Emergency Medicine

Type of bystander and rate of cardiopulmonary resuscitation in nursing home patients suffering out-of-hospital cardiac arrest

a b s t r a c t

Aim: We investigated bystander cardiopulmonary resuscitation (CPR) provision rate and survival outcomes of out-of-hospital cardiac arrest (OHCA) patients in Nursing homes by bystander type.

Methods: A population-based observational study was conducted for nursing home OHCAs during 2013-2018. The exposure was the bystander type: medical staff, non-medical staff, or family. The primary outcome was by- stander CPR provision rate; the secondary outcomes were prehospital return of spontaneous circulation (ROSC) and survival to discharge. Multivariable logistic regression analysis which corrected for various demographic and clinical characteristics evaluated bystander type impact on study outcomes. Bystander CPR rate trend was inves- tigated by bystander type.

Results: Of 8281 eligible OHCA patients, 26.0%, 70.8%, and 3.2% cases were detected by medical staff, non-medical staff, and family, respectively. Provision rate of bystander CPR was 69.9% and rate of bystander defibrillation was 0.4% in total. Bystander CPR was provided by medical staff, non-medical staff, and families in 74.8%, 68.9%, and 52.1% respectively. Total survival rate was 2.2%, out of which, 3.3% was for medical staff, 3.2% for non-medical staff, and 0.6% for family. Compared to the results of detection by medical staff, the adjusted odds ratios (95% CIs) for provision of bystander CPR were 0.56 (0.49-0.63) for detection by non-medical staff and 0.33 (0.25-0.44) for detection by family. The bystander CPR rates of all three groups increased over time, and among them, the medical staff group increased the most. For prehospital ROSC and survival to discharge, no sig- nificant differences were observed according to bystander type.

Conclusion: Although OHCA was detected more often by non-medical staff, they provided bystander CPR less fre-

quently than the medical staff did. To improve survival outcome of nursing home OHCA, bundle interventions in- cluding increasing the usage of automated external defibrillators and expanding CPR training for non-medical staff in nursing home are needed.

(C) 2021

  1. Introduction

Out-of-hospital cardiac arrest (OHCA) is a major public health bur- den worldwide [1]. As the population is aging, the number of nursing homes and proportion of elderly living in nursing homes are growing. Since cardiac arrest incidence increases with age, OHCA in nursing homes is becoming a common occurrence [2]. Despite improvement

* Corresponding author at: Public Healthcare Center, Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, 101 Daehak- Ro, Jongno-Gu, Seoul 03080, South Korea.

E-mail address: [email protected] (S.Y. Lee).

in overall cardiac arrest prognosis, however, OHCA outcomes in nursing homes remain unimproved [3].

OHCAs occurring in nursing homes known to have poor outcomes [4]. In the 1990s, resuscitation was not recommended for nursing home OHCA except in very selected cases, such as witnessed, or those with an Initial shockable rhythm [5,6]. However, another study reported that nursing home residents had similar prognoses with community- residing older persons experiencing OHCA and nursing home patients could have favourable neurological outcomes when appropriate resus- citation was provided [7-9]. The witnessed, initial shockable rhythm, and bystander cardiopulmonary resuscitation (CPR) were known fac- tors associated with favourable OHCA outcomes [10]. Nursing home OHCA patients also had a higher chance of survival if they were

https://doi.org/10.1016/j.ajem.2021.03.021

0735-6757/(C) 2021

witnessed and received early bystander CPR [9,11]. Bystander CPR is particularly important because it is modifiable. Bystander CPR is pro- vided more often in public than inside a residence [12]. A nursing home is a residence but also has a space accessible to the public. The fre- quency of nursing home residents receiving bystander CPR was higher than that of private housing residents [11]. However, who provides by- stander CPR and the factors associated with the provision of bystander CPR in nursing home OHCA cases are unknown.

The type of bystander affects bystander CPR provision and OHCA outcomes [13,14]. Bystanders are more likely to provide CPR if they were previously trained in bystander CPR. Designated, trained re- sponders provided CPR frequently with better survival outcomes [13,15]. Family bystanders rarely provided CPR with worse outcomes than non-family bystanders did [16,17]. Bystanders are usually family members in private homes, and strangers in public [18]. Although nurs- ing homes are a high-risk place for OHCA, it is unclear who detects OHCA in nursing homes and whether provision of bystander CPR and patient outcomes vary depending on the type of the bystander.

We investigated the provision rate of bystander CPR and survival outcomes of nursing home OHCA according to the type of bystander. The trends of the 6-year bystander CPR rate and patient outcomes ac- cording to the type of bystander were investigated.

  1. Methods
    1. Study setting

The Korean emergency medical service (EMS) is a fire-based government-sponsored system. The National Fire Agency operates a single-tiered EMS system for the whole country, with 18 provincial of- fices. emergency medical technicians provide CPR until the re- turn of spontaneous circulation (ROSC), or the arrival at emergency department (ED). Since only doctors can declare death, all EMS- treated patients are transferred to the ED [19].

Korea is a rapidly aging country with a low fertility rate and an in- creased Life expectancy. [20] Korea operates a long-term care insurance (LTCI) system, and the national health insurance (NHI) system covers the entire population. Elderly people who need long-term care, and are unable to live independently, live in nursing homes or long-term care hospitals (LTCHs), according to their medical needs. A LTCH is a place for people who need medical care or rehabilitation under NHI, and a nursing home is a place for people who need assistance with daily living under the LTCI. According to the nursing home manpower regulations, nursing homes should have a nurse, a social worker, and a physiotherapist according to the number of residents. Although physi- cians are not mandatory in nursing homes, contracted physicians are re- quired to visit nursing homes at least twice a month to clinically examine residents [20,21]. Institutions that function as hospice or step-down facilities are also classified into nursing home or LTCH de- pending on whether or not physician obligated to reside.

In Korea, the Life-Sustaining Treatment decisions Act on end-of-life care was passed in 2018 and Advance directives (AD) and Physician Or- ders for Life-Sustaining Treatment (POLST) are on the rise [22]. Before that, AD or POLST was not common practice and nursing home patients rarely had an AD or POLST. Since nursing homes are not hospital facili- ties and have no physicians, when OHCA occurs in nursing homes, EMS is activated and patients are transferred to the hospital. For first aid until EMS arrives, nursing home staff should receive bystander CPR training every year as the subject of mandatory CPR education accord- ing to the Korean National EMS Act [18].

    1. Study design and data collection

This is a population-based, cross-sectional observational study. This study used a nationwide prospective OHCA database in Korea.

All incidences of EMS-treated OHCA are included in the Korean OHCA database. It was constructed in 2006 and incorporates of the fol- lowing four databases: ambulance run sheet, EMS cardiac arrest regis- try, dispatch CPR registry, and the national OHCA registry for hospital care and patient outcomes. EMTs documented ambulance run sheets for basic ambulance operation information and EMS cardiac arrest registry for Utstein factors, including the place of occurrence and type of bystander. They document it in the field using a tablet device and complete the registry immediately after Patient transport. Dis- patchers working in the dispatch centre document the dispatch CPR registry for dispatcher-assisted bystander CPR (DA-CPR)-related fac- tors. For all EMS-treated OHCA cases, the above three registries are in- tegrated to complete the EMS OHCA database. Based on this EMS OHCA database, the Korea Disease Control and Prevention Agency (KDCA) dispatches trained medical record investigators to the hospi- tal. According to the national statistics law, they review medical re- cords, and collect hospital care and patient outcome information to complete the OHCA database. To maintain the quality of the database, the Data quality improvement (QI) team has monthly QI meetings. Detailed information on database construction has been reported previously [23].

    1. Study population

Among all EMS-treated adult (>=18 years old) OHCA patients with medical aetiology from January 2013 to December 2018, OHCA that oc- curred in nursing homes were included. In EMS cardiac arrest registry, those classified as nursing home occurrences rather than hospitals were included. Patients whose cardiac arrest was witnessed by EMS, pa- tients with unknown information of witnessed status, and patients for whom resuscitation was not attempted, were excluded.

    1. Outcome measures

The primary outcome was provision of bystander CPR before EMS arrival. The secondary outcome was prehospital return of spontaneous circulation (PROSC), and survival to discharge from the hospital.

    1. Variable definitions and measurements

The main exposure was the type of bystander, which was captured through the EMS cardiac arrest registry. In the Korean OHCA database, EMTs who treat OHCA patients on the scene document the type of by- stander as follows: EMT, medical personnel (doctor or nurse), desig- nated trained responder (police, health teacher, driver of transport business vehicle, safety officer of sports facility, lifeguard, person in charge of occupational safety and health education, person in charge of medical or safety work among tourist businesses, fire safety manager, and sports instructor), family, passer-by, colleague (friend), other, or unknown. The types of bystanders of nursing homes were re- categorized according to their role in the nursing home: medical staff (doctors or nurses), non-medical staff, and family. The non-medical staff included everyone who works in a nursing home, but are not doc- tors or nurses, such as physiotherapists, office workers, cleaners, etc.

We collected the following variables from the database: 1) patient

demographics (age, gender, date of arrest, comorbidities {diabetes mellitus, hypertension, heart disease, and stroke}, first documented car- diac arrest rhythm {shockable, PEA, and asystole}), 2) community fac- tors (witnessed status, bystander CPR, and bystander defibrillation),

3) EMS factor (response time interval, scene time interval, transport time interval, and EMS defibrillation), 4) hospital outcome (PROSC, sur- vival to discharge, and good neurological outcome defined as Cerebral Performance Categories scale I or II).

Image of Fig. 1

Fig. 1. Patient enrolment flow.

    1. Statistical analysis

Descriptive analyses were performed to investigate the distribution of the variables. The characteristics and outcomes of OHCA were com- pared by type of bystander. Counts and proportions were used for cate- gorical variables, and medians and interquartile ranges were used for continuous variables. The chi-square test was used for comparison of categorical variables, and the Kruskal-Wallis test was used for continu- ous variables [24,25].

Multivariable logistic regression analysis was used to evaluate the association of the type of bystander with the study outcomes. The ad- justed odds ratios (AORs) and 95% confidence intervals (95% CIs) for the study outcomes were calculated after controlling for potential con- founders. Model I adjusted for age groups and gender. In Model II, co- morbidities (diabetes mellitus, hypertension, heart disease, and stroke), year, weekend (or weekday), and night-time (6 PM-6 AM) were added to Model I.

Sensitivity analysis was conducted for witnessed patients of total study population. The same logistic regression model was used for sen- sitivity analysis.

The yearly outcome rate according to the type of bystander is pre- sented as a graph. The Cochran-Armitage test was used to evaluate the temporal trends of outcome rate.

All statistical analyses were conducted using SAS software, version

9.4 (SAS Institute Inc., Cary, NC, USA). P-values were based on a two- sided significance level of 0.05.

    1. Ethics statements

The study was approved by the Institutional Review Board of Seoul National University Hospital (IRB No. H-1103-153-357), and the re- quirement for informed consent was waived.

  1. Results

Of the 175,182 EMS-assessed OHCA cases between 2013 and 2018, 117,856 resuscitation-attempted adult medical aetiology patients were included. Of the 9137 OHCAs that occurred in nursing homes, a total of 8281 patients were included as the study population (Fig. 1).

    1. Demographics of OHCA that occurred in a nursing home

Of the total 8281 nursing home OHCA patients, medical staff de- tected 2150 (26.0%) patients, non-medical staff detected 5785 (66.9%) patients, and family detected 265 (3.2%) patients. Bystander CPR was provided by medical staff, non-medical staff, and families in 74.8%, 68.9%, and 52.1% respectively (p < 0.01). Bystander defibrillation was provided in only 0.4% of all patients. PROSC was 3.9% in total, 3.8% in medical staff, 4.0% in non-medical staff, and 2.6% in family detected (p = 0.55). Survival to discharge was 2.2% in total, 2.5% in medical staff, 2.1% in non-medical staff, and 1.1% in family detected (p = 0.27) (Table 1).

Table 1

Demographics of all out-of-hospital cardiac arrest patients occurred in nursing home by the type of bystander.

Table 2

Multivariable logistic regression analysis of outcome by type of bystander for all out-of- hospital cardiac arrest patients.

Total Medical staff

Non-medical staff

Family P

value

Total Outcome Model I Model II

N % N % N % N %

N

N

%

OR

95% CI

OR 95% CI

Bystander CPR Total

8281

5785

69.9

Medical staff

2150

1608

74.8

1.00

1.00

Total 8281 100.0 2150 100.0 5866 100.0 265 100.0

Female 2955 35.7 765 35.6 2087 35.6 103 38.9 0.55

Age, years

<0.01

Non-medical staff

5866

4039

68.9

0.75

0.67

0.83

0.56

0.50

0.64

~59

223

2.7

55

2.6

149

2.5

19

7.2

Family

265

138

52.1

0.36

0.28

0.47

0.33

0.25

0.43

60-79

2265

27.4

593

27.6

1596

27.2

76

28.7

80~

5793

70.0

1502

69.9

4121

70.3

170

64.2

Median (IQR)

Year

84 (78-89)

84 (78-89)

84 (78-89)

83 (77-88)

0.22

<0.01

Prehospital ROSC

Total

8281

321

3.9

Medical staff

2150

82

3.8

1.00

1.00

Non-medical staff

5866

232

4.0

1.04

0.81

1.35

0.93

0.71

1.21

Family

265

7

2.6

0.64

0.29

1.40

0.69

0.31

1.51

Survival to discharge

2013

832

10.0

514

23.9

275

4.7

43

16.2

2014

1234

14.9

286

13.3

897

15.3

51

19.2

2015

1505

18.2

328

15.3

1124

19.2

53

20.0

2016

1499

18.1

357

16.6

1108

18.9

34

12.8

2017

1479

17.9

290

13.5

1143

19.5

46

17.4

2018

1732

20.9

375

17.4

1319

22.5

38

14.3

Total 8281 181

2.2

Medical staff 2150 54

2.5

1.00

1.00

Non-medical staff 5866 124

2.1

0.84

0.61

1.16

0.86

0.61

1.20

Family 265 3

1.1

0.40

0.13

1.31

0.45

0.14

1.46

Time

Weekend

2561

30.9

620

28.8

1845

31.5

96

36.2

0.01

Nighttime

5890

71.1

1695

78.8

4024

68.6

171

64.5

<0.01

N, number; OR, odds ratio; CI, confidence interval.

(6 PM-6 AM)

Model I: adjusted for age group and gender.

Witnessed

4265

51.5

1249

58.1

2854

48.7

162

61.1

<0.01

Model II: adjusted for age group, gender, comorbidities (DM, HTN, heart ds, stroke), year,

Comorbidities

weekend, and nighttime.

Diabetes

1719

20.8

486

22.6

1177

20.1

56

21.1

0.05

Hypertension

3175

38.3

883

41.1

2198

37.5

94

35.5

0.01

Heart disease

1016

12.3

254

11.8

722

12.3

40

15.1

0.30

Stroke

1471

17.8

418

19.4

1002

17.1

51

19.2

0.04 82.9%, 77.3%, and 62.3% respectively (p < 0.01). Survival to discharge

Bystander effort

was 3.1% in total, 3.3% in medical staff, 3.2% in non-medical staff, and

Primary ECG

CPR

5785

69.9

1608

74.8

4039

68.9

138

52.1

<0.01

Defibrillation

31

0.4

12

0.6

19

0.3

0.0

0.19

VF/VT 182 2.2 41 1.9 133 2.3 8

0.60

3.0

PEA

832

10.0

206

9.6

601

10.2

25

9.4

Asystole

7267

87.8

1903

88.5

5132

87.5

232

87.5

0.6% in family-detected groups (p = 0.17) (Supplement Table 1).

Compared to the results of medical staff-detected cases, AORs (95% CIs) for bystander CPR were 0.53 (0.44 to 0.64) in the non-medical staff and 0.30 (0.21 to 0.43) in the family-detected group. Neither the AOR for prehospital ROSC nor survival to discharge was statistically sig-

EMS time, min, Response time

Scene time

median (IQR) 7 (5-10)

11 (8-15)

7 (5-10)

10 (7-14)

7 (5-10)

12 (8-16)

7 (5-9)

10 (7-14)

<0.01

<0.01

nificant in the multivariable logistic model (Table 3).

3.4. Trends of bystander CPR rate by type of bystander

Transport

7 (4-12)

7 (5-12)

7 (4-11)

6 (4-10)

<0.01

time

EMS

defibrillation patients outcome

883 10.7 232 10.8 610 10.4 41 15.5 0.03

From 2013 to 2018, the bystander CPR rate increased from 51.2% to 88.0% in medical staff-detected, and from 48.7% to 76.6% in the non- medical staff-detected group (p < 0.01). The change in family detected

PROSC 321 3.9 82 3.8 232 4.0 7 2.6 0.55

group from 51.2% to 52.6% was smaller than that in both medical and

Survival to discharge

181 2.2 54 2.5 124 2.1 3 1.1 0.27

non-medical staff groups (p = 0.02) For witnessed patients, the

Good CPC 24 0.3 6 0.3 18 0.3 – 0.0 0.66

IQR, interquartile range; CPR, cardiopulmonary resuscitation; ECG, electrocardiogram; VF, ventricular fibrillation; VT, ventricular tachycardia; PEA, pulseless electrical activity; EMS, emergency medical service; PROSC, prehospital return of spontaneous circulation; good CPC, Cerebral Performance Categories scale I or II.

    1. Logistic regression analysis of type of bystander and study outcomes

Compared to the medical staff-detected group, AORs (95% CIs) for bystander CPR were 0.56 (0.50 to 0.64) in the non-medical staff and

0.33 (0.25 to 0.43) in the family-detected group. The AORs (95% CIs) of PROSC compared to the medical staff-detected were 0.93 (0.71 to 1.21) in the non-medical staff and 0.69 (0.31 to 1.51) in the family-detected group. In terms of survival to discharge, compared with medical staff-detected, AORs (95% CIs) were 0.86 (0.61 to 1.20) for non-medical staff and 0.45 (0.14 to 1.46) in the family-detected group (Table 2).

    1. Sensitivity analysis of type of bystander and study outcomes for witnessed patients

Of the total 4265 witnessed nursing home OHCAs, bystander CPR was provided by medical staff, non-medical staff, and families in

Table 3

Multivariable logistic regression analysis of outcome by type of bystander for witnessed out-of-hospital cardiac arrest patients.

Total Outcome Model I Model II

N N % OR 95% CI OR 95% CI

Bystander CPR Total

4265

3341

78.3

Medical staff

1249

1035

82.9

1.00

1.00

Non-medical staff

2854

2205

77.3

0.70

0.59

0.83

0.53

0.44

0.64

Family

162

101

62.3

0.34

0.24

0.48

0.30

0.21

0.43

Prehospital ROSC Total

4265

216

5.1

Medical staff

1249

60

4.8

1.00

1.00

Non-medical staff

2854

153

5.4

1.13

0.83

1.54

1.02

0.74

1.39

Family

162

3

1.9

0.36

0.11

1.17

0.39

0.12

1.28

Survival to discharge

Total

4265

132

3.1

Medical staff

1249

41

3.3

1.00

1.00

Non-medical staff

2854

90

3.2

0.97

0.66

1.41

0.98

0.66

1.45

Family

162

1

0.6

0.17

0.02

1.27

0.19

0.03

1.42

N, number; OR, odds ratio; CI, confidence interval. Model I: adjusted for age group and gender.

Model II: adjusted for age group, gender, comorbidities (DM, HTN, heart ds, stroke), year, weekend, and nighttime.

Image of Fig. 2

Fig. 2. Trends in the rate of bystander cardiopulmonary resuscitation by the type of bystander. A. All OHCA occurred in nursing home. B. Witnessed OHCA occurred in nursing home.

Image of Fig. 3

Fig. 3. Trends in the rate of prehospital ROSC and survival to discharge of all OHCA occurred in nursing home by the type of bystander. A. Prehospital return-of-spontaneous circulation. B. Survival to discharge.

bystander CPR rate increased from 60.5% to 93.6% in medical staff- detected, and from 59.7% to 83.8% in the non-medical staff-detected groups (p < 0.01). The change in family-detected from 68.2% to 63.0% was not statistically significant (p = 0.29) (Fig. 2).

PROSC improved in medical staff and non-medical staff detected (both group all p < 0.01), but improvement in survival to discharge was not statistically significant in all three groups in total population and witnessed population (Fig. 3).

  1. Discussion

Of all OHCAs occurring in nursing homes, about 25% of cases are de- tected by doctors or nurses, 70% of cases are detected by non-medical staff, and 3% are detected by family members. Although non-medical staff detected more OHCAs than medical staff did, non-medical staff provided less bystander CPR. From 2013 to 2018, bystander CPR rate for nursing home OHCAs increased and degree of increase by non-

medical staff was smaller than that by medical staff. While overall prehospital ROSC and survival to discharge were low, there was no dif- ference according to the type of bystander.

Nursing homes are a common residential place for the elderly [21]. As the global population ages, the proportion of the elderly living in nursing homes and the incidence of nursing home OHCAs are increasing. Cardiac arrest is more frequent in older patients, and the prognosis is poorer [2]. Since cardiac arrest treatments are resource-intensive, resuscitation for cardiac arrests in the elderly or nursing home residents is controversial [26,27]. In the early 1990s, resuscitation of nursing home residents was not recommended, except for very selected cases. However, as Medical technology improved, factors associated with improving outcomes were identified [3,5]. The most important interventions are bystander CPR and Early defibrillation [3,9,11,28]. Based on this evidence, installing Automated external defibrillators in nursing homes and early by- stander resuscitation is recommended for nursing home patients [9,11]. However, nursing home OHCA outcomes are still poor [3].

Bystander CPR is an evidence-established intervention for improv- ing the outcome of OHCA [29,30]. Since bystanders with experience in CPR training provide more bystander CPR, CPR training is expanding worldwide [15]. However, providing CPR training to everyone is im- practical. Focusing on a targeted population is needed. OHCAs are more likely to be detected by laypersons in public place and family in private places [18]. Previous studies reported that family bystanders performed less bystander CPR, and the outcome was poorer than that of non-family bystanders [16,17]. Based on these, targeted intervention was introduced to provide CPR training for family members [31]. How- ever, even though nursing home residents are at high risk of cardiac ar- rest, no studies have been conducted on who detect cardiac arrest and who provide bystander CPR in nursing homes.

The strength of this study is that we investigated resuscitation process in nursing homes in detail according to the bystander type. Nursing homes are a type of residential place, but are unique in that medical and non-medical staff work in. In this study, only about 25% of OHCAs were detected by medical staff and 70% of OHCAs were detected by non-medical staff. Non-medical staff discovered most cardiac arrests, but they provided less bystander CPR than medical staff did. During the study period, both medical and non-medical staff increased the rate of performing CPR. This is consistent with the increase in the provision rate of bystander CPR in Korea after the DA-CPR program was imple- mented in 2013 [32]. However, the degree of increase was greater in the medical staff than non-medical staff. Although all nursing home staff are subject to mandatory CPR training in Korea, this study revealed that non-medical staff did not provide bystander CPR as often as medical staff did. When adjusting confounding factor in the logistic model and analysing only witnessed cases, similar results were observed. Even when they witnessed a cardiac arrest, the non-medical staff were half as likely as medical staff to perform bystander CPR. Family witnessed pro- vided the least bystander CPR and showed sharp decline of bystander CPR rate in 2018. It is difficult to know the reason such as because they did not receive bystander CPR training or lack of willingness, but both are possible. In addition, since the number of family witnesses is small, the annual variation is likely to be large. It should be interpreted carefully. Noteworthy is that although bystander CPR rates differed by type of bystander, no statistically significant difference was observed in PROSC and survival to discharge rate according to the bystander type. The dif- ference in patient outcome was also nonsignificant depending on whether bystander CPR was provided (Supplement Table 2). The result was different from the study that the family member provided less by- stander CPR and associated with poorer outcome [16,17]. In this study, the overall patient prognosis in nursing homes was very poor, with a rate of 3.9% prehospital ROSC and survival to discharge of 2.2%. A good neurological outcome was only 0.3%. For that reason, not only low pro- vision rate of bystander CPR, but also systemic problems such as low CPR quality or low AED utilization may exist. Since bystander CPR is an intervention that known to be associated with improved outcomes, even in nursing home residents, there is room for improvement first [9,11,33,34]. In addition, bundle intervention including increasing CPR quality and AED accessibility are required [35]. Even the elderly or nurs- ing home residents can achieve good neurological outcomes if appropri- ate resuscitation is provided [27,36]. Since trained responders could achieve better CPR outcomes than laypersons could, a nursing home with a fixed employee is a good training target [37]. Further, considering the risk of cardiac arrest and limited space, nursing homes are appropri- ate candidates for targeted public intervention [2,38]. In the context of increased cardiac arrest in nursing homes, increasing the accessibility of AED and CPR training for non-medical staff are the missing link for

improving outcomes of nursing home OHCA.

    1. Limitations

This study has several limitations. First, information on bystander CPR is limited. The bystander type was classified based on the

documentation of the EMS cardiac arrest registry. Since EMTs arriving at the scene directly ask the bystander and complete records, the possi- bility of misclassification is low. However, detailed information, such as previous CPR training experience, and Quality of CPR was unavailable. When “social resuscitation” is performed in a manner that is shown, the rate of bystander CPR increased, but the survival rate does not im- prove. These are not distinguished in this study. Second, as an observa- tional study, there is potential for confounding factors not considered in this study. Considering that Randomised controlled trials are impossible for this subject, we accepted the methodological limitations inherent to an observational study. Third, bystander defibrillation is another impor- tant factor in improving prognosis in nursing home OHCA patients [9,28]. The difference in bystander defibrillation according to the by- stander type could not be analysed because bystander defibrillation was provided only in 0.4% of patients in this study. Future studies are needed. Fourth, it is difficult to generalise the results of this study be- cause the ratio of medical staff and non-medical staff may differ accord- ing to the nursing home manpower regulations in other countries. However, since usually many non-medical staff work in nursing homes, the results of this study will inspire public health interventions in other countries. Fifth, the family-detected group with a small popula- tion has a wide confidence interval in multivariable logistic regression. The wide CI for OR are suggestive of insufficient power.

  1. Conclusions

Although three-quarters of OHCA cases are detected by non-medical personnel, less bystander CPR was provided when non-medical staff or family detected than medical staff detected. Bundle interventions in- cluding expanding deployment of AED and active CPR training for non-medical staff are needed to improve the outcome of cardiac arrest in nursing homes.

Funding

None.

Author Contributors

Drs. Lee (SY) and Lee (SH) had full access to all of the data in the study and take responsibility for the integrity of the data as well as the accuracy of the data analysis. Conceptualization; Lee (SY), Park, and Shin. Data curation; Lee (SY), Lee (SH). Formal analysis; Lee (SY), Lee (SH). Investigation; Lee (SY), Park, and Song. Methodology; Lee (SY), Park. Project administration; Lee (SY), Park, Song, and Shin. Supervision; Lee (SY), Park, and Song. Writing – original draft; Lee (SY), Lee (SH). Writing – review & editing: Lee (SY), Lee (SH). Man- uscript approval: All authors.

Declaration of Competing Interest

No authors have any other relationships/conditions/circumstances that present potential conflicts of interest.

Acknowledgements

We would like to acknowledge and thank the Korea Centers for Dis- ease Control and the Prevention for Out-of-Hospital Cardiac Arrest Sur- veillance, 2013 to 2018.

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi. org/10.1016/j.ajem.2021.03.021.

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