cardiac arrest and cardiopulmonary resuscitation … · please cite this article in press as:...

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ARTICLE IN PRESSG ModelESUS 6188 1–12

Resuscitation xxx (2014) xxx–xxx

Contents lists available at ScienceDirect

Resuscitation

j ourna l h o me pa g e : www.elsev ier .com/ locate / resusc i ta t ion

ardiac arrest and cardiopulmonary resuscitation outcome reports:pdate of the Utstein resuscitation registry templates forut-of-hospital cardiac arrest

Statement for Healthcare Professionals From a Task Force of thenternational Liaison Committee on Resuscitation (American Heartssociation, European Resuscitation Council, Australian and Newealand Council on Resuscitation, Heart and Stroke Foundation ofanada, InterAmerican Heart Foundation, Resuscitation Council ofouthern Africa, Resuscitation Council of Asia); and the Americaneart Association Emergency Cardiovascular Care Committee and theouncil on Cardiopulmonary, Critical Care, Perioperative andesuscitation1�

avin D. Perkins ∗, Ian G. Jacobs2,3, Vinay M. Nadkarni, Robert A. Berg, Farhan Bhanji,ominique Biarent, Leo L. Bossaert, Stephen J. Brett, Douglas Chamberlain,llan R. de Caen, Charles D. Deakin, Judith C. Finn, Jan-Thorsten Gräsner,ary Fran Hazinski, Taku Iwami, Rudolph W. Koster, Swee Han Lim,atthew Huei-Ming Ma, Bryan F. McNally, Peter T. Morley, Laurie J. Morrison,

oenraad G. Monsieurs, William Montgomery, Graham Nichol, Kazuo Okada,arcus Eng Hock Ong, Andrew H. Travers, Jerry P. Nolan, for the Utstein Collaborators

arwick Medical School Clinical T, University of Warwick, Coventry CV4 7AL, United Kingdom

r t i c l e i n f o

eywords:ardiac arrestardiopulmonary resuscitation outcomeeports: Update of the Utstein resuscitationegistry templates

a b s t r a c t

Utstein-style guidelines contribute to improved public health internationally by providing a structuredframework with which to compare emergency medical services systems. Advances in resuscitation sci-ence, new insights into important predictors of outcome from out-of-hospital cardiac arrest, and lessonslearned from methodological research prompted this review and update of the 2004 Utstein guide-
lines. Representatives of the International Liaison Committee on Resuscitation developed an updatedUtstein reporting framework iteratively by meeting face to face, by teleconference, and by Web sur-vey during 2012 through 2014. Herein are recommendations for reporting out-of-hospital cardiac
Please cite this article in press as: Perkins GD, et al. Cardiac arrest and cardiopulmonary resuscitation outcome reports: Update of theUtstein resuscitation registry templates for out-of-hospital cardiac arrest. A Statement for Healthcare Professionals From a Task Forceof the International Liaison Committee on Resuscitation. . . . Resuscitation (2014), http://dx.doi.org/10.1016/j.resuscitation.2014.11.002

arrest. Data elements were grouped by system factors, dispatch/recognition, patient variables, resus-citation/postresuscitation processes, and outcomes. Elements were classified as core or supplementalusing a modified Delphi process primarily based on respondents’ assessment of the evidence-basedimportance of capturing those elements, tempered by the challenges to collect them. New or modified

� A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2014.11.002.∗ Corresponding author.

E-mail address: [email protected] (G.D. Perkins).1 See Appendix A.2 Deceased.3 We dedicate this publication to the late Dr. Ian Jacobs, who led ILCOR with passion and vision through to October 19, 2014.

ttp://dx.doi.org/10.1016/j.resuscitation.2014.11.002300-9572/© 2014 Elsevier Ireland Ltd. All rights reserved.

dx.doi.org/10.1016/j.resuscitation.2014.11.002


http://www.sciencedirect.com/science/journal/03009572

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http://dx.doi.org/10.1016/j.resuscitation.2014.11.002

mailto:[email protected]


ARTICLE IN PRESSG ModelRESUS 6188 1–12

2 G.D. Perkins et al. / Resuscitation xxx (2014) xxx–xxx

elements reflected consensus on the need to account for emergency medical services system fac-tors, increasing availability of automated external defibrillators, data collection processes, epidemiologytrends, increasing use of dispatcher-assisted cardiopulmonary resuscitation, emerging field treatments,postresuscitation care, prognostication tools, and trends in organ recovery. A standard reporting tem-plate is recommended to promote standardized reporting. This template facilitates reporting of thebystander-witnessed, shockable rhythm as a measure of emergency medical services system efficacyand all emergency medical services system – treated arrests as a measure of system effectiveness. Sev-eral additional important subgroups are identified that enable an estimate of the specific contribution ofrhythm and bystander actions that are key determinants of outcome.

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. Introduction

The term “Utstein style” is synonymous with consensus report-ng guidelines for resuscitation. It originated from an international

ultidisciplinary meeting held at the Utstein Abbey near Sta-anger, Norway, in June 1990.1 The purpose of this inauguraleeting was to develop, by consensus, uniform terms and defini-

ions for out-of-hospital resuscitation. It was anticipated that thisould lead to a better understanding of the epidemiology of car-iac arrest, facilitate inter- and intrasystem comparisons, enableomparison of the benefits of different system approaches, act as

driver to quality improvement, identify gaps in knowledge, andupport clinical research.2,3 The widespread implementation ofhese recommendations has encouraged the development of othertstein-like consensus guidelines addressing pediatric advanced

ife support,4 laboratory research,5 in-hospital resuscitation,6

ducation,7 drowning,8 postresuscitation care,9 and emergencyedical dispatch.10

The original Utstein definitions were revised in 2004 with theim of reducing complexity and updating data elements basedn advances in resuscitation science.11 The original Utstein rec-mmendations focused efforts to report on patients with a non

emergency medical services (EMS)-witnessed cardiac arrest ofresumed cardiac cause, with ventricular fibrillation at the pointf first rhythm analysis. The Utstein 2004 revision broadened thisocus to include all EMS12-treated cardiac arrests irrespective ofrst monitored rhythm and whether or not the arrests were wit-essed. Other major changes in 2004 related to the definitionf cardiac arrest (transition from presence/absence of a carotidulse to signs of circulation), inclusion of defibrillation attemptsy bystanders, and extension of the template to include reportingf in-hospital cardiac arrest in both adults and children in the sameemplate.

Since the 2004 update, there has been a substantial increase inhe number and scope of resuscitation registries and clinical trialroups with major national and regional registries established inhe United States,13,14 Europe,15 Asia,16 Australia,17 and Japan.18

ata from such registries are being used increasingly to com-are the epidemiology and outcome of cardiac arrest,19 explorehe relation between key treatments and outcome,20,21 identifynd prioritize gaps in resuscitation science knowledge, and driveuality improvement.22,23 With this background, in 2013, the Inter-ational Liaison Committee on Resuscitation (ILCOR) proposed aroup forum to review and, if necessary, update the Utstein tem-lates for cardiac arrest. This article reports the results of thateview with recommendations for further refinement of the Utsteineporting guidelines and reporting templates and a specific focusn out-of-hospital cardiac arrest (OHCA). Because of substantial

Please cite this article in press as: Perkins GD, et al. Cardiac arrest andUtstein resuscitation registry templates for out-of-hospital cardiac arof the International Liaison Committee on Resuscitation. . . . Resuscitat

ifferences between in-hospital and out-of-hospital epidemiology,rocess of care, and treatments, a decision was made once moreo use separate reporting templates. Thus, this article focuses onHCA, and a subsequent article will focus on recommendations

© 2014 Elsevier Ireland Ltd. All rights reserved.

for in-hospital cardiac arrest (IHCA) process of care and outcomereporting.

2. Current uses and applications

A review of articles citing the 2004 Utstein manuscript (Scopus,Elsevier, Amsterdam, The Netherlands: March 2014) identified 584citations. These originated from 50 countries; most citations (493[84%]) were classified as research articles. One third of the cita-tions focused on epidemiology and outcome (OHCA, n = 126 [22%];IHCA, n = 41 [7%]); and specialized populations (e.g., drowning, chil-dren), n = 43 (7%). Another third focused on links in the Chain ofSurvival (early access, including dispatcher, n = 19 [3%]; cardiopul-monary resuscitation [CPR], n = 43 [7%], and defibrillation, n = 31[5%]; advanced life support, including drugs, n = 19 [3%]; airway,n = 7 [1%]; and postresuscitation care, n = 63 [11%]). The remainingarticles examined elements related to outcome and prognostication(n = 76 [13%]); described registries/registry methodology (n = 14[2%]), quality improvement (n = 33 [6%]), or primary research (n = 44[8%]); were review articles (n = 22 [4%]); or addressed other factors(n = 3 [0.5%]).

Despite substantial application to a variety of clinical andresearch projects, a recent evaluation of 13 registries enrollingpatients with OHCA in 13 countries noted variation in inclusioncriteria, definition, coding, and process-of-care elements.12 Over-all, the registries collected only two thirds of the recommended2004 core elements. Recommended timed event elements werecollected for 43% of events. Thus, the current proposed iteration ofthe revised Utstein templates attempts to balance (1) the desirabil-ity of uniform collection of evidence-based factors associated withoutcome and (2) the practical challenges of real-life data collectionand validation.

3. What have we learned about the Utstein elements forcardiac arrest?

Several core elements have consistently been associated withsurvival to hospital discharge: witnessed arrest (by a bystander orEMS); bystander CPR; shorter EMS response interval; first shock-able rhythm; and return of spontaneous circulation (ROSC) in thefield.24–27 However, it has become evident that the Utstein coreelements incompletely explain the variability in OHCA survivalacross populations,25–27 even allowing for the declining incidenceof ventricular fibrillation in OHCA.28,29 Since the last iteration ofthe Utstein style,11 there has been increased recognition of theimportance of additional factors associated with the likelihoodof survival after OHCA, such as public access defibrillation,24,30

dispatcher-assisted CPR,31 the quality of CPR,32,33 postresuscita-

cardiopulmonary resuscitation outcome reports: Update of therest. A Statement for Healthcare Professionals From a Task Forceion (2014), http://dx.doi.org/10.1016/j.resuscitation.2014.11.002

tion care,34–36 variability in “not for resuscitation” order policiesand procedures,37 and accurate prognostication,38 In addition therehas been changing trends in organ recovery and transplantation.39

Short-term outcomes such as ROSC and survival to hospital

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ischarge (the latter being susceptible to local health system prac-ices) do not take into account patients’ health-related quality ofife.40,41 Given the advances in understanding of the prognosticeterminants of survival in OHCA, the need to revisit and updatehe 2004 Utstein guidelines was evident.11

. Methods

The Utstein collaborator group met face to face on two occasionso discuss the revisions to the Utstein reporting template. The first

eeting was in Vienna in October 2012 and was linked to the Euro-ean Resuscitation Council Scientific Congress. The second meetingollowed the ILCOR 2013 Task Force meeting in Melbourne in April013. During these meetings the strengths and weaknesses of therevious Utstein consensus articles for cardiac arrest11,42,43 wereeviewed, and opportunities to update and improve them wereiscussed.

Consensus was reached for several overarching principles. Afterepeated attempts to address key issues related to OHCA and IHCAn the same template, it became apparent that separate reportingemplates would facilitate end-user acceptance and use of updatedeporting templates. Consistency was sought in data elements andefinitions between IHCA and OHCA unless there was a strongationale for deviation. Core elements were defined as elementshat all registries should aim to capture and report. The decisiono assign an element as core was based on the evidence-basedmportance of capturing that element, tempered by the practicalhallenges of real-life data collection and validation. Collection anderification of core elements was considered the minimum rec-


mmended standard for quality assurance/improvement purposes.upplemental elements were defined as elements that were desir-ble but not essential to capture and report, including elementsore relevant to research than quality assurance.

ig. 1. Data element domains. Core and supplemental elements are shown for each of tPR, cardiopulmonary resuscitation; DNAR, do not attempt resuscitation; ECG, electrocarump; ROSC, return of spontaneous circulation; and STEMI, ST-segment elevation myoca

PRESSion xxx (2014) xxx–xxx 3

Breakout groups considered core and supplemental data ele-ments under the domains of system factors, dispatch/recognition,patient variables, resuscitation and postresuscitation processes,and outcomes. After the Melbourne meeting, a 2-stage Delphiprocess was conducted to refine the recommendations for coreand supplemental elements. During stage 1, the output from thebreakout groups was presented to the wider collaborator group.Agreement for core and supplemental element designations wassought using a 5-point Likert scale. Participants were also able tosubmit additional elements for consideration. New elements, orelements for which there was less than 85% agreement on desig-nation as core or supplemental, were submitted to a second roundof voting. There was greater than 85% agreement for designationsfor all elements by the end of the second round, so further roundswere not required.

Data definitions were based where possible on current 2004Utstein definitions. New element definitions were proposed by thewriting group and circulated to the collaborator group for vetting.

The writing group, on behalf of collaborators, summarized theoutput from this process in a draft of the manuscript that was cir-culated and discussed electronically with the Utstein collaborators.This led to further development of the Utstein reporting templateand classification of etiology. The final manuscript was approvedby the coauthors and ILCOR.

5. Results

5.1. OHCA Utstein definitions


The Utstein elements were grouped into five domains (Fig. 1).Each domain contained core and supplemental elements that aredescribed in Table 1.

he 5 domains. AED indicates automated external defibrillator; BP, blood pressure;diogram; ECMO, extracorporeal membrane oxygenation; IABP, intra-aortic balloonrdial infarction.

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Table 1Utstein data definitions.

Utstein OHCA elements Consensus definition 2014 Data options

Population serveda Total population of service area of EMS system Number of casesNumber of cardiac arrests attendeda Number of cardiac arrests attended (arrests defined by

absence of signs of circulation)Number of cases

Resuscitation attempted When EMS personnel perform chest compressions orattempt defibrillation, it is recorded as a resuscitationattempt by EMS personnel

Number of cases

Resuscitation not attempted Total number of cardiac arrests in which resuscitation wasnot attempted and the number of those arrests notattempted because a written DNACPR order was present orvictim was obviously dead or signs of circulation werepresent

Total number of cases, number with DNAR,number considered futile, number with signsof circulation, number unknown

System descriptiona A description of the organizational structure of the EMSservice being provided. This should encompass the levelsof service delivery, annual case numbers, and size ofgeographic region covered.

Number and type of EMS tier; providers’ skillset; number of EMS calls, excludinginterfacility transfers; population served basedon census data; footprint served in squarekilometers or square miles

System description (supplemental)a System information: Free text description defining (A) thepresence or existence of legislation that mandates noresuscitation should be started by EMS or health servicesin specific circumstances or clinical cohorts of patients; (B)systems for limiting/terminating prehospital resuscitation;(C) termination of resuscitation rules; (D) whetherdispatch software is used (and type, version); (E)resuscitation algorithms followed (e.g., AHA, ERC, any localvariations, CPR or shock first, compression-only CPRinitially/compressions and ventilations). (F) Describe anyformalized data quality activities in place. (G) Describeprehospital ECG capability: if EMS system has ability toperform and interpret (or have interpreted via telemetry)12-lead ECGs in the field.

Free text

Dispatcher identified presence ofcardiac arresta

Did the dispatcher identify the presence of cardiac arrestbefore arrival of EMS?

Yes/No/Unknown/Not recorded

Dispatcher provided CPR instructionsa Did the dispatcher provide telephone CPR instructions tothe caller?


Age If the victim’s date of birth is known, it should be recordedin an acceptable format. If the date of birth is not knownbut the victim’s age is known, age should be recorded. Ifthe victim’s age is not known, age should be estimated andrecorded.

3 Digits (state units – years, months, or days)Indicate if Estimated/Unknown/Not recorded.Specify if reported average ages include orexclude estimated ages.

Gender Sex Male/Female/Unknown/Not recordedWitnessed arrest A cardiac arrest that is seen or heard by another person or

is monitored. EMS personnel respond to a medicalemergency in an official capacity as part of an organizedmedical response team. Bystanders are all other groups. Bythis definition, physicians, nurses, or paramedics whowitness a cardiac arrest and initiate CPR but are not part ofthe organized rescue team are characterized as bystanders,and the arrest is not described as EMS witnessed.

Bystander witnessed/EMSwitnessed/Unwitnessed/Unknown

Arrest location The specific location where the event occurred or thepatient was found. Knowledge of where cardiac arrestsoccur may help a community to determine how it canoptimize its resources to reduce response intervals. A basiclist of predefined locations will facilitate comparisons.Local factors may make creation of subcategories useful.

Home/residence; Industrial/workplace;Sports/recreation event; Street/highway;Public building; Assisted living/nursing home;Educational institution; Other;Unspecified/Unknown/Not recorded

Bystanderresponse

Bystander CPR is cardiopulmonary resuscitationperformed by a person who is not responding as part of anorganized emergency response system to a cardiac arrest.Physicians, nurses, and paramedics may be described asperforming bystander CPR if they are not part of theemergency response system involved in the victim’sresuscitation. Bystander CPR may be compression only orcompression with ventilations (the act of inflating thepatient’s lungs by rescue breathing with or without abag-mask device or any other mechanical device).

Bystander CPR (subset: compression only,compression and ventilations)/No bystanderCPR/Unknown/Not recorded

Bystander AED use AED used, shock delivered/AED used, no shockdelivered/AED not used/Unknown/Notrecorded

First monitored rhythm The first cardiac rhythm present when the monitor ordefibrillator is attached to the patient after a cardiac arrest.

VF/PulselessVT/PEA/Asystole/Bradycardia/Unknown/Notrecorded

Etiology Etiology is reported as Medical (Presumed cardiac orunknown, other medical etiologies); Traumatic cause;Drug overdose; Drowning; Electrocution; Asphyxial(external cause).

Medical (Presumed cardiac or unknown, othermedical etiologies)/Traumatic cause/Drugoverdose/Drowning/Electrocution/Asphyxial(external cause)/Not recorded




G.D. Perkins et al. / Resuscitation xxx (2014) xxx–xxx 5

Table 1 (Continued)


Medical (presumed cardiac or unknown, other medicaletiologies): Includes cases where the cause of the cardiacarrest is presumed to be cardiac, other medical (e.g.,anaphylaxis, asthma, GI bleed), and where there is noobvious cause of the cardiac arrestTraumatic: Cardiac arrest directly caused by blunt,penetrating, or burn injuryDrug overdose: Evidence that the cardiac arrest wascaused by deliberate or accidental overdose of prescribedmedications, recreational drugs, or ethanolDrowning: Victim is found submersed in water without analternative causationElectrocutionAsphyxial: External causes of asphyxia, such asforeign-body airway obstruction, hanging, or strangulation

Independent livinga Before the cardiac arrest, the patient was able to performall activities of daily living without the assistance ofcaregivers.


Comorbiditiesa The patient has a documented history of other diseaseconditions that existed before the cardiac arrest.


VAD The patient is supported by any form of VAD to augmentcardiac output and coronary perfusion.


Cardioverter-defibrillatora The patient has an internal or externalcardioverter-defibrillator.

Internal/External/No/Unknown/Not recorded

Presence of STEMIa At the time of the first 12-lead ECG performed after ROSC,the presence of STEMI is observed.


Response times The time interval from incoming call to the time the firstemergency response vehicle stops at a point closest to thepatient’s location. The time of the incoming call is when itis first registered at the center answering emergency calls,regardless of when the call is answered.

mm:ss/Unknown/Not recorded

Defibrillation time The time interval from incoming call to the time the firstshock is delivered


TTCa The time and setting where TTC was initiated Intra-arrest/Post-ROSC prehospital/Post-ROSCin-hospital,/TTC indicated but not done/TTCnot indicated/Unknown/Not recordedSupplemental: If TTC used, what was targettemperature (data options: TemperatureC/Unknown/Not recorded)?

Drugs given The term drugs refers to delivery of any medication (by IVcannula, IO needle, or tracheal tube) during theresuscitation event.

Adrenaline/Amiodarone/Vasopressin/Nonegiven/Unknown/Not recorded

Airway control (type) Prehospital airway control: During the resuscitation, whatwas the main airway device used?

None used/Oropharyngeal airway/Supraglotticairway/Endotracheal tube/Surgicalairway/Multiple/Unknown/Not recorded

CPR qualitya During the resuscitation, were there mechanisms orprocesses in place to measure the quality of CPR beingdelivered?


Number of shocks The number of shocks delivered (including shocksdelivered by public access defibrillators)

Number/Unknown/Not recorded

Drug timings The time interval from incoming call to the time vascularaccess is obtained and the first drug is given


Vascular access (type)* The main route through which drugs were administeredduring the arrest

Central line/PeripheralIV/IO/Endotracheal/Unknown/Not recorded

Mechanical CPRa At any time during the resuscitation was a mechanical CPRdevice deployed?

Mechanical compression-decompressiondevice/Load distributing band/Othermechanical device/Unknown/Not recorded

Targeted oxygenation/ventilationa After ROSC, was targeted ventilation applied? O2 and CO2/O2 only/CO2 only/Notused/Unknown/Not recorded. If this variable isreported, include details of specific targets insystem description.

Reperfusion attempteda Was coronary reperfusion attempted? Type: Angiographyonly/PCI/Thrombolysis/None/Unknown/NotrecordedTiming: Intra-arrest/Within 24 h ofROSC/>24 h but beforedischarge/Unknown/Not recorded

ECLSa When was ECLS used? Before ROSC/After ROSC/Notused/Unknown/Not recorded

IABPa Was an IABP used? Yes/No/Unknown/Not recordedpHa What was the first pH recorded after ROSC? pH value/Unknown/Not recordedLactatea What was the first lactate recorded after ROSC? Lactate value mmol L-1/Unknown/Not

recordedGlucosea After ROSC, was glucose titrated to a specific target? Yes/No/Unknown/Not recorded




Table 1 (Continued)


Number and type of neuroprognostictestsa

Number and type of neuroprognostic tests used SSEP—Yes/No/Unknown/Not recordedNSE—Yes/No/Unknown/Not recordedEEG—Yes/No/Unknown/Not recordedCT of brain—Yes/No/Unknown/Not recordedMRI of brain—Yes/No/Unknown/Not recordedClinical examination—Yes/No/Unknown/NotrecordedOther (define)—Yes/No/Unknown/NotrecordedIndicate timing of test and whether test led todiscontinuation of treatment.

Hospital typea Was the patient’s primary transfer to a healthcare facilityable to perform all forms of peri- and postarrest care andallocated this role by the area of administration?

Specialist center/Nonspecialistcenter/Unknown/Not recorded

Hospital volumea How many cases of OHCA does the hospital treat eachyear?

Number of cases per year

12-Lead ECGa Was a 12-lead ECG performed after ROSC? Yes/No/Unknown/Not recordedTargeted blood pressure managementa What target blood pressure was used? mm Hg/No target set/Unknown/Not recordedSurvived event ROSC sustained until arrival at the emergency department

and transfer of care to medical staff at the receivinghospital


Any ROSC Did the patient achieve a ROSC at any point during theresuscitation attempt?


30-days survival or survival todischarge

Was the patient alive at the point of hospital discharge/30days?


Neurologic outcome at hospitaldischarge

Record CPC and/or mRS or pediatric equivalent at hospitaldischarge. Include a definition of how it was measured(face to face, extracted from notes, combination).

CPC score (1-5)/Unknown/Not recorded mRS(0-6)/Unknown/Not recorded

Survival status The patient is alive at 12 months after cardiac arrest. Yes/No/Unknown/Not recordedTransported to hospitala Was the patient transported to the hospital? Yes/No/Unknown/Not recordedTreatment withdrawn (includingtiming)a

A decision to withdraw active treatment was made. Recordthe time that this occurred after ROSC.

Yes/No/Unknown/Not recorded Days/hours

Cause of deatha Cause of death as officially recorded in the patient’smedical records or death certificate

Organ donationa The number of patients who had 1 or more solid organsdonated for transplantation

Number of cases/Unknown/Not recorded

Patient-reported outcome measures(outcomes selected by patients asbeing important)a

Patient-focused health outcomes were assessed. Free text

Quality-of-life measurements(standardized questionnaires, e.g.,EQ-5D, SF-12)a

A validated quality-of-life measure was used to assesshealth quality of life.

Yes/No/UnknownList quality-of-life instrument(s) used andoutcomes/scores.

a New variables.Data definitions have been categorized as core and supplemental. Data definitions have mostly been updated. Registries and researchers may wish to check against theircurrent definitions.AED indicates automated external defibrillator; AHA, American Heart Association; CPC, Cerebral Performance Category; CPR, cardiopulmonary resuscitation; CT, computedtomography; DNACPR, do not attempt cardiopulmonary resuscitation; DNAR, do not attempt resuscitation; ECG, electrocardiogram; ECLS, extracorporeal life support; EEG,electroencephalogram; EMS, emergency medical services; ERC, European Resuscitation Council; GI, gastrointestinal; IABP, intra-aortic balloon pump; IO, intraosseous; IV,intravenous; MRI, magnetic resonance imaging; mRS, modified Rankin Scale; NSE, neuron-specific enolase; OHCA, out-of-hospital cardiac arrest; PCI, percutaneous coronaryintervention; PEA, pulseless electrical activity; ROSC, return of spontaneous circulation; SSEP, somatosensory evoked potentials; STEMI, ST-segment elevation myocardiali ntricu

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nfarction; TTC, targeted temperature control; VAD, ventricular assist device; VF, ve

.1.1. System descriptionThe system description defines the characteristics of the pop-

lation served and the structure of the EMS response. It includeshe number of cases of cardiac arrest attended by EMS (cardiacrrest is defined by the absence of signs of circulation irrespectivef whether the assessment was made by EMS or bystander), theumber of cases for which resuscitation was attempted by EMS,nd the reasons why resuscitation was not attempted. A resuscita-ion attempt is defined as the act of trying to maintain or restoreife by establishing and/or maintaining breathing and circulationhrough CPR, defibrillation, and other related emergency care). Atructured system description has been added to improve consis-ency when describing the components of the healthcare systemesponsible for responding to OHCA.


.1.2. DispatchDispatcher-identified cardiac arrest and dispatcher-assisted

PR have been included as core elements to reflect the impact these

lar fibrillation; and VT, ventricular tachycardia.

processes can have on patient outcome.44,45 The system descriptionprovides the opportunity to describe operation of the local EMS dis-patch. Researchers and clinical service directors who wish to recordadditional information (e.g., dispatcher diagnostic code, bystanderresponse) are directed to a consensus paper on dispatcher assis-tance for OHCA.46

5.1.3. Patient variablesPatient variables include patient demographics, comorbidities,

etiology, initial presentation, and bystander response. The locationof the arrest and whether it was witnessed should be recorded.

The designation of etiology was one of the most contentiousareas discussed during this revision. The Utstein process has for


decades tried to separate cardiac (or presumed cardiac) from non-cardiac (or presumed noncardiac). The original intention was tocreate case equivalency; however, separation into cardiac and non-cardiac has proved to be subjective,47,48 with some communities

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eporting noncardiac percentages of all arrests as several percentnd others up to 40%.49,50

Given this variation, we suggest that the primary reportingy systems should state the outcomes of all EMS-treated car-iac arrests (measuring system effectiveness) and those that areystander witnessed and the first monitored rhythm is shockablemeasuring system efficacy). Registries and researchers should con-inue to record the etiology of cardiac arrest and report it as partf the overall description of EMS-treated cardiac arrests. Etiologyhould be categorized under the following headings which alsoecognize the importance of backward compatibility with existingefinitions: medical (presumed cardiac or unknown, other medicaltiologies); traumatic cause; drug overdose; drowning; electrocu-ion; asphyxial (external). Where more than one etiology is possiblee.g., ventricular fibrillation arrest leading to a fall from a height),he most likely primary cause should be cited (in this example,resumed cardiac). Table 1 provides further information about clas-ification into different etiological categories.

The first monitored rhythm is the rhythm recorded at the time ofrst analysis of the monitor or defibrillator after a cardiac arrest. Ifhe automated external defibrillator (AED) does not have a rhythmisplay, it may be possible to determine the first monitored rhythmrom a data storage card, hard drive, or other device used by theED to record data. If the AED has no data-recording device, the firstonitored rhythm should be classified simply as shockable or non-

hockable. This data point can be updated at a later time if the AEDas data download capability. Bradycardia has been retained as anption to enable appropriate reporting when chest compressionsre provided for severe bradycardia with pulses and poor perfu-ion (most commonly in children). When CPR is started becausef the absence of signs of circulation despite electrocardiographicvidence of electrical activity (i.e., pulseless electrical activity), ithould be recorded as pulseless electrical activity even if the elec-rocardiographic rhythm is slow. Asystole is defined by a periodf at least 6 s without any electrical activity of >0.2 mV (that couldepresent atrial complexes).

Bystander responses are critical to patient outcomes. All systemshould capture the number of cases in which bystander resuscita-ion is started (chest compressions or standard CPR), whether orot an AED is deployed, and whether or not it delivered a shock.

Supplemental information includes whether a patient was livingndependently before the arrest, comorbidities, and new treat-

ents (cardioverter-defibrillators, ventricular assist devices).

.1.4. Process elementsCore process elements include the EMS response time, time

o first shock, whether targeted temperature management wassed before or after ROSC, and whether coronary reperfusionas attempted. Twelve supplemental elements are included (six

lements related to treatments initiated out-of-hospital and sixlements related to treatments initiated in-hospital).

.1.5. OutcomeRecommendations on the documentation of survival outcomes

emain largely unchanged from the 2004 Utstein style. The coreeporting outcome for initial survival is “survived event” (whichs defined ROSC sustained until arrival at the emergency depart-

ent and transfer of care to medical staff at the receiving hospital).o ensure compatibility with historical datasets, any ROSC remains

core outcome. ROSC is defined following a clinical assessmenthowing signs of life comprising a palpable pulse or generating alood pressure. Assisted circulation (e.g., extracorporeal life sup-


ort, ventricular assist devices, or mechanical CPR) should not beonsidered ROSC until patient-generated circulation is established.or nonsurvivors, a supplemental element may be recorded to showhether any solid organs were recovered for transplantation.


Long-term survival can be reported as either survival to 30days or survival to hospital discharge according to the ease ofcollecting this information within each healthcare system. Survivalat 12 months should be reported when possible, but is consid-ered supplemental because of the challenge of such long-termfollow-up. Neurologic outcome may be reported using the CerebralPerformance Category (CPC),51 modified Rankin Scale (mRS),52 orequivalent pediatric tools.4 The CPC is a 5-point scale ranging from 1(good cerebral performance) to 5 (dead). The mRS is a 7-point scaleranging from 0 (no symptoms) to 6 (dead). We define survival withfavorable neurologic outcome as a CPC 1/2 or mRS 0–3 or no changein CPC or mRS from the patient’s baseline status. Patient-reportedoutcomes and health-related quality of life are included to reflectthe importance of the quality of recovery beyond simply survival.

5.2. Time points and intervals

Survival from cardiac arrest is related inversely to the intervalfrom collapse to definitive care.53,54 In this revised Utstein tem-plate, we have limited the core time point/interval elements toresponse-time and time to first defibrillation (Table 1). The timeof drug administration remains as a supplemental element. Theprevious Utstein documents recommended several additional coreand supplemental time points/intervals. Certain time points areimpossible to estimate (e.g., time of collapse in an unwitnessedarrest), many are not routinely collected (e.g., in OHCA, arrival atthe patient’s side), and others are unlikely to be recorded accurately(e.g., time of first compression, time vascular access achieved, timeof ROSC). It is recognized that additional time points/intervals maybe collected routinely by some agencies: this revised template is notintended to suggest that such data points are redundant. Moreover,the collection of additional elements may be required for specificresearch studies.55

The problem of lack of synchronization of clocks and other time-recording devices persists56–58 and can result in intervals beingreported inaccurately. The recommendation remains that 1 clock(or synchronization to a single clock) be used to determine all timesthroughout the resuscitation attempt.

5.3. Utstein reporting template

The purpose of the revised Utstein template is to provide aframework combining the core elements of resuscitation per-formance for OHCA, including the community response, EMStreatments, and hospital systems of care. In previous iterations ofthe Utstein template, the target user was primarily a resuscitationresearch scientist. In the 2014 Utstein template (Fig. 2), the authorsrecognized the need to widen the scope of the reporting template toencompass the needs of those involved in research, program eval-uation, and/or continuous quality improvement. The goal in 2014is to make the template intuitive to complete, effective in mappingthe patient’s journey through the local resuscitation system, and toenable knowledge sharing between resuscitation networks. To thisend, the template has been reengineered in the following ways:First, the template follows the natural flow of the patient throughcommunity, out-of-hospital, and in-hospital systems of care. It isexpected that this format will facilitate data collection. Second, thetemplate encompasses the core system structure, process, and out-come of care as well as performance measures similar to thoseused in other systems of models of care (e.g., ST-segment eleva-tion myocardial infarction, stroke, trauma).59 Third, the variousdata dictionary and data formats are embedded within the tem-


plate, enabling easier data entry by the user. Outcomes are definedat four levels: any ROSC, survived event, survived to discharge,and favorable neurologic outcome at discharge if known. Registriesmay report survival to 30 days as an alternative to survival to

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Fig. 2. Utstein standardized template for reporting outcomes from out-of-hospital cardiac arrest. AED indicates automated external defibrillator; ASYS, asystole; bCPR,bystander cardiopulmonary resuscitation; Brady, bradycardia; CA, cardiac arrest; CC, chest compressions; CPC, Cerebral Performance Category; CPR, cardiopulmonary resus-citation; DC; discharge; DNAR; do not attempt resuscitation; Educ, educational institution; EMS; emergency medical services; ID, identified; mRS, modified Rankin Scale;PEA, pulseless electrical activity; Rec, sports/recreation event; ROSC, return of spontaneous circulation; SD, standard deviation; Temp, temperature; Vent, ventilations; VF,ventricular fibrillation; and VT, ventricular tachycardia.


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Table 2Utstein checklist for standardized reporting.

Section Checklist item Yes/NoPage reported

Abstract Abstract includes the term“Utstein”

Methods System descriptionSetting and location where datawere collectedMethods used to identify cases,including any quality assuranceprocesses for completeness ofmeasuring case ascertainmentPopulation of patients beingreported (e.g., Utstein comparator,EMS-treated arrests, or otherpopulation)Systems used to obtain timed data,including any synchronizationbetween clocksDefinitions used for core andsupplemental elements are inconcordance with Utstein 2014style (or alternative definitions areidentified)Data source (e.g., registry) andwhether complete or partial datausedAppropriate EQUATOR tool used tosupport study reporting(http://www.equator-network.org/reporting-guidelines/)

Statistical analysis Analytical methods used to handlemissing data (e.g., complete caseanalysis, multiple imputation)

Results Time period from which data werecollectedUtstein comparator populationresultsEMS-treated population resultsProportion of missing data

Discussion Limitations, addresses sources ofpotential bias, imprecision, and, ifrelevant, multiplicity of analysesExternal validity of findingsInterpretation consistent withresults, balancing benefits andharms and considering otherrelevant evidence

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ischarge. The 2014 template allows reporting of the witnessedardiac arrest, who received bystander CPR and had a first recordedhythm that was shockable (which is recommended as a compara-or of system efficacy), and all EMS-treated cardiac arrests (which isecommended for system effectiveness comparisons). Outcomes ofeveral important subgroups are identified that allow an estimatef the specific contribution of rhythm and bystander actions thatre key determinants of outcome. This is particularly important formproving bystander CPR and outcome of the increasingly preva-ent nonshockable rhythms. Only with knowledge of these specificutcomes can differences between systems and improvement overime be understood. The template includes the capability to addther user-defined outcomes for specific purposes.

.4. Scope for improving Utstein-style reporting

Previous Utstein templates do not characterize the nature of therganized EMS response. EMS systems are commonly grouped asither 1- or 2-tier systems, depending on the number and skill ofroviders who respond. In some settings, multiple EMS agenciesover a region in a patchwork fashion, with variable geographicnd administrative overlap. Some municipal EMS systems use arivate EMS agency for nonurgent transportation. Other agenciesccasionally dispatch a paramedic supervisor to the scene. Mostxperts would not classify either of these as 3-tier services. Addi-ional details about how services are provided may yield additionalnsight into regional differences in process and outcome.

Some, but not all, cardiac arrest registries monitor routinely forompleteness of case capture. A comparison of patients not enrolledersus those enrolled in a registry designed to capture consecutiveatients with acute coronary syndrome found that 30% of eligibleatients were missing.60 The missing patients were at higher risk,eceived poorer quality of care, and had a higher mortality ratehan those who were included.60 A similar analysis of the Swedishardiac arrest registry reported that 25% of eligible cases wereissing.61 These missing cases tended to be older and less likely to

eceive bystander CPR but had significantly higher survival rates.uch selection bias limits the ability of registries to reliably assesspidemiology and the effectiveness of quality improvement initia-ives or other interventions.62 Each EMS agency participating inhe Resuscitation Outcomes Consortium (ROC) Epistry63 uses rou-ine monitoring and necessary corrections for completeness of caseapture. By consistently applying such monitoring, the estimatedncidence of EMS-treated OHCA in participating North AmericanOC sites has increased by more than 20% since the inception ofhe ROC Epistry.64,65 Organizers of cardiac arrest registries shouldmplement monitoring and remediation for completeness of caseapture.

There is variation in the magnitude and coding of missing dataetween registries. Missing data arise in most clinical studies andan bias inferences if data are not missing completely at random.66

n addition, some registries combine “not done” and “unknown”nto a single response. Organizers of registries should work toeduce unknown and missing data.

.5. Implementation

Since 1990, implementation, update, and simplification of ILCORtstein templates for cardiac arrest resuscitation audit, registry,nd research have improved transparency and comparability ofeports. Challenges lie ahead for future implementation, partic-larly in the balance of feasibility versus desirability of data


lements. Challenges with adherence to “not-for-resuscitation”ules, capture of actual measured quality of CPR parameters (e.g.,epth, rate, chest compression fraction, ventilation rate, perishockause intervals), and linkage of out-of-hospital and in-hospital

EMS indicates emergency medical services; and EQUATOR, Enhancing the Qualityand Transparency of Health Research.

interventions and outcomes persist. We have continued to iden-tify a few core elements that we think every system of care shouldcollect and report, as well as many supplemental elements thatwe think may be applicable to research-oriented systems, spe-cial resuscitation circumstances or processes, or EMS systems withadvanced capability to routinely capture information on CPR qual-ity. Recognition and focus on a core outcome comparator (i.e.,bystander-witnessed, shockable cardiac arrest) may offer a univer-sal comparator for all systems, as a tracer methodology for efficacyin all systems. Increased implementation of these updated consen-sus definitions and reporting templates will inform and improvefuture formulas for survival67 and enable meta-analysis and inclu-sion of larger numbers of patients in studies of cardiac arrest whereappropriate.

Just as the Consolidated Standards of Reporting Trials (CON-68


SORT) Statement is designed to assist reporting researchby using a checklist and flow diagram (http://www.consort-statement.org/consort-2010), the application of the Utstein tem-plate is intended to improve transparency and consistency of

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0 G.D. Perkins et al. / Resu

eports of cardiac arrest process of care and outcomes (Table 2).n addition to reporting Utstein elements, researchers shouldnsure that appropriate reporting guidelines relevant to the specifictudy design are followed (e.g., CONSORT Statement for clini-al trials; Strengthening the Reporting of Observational Studiesn Epidemiology [STROBE] statement for observational studieshttp://www.equator-network.org]).

. Conclusion

Utstein-style guidelines standardize reporting of the process ofare and outcomes for patients with cardiac arrest. By using theLCOR infrastructure, face-to-face meetings, and an Internet-based

odified Delphi approach, the 2004 OHCA Utstein reporting defi-itions and templates were updated for the five domains: system

actors, dispatch/recognition, patient variables, process variables,nd outcomes. New or modified elements reflect consensus onhe need to account for EMS system factors, increasing availabil-ty of AEDs, variability in the data collection process, trends inpidemiology, increasing use of dispatcher-assisted CPR, emerg-ng field treatments, postresuscitation care, prognostication tools,nd trends in organ recovery and transplantation.39 The consensuseporting template, which resembles a CONSORT diagram, facil-tates reporting of bystander-witnessed, shockable rhythm as a

easure of EMS system efficacy and all EMS-treated arrests as aeasure of system effectiveness. Several important subgroups are

dentified that allow an estimate of the specific contribution ofhythm and bystander actions that are key determinants of out-ome.

ontributions

The detailed contributions are summarized in the electronicupplemental material. In brief, GDP ran the Delphi surveys andrepared the first draft of the manuscript under the oversight of

GJ and VN. AHT and RWK developed and refined the reportingemplate. The draft manuscript and templates were revised afternput from a core writing group initially (VMN, AHT, J-TG, JCF,N, RAB, PTM, AHT, JPN). These outputs were then circulated andiscussed in detail with coauthors and collaborators who added

mportant intellectual content to the manuscript’s refinement. Thenal manuscript was approved by all authors and collaborators.

onflict of interest statement

The American Heart Association makes every effort to avoid anyctual or potential conflicts of interest that may arise as a resultf an outside relationship or a personal, professional, or businessnterest of a member of the writing panel. Specifically, all membersf the writing group are required to complete and submit a Dis-losure Questionnaire showing all such relationships that might beerceived as real or potential conflicts of interest.

This statement was approved by the American Heart Associationcience Advisory and Coordinating Committee on September 18,014.

cknowledgments

Along with the writing group, the Utstein Collaborators includeichard P. Aikin, Bernd W. Böttiger, Clifton W. Callaway, Maaret K.


astren, Mickey S. Eisenberg, Monica E. Kleinman, David A. Kloeck,alter G. Kloeck, Mary E. Mancini, Robert W. Neumar, Joseph P.

rnato, Edison F. Paiva, Mary Ann Peberdy, Jasmeet Soar, Thomasea, Alfredo F. Sierra, David Stanton, and David A. Zideman.

PRESSion xxx (2014) xxx–xxx

We acknowledge the giants whose shoulders we stand on: Pet-ter Steen, Richard Cummins, the late Max Harry Weil, and the latePeter Safar.

Appendix A. Supplementary data

Supplementary data associated with this article can befound, in the online version, at http://dx.doi.org/10.1016/j.resuscitation.2014.11.002.

Appendix C. Appendix A

The American Heart Association makes every effort to avoid anyactual or potential conflicts of interest that may arise as a resultof an outside relationship or a personal, professional, or businessinterest of a member of the writing panel. Specifically, all membersof the writing group are required to complete and submit a Dis-closure Questionnaire showing all such relationships that might beperceived as real or potential conflicts of interest.

This statement was approved by the American HeartAssociation Science Advisory and Coordinating Committeeon September 18, 2014. A copy of the document is avail-able at http://my.americanheart.org/statements by selectingeither the “By Topic” link or the “By Publication Date” link.To purchase additional reprints, call 843-216-2533 or [email protected].

The American Heart Association requests that this documentbe cited as follows: Perkins GD, Jacobs IG, Nadkarni VM, Berg RA,Bhanji F, Biarent D, Bossaert LL, Brett SJ, Chamberlain D, de CaenAR, Deakin CD, Finn JC, Gräsner J-T, Hazinski MF, Iwami T, KosterRW, Lim SH, Huei-Ming Ma M, McNally BF, Morley PT, MorrisonLJ, Monsieurs KG, Montgomery W, Nichol G, Okada K, Eng HockOng M, Travers AH, Nolan JP; for the Utstein Collaborators. Cardiacarrest and cardiopulmonary resuscitation outcome reports: updateof the Utstein Resuscitation Registry Templates for Out-of-HospitalCardiac Arrest: a statement for healthcare professionals from atask force of the International Liaison Committee on Resuscitation(American Heart Association, European Resuscitation Council, Aus-tralian and New Zealand Council on Resuscitation, Heart and StrokeFoundation of Canada, InterAmerican Heart Foundation, Resuscita-tion Council of Southern Africa, Resuscitation Council of Asia); andthe American Heart Association Emergency Cardiovascular CareCommittee and the Council on Cardiopulmonary, Critical Care, Peri-operative and Resuscitation. Circulation. 2014;131:•••–•••.

This article has been copublished in Resuscitation.Expert peer review of AHA Scientific Statements is con-

ducted by the AHA Office of Science Operations. For moreon AHA statements and guidelines development, visithttp://my.americanheart.org/statements and select the “Policiesand Development” link.

Permissions: Multiple copies, modification, alteration, enhance-ment, and/or distribution of this document are not permittedwithout the express permission of the American Heart Asso-ciation. Instructions for obtaining permission are located athttp://www.heart.org/HEARTORG/General/Copyright-Permission-Guidelines UCM 300404 Article.jsp. A link to the “CopyrightPermissions Request Form” appears on the right side of the page.

(Circulation. 2014;131:000-000.)Copyright 2014 European Resuscitation Council and American

Heart Association, Inc.Circulation is available at http://circ.ahajournals.org


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mailto:[email protected]

http://my.americanheart.org/statements

http://www.heart.org/HEARTORG/General/Copyright-Permission-Guidelines_UCM_300404_Article.jsp

http://www.heart.org/HEARTORG/General/Copyright-Permission-Guidelines_UCM_300404_Article.jsp

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