020 641 PICO “Community Initiatives to promote BLS Implementation”. For this reason, the present search strategy has no time limit.
For the purpose of this review, we included in the term “community” the general population of the studied area (i.e. a group of neighborhoods, one or more cities/towns or regions, a part of or a whole Nation), in which individuals can act as potential witnesses or bystanders of a CA patient. We excluded the role played by healthcare professionals or first responders with any duty to respond.
With the term “initiative”, we intended all those interventions aimed to increase the engagement of the community (as defined above) in providing BLS (i.e. any kind of CPR and early defibrillation). Many interventions have been implemented to improve community response to CA: dispatcher-assisted CPR or telephone-CPR, public access defibrillator (PAD) programs and AEDs dissemination including drones deployment, simplification of CPR protocol (i.e. chest compressions only CPR), apps to localize and engage first responders and/or the nearest AED. However, all these interventions have been evaluated in other specific PICOs of 2020 Guidelines process. Therefore, the aim of this review is to assess the impact of any other intervention involving community, as defined above, which can affect BLS implementation in term of bystander CPR and other consistent clinical outcomes.
2. Narrative summary of evidence identified
Studies’ characteristics
A considerable number of relevant studies were identified but because of the high heterogeneity among them, TF considered to use a scoping review in a narrative form as the more appropriate way to summarize the results of evidence evaluation.
The included studies (n=17) were conducted predominantly in the USA (47%){Del Rios 2018 423; Fordyce 2017 1226; Hansen 2015 255; Boland 2017 33; Uber 2019 ;, Eisenberg 1995 198; Bergamo 2016 75; Becker 1999 353}, followed by Denmark (23%){Nielsen 2014 1450; Nielsen 2012 1067; Wissenberg 2013 1377; Isbye 2007 1380} and Korea (18%){Hwang 2017 87; Ro 2019 291; Ro 2016 17}, Japan (6%){Nishiyama 2019 e009436} and Singapore (6%){Tay 2019 9}. The majority of the included studies had a cross sectional design (42%){Bergamo 2016 75; Ro 2016 17; Del Rios 2018 423; Wissenberg 2013 1377; Ro 2019 291; Fordyce 2017 1226; Hansen 2015 255} followed by before-after studies (29%){Hwang 2017 87; Boland 2017 33; Tay 2019 9; Uber 2018 1; Becker 1999 353} cohort studies (23%){Nielsen 2014 1450; Nishiyama 2019 e009436; Nielsen 2012 1067; Isbye 2007 1380} and RCT (6%){Eisenberg 1995 198}. More than half of the studies had a prospective design (59%), while the rest were retrospective (41%). Almost all studies were published during the last decade (2012-2019) (88%), with only two studies (12%) published earlier{Eisenberg 1995 198; Becker 1999 353}. All OHCA cases included adult population only. The main settings where the interventions took place were workplaces, schools, governmental offices, major civic events, community-shared spaces, etc.
Type of interventions and outcomes
To allow an easier summary of findings, we grouped the main community initiatives identified in the included studies in three categories:
- Community CPR training interventions: instructor-led, self-training, peer-to-peer training
- Mass-media interventions
- Bundle interventions
More than half of the studies{Bergamo 2016 75; Hwang 2017 87; Ro 2019 291; Ro 2016 17; Nielsen 2014 1450; Nielsen 2012 1067; Del Rios 2018 423; Wissenberg 2013 1377; Isbye 2007 1380} assessed the impact of concurrent (bundle) initiatives on different OHCAs’ outcomes, without the possibility to isolate specific interventions and evaluate their impact separately. Six studies (35%){Fordyce 2017 1226; Hansen 2015 255; Boland 2017 33; Uber 2019 1; Nishiyama 2019 e009436; Tay 2019 9} assessed only the impact of an instructor-led CPR training and 2 (12%) studies{Becker 1999 353; Eisenberg 1995 198} the role of mass media on OHCAs’ outcomes. Three studies{Ro 2019 291; Ro 2016 17; Wissenberg 2013 1377}, along with different community initiatives, reported also the impact of other interventions concerning first responders and EMS roles, mandatory courses for first responders, introduction of therapeutic hypothermia and of health care professionals at dispatch centers. These interventions were excluded from our narrative analysis since did not concern our research question.
We evaluated 6 outcomes:
- Survival with good neurological outcome,
- Survival to discharge (hospital discharge or 1 month),
- ROSC,
- Bystander CPR rate,
- Time to first compressions
- Proportion of trained people.
The most reported outcome was bystander CPR rate (94% of studies){Fordyce 2017 1226; Hansen 2015 255; Boland 2017 33; Uber 2019 1; Eisenberg 1995 198; Bergamo 2016 75; Becker 1999 353; Nielsen 2014 1450; Nielsen 2012 1067; Wissenberg 2013 1377; Isbye 2007 1380; Hwang 2017 87; Ro 2019 291; Ro 2016 17; Nishiyama 2019 e009436; Tay 2019 9}, followed by survival (hospital discharge or 1 month; 41% of studies){Fordyce 2017 1226; Tay 2019 9; Boland 2017 33; Uber 2019 1; Nishiyama 2019 e009436; Nielsen 2014 1450; Nielsen 2012 1067} and proportion of population trained (35%){Nishiyama 2019 e009436; Bergamo 2016 75; Hwang 2017 87; Del Rios 2018 423; Isbye 2007 1380}.
Survival with good neurological outcome was reported in 4 studies (23%){Fordyce 2017 1226; Hansen 2015 255; Uber 2019 1; Nishiyama 2019 e009436} and ROSC in two studies (12%){Tay 2019 9; Uber 2019 1}. We identified no studies that reported time to first compression outcome.
- Bystander CPR: most of the studies (75%){Fordyce 2017 1226; Hansen 2015 255; Tay 2019 9; Boland 2017 33; Bergamo 2016 75; Becker 1999 353; Hwang 2017 87; Ro 2016 17; Nielsen 2014 1450; Nielsen 2012 1067; Wissenberg 2013 1377; Ro 2019 291} that reported bystander CPR rate concluded that there was an improvement in this outcome with the implementation of community initiatives.
- Survival: only 40% of the studies{Fordyce 2017 1226; Tay 2019 9} that reported survival to hospital discharge showed a benefit with the intervention. Meanwhile, 60% of the studies that reported survival to hospital discharge and all the studies{Nielsen 2014 1450; Nishiyama 2019 e009436} that reported 1 month-survival showed no benefit with the intervention.
- Most of the studies (75%){Fordyce 2017 1226; Nishiyama 2019 e009436; Uber 2019 1} reporting survival with good neurological outcome showed no benefit with the intervention.
- Between the two studies{Tay 2019 9; Uber 2019 1} reporting ROSC, one showed a benefit with the implementation of community initiatives{Tay 2019 9}, while the other one did not show such benefit{Uber 2019 1}.
The impact of community initiatives on specific outcomes
- Instructor-led training
All the studies that implemented instructor-led training reported bystander CPR rate as outcome, with 67% of them showing a benefit with the intervention{Fordyce 2017 1226; Hansen 2015 255; Tay 2019 9; Boland 2017 33}. Survival to discharge was reported in 83% of cases and improved in 40% of these studies{Fordyce 2017 1226; Tay 2019 9}. Survival with good neurological outcome was reported in 67% of these studies and showed benefit with the intervention in only 25% of cases{Hansen 2015 255}. ROSC was assessed in 33% of these studies and in half of the cases showed improvement with the intervention{Tay 2019 9}.
- Mass-media
The two studies assessing the impact of this type of intervention reported only bystander CPR rate outcome, with one of them showing benefit{Becker 1999 353} and the other one showing no such benefit{Eisenberg 1995 198}.
- Bundle intervention
None of these nine studies studies{Bergamo 2016 75; Hwang 2017 87; Ro 2019 291; Ro 2016 17; Nielsen 2014 1450; Nielsen 2012 1067; Del Rios 2018 423; Wissenberg 2013 1377; Isbye 2007 1380} reported Survival with good neurological outcome or ROSC. Survival to discharge was reported in only two studies and showed no benefit with the intervention{Nielsen 2014 1450; Nielsen 2012 1067}. Bystander CPR rate was reported in 8 of these studies, showing benefit in all cases{Bergamo 2016 75; Hwang 2017 87; Ro 2019 291; Ro 2016 17; Nielsen 2014 1450; Nielsen 2012 1067; Del Rios 2018 423; Wissenberg 2013 1377}, but one{Isbye 2007 1380}.
3. Narrative Reporting of the task force discussions
In the first steps of the search strategy, the Task Force discussed the inclusion/exclusion criteria. Considering possible overlapping, it was decided to exclude all the studies that addressed PAD programs or other AED dissemination, dispatched and/or Telephone CPR/Apps, the impact of social or economic factors in bystander’s engagement and the effect of different CPR Techniques or protocols including changes in resuscitation guidelines. This decision was justified by the fact that there are other PICOST specifically addressing these issues.
Furthermore, after performing the search strategy, the Task Force discussed the type of review (i.e. scoping; systematic). Considering the high heterogeneity of the included studies, it was decided that a scoping review would be more appropriate to report narratively the findings.
The only outcome that was assessed in almost all the included studies was bystander CPR rate and almost all the studies showed a benefit with the implementation of community initiatives. This benefit was more frequent when the type of intervention was a ‘bundle’ of interventions compared to training or mass-media. Furthermore, there was a slight benefit (only 40% of studies that reported it) in the survival at hospital discharge.
In the case of studies assessing bundle interventions, there were other outcomes reported that we could not include, since there was not the possibility to isolate the specific intervention (respecting the inclusion/exclusion criteria) which was associated with each outcome.
Based on the results of our review we propose a systematic review be conducted, as it appears that the implementation of community initiatives such as CPR training involving large portion of population or bundle intervention may improve the bystander CPR rate among laypersons in cases of OHCAs.
Knowledge Gaps
Although this is not a systematic review, it highlights some important knowledge gaps that we recommend being addressed in future research:
- There is a lack of evidence regarding this issue in Europe, with only Denmark having conducted relevant studies.
- There is a need for more high-evidence RCT in order to have more robust evidence.
- There is a need to evaluate effect in term of implementation of BLS, Bystander CPR and clinical outcomes of public campaign (WRAH-World Restart A Heart) and/or mandatory training at school (KSL-Kids Save Life).
- There is a need to evaluate effect of specific laws and regulations which can facilitate CPR deployment by general population
- There were no studies identified that evaluated this issue in the children
- There is the need for more studies that report outcomes such as time to first compression, ROSC, survival to discharge (hospital discharge and 1 month) and survival with good neurological outcome.
- In the case of studies assessing the impact of bundle interventions, there is the need to isolate which is the specific intervention that is associated with the improvement or not of each specific outcome.
- There is the need to investigate the cost-effectiveness of any single intervention and their specific impact on clinical outcomes.
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