CoSTR Citation
Ko YC, Breckwoldt J, Lee TY, Lockey A, Cheng A, Greif R on behalf of the International Liaison Committee on Resuscitation Education, Implementation and Teams Task Force (EIT) Life Support Task Force. Consensus on Science with Treatment Recommendations. [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Education, Implementation, and Team Task Force, 2023 Dec 01. Available from: http://ilcor.org
Methodological Preamble and Link to Published Systematic Review
A previous systematic review (2020) and an evidence updates (2021) were conducted. The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with an updated systematic review of system performance improvement. Evidence for literature associated system performance improvement was sought and considered by the Education, Implementation and Teams Task Force.
PICOST
The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)
Population: Among resuscitation systems who are caring for patients in cardiac arrest in any setting
Intervention: System performance improvement initiative(s)
Comparators: No system performance improvement initiative(s)
Outcomes: Survival with favorable neurologic outcome at discharge (critical), Survival to hospital discharge (critical), Skill performance in actual resuscitations (important), Survival to admission (important), System level variables (important)
Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies, case-control studies) are eligible for inclusion. Unpublished studies (e.g., conference abstracts, trial protocols), letters, editorials, comments, case reports are excluded.
Timeframe: All years and all languages were included as long as there was an English abstract; Literature search updated from Jan 01, 2021 to June 30, 2024.
Consensus on Science
We searched the following electronic databases on the June 30, 2024: MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) databases for studies regarding system improvement initiatives published since Jan 1, 2021. System performance improvement is defined as hospital-level, community-level, or country-level advancements related to structure, care pathways, processes, and quality of care. Single intervention (e.g., CPR quality evaluation or debriefing) as well as multidisciplinary approaches (e.g., optimizing CPR quality and protocols, enhancing response program of emergency medical service, etc.) deployed to enhance links in the chain of survival improve outcomes of cardiac arrest patients were included. Through the electronic database searches, 4,127 publications were identified which after the removal of duplicates was reduced to 3,835 publications. Of these, 32 publications were considered for full text review, and 15 studies were finally included. (3, 4, 9, 12, 20-22, 26-29, 31, 32, 37, 41) Twenty-seven publications (1, 2, 5-8, 10, 11, 14-19, 23, 24, 30, 33-36, 38-40, 42-44) from the 2020 ILCOR review were also included. (13) (Figure1)
Figure 1. PRISMA Flowchart: EIT 6310 PRISMA
Risk of bias
The risk of bias in the 15 updated article was assessed. (Table 1) The risk of bias assessment for the previously included 27 articles were included in the earlier publication. (25)
Table 1. Risk of Bias for nonrandomized studies (ROBINS-I). |
|||||||||
No |
Study Acronym; Author; Year Published |
Confounding |
Selection of participants |
Classification of interventions |
Deviation from intended intervention |
Missing data |
Measurement of outcomes |
Selection of the reported result |
Overall |
1 |
Blewer, A. L. (2020) |
Moderate |
Low |
Low |
Moderate |
Low |
Low |
Low |
Moderate |
2 |
Lee, D. E. (2020) |
Moderate |
Low |
Low |
Moderate |
Low |
Moderate |
Low |
Moderate |
3 |
Kim, J. Y. (2020) |
Serious |
Low |
Low |
Moderate |
Moderate |
Moderate |
Low |
Serious |
4 |
Kim, G. W. (2020) |
Moderate |
Low |
Low |
Low |
Moderate |
Moderate |
Low |
Moderate |
5 |
Auricchio A (2020) |
Moderate |
Low |
Low |
Moderate |
Low |
Moderate |
Low |
Moderate |
6 |
Nehme Z (2021) |
Moderate |
Low |
Low |
Moderate |
Low |
Low |
Low |
Moderate |
7 |
Dong X (2022) |
Serious |
Low |
Low |
Moderate |
Low |
Low |
Low |
Serious |
8 |
Kim GW (2022) |
Moderate |
Low |
Low |
Low |
Moderate |
Moderate |
Low |
Moderate |
9 |
Lin HY (2022) |
Moderate |
Low |
Low |
Moderate |
Low |
Moderate |
Low |
Moderate |
10 |
McCoy C (2023) |
Critical |
Low |
Low |
Low |
Low |
Moderate |
Low |
Critical |
11 |
Freedman AJ (2023) |
Critical |
Low |
Low |
Moderate |
Low |
Low |
Low |
Critical |
12 |
Li T (2023) |
Critical |
Low |
Low |
Moderate |
Moderate |
Moderate |
Low |
Critical |
13 |
Lyngby RM (2023) |
Serious |
Low |
Low |
Low |
Moderate |
Low |
Low |
Serious |
14 |
Riyapan S (2024) |
Moderate |
Low |
Low |
Moderate |
Moderate |
Low |
Low |
Moderate |
15 |
Vaillancourt C (2024) |
Moderate |
Low |
Moderate |
Moderate |
Low |
Low |
Low |
Moderate |
Interventions
Different interventions were performed for patients with cardiac arrest, as described below. (Table 2) The outcome description for the previously included 27 articles were included in the earlier publication. (25)
Table 2. Interventions among included studies
No |
Author (Year) |
Interventions |
1 |
Blewer, A. L. (2020) (OHCA) |
National bystander-focused public health interventions include dispatch-assisted CPR, CPR training programs, and the MyResponder application. |
2 |
Lee, D. E. (2020) (OHCA) |
Citywide interventions include the following: (1) mandatory CPR and AED training, DA-CPR, and the establishment and actions of the Daegu Emergency Medical Collaboration Committee; (2) public access defibrillation program, team CPR program, dual-patch system, standardized post-cardiac arrest treatment, education program for medical staff, regional OHCA registry, and public reporting and feedback to provinces, hospitals, and EMTs. |
3 |
Kim, J. Y. (2020) (OHCA) |
Implementing the PDSA (“Plan-Do-Study-Act”) model for quality improvement: (1) bystander CPR education and dispatcher training; (2) regular skills training sessions for EMTs; (3) detailed data collection instrument; (4) medical director assignment. |
4 |
Kim, G. W. (2020) (OHCA) |
A multidisciplinary approach including (1) re-education of BLS, (2) simulation training for real-time medical direction via video call, (3) two-tier dispatch. |
5 |
Auricchio A (2020) (OHCA) |
State-wide initiatives including recording of out-of-hospital cardiac arrests; initiatives on AED density, bystander and layperson recruitment; first responder network. |
6 |
Nehme Z (2021) (OHCA) |
High-performance CPR (focusing on team dynamics and communication with emphasis on optimizing resuscitation flow and minimizing delays. |
7 |
Dong X (2022) (OHCA) |
Citywide quality improvement program consisting of the following: (1) standardized ambulance treatment protocol adopted, (2) ambulance crew targeted training, (3) quality monitoring, feedback, and post-event debriefing. |
8 |
Kim GW (2022) (OHCA) |
Smart Advanced Life Support (SALS) protocol incorporating changes in cardiopulmonary resuscitation (CPR) assistance and coaching by physicians via real-time video calls. |
9 |
Lin HY (2022) (OHCA) |
Citywide bundle initiative including (1) commencement of medical direction and public-access defibrillation project; (2) digitised Utstein-based registry; (3) public involvement and continuous QA process; (4) proactive CPR promotion and PAD; (5) built culture of excellence and smart technology implemented. |
10 |
McCoy C (2023) (IHCA) |
Bundled intervention on IHCA survival in patients on centralised telemetry: (1) a telemetry hotline for telemetry technicians to reach nursing staff; (2) empowerment of telemetry technicians to directly activate the IHCA response team; and (3) a standardised escalation system for automated critical alerts within the nursing mobile phone system. |
11 |
Freedman AJ (2023) (IHCA) |
Bundled intervention on IHCA including Emergency Management Committee (EMC) restructuring, CPR coach, replacing defibrillators, defibrillator data review, training program, metronomes, code documentation, debriefing, and event reviews. |
12 |
Li T (2023) (OHCA) |
Resuscitation Quality Improvement (RQI ) HeartCode Complete program: designed to enhance cardiopulmonary resuscitation (CPR) training by using real-time feedback manikins |
13 |
Lyngby RM (2023) (OHCA) |
Real-time feedback displayed on the defibrillator screen, presenting compression depth, compression rate and audible rate guidance. |
14 |
Riyapan S (2024) (OHCA) |
CQI (Continuous Quality Improvement) interventions included low-dose high-frequency training in advanced airway management, high-performance CPR, and post-debriefing with video recording. |
15 |
Vaillancourt C (2024) (IHCA) |
Implementation of a medical directive allowing nurses to use defibrillators in automated external defibrillator-mode (AED) on in-hospital cardiac arrest (IHCA). |
Outcomes
For the critical outcome of survival with favorable neurologic outcome at discharge
We identified moderate certainty of evidence from one cluster-randomized trial (downgraded for imprecision) (16) and very low certainty of evidence from evidence from 24 non-RCTs (downgraded for risk of bias, inconsistency). (2, 3, 5-8, 11, 14, 15, 17, 19-24, 26, 28, 35, 36, 39, 40, 42, 44) Seventeen of these studies showed that patients had significantly higher chance of survival with favorable neurologic outcome at discharge after interventions for system performance improvement were implemented. (2, 7, 8, 11, 14, 17, 19-21, 23, 26, 28, 35, 36, 39, 40, 44) The other eight studies, including 1 cluster-RCT, showed no significant improvement after interventions were implemented. (3, 5, 6, 15, 16, 22, 24, 42)
For the critical outcome of survival to hospital discharge
We identified moderate-certainty evidence from 1 cluster-randomized trial (downgraded for imprecision) (16) and very low-certainty evidence from 34 non-RCT (downgraded for risk of bias, inconsistency). (2-8, 10-12, 14, 15, 17, 19-24, 26, 28, 29, 31-33, 35-42, 44) Twenty of these studies showed that patients had significantly higher chance of survival to hospital discharge after interventions for system performance improvement were implemented. (2-4, 7, 8, 11, 14, 17, 19, 21, 23, 24, 26, 28, 32, 33, 35, 36, 40, 44) The other fifteen studies, including 1 cluster-RCT, showed no significant improvement after interventions were implemented. (5, 6, 10, 12, 15, 16, 20, 22, 29, 31, 37-39, 41, 42)
For the important outcome of skill performance in actual resuscitations
We identified moderate certainty of evidence from one cluster-randomized trial (downgraded for risk of bias) (16) and very low certainty of evidence from 18 non-RCT (downgraded for risk of bias, inconsistency). (5, 6, 10, 14, 17-20, 24, 27, 29, 30, 32, 34, 38, 41, 43, 44) Seventeen of studies, including 1 cluster-RCT, reported that rescuers had significantly improved skill performance in actual resuscitations after interventions were implemented. (5, 10, 14, 16-20, 24, 27, 29, 30, 32, 38, 41, 43, 44) The other two studies showed no significant improvement after interventions were implemented. (6, 34)
For the important outcome of survival to admission
We identified moderate certainty of evidence, from one cluster-randomized trial (downgraded for imprecision) (16) and very low certainty of evidence from 9 non-RCT (downgraded for risk of bias, inconsistency). (8, 15, 20, 28, 29, 33, 36, 37, 39) Three of these studies showed that patients had a significantly higher chance of survival to admission after interventions for system performance improvement were implemented. (8, 33, 36) The other study, including 1 cluster-RCT, showed no significant improvement after interventions were implemented. (15, 16, 20, 28, 29, 37, 39)
For the important outcome of system level variables
We identified very low certainty of evidence from 18 non-RCT (downgraded for risk of bias, inconsistency). (1, 3, 4, 7, 8, 14, 15, 19, 20, 22, 23, 26, 28, 29, 33, 35, 39, 42) All studies included individual interventions to improve specific system-level variables, and all studies achieved all or partial goals. These system level variables included rate of bystander cardiopulmonary resuscitation (CPR) or automated external defibrillators, rate of prehospital or in-hospital therapeutic hypothermia, the use of automatic CPR device and CPR feedback device, or percutaneous coronary intervention.
Treatment Recommendations
We recommend that organizations or communities that treat cardiac arrest use system improvement strategies to improve patient outcomes. (strong recommendation, very low-certainty evidence).
Justification and Evidence to Decision Framework Highlights
This systematic review found new evidence from fifteen non-randomised studies in addition to previously included twenty-seven studies regarding system improvement intervention to treat patients with cardiac arrest with favorable neurologic outcome at discharge, survival to hospital discharge, and improved skill performance in actual resuscitations, survival to admission, and system level variables. Studies investigating E-CPR which were initially included in an update in 2021 were excluded in this review after discussion in the TF, as studies exclusively focusing on ECPR are assessed in another PICOST as the prevalence of ECPR is increasing and several RCT outcomes were released.
We recognize that the evidence supporting this recommendation is derived from studies with very low certainty across all evaluated outcomes, primarily due to risks of bias and inconsistencies. However, the majority of studies found that interventions to improve system performance not only improve system level variables and skill performance in actual resuscitations among rescuers, but also clinical outcomes of patients with out-of-hospital or in-hospital cardiac arrest, such as survival to hospital discharge and survival with favorable neurologic outcome at discharge. We acknowledge that these interventions demand funding, personnel, and stakeholder support to improve system performance. Varying levels of resources across settings may influence the effectiveness of implementing these performance improvements.
Values and preferences statement: In making this recommendation, we prioritize the benefits of system performance improvements, recognizing that they present no known risks and hold substantial potential for positive impact.
Knowledge Gaps
The following knowledge gaps were identified:
To evaluate the cost-effectiveness of individual interventions aimed at improving system performance.
- To assess the feasibility of implementing community interventions across diverse resource settings.
To investigate the effects of individual and bundled interventions in future studies to determine their impact on outcomes.
ETD summary table: EIT 6310 Et D Table V3
Attachments: EIT 6310 Updated SR Evidence profile V2; Endnote library for EIT 6310 enlp
References
1. Adabag S, Hodgson L, Garcia S, Anand V, Frascone R, Conterato M, et al. Outcomes of sudden cardiac arrest in a state-wide integrated resuscitation program: Results from the Minnesota Resuscitation Consortium. Resuscitation. 2017;110:95-100.
2. Anderson ML, Nichol G, Dai D, Chan PS, Thomas L, Al-Khatib SM, et al. Association between hospital process composite performance and patient outcomes after in-hospital cardiac arrest care. JAMA Cardiology. 2016;1(1):37-45.
3. Auricchio A, Caputo ML, Baldi E, Klersy C, Benvenuti C, Cianella R, et al. Gender-specific differences in return-to-spontaneous circulation and outcome after out-of-hospital cardiac arrest: Results of sixteen-year-state-wide initiatives. Resusc Plus. 2020;4:100038.
4. Blewer AL, Ho AFW, Shahidah N, White AE, Pek PP, Ng YY, et al. Impact of bystander-focused public health interventions on cardiopulmonary resuscitation and survival: a cohort study. Lancet Public Health. 2020;5(8):e428-e36.
5. Bradley SM, Huszti E, Warren SA, Merchant RM, Sayre MR, Nichol G. Duration of hospital participation in Get With the Guidelines-Resuscitation and survival of in-hospital cardiac arrest. Resuscitation. 2012;83(11):1349-57.
6. Couper K, Kimani PK, Abella BS, Chilwan M, Cooke MW, Davies RP, et al. The system-wide effect of real-time audiovisual feedback and postevent debriefing for in-hospital cardiac arrest: The cardiopulmonary resuscitation quality improvement initiative. Critical Care Medicine. 2015;43(11):2321-31.
7. Davis DP, Graham PG, Husa RD, Lawrence B, Minokadeh A, Altieri K, et al. A performance improvement-based resuscitation programme reduces arrest incidence and increases survival from in-hospital cardiac arrest. Resuscitation. 2015;92:63-9.
8. Del Rios M, Weber J, Pugach O, Nguyen H, Campbell T, Islam S, et al. Large urban center improves out-of-hospital cardiac arrest survival. Resuscitation. 2019;139:234-40.
9. Dong X, Wang L, Xu H, Ye Y, Zhou Z, Zhang L. Effect of a Targeted Ambulance Treatment Quality Improvement Programme on Outcomes from Out-of-Hospital Cardiac Arrest: A Metropolitan Citywide Intervention Study. J Clin Med. 2022;12(1).
10. Edelson DP, Litzinger B, Arora V, Walsh D, Kim S, Lauderdale DS, et al. Improving in-hospital cardiac arrest process and outcomes with performance debriefing. Archives of internal medicine. 2008;168(10):1063-9.
11. Ewy GA, Sanders AB. Alternative Approach to Improving Survival of Patients With Out-of-Hospital Primary Cardiac Arrest. Journal of the American College of Cardiology. 2013;61(2):113-8.
12. Freedman AJ, Madsen EC, Lowrie L. Establishing a Quality Improvement Program for Pediatric In-hospital Cardiac Arrest. Pediatr Qual Saf. 2023;8(6):e706.
13. Greif R, Bhanji F, Bigham BL, Bray J, Breckwoldt J, Cheng A, et al. Education, Implementation, and Teams: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation. 2020;156:A188-a239.
14. Grunau B, Kawano T, Dick W, Straight R, Connolly H, Schlamp R, et al. Trends in care processes and survival following prehospital resuscitation improvement initiatives for out-of-hospital cardiac arrest in British Columbia, 2006-2016. Resuscitation. 2018;125:118-25.
15. Hopkins CL, Burk C, Moser S, Meersman J, Baldwin C, Youngquist ST. Implementation of pit crew approach and cardiopulmonary resuscitation metrics for out-of-hospital cardiac arrest improves patient survival and neurological outcome. Journal of the American Heart Association. 2016;5(1).
16. Hostler D, Everson-Stewart S, Rea TD, Stiell IG, Callaway CW, Kudenchuk PJ, et al. Effect of real-time feedback during cardiopulmonary resuscitation outside hospital: prospective, cluster-randomised trial. Bmj. 2011;342(feb04 1):d512-d.
17. Hubner P, Lobmeyr E, Wallmüller C, Poppe M, Datler P, Keferböck M, et al. Improvements in the quality of advanced life support and patient outcome after implementation of a standardized real-life post-resuscitation feedback system. Resuscitation. 2017;120:38-44.
18. Hunt EA, Jeffers J, McNamara L, Newton H, Ford K, Bernier M, et al. Improved cardiopulmonary resuscitation performance with CODE ACES2: A resuscitation quality bundle. Journal of the American Heart Association. 2018;7(24).
19. Hwang WS, Park JS, Kim SJ, Hong YS, Moon SW, Lee SW. A system-wide approach from the community to the hospital for improving neurologic outcomes in out-of-hospital cardiac arrest patients. Eur J Emerg Med. 2017;24(2):87-95.
20. Kim GW, Lee DK, Kang BR, Jeong WJ, Lee CA, Oh YT, et al. A multidisciplinary approach for improving the outcome of out-of-hospital cardiac arrest in South Korea. Eur J Emerg Med. 2020;27(1):46-53.
21. Kim GW, Moon HJ, Lim H, Kim YJ, Lee CA, Park YJ, et al. Effects of Smart Advanced Life Support protocol implementation including CPR coaching during out-of-hospital cardiac arrest. Am J Emerg Med. 2022;56:211-7.
22. Kim JY, Cho H, Park JH, Song JH, Moon S, Lee H, et al. Application of the "Plan-Do-Study-Act" Model to Improve Survival after Cardiac Arrest in Korea: A Case Study. Prehosp Disaster Med. 2020;35(1):46-54.
23. Kim YT, Shin SD, Hong SO, Ahn KO, Ro YS, Song KJ, et al. Effect of national implementation of utstein recommendation from the global resuscitation alliance on ten steps to improve outcomes from Out-of-Hospital cardiac arrest: A ten-year observational study in Korea. BMJ Open. 2017;7(8).
24. Knight LJ, Gabhart JM, Earnest KS, Leong KM, Anglemyer A, Franzon D. Improving code team performance and survival outcomes: implementation of pediatric resuscitation team training. Crit Care Med. 2014;42(2):243-51.
25. Ko YC, Hsieh MJ, Ma MH, Bigham B, Bhanji F, Greif R. The effect of system performance improvement on patients with cardiac arrest: A systematic review. Resuscitation. 2020;157:156-65.
26. Lee DE, Ryoo HW, Moon S, Park JH, Shin SD. Effect of citywide enhancement of the chain of survival on good neurologic outcomes after out-of-hospital cardiac arrest from 2008 to 2017. PLoS One. 2020;15(11):e0241804.
27. Li T, Essex K, Ebert D, Levinsky B, Gilley C, Luo D, et al. Resuscitation Quality Improvement® (RQI®) HeartCode Complete® program improves chest compression rate in real world out-of hospital cardiac arrest patients. Resuscitation. 2023;188:109833.
28. Lin HY, Chien YC, Lee BC, Wu YL, Liu YP, Wang TL, et al. Outcomes of out-of-hospital cardiac arrests after a decade of system-wide initiatives optimising community chain of survival in Taipei city. Resuscitation. 2022;172:149-58.
29. Lyngby RM, Quinn T, Oelrich RM, Nikoletou D, Gregers MCT, Kjølbye JS, et al. Association of Real-Time Feedback and Cardiopulmonary-Resuscitation Quality Delivered by Ambulance Personnel for Out-of-Hospital Cardiac Arrest. J Am Heart Assoc. 2023;12(20):e029457.
30. Lyon RM, Clarke S, Milligan D, Clegg GR. Resuscitation feedback and targeted education improves quality of pre-hospital resuscitation in Scotland. Resuscitation. 2012;83(1):70-5.
31. McCoy C, Keshvani N, Warsi M, Brown LS, Girod C, Chu ES, et al. Empowering telemetry technicians and enhancing communication to improve in-hospital cardiac arrest survival. BMJ Open Qual. 2023;12(3).
32. Nehme Z, Ball J, Stephenson M, Walker T, Stub D, Smith K. Effect of a resuscitation quality improvement programme on outcomes from out-of-hospital cardiac arrest. Resuscitation. 2021;162:236-44.
33. Nehme Z, Bernard S, Cameron P, Bray JE, Meredith IT, Lijovic M, et al. Using a Cardiac Arrest Registry to Measure the Quality of Emergency Medical Service Care. Circulation: Cardiovascular Quality and Outcomes. 2015;8(1):56-66.
34. Olasveengen TM, Tomlinson A-E, Wik L, Sunde K, Steen PA, Myklebust H, et al. A Failed Attempt to Improve Quality of Out-of-Hospital CPR Through Performance Evaluation. Prehospital Emergency Care. 2009;11(4):427-33.
35. Park JH, Shin SD, Ro YS, Song KJ, Hong KJ, Kim TH, et al. Implementation of a bundle of Utstein cardiopulmonary resuscitation programs to improve survival outcomes after out-of-hospital cardiac arrest in a metropolis: A before and after study. Resuscitation. 2018;130:124-32.
36. Pearson DA, Darrell Nelson R, Monk L, Tyson C, Jollis JG, Granger CB, et al. Comparison of team-focused CPR vs standard CPR in resuscitation from out-of-hospital cardiac arrest: Results from a statewide quality improvement initiative. Resuscitation. 2016;105:165-72.
37. Riyapan S, Sanyanuban P, Chantanakomes J, Roongsaenthong P, Somboonkul B, Rangabpai W, et al. Enhancing survival outcomes in developing emergency medical service system: Continuous quality improvement for out-of-hospital cardiac arrest. Resusc Plus. 2024;19:100683.
38. Spitzer CR, Evans K, Buehler J, Ali NA, Besecker BY. Code blue pit crew model: A novel approach to in-hospital cardiac arrest resuscitation. Resuscitation. 2019;143:158-64.
39. Sporer K, Jacobs M, Derevin L, Duval S, Pointer J. Continuous Quality Improvement Efforts Increase Survival with Favorable Neurologic Outcome after Out-of-hospital Cardiac Arrest. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors. 2017;21(1):1-6.
40. Stub D, Schmicker RH, Anderson ML, Callaway CW, Daya MR, Sayre MR, et al. Association between hospital post-resuscitative performance and clinical outcomes after out-of-hospital cardiac arrest. Resuscitation. 2015;92:45-52.
41. Vaillancourt C, Charette M, Lanos C, Godbout J, Buhariwalla H, Dale-Tam J, et al. Multi-phase implementation of automated external defibrillator use by nurses during in-hospital cardiac arrest and its impact on survival. Resuscitation. 2024;197:110148.
42. van Diepen S, Girotra S, Abella BS, Becker LB, Bobrow BJ, Chan PS, et al. Multistate 5-Year Initiative to Improve Care for Out-of-Hospital Cardiac Arrest: Primary Results From the HeartRescue Project. J Am Heart Assoc. 2017;6(9).
43. Weston BW, Jasti J, Lerner EB, Szabo A, Aufderheide TP, Colella MR. Does an individualized feedback mechanism improve quality of out-of-hospital CPR? Resuscitation. 2017;113:96-100.
44. Wolfe H, Zebuhr C, Topjian AA, Nishisaki A, Niles DE, Meaney PA, et al. Interdisciplinary ICU cardiac arrest debriefing improves survival outcomes*. Crit Care Med. 2014;42(7):1688-95.