Victorian Ambulance Cardiac

Arrest Registry (VACAR)

Dr Karen Smith (PhD)

VACAR Chair

Manager Research and Evaluation Ambulance Victoria

Smith K, Bray J, Barnes V, Lodder M, Cameron P, Bernard S

and Currell A on behalf of the VACAR Steering Committee

Ambulance Victoria

• Provides EMS for state of Victoria (amalgamation of two services MAS and RAV in 2008) –pop of

5.4 million

• Operates a two-tiered emergency medical service (EMS) response for all suspected cardiac

arrests

– 2143 ALS paramedics who are authorised to provide defibrillation, laryngeal mask airway

insertion and intravenous administration of epinephrine.

– 416 intensive care paramedics are authorised to perform endotracheal intubation and

administer a range of additional cardiac drugs such as amiodarone and sodium

biacarbonate.

• Response to suspected cardiac arrests also includes fire first responders for inner Melbourne and

CERTS (29 teams) in rural areas

• Cardiac arrest protocols follow the recommendations of the Australian Resuscitation Council

• Patients with ROSC are transported to the nearest hospital with an emergency department.

VACAR

• Funded by Victorian Dept Health

• Classified as Quality Assurance

• Employs 5 staff including a Senior Research Fellow

• Overseen by Steering Committee including AV, Medical

Directors and Monash University

• Aims to collect data on all cardiac arrest patients

attended by ambulance in Victoria

• Data collection dates back to 1999

Value of Registry

• Benchmark patient outcomes and ambulance response intervals

• Describe the epidemiology of out-of-hospital cardiac arrest in Victoria

• Identify modifiable predictors of outcome and model impact of changes

• Assist in the analysis of the sensitivity and specificity of the ambulance dispatch protocol

• Aid in the audit of ambulance patient care record compliance and quality assurance (provide feedback to teams)

• Monitor trends and impact of new treatment regimes and programs

• Base-line for clinical trials

• Aid in monitoring paramedic treatment experience.

Registry

Cases identified

• via data filter, manual PCR sort, Team Managers and clinical

audits

Registry

• Based on Utstein template and definitions

• Extracts clinical and operational data from PCRs (AV and Fire) and

operational databases

• Supplemented with hospital discharge data (date, direction,

diagnosis) (Ethics approvals from > 100 participating hospitals)

• Data entry lags 2-3 weeks post event

• Some coroners data (aetiology) included for discrete projects

Quality of Life

• VACAR has commenced a QOL follow-up on adult patients arresting

from Jan 2010 onwards

• Follow-up at 12-months post arrest

• Death registry checked prior to contact

• Built into ongoing DH funding

• Tools:

• Residential and work status question

• GOSE

• EQ5D

• SF-12

• Discharged patients sent a letter explaining intended follow-up

• Phoned – approx 30 minute interview

• Outsourced to Monash University- experience and align with VSTR

• For Jan- Mar 2010: QOL obtained for 84% of discharged adult

patients who are alive at 12-months

Quality Control

• Mandatory fields

• Validation of field combinations

• Range validations

• Rhythm confirmation from ECG

• Monthly retrospective audit (10% cases-random)

• Targeted retrospective reviews

• Senior paramedics audit all cases for:

• Defibrillated patients

• Death in AV care

Data Reasonably Complete

All cardiac arrests attended by AV 2000-2009 (n=46,388)

Key field Missing items (%)

Age 1939 (4.2%)

Gender 373 (0.8%)

Arrest location type 4

Witnessed status 600 (1.3%)

Bystander CPR 2719 (5.9%)

Outcome at scene 49 (0.1%)

Hospital discharge status 592 (1.3%)

EMS response time 1352 (2.9%)

Presenting rhythm 169 (0.4%)

Epidemiology

All arrests attended by AV over 10 years (2000-2009)

Item Number (%)

Total patients 46,399 (range 3,779 – 5,259 per year)

Presumed cardiac aetiology 33847 (73.0%)

Witnessed

By public

By paramedics

13,641 (29.4%)

3,065 (6.6%)

Male Gender 30,353 (65.6%)

Adult arrests (>15 years) 45,520 (98.1%)

Median age (IQR) 70 years (28)

Arrest at home 34, 125 (73.6%)

Resuscitation initiated by EMS 19,911 (42.9%)

EMS response time (call to scene):

Median

90th percentile

8

16

Metropolitan location 34335 (74%)

Precipitating event

Proportion with resuscitation attempted by EMS (adult patients)

Cardiac

Trauma

Respiratory

Overdose

Drowning

Hanging

Other

Age cohorts (all OHCA 2000-2010)

Series1, <2 years, 1.0% Series1, 3-17 years,

1.0%

Series1, 18-39 years, 11%

Series1, 40-59 years, 20%

Series1, 60-79 years, 38%

Series1, >80 years, 26%

Series1, Missing, 3%

Arrest Location (all OHCA 2000-2010)

Series1, Home , 73%

Series1, Public place, 16%

Series1, Nursing home /hostel, 7%

Series1, Work, 2% Series1, Medical

center, 2%

Survival influenced by usual predictors

Odds ratio P value 95% CI

VF/VT 5.76 <0.001 4.83 – 6.87

Witnessed 2.03 <0.001 1.70 – 2.43

Bystander CPR 1.34 <0.001 1.16 – 1.56

Female 1.20 0.028 1.02 – 1.42

Year of arrest 1.12 <0.001 1.09 – 1.15

Age 0.98 <0.001 0.97 – 0.98

EMS response time 0.90 <0.001 0.88 – 0.92

Arrest at home 0.62 <0.001 0.54 – 0.72

Adult, presumed cardiac, resuscitation attempted by EMS (n= 11,829)

Excludes EMS witnessed

Survival (adult all aetiologies)

Increased survival over the decade

Adult, presumed cardiac, resuscitation attempted by EMS

•Metro survival increased from 7% in 2000 to 13% in 2009, p<0.001

•Rural survival increased from 6% in 2000 to 7% in 2009

Survival increase predominantly in VF/VT patients

Adult, presumed cardiac, VF/VT, resuscitation attempted by EMS

•Metro survival increased from 14% in 2000 to 34% in 2009, p<0.001

VACAR Research

Epidemiology

• All patients1

• Traumatic 2

• Urban/rural3

• Age cohorts (paediatric4, young adult (inc

coroners findings), elderly5)

• Nursing homes, terminally ill

• EMS witnessed

• Paediatric hangings6

• Asystolic cardiac arrests7

Clinical Trials

• Therapeutic hypothermia by paramedics

following resuscitation from VF: RCT8

• Autopulse in rural areas

• The Rinse Trial. The Rapid Infusion of

Normal cold SalinE by paramedics during

CPR. NHMRC $678k

• AVOID- RCT on oxygen in STEMI

Treatment / programs

• Dispatcher CPR

• 2005 guidelines

• Fire First Responders9,10

• Sensitivity of AMPDS11

• Impact of hospitals (ICS)

• Impact of post ROSC BP

Environmental

• Impact of air pollution on OHCA incidence12

1. Fridman et al Resuscitation 2007

2. Ashour et al Emerg Med J 2007

3. Jennings et al MJA 2006

4. Deasy et al Resuscitation 2010

5. Deasy et al ResuscittaionJ2011

6. Deasy et al Emerg Med J In press

7. Meyer et al Emerg Med 2001

8. Bernard et al Circulation 2010

9. Smith et al Resuscitation2001

10. Smith et al MJA 2002

11. Flynn et al Prehosp Disaster Med 2006

12. Dennekamp et al Epidemiology 2010

Conclusion

• VACAR is one of the largest cardiac arrest registries in

the world (currently n>53,000).

• Data is collected from a single state-wide ambulance

service (two services prior to 2008) which reduces

heterogeneity.

• Despite increasing response times, significant

improvements in survival have been observed in the

metropolitan area of Victoria.

• Used to benchmark AV and monitor quality of care

• Currently a significant body of research using VACAR

data

Acknowledgements

• Acknowledge the VACAR team –

Janet Bray

Marian Lodder

Vanessa Barnes

Resmi Nair

Devina Vaughan

Karen.smith@ambulance.vic.gov.au