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First responder engaged by technology (EIT #878): Systematic Review

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This CoSTR is a draft version prepared by ILCOR, with the purpose to allow the public to comment and is labeled “Draft for Public Comment". The comments will be considered by ILCOR. The next version will be labelled “draft" to comply with copyright rules of journals. The final COSTR will be published on this website once a summary article has been published in a scientific Journal and labeled as “final”.

Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: (none applicable)

The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: (none applicable)

CoSTR Citation

Semeraro F, Zace D, Bigham BL, Scapigliati A, Ristagno G, Bhanji F, Bray JE, Breckwoldt J, Cheng A, Duff JP, Gilfoyle E, Glerup Lauridsen KG, 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 EIT Task Force.

First responder engaged by technology Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) EIT Task Force, 2019 January 5 Available from http://ilcor.org

Methodological Preamble

The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic review of conducted by two ILCOR evidence reviewers (Semeraro, Bigham) with involvement of clinical content experts (Greif, Finn, Zace, Ristagno, Scapigliati). Evidence was sought and considered by the Education, Implementation and Teams (EIT) Task Force. We searched for the role of the citizen as a first responder, defined as all individuals who were engaged/notified by a smartphone’s app with mobile positioning system (MPS) or Text Message-alert system to attend Out-Of-Hospital Cardiac Arrest (OHCA) events and initiate early CPR and early defibrillation.

Three of the included studies {Lee 2019 198; Zijlstra 2014 1444; Pijls 2016 182} assessed the role of Text Message (TM)-alert system, three studies {Berglund 2018 160; Ringh 2015 372; Stroop 2019 PMID: 31887366} assessed the role of smartphone’s app with mobile positioning system (MPS) and one study {Caputo 2017 73} assessed both.

Most studies’ outcomes were compared between the intervention and the control period, while two studies {Stroop 2019 PMID: 31887366, Berglund 2018 160} compared time to compression/shock in the intervention group to that of the EMS.

Studies had covered different search radius (i.e 500 m, 1000m). When it was possible, we extracted from the studies only adjusted outcomes.

The most important confounders (e.g. primary rhythm, etiology, witnessed status, location of arrest, gender, age, comorbidities response time, time of the arrest) were controlled for in the multivariable analysis.

However, some studies did not report adjusted data, or did so only for certain outcomes (mainly primary outcomes). In these cases, we reported unadjusted RR with 95% CI. In the case of studies assessing the same outcomes a pooled RR was calculated and reported along with the 95% CI.

PICOST

The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)

Population: Adults and children in out-of-hospital with cardiac arrest

Intervention: having a citizen CPR responder notified of the event via technology or social media

Comparators: no such notification

Outcomes: survival to hospital discharge with good neurological outcome, survival to hospital discharge/30-day survival, hospital admission, ROSC, bystander CPR rate, time to first compression/shock

Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) were eligible for inclusion. Unpublished studies (e.g., conference abstracts, trial protocols), animal studies, case series, and simulation studies were excluded.

Timeframe: All years and all languages were included as long as there is an English abstract. The search strategy was performed on the same day (25/10/2019) for the three databases.

PROSPERO Registration: submitted to PROSPERO on 11/12/2019.

Consensus on Science

For the critical outcome “survival with favourable neurologic outcome at discharge”, we identified low-certainty evidence from two observational studies (downgraded for study design) enrolling 2149 OHCAs showing no benefit for having a citizen CPR responder notified of the event via technology or social media [Adj. pooled RR, 1.4 (95% CI, 0.6-3.4) ] {Lee 2019 198; Stroop 2019 PMID: 31887366}.

For the critical outcome “survival hospital discharge/30-day survival”, we identified moderate-evidence from 1 RCT (downgraded for serious risk of bias) {Ringh 2015 372} and very low-evidence (downgraded for serious risk of bias, and serious inconsistency) from 4 observational studies {Lee 2019 198; Caputo 2017 73; Pijls 2016 182; Stroop 2019 PMID: 31887366}. The RCT reported no benefit in 1-month survival between the intervention and the control group [Unadjusted RR 1.3 (95% CI 0.8-2.1)]. The meta-analysis of adjusted data included 2905 OHCAs (4 studies) and showed benefit in survival to hospital discharge when having a citizen CPR responder notified of the event by smartphone’s app with mobile positioning system (MPS) or Text Message (TM)-alert system [Adj. pooled RR 1.70 (95% CI 1.16-2.48) (I2=69%, P=0.02)]*; 98/1000 more patients benefited with the intervention (95% CI 22 more patients/1000 to 208 more patients/1000 when compared to notification by an smartphone’s app with mobile positioning system (MPS) or Text Message (TM)-alert system not being offered. These results are confirmed by RRs reported separately in three of the four studies, showing benefit in survival to hospital discharge when having a citizen CPR responder notified by technology [RR 1.7 (95% CI 1.17-2.5) {Caputo 2017 73}; RR 2.23 (95% CI 1.41-3.23) {Pijls 2016 182}; RR 2.37 (1.07-4.55) {Stroop 2019 PMID: 31887366}. One of the studies did not report any significant benefit [RR 1.06 (95% CI 0.72-1.51)] {Lee 2019 198}.

For the critical outcome “survival to hospital admission”, we identified no studies.

For the important outcome “ROSC”, we identified moderate-certainty evidence (downgraded for serious risk of bias) from one RCT enrolling 667 OHCAs showing no significant benefit for having a citizen CPR responder notified of the event via technology or social media (0.3 percentage points higher for the intervention group, 95% CI 6.5 lower-7.3 higher) [Unadjusted RR 1.01 (95% CI 0.79-1.28)] {Ringh 2015 372}. We also identified very low-certainty evidence (downgraded for study design and serious risk of bias) from three observational cohort studies enrolling 2571 OHCAs showing no benefit for having a citizen CPR responder notified of the event via technology or social media [Unadjusted pooled RR 0.97 (95% CI, 0.60-1.57)] {Pijls 2016 182; Lee 2019 198; Stroop 2019 PMID: 31887366}.

For the important outcome “bystander CPR”, we identified high-certainty evidence from one RCT {Ringh 2015 372} and one before-after study {Lee 2019 198}. The RCT enrolled 667 OHCAs, showing an absolute difference for intervention vs. control of 14 percentage points (6 higher to 21 higher) [Adj. RR 1.27 (95% CI 1.10-1.46)]; 129/1000 more patients benefited with the intervention (95% CI 48 more patients/1000 to 219 more patients/1000 when compared to notification by an smartphone’s app with mobile positioning system (MPS) or Text Message (TM)-alert system not being offered {Ringh 2015 372}. The second study enrolled 1696 OHCAs, showing benefits for having a citizen CPR responder notified of the event via technology or social media (Adj. RR, 1.29 (95% CI 1.20-1.37); 160/1000 more patients benefited with the intervention (95% CI 110 more patients/1000 to 204 more patients/1000 when compared to no intervention {Lee 2019 198}.

For the important outcome of “time to first compression/shock delivery”, we identified very low-certainty evidence (downgraded for serious risk of bias, inconsistency, and study design) from four observational studies enrolling 1833 OHCAs showing that having a citizen CPR responder notified of the event via technology or social media led to significantly lower response times compared to no technology, i.e. median response time (minutes: seconds) 6:17 (IQR 4:49– 7:57) vs. 9.38 (IQR 7.14–12.51), Z=−14.498, p < 0.0001) {Berglund 2018 160} and median time for defibrillation delivery (minutes: seconds) 8:00 [IQR 6:35–9:49] vs. 10:39 [IQR, 8:18–13:23], P < 0.001) {Zijlstra 2014 1444}. Another study showed a significant difference in median response time between Mobile-Rescuers (4 minutes; IQR 3-6) and EMS teams (7 minutes; IQR 6-10]), (p<0.001) {Stroop 2019 PMID: 31887366}. Comparing an app based system with a SMS based system, more benefit was found in using the app; responders' median time 3.5 minutes [IQR 2.8–5.2) compared to the SMS based system 5.6 min[ IQR 4:2–8:5, p=0.0001) {Caputo 2017 73}.

Treatment Recommendations

We recommend that citizen/individuals who are in close proximity to a suspected Out-Of-Hospital Cardiac Arrest (OHCA) event and willing to be engaged/notified by a smartphone app with mobile positioning system (MPS) or Text Message (TM)-alert system should be notified (strong recommendation, very low-certainty evidence).

Justification and Evidence to Decision Framework Highlights

  • Notifying a citizen CPR responder by a smartphone’s app with mobile positioning system (MPS) or Text Message (TM)-alert system to attend Out-Of-Hospital Cardiac Arrest (OHCA) events can lead to an increase early CPR and defibrillation, improving survival.
  • We considered the improved outcomes in OHCA patients when a citizen CPR responder was notified by a smartphone app or text message for the event and started CPR or delivered defibrillation across most studies.
  • Even though the certainty of the evidence is very low/low among the observational cohort studies, there was one RCT and one before-after study of a high quality, reporting improved outcomes when first responders were notified by an smartphone’s app with mobile positioning system (MPS) or Text Message (TM)-alert system for the OHCA event and started CPR or delivered defibrillation.
  • Pooled RR were estimated using a random effect model, as it takes into account the between studies variability. Heterogeneity between studies was assessed using the I2 statistics and was evaluated to be was moderate (I2=69%, p=0.021 for the outcome survival to hospital discharge). Sensitivity analyses were conducted to investigate the impact each study had on the overall estimate. The presence of the statistical heterogeneity suggests the presence of variability among the clinical characteristics of the studies’ populations (ie comorbidities, cause of cardiac arrest, time and location of the arrest, arrival time of lay persons or first responders at the location) as well as methodological heterogeneity (ie study design, data collection).
  • There is the need for more high-evidence quality prospective studies including long term survival assessment. Especially risk of bias is a predominant issue, with studies controlling for confounding factors only for a few outcomes. More RCT studies are needed for more robust evidence.
  • There is no evidence of the cost-effectiveness of notifying laypersons through a smartphone’s app with mobile positioning system (MPS) or Text Message (TM)-alert system in the case of OHCAs.
  • There was only one study assessing which of the technologies used could be more beneficial in order to improve the outcomes of OHCAs (APP vs SMS). There is the need for more high-quality evidence to determine the best technology to use in terms of OHCAs outcomes.
  • There is the need for the extension of these studies in different social, cultural, ethnic and geographical contexts.
  • The results of the included studies apply only on OHCAs of cardiac origin, hence the need for more evidence regarding OHCAs in cases trauma, drowning, intoxication, or suicide.
  • There is the need for more consistent high-quality evidence on the impact of engaged/notified versus unnotified bystander responses on survival with favourable neurologic outcome at hospital discharge, ROSC and survival to hospital admission?
  • What is the impact of engaged/notified versus unnotified bystander responses on bystander CPR rates and time to first compressions/shock delivery?
  • Safety of notifying CPR responders by a smartphone’s app with mobile positioning system (MPS) or Text Message (TM)-alert system to attend Out-Of-Hospital Cardiac Arrest (OHCA) events.
  • The psychological or emotional impact imposed on responders by potential or actual engagement in a call to rescue.

Knowledge Gaps

  • There is the need for more high-evidence quality prospective studies including long term survival assessment. Especially risk of bias is a predominant issue, with studies controlling for confounding factors only for a few outcomes. More RCT studies are needed for more robust evidence.
  • There is no evidence of the cost-effectiveness of notifying laypersons through a smartphone’s app with mobile positioning system (MPS) or Text Message (TM)-alert system in the case of OHCAs.
  • There was only one study assessing which of the technologies used could be more beneficial in order to improve the outcomes of OHCAs (APP vs SMS). There is the need for more high-quality evidence to determine the best technology to use in terms of OHCAs outcomes.
  • There is the need for the extension of these studies in different social, cultural, ethnic and geographical contexts.
  • The results of the included studies apply only on OHCAs of cardiac origin, hence the need for more evidence regarding OHCAs in cases trauma, drowning, intoxication, or suicide.
  • There is the need for more consistent high-quality evidence on the impact of engaged/notified versus unnotified bystander responses on survival with favourable neurologic outcome at hospital discharge, ROSC and survival to hospital admission?
  • What is the impact of engaged/notified versus unnotified bystander responses on bystander CPR rates and time to first compressions/shock delivery?
  • Safety of notifying CPR responders by a smartphone’s app with mobile positioning system (MPS) or Text Message (TM)-alert system to attend Out-Of-Hospital Cardiac Arrest (OHCA) events.
  • The psychological or emotional impact imposed on responders by potential or actual engagement in a call to rescue.

Attachments

Evidence-to-Decision Table: EIT 878 First responder engaged by technology

References

Berglund E, Claesson A, Nordberg P, Djärv T, Lundgren P, Folke F, Forsberg S, Riva G, Ringh M. A smartphone application for dispatch of lay responders to out-of-hospital cardiac arrests. Resuscitation. 2018 May;126:160-165.

Caputo ML, Muschietti S, Burkart R, Benvenuti C, Conte G, Regoli F, Mauri R, Klersy C, Moccetti T, Auricchio A. Lay persons alerted by mobile application system initiate earlier cardio-pulmonary resuscitation: A comparison with SMS-based system notification. Resuscitation. 2017 May;114:73-78.

Lee SY, Shin SD, Lee YJ, Song KJ, Hong KJ, Ro YS, Lee EJ, Kong SY.Text message alert system and resuscitation outcomes after out-of-hospital cardiac arrest: A before-and-after population-based study.Resuscitation. 2019 May;138:198-207.

Pijls RW, Nelemans PJ, Rahel BM, Gorgels AP. Factors modifying performance of a novel citizen text message alert system in improving survival of out-of-hospital cardiac arrest. Eur Heart J Acute Cardiovasc Care. 2018 Aug;7(5):397-404.

Ringh M, Rosenqvist M, Hollenberg J, Jonsson M, Fredman D, Nordberg P, Järnbert-Pettersson H, Hasselqvist-Ax I, Riva G, Svensson L. Mobile-phone dispatch of laypersons for CPR in out-of-hospital cardiac arrest. N Engl J Med. 2015 Jun 11;372(24):2316-25

Stroop R, Kerner T, Strickmann B, Hensel M, Mobile phone-based alerting of CPR-trained volunteers simultaneously with the ambulance can reduce the resuscitation-free interval and improve outcome after out-of-hospital cardiac arrest: A German, population-based cohort study. Resuscitation. 2019 Dec 27. PMID: 31887366 DOI: 0.1016/j.resuscitation.2019.12.012

Zijlstra JA, Stieglis R, Riedijk F, Smeekes M, van der Worp WE, Koster RW. Local lay rescuers with AEDs, alerted by text messages, contribute to early defibrillation in a Dutch out-of-hospital cardiac arrest dispatch system. Resuscitation. 2014 Nov;85(11):1444-9.

Education, Implementation and Teams
Education

Discussion

Maria Luce Caputo
(1 posts)

(modified: )

It is a matter of fact that the technology is more and more improving the lay citizens' knowledge and involvment in the out-of-hospital cardiac arrest care. This review document by ILCOR summarize very well what we know right now about the impact of the mobile phones technology on the critical outcomes of OHCAs. However, more studies are needed to better assess some key points, including the use of the technology to select the person who has to retrieve the Automatic external defibrillator or the development of specific protocols of intervention in case of trauma or intoxication.
Reply
Виктория Антонова
(397 posts)

(modified: )

Thanks for the encouraging comment, we will consider if your suggestions need to be included in the gap of knowledge.
Виктория Антонова
(397 posts)

(modified: )

Conflicts of interest: Financial relationships, Consulting, Grants
Dear Sir´s As a complement to your outstanding guidelines work I have a short comment: In the Swedish study (Ring et al NEJM 2015) primary endpoint was bystander CPR. Not survival. In summary, The mobile-phone positioning system was activated in 667 out-of-hospital cardiac arrests: 46% (306 patients) in the intervention group and 54% (361 patients) in the control group. The rate of bystander-initiated CPR (primary endpoint) was 62% (188 of 305 patients) in the intervention group and 48% (172 of 360 patients) in the control group (absolute difference for intervention vs. control, 14 percentage points; 95% confidence interval, 6 to 21; P<0.001). To my opinion you should therefore not report this study as a non-concluded or negative in regards to survival at 30 days. The study did not have power nor were design to study survival. Keep up the good work! Leif Svensson Professor cardiology, senior and principal investigator in the Ringh study
Reply
Виктория Антонова
(397 posts)

(modified: )

Thanks for the comment. We were aware of the secondary outcome survival in your study. The inclusion criteria defined in this systematic review every article that reports outcomes of technology engagement on OHCAs, without specifying if it is a primary or secondary outcome. Therefore, we used the outcomes form your study. Because such studies are not powered for secondary outcomes GRADE downgrades these studies in the risk of bias assessment. Despite of that, your results are a very important contribution in the field of first responders engagement with the help of modern technology.

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