Bio

Bio


Blair is a critical care fellow at Stanford, an attending emergency physician at St Michael's Toronto, and a medical journalist. Born and raised in Toronto, his training has taken him to New York, London, Perth, Cape Town and now the San Francisco Bay area. He completed his science training at University of Toronto, his medical training at McMaster University and his journalism training at the Munk School of Global Affairs. He is a guideline author with the American Heart Association and a collaborator with the CIHR-funded Canadian Sepsis Network. His breaking and investigative journalism has been published in all three of Canada's national newspapers and he frequently appears on television and radio. He has won awards for his scientific work and journalism, and has been recognized as a national leader in Canadian healthcare and health advocacy.

Clinical Focus


  • Fellow
  • Critical care and emergency medicine

Boards, Advisory Committees, Professional Organizations


  • Director, Canadian Association of Emergency Physicians (2017 - 2018)
  • Vice-Chair, MedicAlert Foundation Canada (2013 - Present)

Publications

All Publications


  • Education, Implementation, and Teams 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations RESUSCITATION Greif, R., Bhanji, F., Bigham, B. L., Bray, J., Breckwoldt, J., Cheng, A., Duff, J. P., Gilfoyle, E., Hsieh, M., Iwami, T., Lauridsen, K. G., Lockey, A. S., Ma, M., Monsieurs, K. G., Okamoto, D., Pellegrino, J. L., Yeung, J., Finn, J. C., Educ Implementation Teams Collabor 2020; 156: A188?A239

    Abstract

    For this 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, the Education, Implementation, and Teams Task Force applied the population, intervention, comparator, outcome, study design, time frame format and performed 15 systematic reviews, applying the Grading of Recommendations, Assessment, Development, and Evaluation guidance. Furthermore, 4 scoping reviews and 7 evidence updates assessed any new evidence to determine if a change in any existing treatment recommendation was required. The topics covered included training for the treatment of opioid overdose; basic life support, including automated external defibrillator training; measuring implementation and performance in communities, and cardiac arrest centers; advanced life support training, including team and leadership training and rapid response teams; measuring cardiopulmonary resuscitation performance, feedback devices, and debriefing; and the use of social media to improve cardiopulmonary resuscitation application.

    View details for DOI 10.1016/j.resuscitation.2020.09.014

    View details for Web of Science ID 000581165500007

    View details for PubMedID 33098918

  • The effect of system performance improvement on patients with cardiac arrest: a systematic review. Resuscitation Ko, Y., Hsieh, M., Ma, M. H., Bigham, B., Bhanji, F., Greif, R., Education, I. a., of the International Liaison Committee on Resuscitation (ILCOR), Bray, J., Breckwoldt, J., Duff, J. P., Lauridsen, K. G., Cheng, A., Lockey, A., Gilfoyle, E., Iwami, T., Okamoto, D., Pellegrino, J. L., Monsieurs, K., Morley, P., Finn, J. 2020

    Abstract

    AIM: The aim of our review was to understand the effect of interventions to improve system-level performance on the clinical outcomes of patients with cardiac arrest.METHODS: We searched PubMed, Ovid EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) databases to identify randomised controlled trials and non-randomised studies published before July 21, 2020 reporting systems interventions to improve outcomes. Characteristics, study design, evaluation methods and outcomes of included studies were extracted. (PROSPERO registration CRD42020161882).RESULTS: One cluster randomised trial and 26 non-randomised studies were included. There were 18 studies focusing on interventions for patients with out-of-hospital cardiac arrest and 9 studies for patients with in-hospital cardiac arrest. Interventions included implementation of a bundle of care strategy, evaluation of cardiopulmonary resuscitation (CPR) quality with feedback/debriefing, data surveillance, and CPR training programs. Although improved survival with favorable neurologic outcome at discharge after the implementation of specific interventions was found in 13 studies, improved survival to hospital discharge in 14 studies and improved survival to admission in 3 studies, there were still 7 studies showing no significant improvement of clinical outcomes after interventions.CONCLUSION: Although only moderate to very low certainty of evidence exists to support the effect of system-level performance improvement on the clinical outcomes of patients, we recommend that organisations or communities evaluate their performance and target key areas with the goal to improve performance because of no known risks and the potential for a large beneficial effect.

    View details for DOI 10.1016/j.resuscitation.2020.10.024

    View details for PubMedID 33129915

  • 2019 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces CIRCULATION Soar, J., Maconochie, I., Wyckoff, M. H., Olasveengen, T. M., Singletary, E. M., Greif, R., Aickin, R., Bhanji, F., Donnino, M. W., Mancini, M. E., Wyllie, J. P., Zideman, D., Andersen, L. W., Atkins, D. L., Aziz, K., Bendall, J., Berg, K. M., Berry, D. C., Bigham, B. L., Bingham, R., Couto, T., Bottiger, B. W., Borra, V., Bray, J. E., Breckwoldt, J., Brooks, S. C., Buick, J., Callaway, C. W., Carlson, J. N., Cassan, P., Castren, M., Chang, W., Charlton, N. P., Cheng, A., Chung, S., Considine, J., Couper, K., Dainty, K. N., Dawson, J., de Almeida, M., de Caen, A. R., Deakin, C. D., Drennan, I. R., Duff, J. P., Epstein, J. L., Escalante, R., Gazmuri, R. J., Gilfoyle, E., Granfeldt, A., Guerguerian, A., Guinsburg, R., Hatanaka, T., Holmberg, M. J., Hood, N., Hosono, S., Hsieh, M., Isayama, T., Iwami, T., Jensen, J. L., Kapadia, V., Kim, H., Kleinman, M. E., Kudenchuk, P. J., Lang, E., Lavonas, E., Liley, H., Lim, S., Lockey, A., Lofgren, B., Ma, M., Markenson, D., Meaney, P. A., Meyran, D., Mildenhall, L., Monsieurs, K. G., Montgomery, W., Morley, P. T., Morrison, L. J., Nadkarni, V. M., Nation, K., Neumar, R. W., Ng, K., Nicholson, T., Nikolaou, N., Nishiyama, C., Nuthall, G., Ohshimo, S., Okamoto, D., O'Neil, B., Ong, G., Paiva, E. F., Parr, M., Pellegrino, J., Perkins, G. D., Perlman, J., Rabi, Y., Reis, A., Reynolds, J. C., Ristagno, G., Roehr, C. C., Sakamoto, T., Sandroni, C., Schexnayder, S. M., Scholefield, B. R., Shimizu, N., Skrifvars, M. B., Smyth, M. A., Stanton, D., Swain, J., Szyld, E., Tijssen, J., Travers, A., Trevisanuto, D., Vaillancourt, C., Van de Voorde, P., Velaphi, S., Wang, T., Weiner, G., Welsford, M., Woodin, J. A., Yeung, J., Nolan, J. P., Hazinski, M. 2019; 140 (24): E826?E880

    Abstract

    The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the third annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. It addresses the most recent published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. This summary addresses the role of cardiac arrest centers and dispatcher-assisted cardiopulmonary resuscitation, the role of extracorporeal cardiopulmonary resuscitation in adults and children, vasopressors in adults, advanced airway interventions in adults and children, targeted temperature management in children after cardiac arrest, initial oxygen concentration during resuscitation of newborns, and interventions for presyncope by first aid providers. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the certainty of the evidence on the basis of the Grading of Recommendations, Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence to Decision Framework Highlights sections. The task forces also listed priority knowledge gaps for further research.

    View details for DOI 10.1161/CIR.0000000000000734

    View details for Web of Science ID 000508367200003

    View details for PubMedID 31722543

  • Attitudes of emergency department physicians and nurses toward implementation of an early warning score to identify critically ill patients: qualitative explanations for failed implementation CANADIAN JOURNAL OF EMERGENCY MEDICINE Bigham, B. L., Chan, T., Skitch, S., Fox-Robichaud, A. 2019; 21 (2): 269?73

    Abstract

    Sepsis, a common, time-sensitive condition, is sometimes not identified at emergency department (ED) triage. The use of early warning scores has been shown to improve sepsis-related screening in other settings.Our objective was to elucidate nurse and physician perceptions with the Hamilton Early Warning Score (HEWS) in combination with the Canadian Triage Acuity Scale.Semi-structured interviews were conducted with nurses, resident physicians and attending physicians to explore perceived feasibility, utility, comfort, barriers, successes, opportunities and accuracy. A constructivist grounded theory approach was used. Transcripts were coded into thematic coding trees.The twelve participants did not value the HEWS in the ED because they felt it was not helpful in identifying critically ill patients. We identified five themes; knowledge of sepsis and HEWS, utility of HEWS in emergency triage, utility of HEWS at the bedside, utility in communicating acuity and deterioration, and feasibility and accuracy of data collection. We also found 9 barriers and 7 enablers to the use of early warning score in the ED.In our emergency departments, we identified potential barriers to implementation of an early warning score. A pre-existing expertise and lexicon related to critically ill patients lessens the perceived utility of an EWS in the ED. Understanding these cultural barriers needs to be addressed through change theory and implementation science.

    View details for DOI 10.1017/cem.2018.392

    View details for Web of Science ID 000462666700022

    View details for PubMedID 29898794

  • Unintentional use of the word "accident"? CLINICAL TOXICOLOGY Bigham, B. L., Harding, S. A., Goldfrank, L. R. 2019; 57 (1): 73?74
  • Position Statement on Resident Wellness CANADIAN JOURNAL OF EMERGENCY MEDICINE Taher, A., Crawford, S., Koczerginski, J., Argintaru, N., Beaumont-Boileau, R., Hart, A., Bigham, B. 2018; 20 (5): 671?84

    View details for DOI 10.1017/cem.2018.8

    View details for Web of Science ID 000444547500007

  • Social Media and the 21st-Century Scholar: How You Can Harness Social Media to Amplify Your Career JOURNAL OF THE AMERICAN COLLEGE OF RADIOLOGY Chan, T. M., Stukus, D., Leppink, J., Duque, L., Bigham, B. L., Mehta, N., Thoma, B. 2018; 15 (5): 705?6

    View details for DOI 10.1016/j.jacr.2018.02.002

    View details for Web of Science ID 000431606400009

    View details for PubMedID 29625820

  • Adding value to scholarship in residency: Supporting and inspiring future emergency medicine research in Canada CANADIAN JOURNAL OF EMERGENCY MEDICINE Ting, D. K., Bigham, B. L., Mehta, S., Stiell, I. 2018; 20 (3): 318?20

    View details for DOI 10.1017/cem.2018.395

    View details for Web of Science ID 000432385200001

    View details for PubMedID 29764536

  • 2017 American Heart Association Focused Update on Pediatric Basic Life Support and Cardiopulmonary Resuscitation Quality An Update to the American Heart Association Guidelines for Cardio-pulmonary Resuscitation and Emergency Cardiovascular Care CIRCULATION Atkins, D. L., de Caen, A. R., Berger, S., Samson, R. A., Schexnayder, S. M., Joyner, B. L., Bigham, B. L., Niles, D. E., Duff, J. P., Hunt, E. A., Meaney, P. A. 2018; 137 (1): E1?E6

    Abstract

    This focused update to the American Heart Association guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care follows the Pediatric Task Force of the International Liaison Committee on Resuscitation evidence review. It aligns with the International Liaison Committee on Resuscitation's continuous evidence review process, and updates are published when the International Liaison Committee on Resuscitation completes a literature review based on new science. This update provides the evidence review and treatment recommendation for chest compression-only CPR versus CPR using chest compressions with rescue breaths for children <18 years of age. Four large database studies were available for review, including 2 published after the "2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care." Two demonstrated worse 30-day outcomes with chest compression-only CPR for children 1 through 18 years of age, whereas 2 studies documented no difference between chest compression-only CPR and CPR using chest compressions with rescue breaths. When the results were analyzed for infants <1 year of age, CPR using chest compressions with rescue breaths was better than no CPR but was no different from chest compression-only CPR in 1 study, whereas another study observed no differences among chest compression-only CPR, CPR using chest compressions with rescue breaths, and no CPR. CPR using chest compressions with rescue breaths should be provided for infants and children in cardiac arrest. If bystanders are unwilling or unable to deliver rescue breaths, we recommend that rescuers provide chest compressions for infants and children.

    View details for DOI 10.1161/CIR.0000000000000540

    View details for Web of Science ID 000428024500001

    View details for PubMedID 29114009

  • Resuscitation Education Science: Educational Strategies to Improve Outcomes From Cardiac Arrest: A Scientific Statement From the American Heart Association. Circulation Cheng, A., Nadkarni, V. M., Mancini, M. B., Hunt, E. A., Sinz, E. H., Merchant, R. M., Donoghue, A., Duff, J. P., Eppich, W., Auerbach, M., Bigham, B. L., Blewer, A. L., Chan, P. S., Bhanji, F. 2018; 138 (6): e82?e122

    Abstract

    The formula for survival in resuscitation describes educational efficiency and local implementation as key determinants in survival after cardiac arrest. Current educational offerings in the form of standardized online and face-to-face courses are falling short, with providers demonstrating a decay of skills over time. This translates to suboptimal clinical care and poor survival outcomes from cardiac arrest. In many institutions, guidelines taught in courses are not thoughtfully implemented in the clinical environment. A current synthesis of the evidence supporting best educational and knowledge translation strategies in resuscitation is lacking. In this American Heart Association scientific statement, we provide a review of the literature describing key elements of educational efficiency and local implementation, including mastery learning and deliberate practice, spaced practice, contextual learning, feedback and debriefing, assessment, innovative educational strategies, faculty development, and knowledge translation and implementation. For each topic, we provide suggestions for improving provider performance that may ultimately optimize patient outcomes from cardiac arrest.

    View details for DOI 10.1161/CIR.0000000000000583

    View details for PubMedID 29930020

  • Going Viral and Interacting with the Press JOURNAL OF THE AMERICAN COLLEGE OF RADIOLOGY Bigham, B. L., Chan, T. M. 2018; 15 (1): 153?54

    View details for DOI 10.1016/j.jacr.2017.09.022

    View details for Web of Science ID 000419663500005

    View details for PubMedID 29129661

  • Social Media and the 21st-Century Scholar: How You Can Harness Social Media to Amplify Your Career JOURNAL OF THE AMERICAN COLLEGE OF RADIOLOGY Chan, T. M., Stukus, D., Leppink, J., Duque, L., Bigham, B. L., Mehta, N., Thoma, B. 2018; 15 (1): 142?48

    Abstract

    To many physicians and professionals, social media seems to be a risky business. However, recent literature has shown that there is potential to enhance your scholarly brand by engaging your stakeholders online. In this article, we discuss the opportunities presented to modern scholars by social media. Using case studies, we highlight two success stories around how scientists and scholars might use social media to enhance their careers. We also outline five key steps you can follow to build and manage your scholarly presence online.

    View details for DOI 10.1016/j.jacr.2017.09.025

    View details for Web of Science ID 000419663500003

    View details for PubMedID 29154102

  • Case Review: What's an Impella? This medical. device supports left ventricular function. EMS world Bigham, B. 2017; 46 (2): 43?44

    View details for PubMedID 29847058

  • What is new in the 2015 American Heart Association guidelines, what is recycled from 2010, and what is relevant for emergency medicine in Canada CANADIAN JOURNAL OF EMERGENCY MEDICINE Morrison, L. J., de Caen, A., Bhanji, F., Bigham, B. L., Blanchard, I. E., Brooks, S. C., Guerguerian, A., Jensen, J. L., Travers, A. H., Vaillancourt, C., Welsford, M., Woolfrey, K. 2016; 18 (3): 223?29

    View details for DOI 10.1017/cem.2016.26

    View details for Web of Science ID 000377467900006

    View details for PubMedID 27138217

  • National Prehospital Evidence-Based Guidelines Strategy: A Summary for EMS Stakeholders. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors Martin-Gill, C., Gaither, J. B., Bigham, B. L., Myers, J. B., Kupas, D. F., Spaite, D. W. 2016; 20 (2): 175?83

    Abstract

    Multiple national organizations have recommended and supported a national investment to increase the scientific evidence available to guide patient care delivered by Emergency Medical Services (EMS) and incorporate that evidence directly into EMS systems. Ongoing efforts seek to develop, implement, and evaluate prehospital evidence-based guidelines (EBGs) using the National Model Process created by a multidisciplinary panel of experts convened by the Federal Interagency Committee on EMS (FICEMS) and the National EMS Advisory Council (NEMSAC). Yet, these and other EBG efforts have occurred in relative isolation, with limited direct collaboration between national projects, and have experienced challenges in implementation of individual guidelines. There is a need to develop sustainable relationships among stakeholders that facilitate a common vision that facilitates EBG efforts. Herein, we summarize a National Strategy on EBGs developed by the National Association of EMS Physicians (NAEMSP) with involvement of 57 stakeholder organizations, and with the financial support of the National Highway Traffic Safety Administration (NHTSA) and the EMS for Children program. The Strategy proposes seven action items that support collaborative efforts in advancing prehospital EBGs. The first proposed action is creation of a Prehospital Guidelines Consortium (PGC) representing national medical and EMS organizations that have an interest in prehospital EBGs and their benefits to patient outcomes. Other action items include promoting research that supports creation and evaluates the impact of EBGs, promoting the development of new EBGs through improved stakeholder collaboration, and improving education on evidence-based medicine for all prehospital providers. The Strategy intends to facilitate implementation of EBGs by improving guideline dissemination and incorporation into protocols, and seeks to establish standardized evaluation methods for prehospital EBGs. Finally, the Strategy proposes that key stakeholder organizations financially support the Prehospital Guidelines Consortium as a means of implementing the Strategy, while together promoting additional funding for continued EBG efforts.

    View details for DOI 10.3109/10903127.2015.1102995

    View details for PubMedID 26808116

  • Collaboration, not stagnation, defines Ontario EMS CANADIAN JOURNAL OF EMERGENCY MEDICINE Bigham, B., Welsford, M., Verbeek, P. 2016; 18 (1): 74?75

    View details for DOI 10.1017/cem.2015.108

    View details for Web of Science ID 000368765600012

    View details for PubMedID 26717296

  • Effect of gender on outcome of out of hospital cardiac arrest in the Resuscitation Outcomes Consortium. Resuscitation Morrison, L. J., Schmicker, R. H., Weisfeldt, M. L., Bigham, B. L., Berg, R. A., Topjian, A. A., Abramson, B. L., Atkins, D. L., Egan, D., Sopko, G., Rac, V. E. 2016; 100: 76?81

    Abstract

    This study examined the relationship between gender and outcomes of non-traumatic out-of-hospital cardiac arrest (OHCA).All eligible, consecutive, non-traumatic Emergency Medical Services (EMS) treated OHCA patients in the Resuscitation Outcomes Consortium between December 2005 and May 2007. Patient age was analyzed as a continuous variable and stratified in two age cohorts: 15-45 and >55 years of age (yoa). Unadjusted and adjusted (based on Utstein characteristics) chi square tests and logistic regression models were employed to examine the relationship between gender, age, and survival outcomes.This study enrolled 14,690 patients: of which 36.4% were women with a mean age of 68.3 and 63.6% of them men with a mean age of 64.2. Women survived to hospital discharge less often than men (6.4% vs. 9.1%, p<0.001); the unadjusted OR was 0.69, 95%CI: 0.60, 0.77 whereas when adjusted for all Utstein predictors the difference was not significant (OR: 1.16, 95%CI: 0.98, 1.36, p=0.07). The adjusted survival rate for younger women (15-45 yoa) was 11.1% vs. 9.8% for younger men (OR: 1.66, 95%CI: 1.04, 2.64, p=0.03) but no difference in discharge rates was observed in the >55 cohort (OR: 0.94, 95%CI: 0.78, 1.15, p=0.57).Women who suffer OHCAs have lower rates of survival and have unfavourable Utstein predictors. When survival is adjusted for these predictors survival is similar between men and women except in younger women suggesting that age modifies the association of gender and survival from OHCA; a result that supports a protective hormonal effect among premenopausal women.

    View details for DOI 10.1016/j.resuscitation.2015.12.002

    View details for PubMedID 26705971

    View details for PubMedCentralID PMC4761304

  • Applying Hospital Evidence to Paramedicine: Issues of Indirectness, Validity and Knowledge Translation CANADIAN JOURNAL OF EMERGENCY MEDICINE Bigham, B., Welsford, M. 2015; 17 (3): 281?85

    Abstract

    The practice of emergency medicine (EM) has been intertwined with emergency medical services (EMS) for more than 40 years. In this commentary, we explore the practice of translating hospital based evidence into the prehospital setting. We will challenge both EMS and EM dogma-bringing hospital care to patients in the field is not always better. In providing examples of therapies championed in hospitals that have failed to translate into the field, we will discuss the unique prehospital environment, and why evidence from the hospital setting cannot necessarily be translated to the prehospital field. Paramedicine is maturing so that the capability now exists to conduct practice-specific research that can inform best practices. Before translation from the hospital environment is implemented, evidence must be evaluated by people with expertise in three domains: critical appraisal, EM, and EMS. Scientific evidence should be assessed for: quality and bias; directness, generalizability, and validity to the EMS population; effect size and anticipated benefit from prehospital application; feasibility (including economic evaluation, human resource availability in the mobile environment); and patient and provider safety.

    View details for DOI 10.1017/cem.2015.65

    View details for Web of Science ID 000356060800011

    View details for PubMedID 26034914

  • Part 8: Education, Implementation, and Teams: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation Bhanji, F., Finn, J. C., Lockey, A., Monsieurs, K., Frengley, R., Iwami, T., Lang, E., Ma, M. H., Mancini, M. E., McNeil, M. A., Greif, R., Billi, J. E., Nadkarni, V. M., Bigham, B. 2015; 132 (16 Suppl 1): S242?68

    View details for DOI 10.1161/CIR.0000000000000277

    View details for PubMedID 26472856

  • Chest compression rates and survival following out-of-hospital cardiac arrest. Critical care medicine Idris, A. H., Guffey, D., Pepe, P. E., Brown, S. P., Brooks, S. C., Callaway, C. W., Christenson, J., Davis, D. P., Daya, M. R., Gray, R., Kudenchuk, P. J., Larsen, J., Lin, S., Menegazzi, J. J., Sheehan, K., Sopko, G., Stiell, I., Nichol, G., Aufderheide, T. P. 2015; 43 (4): 840?48

    Abstract

    Guidelines for cardiopulmonary resuscitation recommend a chest compression rate of at least 100 compressions/min. A recent clinical study reported optimal return of spontaneous circulation with rates between 100 and 120/min during cardiopulmonary resuscitation for out-of-hospital cardiac arrest. However, the relationship between compression rate and survival is still undetermined.Prospective, observational study.Data is from the Resuscitation Outcomes Consortium Prehospital Resuscitation IMpedance threshold device and Early versus Delayed analysis clinical trial.Adults with out-of-hospital cardiac arrest treated by emergency medical service providers.None.Data were abstracted from monitor-defibrillator recordings for the first five minutes of emergency medical service cardiopulmonary resuscitation. Multiple logistic regression assessed odds ratio for survival by compression rate categories (<80, 80-99, 100-119, 120-139, ?140), both unadjusted and adjusted for sex, age, witnessed status, attempted bystander cardiopulmonary resuscitation, location of arrest, chest compression fraction and depth, first rhythm, and study site. Compression rate data were available for 10,371 patients; 6,399 also had chest compression fraction and depth data. Age (mean±SD) was 67±16 years. Chest compression rate was 111±19 per minute, compression fraction was 0.70±0.17, and compression depth was 42±12 mm. Circulation was restored in 34%; 9% survived to hospital discharge. After adjustment for covariates without chest compression depth and fraction (n=10,371), a global test found no significant relationship between compression rate and survival (p=0.19). However, after adjustment for covariates including chest compression depth and fraction (n=6,399), the global test found a significant relationship between compression rate and survival (p=0.02), with the reference group (100-119 compressions/min) having the greatest likelihood for survival.After adjustment for chest compression fraction and depth, compression rates between 100 and 120 per minute were associated with greatest survival to hospital discharge.

    View details for DOI 10.1097/CCM.0000000000000824

    View details for PubMedID 25565457

  • What Is the Optimal Chest Compression Depth During Out-of-Hospital Cardiac Arrest Resuscitation of Adult Patients? CIRCULATION Stiell, I. G., Brown, S. P., Nichol, G., Cheskes, S., Vaillancourt, C., Callaway, C. W., Morrison, L. J., Christenson, J., Aufderheide, T. P., Davis, D. P., Free, C., Hostler, D., Stouffer, J. A., Idris, A. H., Resuscitation Outcomes Consortium 2014; 130 (22): 1962-+

    Abstract

    The 2010 American Heart Association guidelines suggested an increase in cardiopulmonary resuscitation compression depth with a target >50 mm and no upper limit. This target is based on limited evidence, and we sought to determine the optimal compression depth range.We studied emergency medical services-treated out-of-hospital cardiac arrest patients from the Resuscitation Outcomes Consortium Prehospital Resuscitation Impedance Valve and Early Versus Delayed Analysis clinical trial and the Epistry-Cardiac Arrest database. We calculated adjusted odds ratios for survival to hospital discharge, 1-day survival, and any return of circulation. We included 9136 adult patients from 9 US and Canadian cities with a mean age of 67.5 years, mean compression depth of 41.9 mm, and a return of circulation of 31.3%, 1-day survival of 22.8%, and survival to hospital discharge of 7.3%. For survival to discharge, the adjusted odds ratios were 1.04 (95% CI, 1.00-1.08) for each 5-mm increment in compression depth, 1.45 (95% CI, 1.20-1.76) for cases within 2005 depth range (>38 mm), and 1.05 (95% CI, 1.03-1.08) for percentage of minutes in depth range (10% change). Covariate-adjusted spline curves revealed that the maximum survival is at a depth of 45.6 mm (15-mm interval with highest survival between 40.3 and 55.3 mm) with no differences between men and women.This large study of out-of-hospital cardiac arrest patients demonstrated that increased cardiopulmonary resuscitation compression depth is strongly associated with better survival. Our adjusted analyses, however, found that maximum survival was in the depth interval of 40.3 to 55.3 mm (peak, 45.6 mm), suggesting that the 2010 American Heart Association cardiopulmonary resuscitation guideline target may be too high.http://www.clinicaltrials.gov. Unique identifier: NCT00394706.

    View details for DOI 10.1161/CIRCULATIONAHA.114.008671

    View details for Web of Science ID 000345517100011

    View details for PubMedID 25252721

  • Mechanical versus manual chest compressions for cardiac arrest. The Cochrane database of systematic reviews Brooks, S. C., Hassan, N., Bigham, B. L., Morrison, L. J. 2014: CD007260

    Abstract

    This is the first update of the Cochrane review on mechanical chest compression devices published in 2011 (Brooks 2011). Mechanical chest compression devices have been proposed to improve the effectiveness of cardiopulmonary resuscitation (CPR).To assess the effectiveness of mechanical chest compressions versus standard manual chest compressions with respect to neurologically intact survival in patients who suffer cardiac arrest.We searched the Cochrane Central Register of Controlled Studies (CENTRAL; 2013, Issue 12), MEDLINE Ovid (1946 to 2013 January Week 1), EMBASE (1980 to 2013 January Week 2), Science Citation abstracts (1960 to 18 November 2009), Science Citation Index-Expanded (SCI-EXPANDED) (1970 to 11 January 2013) on Thomson Reuters Web of Science, biotechnology and bioengineering abstracts (1982 to 18 November 2009), conference proceedings Citation Index-Science (CPCI-S) (1990 to 11 January 2013) and clinicaltrials.gov (2 August 2013). We applied no language restrictions. Experts in the field of mechanical chest compression devices and manufacturers were contacted.We included randomised controlled trials (RCTs), cluster RCTs and quasi-randomised studies comparing mechanical chest compressions versus manual chest compressions during CPR for patients with atraumatic cardiac arrest.Two review authors abstracted data independently; disagreement between review authors was resolved by consensus and by a third review author if consensus could not be reached. The methodologies of selected studies were evaluated by a single author for risk of bias. The primary outcome was survival to hospital discharge with good neurological outcome. We planned to use RevMan 5 (Version 5.2. The Nordic Cochrane Centre) and the DerSimonian & Laird method (random-effects model) to provide a pooled estimate for risk ratio (RR) with 95% confidence intervals (95% CIs), if data allowed.Two new studies were included in this update. Six trials in total, including data from 1166 participants, were included in the review. The overall quality of included studies was poor, and significant clinical heterogeneity was observed. Only one study (N = 767) reported survival to hospital discharge with good neurological function (defined as a Cerebral Performance Category score of one or two), demonstrating reduced survival with mechanical chest compressions when compared with manual chest compressions (RR 0.41, 95% CI 0.21 to 0.79). Data from four studies demonstrated increased return of spontaneous circulation, and data from two studies demonstrated increased survival to hospital admission with mechanical chest compressions as compared with manual chest compressions, but none of the individual estimates reached statistical significance. Marked clinical heterogeneity between studies precluded any pooled estimates of effect.Evidence from RCTs in humans is insufficient to conclude that mechanical chest compressions during cardiopulmonary resuscitation for cardiac arrest are associated with benefit or harm. Widespread use of mechanical devices for chest compressions during cardiac events is not supported by this review. More RCTs that measure and account for the CPR process in both arms are needed to clarify the potential benefit to be derived from this intervention.

    View details for DOI 10.1002/14651858.CD007260.pub3

    View details for PubMedID 24574099

  • Paramedic self-reported exposure to violence in the emergency medical services (EMS) workplace: a mixed-methods cross-sectional survey. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors Bigham, B. L., Jensen, J. L., Tavares, W., Drennan, I. R., Saleem, H., Dainty, K. N., Munro, G. 2014; 18 (4): 489?94

    Abstract

    Studies from Australia, Sweden, the United States, and elsewhere have found that paramedics experience violence in the emergency medical services (EMS) workplace. The objective of this study was to describe and explore violence experienced by paramedics in the ground ambulance setting, including types of violence experienced, by whom the violence was perpetrated, actions taken by paramedics, and effects of these episodes.A cross-sectional study utilizing a mixed-methods paper survey was provided to a convenience sample of rural, suburban, and urban-based ground ambulance paramedics in two Canadian provinces. Paramedics were asked to describe episodes of verbal assault, intimidation, physical assault, sexual harassment, and sexual assault they were exposed to during the past 12 months. Qualitative questions inquired about the impact of these experiences. Response selections were analyzed using descriptive statistics and regression analysis, and qualitative data was analyzed using descriptive content analysis.A total of 1,884 paramedics were invited to participate and 1,676 responded (89.0%). Most participants (75%) reported experiencing violence in the past 12 months. The most common form of violence reported was verbal assault (67%), followed by intimidation (41%), physical assault (26%), sexual harassment (14%), and sexual assault (3%). Patients were identified as the most common perpetrators of violence. Serious sequellae were qualitatively reported.The majority of Canadian paramedics surveyed experience violence in the workplace, which can lead to serious personal and professional sequellae. Strategies should be devised and studied to reduce violent events toward paramedics and to mitigate the impact such events have on the wellbeing of paramedics.

    View details for DOI 10.3109/10903127.2014.912703

    View details for PubMedID 24830544

  • EXPANDING PARAMEDIC SCOPE OF PRACTICE IN THE COMMUNITY: A SYSTEMATIC REVIEW OF THE LITERATURE PREHOSPITAL EMERGENCY CARE Bigham, B. L., Kennedy, S. M., Drennan, I., Morrison, L. J. 2013; 17 (3): 361?72

    Abstract

    Paramedics are an important health human resource and are uniquely mobile in most communities across Canada. In the last dozen years, challenges in the delivery of health care have prompted governments from around the globe to consider expanding the role paramedics play in health systems. Utilizing paramedics for the management of urgent, low-acuity illnesses and injuries has been coined "community paramedicine," but the role, safety, and effectiveness of this concept are poorly understood.We undertook a systematic review of the international literature to describe existing community paramedic programs.We used the Cochrane methodology for systematic reviews. An international group of experts developed a search strategy and a health information specialist executed this search in Medline, Embase, and CINAHL starting January 1, 2000. We included all research articles in the English language that reported a research methodology. We excluded commentaries and letters to the editor. Two investigators independently screened citations in a hierarchical manner and abstracted data.Of 3,089 titles, 10 articles were included in the systematic review and one additional paper was author-nominated. The nature of the 11 articles was heterogeneous, and only one randomized controlled trial (RCT) was found. This trial showed community paramedicine to be beneficial to patients and health systems. The other articles drew conclusions favoring community paramedicine.Community paramedicine research to date is lacking, but programs in the United Kingdom, Australia, and Canada are perceived to be promising, and one RCT shows that paramedics can safely practice with an expanded scope and improve system performance and patient outcomes. Further research is required to fully understand how expanding paramedic roles affect patients, communities, and health systems.

    View details for DOI 10.3109/10903127.2013.792890

    View details for Web of Science ID 000319886200010

    View details for PubMedID 23734989

  • Developing a Canadian emergency medical services research agenda: a baseline study of stakeholder opinions CANADIAN JOURNAL OF EMERGENCY MEDICINE Dainty, K. N., Jensen, J. L., Bigham, B. L., Blanchard, I. E., Brown, L. H., Carter, A. E., Socha, D., Morrison, L. J. 2013; 15 (2): 83?89

    Abstract

    This study forms the first phase in the development of the Canadian National EMS Research Agenda. The purpose was to understand the current state of emergency medical services (EMS) research through the barriers and opportunities perceived by key stakeholders in the Canadian system and to identify the recommendations this group had for moving forward.This qualitative study was conducted in the spring of 2011 using one-on-one semistructured telephone interviews. Purposeful sampling was used to recruit a cross section of EMS research stakeholders, representing a breadth of geographic regions and roles. Data were collected until thematic saturation was reached. A constant comparative approach was used to develop a basic coding framework and identify emerging themes.Twenty stakeholders were invited to participate, and saturation was reached after 13 interviews. Thematic saturation was used to ensure that the findings were grounded in the data. Four major themes were identified: 1) the need for additional research education within EMS; 2) the importance of creating an infrastructure to support pan-Canadian research collaboration; 3) addressing the complexities of involving EMS providers in research; and 4) considerations for a national research agenda.This hypothesis-generating study reveals key areas regarding EMS research in Canada and through the guidance it provides is a first step in the development of a comprehensive national research agenda. Our intention is to collate the identified themes with the results of a larger roundtable discussion and Delphi survey and, in doing so, guide development of a Canadian national EMS research agenda.

    View details for DOI 10.2310/8000.2013.131022

    View details for Web of Science ID 000331144000005

    View details for PubMedID 23458139

  • The Canadian National EMS Research Agenda: a mixed methods consensus study. CJEM Jensen, J. L., Bigham, B. L., Blanchard, I. E., Dainty, K. N., Socha, D., Carter, A., Brown, L. H., Travers, A. H., Craig, A. M., Brown, R., Morrison, L. J. 2013; 15 (2): 73?82

    Abstract

    Research is essential for the development of evidence-based emergency medical services (EMS) systems of care. When resources are scarce and gaps in evidence are large, a national agenda may inform the growth of EMS research in Canada. This mixed methods consensus study explores current barriers and existing strengths within Canadian EMS research, provides recommendations, and suggests EMS topics for future study.Purposeful sampling was employed to invite EMS research stakeholders from various roles across the country. Study phases consisted of 1) baseline interviews of a subsample, 2) roundtable discussion, and 3) an online Delphi survey, in which participants scored each statement for importance. Consensus was defined a priori and met if 80% scored a statement as "important" or "very important."Fifty-three stakeholders participated, representing researchers (37.7%), EMS administrators (24.6%), clinicians/providers (20.7%), and educators (17.0%). Participation rates were as follows: interviews, 13 of 13 (100%); roundtable, 47 of 53 (89%); survey round 1, 50 of 53 (94%); survey round 2, 47 of 53 (89%); and survey round 3, 40 of 53 (75%). A total of 141 statements were identified as important: 20 barriers, 54 strengths/opportunities, 31 recommendations, and 36 suggested topics for future research. Like statements were synthesized, resulting in barriers (n ?=? 10), strengths/opportunities (n ?=? 24), and recommendations (n ?=? 19), which were categorized as time, opportunities, and funding; education and mentorship; culture of research and collaboration; structure, process, and outcome of research; EMS and paramedic practice; and the future of the EMS Research Agenda.Consensus-based key messages from this agenda should be considered when designing, funding, and publishing EMS research and will advance EMS research locally, regionally, and nationally.

    View details for DOI 10.2310/8000.2013.130894

    View details for PubMedID 23458138

  • What is the role of chest compression depth during out-of-hospital cardiac arrest resuscitation?. Critical care medicine Stiell, I. G., Brown, S. P., Christenson, J., Cheskes, S., Nichol, G., Powell, J., Bigham, B., Morrison, L. J., Larsen, J., Hess, E., Vaillancourt, C., Davis, D. P., Callaway, C. W. 2012; 40 (4): 1192?98

    Abstract

    The 2010 international guidelines for cardiopulmonary resuscitation recently recommended an increase in the minimum compression depth from 38 to 50 mm, although there are limited human data to support this. We sought to study patterns of cardiopulmonary resuscitation compression depth and their associations with patient outcomes in out-of-hospital cardiac arrest cases treated by the 2005 guideline standards.Prospective cohort.Seven U.S. and Canadian urban regions.We studied emergency medical services treated out-of-hospital cardiac arrest patients from the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest for whom electronic cardiopulmonary resuscitation compression depth data were available, from May 2006 to June 2009.We calculated anterior chest wall depression in millimeters and the period of active cardiopulmonary resuscitation (chest compression fraction) for each minute of cardiopulmonary resuscitation. We controlled for covariates including compression rate and calculated adjusted odds ratios for any return of spontaneous circulation, 1-day survival, and hospital discharge.We included 1029 adult patients from seven U.S. and Canadian cities with the following characteristics: Mean age 68 yrs; male 62%; bystander witnessed 40%; bystander cardiopulmonary resuscitation 37%; initial rhythms: Ventricular fibrillation/ventricular tachycardia 24%, pulseless electrical activity 16%, asystole 48%, other nonshockable 12%; outcomes: Return of spontaneous circulation 26%, 1-day survival 18%, discharge 5%. For all patients, median compression rate was 106 per minute, median compression fraction 0.65, and median compression depth 37.3 mm with 52.8% of cases having depth <38 mm and 91.6% having depth <50 mm. We found an inverse association between depth and compression rate ( p < .001). Adjusted odds ratios for all depth measures (mean values, categories, and range) showed strong trends toward better outcomes with increased depth for all three survival measures.We found suboptimal compression depth in half of patients by 2005 guideline standards and almost all by 2010 standards as well as an inverse association between compression depth and rate. We found a strong association between survival outcomes and increased compression depth but no clear evidence to support or refute the 2010 recommendations of >50 mm. Although compression depth is an important component of cardiopulmonary resuscitation and should be measured routinely, the most effective depth is currently unknown.

    View details for DOI 10.1097/CCM.0b013e31823bc8bb

    View details for PubMedID 22202708

    View details for PubMedCentralID PMC3307954

  • Relationship between chest compression rates and outcomes from cardiac arrest. Circulation Idris, A. H., Guffey, D., Aufderheide, T. P., Brown, S., Morrison, L. J., Nichols, P., Powell, J., Daya, M., Bigham, B. L., Atkins, D. L., Berg, R., Davis, D., Stiell, I., Sopko, G., Nichol, G. 2012; 125 (24): 3004?12

    Abstract

    Guidelines for cardiopulmonary resuscitation recommend a chest compression rate of at least 100 compressions per minute. Animal and human studies have reported that blood flow is greatest with chest compression rates near 120/min, but few have reported rates used during out-of-hospital (OOH) cardiopulmonary resuscitation or the relationship between rate and outcome. The purpose of this study was to describe chest compression rates used by emergency medical services providers to resuscitate patients with OOH cardiac arrest and to determine the relationship between chest compression rate and outcome.Included were patients aged ? 20 years with OOH cardiac arrest treated by emergency medical services providers participating in the Resuscitation Outcomes Consortium. Data were abstracted from monitor-defibrillator recordings during cardiopulmonary resuscitation. Multiple logistic regression analysis assessed the association between chest compression rate and outcome. From December 2005 to May 2007, 3098 patients with OOH cardiac arrest were included in this study. Mean age was 67 ± 16 years, and 8.6% survived to hospital discharge. Mean compression rate was 112 ± 19/min. A curvilinear association between chest compression rate and return of spontaneous circulation was found in cubic spline models after multivariable adjustment (P=0.012). Return of spontaneous circulation rates peaked at a compression rate of ? 125/min and then declined. Chest compression rate was not significantly associated with survival to hospital discharge in multivariable categorical or cubic spline models.Chest compression rate was associated with return of spontaneous circulation but not with survival to hospital discharge in OOH cardiac arrest.

    View details for DOI 10.1161/CIRCULATIONAHA.111.059535

    View details for PubMedID 22623717

    View details for PubMedCentralID PMC3388797

  • PATIENT SAFETY IN EMERGENCY MEDICAL SERVICES: A SYSTEMATIC REVIEW OF THE LITERATURE PREHOSPITAL EMERGENCY CARE Bigham, B. L., Buick, J. E., Brooks, S. C., Morrison, M., Shojania, K. G., Morrison, L. J. 2012; 16 (1): 20?35

    Abstract

    Preventable harm from medical care has been extensively documented in the inpatient setting. Emergency medical services (EMS) providers care for patients in dynamic and challenging environments; prehospital emergency care is a field that represents an area of high risk for errors and harm, but has received relatively little attention in the patient safety literature.To identify the threats to patient safety unique to the EMS environment and interventions that mitigate those threats, we completed a systematic review of the literature.We searched MEDLINE, EMBASE, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) for combinations of key EMS and patient safety terms composed by a pan-canadian expert panel using a year limit of 1999 to 2011. We excluded commentaries, opinions, letters, abstracts, and non-english publications. Two investigators performed an independent hierarchical screening of titles, abstracts, and full-text articles blinded to source. We used the kappa statistic to examine interrater agreement. Any differences were resolved by consensus.We retrieved 5,959 titles, and 88 publications met the inclusion criteria and were categorized into seven themes: adverse events and medication errors (22 articles), clinical judgment (13), communication (6), ground vehicle safety (9), aircraft safety (6), interfacility transport (16), and intubation (16). Two articles were randomized controlled trials; the remainder were systematic reviews, prospective observational studies, retrospective database/chart reviews, qualitative interviews, or surveys. The kappa statistics for titles, abstracts, and full-text articles were 0.65, 0.79, and 0.87, respectively, for the first search and 0.60, 0.74, and 0.85 for the second.We found a paucity of scientific literature exploring patient safety in EMS. Research is needed to improve our understanding of problem magnitude and threats to patient safety and to guide interventions.

    View details for DOI 10.3109/10903127.2011.621045

    View details for Web of Science ID 000297518500003

    View details for PubMedID 22128905

  • Socioeconomic status and incidence of sudden cardiac arrest CANADIAN MEDICAL ASSOCIATION JOURNAL Reinier, K., Thomas, E., Andrusiek, D. L., Aufderheide, T. P., Brooks, S. C., Callaway, C. W., Pepe, P. E., Rea, T. D., Schmicker, R. H., Vaillancourt, C., Chugh, S. S., Resuscitation Outcomes Consortium 2011; 183 (15): 1705?12

    Abstract

    Low socioeconomic status is associated with poor cardiovascular health. We evaluated the association between socioeconomic status and the incidence of sudden cardiac arrest, a condition that accounts for a substantial proportion of cardiovascular-related deaths, in seven large North American urban populations.Using a population-based registry, we collected data on out-of-hospital sudden cardiac arrests occurring at home or at a residential institution from Apr. 1, 2006, to Mar. 31, 2007. We limited the analysis to cardiac arrests in seven metropolitan areas in the United States (Dallas, Texas; Pittsburgh, Pennsylvania; Portland, Oregon; and Seattle-King County, Washington) and Canada (Ottawa and Toronto, Ontario; and Vancouver, British Columbia). Each incident was linked to a census tract; tracts were classified into quartiles of median household income.A total of 9235 sudden cardiac arrests were included in the analysis. For all sites combined, the incidence of sudden cardiac arrestin the lowest socioeconomic quartile was nearly double that in the highest quartile (incidence rate ratio [IRR] 1.9, 95% confidence interval [CI] 1.8-2.0). This disparity was greater among people less than 65 years old (IRR 2.7, 95% CI 2.5-3.0) than among those 65 or older (IRR 1.3, 95% CI 1.2-1.4). After adjustment for study site and for population age structure of each census tract, the disparity across socioeconomic quartiles for all ages combined was greater in the United States (IRR 2.0, 95% CI 1.9-2.2) than in Canada (IRR 1.8, 95% CI 1.6-2.0) (p<0.001 for interaction).The incidence of sudden cardiac arrest at home or at a residential institution was higher in poorer neighbourhoods of the US and Canadian sites studied, although the association was attenuated in Canada. The disparity across socioeconomic quartiles was greatest among people younger than 65. The association between socioeconomic status and incidence of sudden cardiac arrest merits consideration in the development of strategies to improve survival from sudden cardiac arrest, and possibly to identify opportunities for prevention.

    View details for DOI 10.1503/cmaj.101512

    View details for Web of Science ID 000295730900026

    View details for PubMedID 21911550

    View details for PubMedCentralID PMC3193117

  • A Trial of an Impedance Threshold Device in Out-of-Hospital Cardiac Arrest NEW ENGLAND JOURNAL OF MEDICINE Aufderheide, T. P., Nichol, G., Rea, T. D., Brown, S. P., Leroux, B. G., Pepe, P. E., Kudenchuk, P. J., Christenson, J., Daya, M. R., Dorian, P., Callaway, C. W., Idris, A. H., Andrusiek, D., Stephens, S. W., Hostler, D., Davis, D. P., Dunford, J. V., Pirrallo, R. G., Stiell, I. G., Clement, C. M., Craig, A., Van Ottingham, L., Schmidt, T. A., Wang, H. E., Weisfeldt, M. L., Ornato, J. P., Sopko, G., ROC Investigators 2011; 365 (9): 798?806

    Abstract

    The impedance threshold device (ITD) is designed to enhance venous return and cardiac output during cardiopulmonary resuscitation (CPR) by increasing the degree of negative intrathoracic pressure. Previous studies have suggested that the use of an ITD during CPR may improve survival rates after cardiac arrest.We compared the use of an active ITD with that of a sham ITD in patients with out-of-hospital cardiac arrest who underwent standard CPR at 10 sites in the United States and Canada. Patients, investigators, study coordinators, and all care providers were unaware of the treatment assignments. The primary outcome was survival to hospital discharge with satisfactory function (i.e., a score of ?3 on the modified Rankin scale, which ranges from 0 to 6, with higher scores indicating greater disability).Of 8718 patients included in the analysis, 4345 were randomly assigned to treatment with a sham ITD and 4373 to treatment with an active device. A total of 260 patients (6.0%) in the sham-ITD group and 254 patients (5.8%) in the active-ITD group met the primary outcome (risk difference adjusted for sequential monitoring, -0.1 percentage points; 95% confidence interval, -1.1 to 0.8; P=0.71). There were also no significant differences in the secondary outcomes, including rates of return of spontaneous circulation on arrival at the emergency department, survival to hospital admission, and survival to hospital discharge.Use of the ITD did not significantly improve survival with satisfactory function among patients with out-of-hospital cardiac arrest receiving standard CPR. (Funded by the National Heart, Lung, and Blood Institute and others; ROC PRIMED ClinicalTrials.gov number, NCT00394706.).

    View details for DOI 10.1056/NEJMoa1010821

    View details for Web of Science ID 000294405200006

    View details for PubMedID 21879897

    View details for PubMedCentralID PMC3204381

  • Early versus Later Rhythm Analysis in Patients with Out-of-Hospital Cardiac Arrest NEW ENGLAND JOURNAL OF MEDICINE Stiell, I. G., Nichol, G., Leroux, B. G., Rea, T. D., Ornato, J. P., Powell, J., Christenson, J., Callaway, C. W., Kudenchuk, P. J., Aufderheide, T. P., Idris, A. H., Daya, M. R., Wang, H. E., Morrison, L. J., Davis, D., Andrusiek, D., Stephens, S., Cheskes, S., Schmicker, R. H., Fowler, R., Vaillancourt, C., Hostler, D., Zive, D., Pirrallo, R. G., Vilke, G. M., Sopko, G., Weisfeldt, M., ROC Investigators 2011; 365 (9): 787?97

    Abstract

    In a departure from the previous strategy of immediate defibrillation, the 2005 resuscitation guidelines from the American Heart Association-International Liaison Committee on Resuscitation suggested that emergency medical service (EMS) personnel could provide 2 minutes of cardiopulmonary resuscitation (CPR) before the first analysis of cardiac rhythm. We compared the strategy of a brief period of CPR with early analysis of rhythm with the strategy of a longer period of CPR with delayed analysis of rhythm.We conducted a cluster-randomized trial involving adults with out-of-hospital cardiac arrest at 10 Resuscitation Outcomes Consortium sites in the United States and Canada. Patients in the early-analysis group were assigned to receive 30 to 60 seconds of EMS-administered CPR and those in the later-analysis group were assigned to receive 180 seconds of CPR, before the initial electrocardiographic analysis. The primary outcome was survival to hospital discharge with satisfactory functional status (a modified Rankin scale score of ?3, on a scale of 0 to 6, with higher scores indicating greater disability).We included 9933 patients, of whom 5290 were assigned to early analysis of cardiac rhythm and 4643 to later analysis. A total of 273 patients (5.9%) in the later-analysis group and 310 patients (5.9%) in the early-analysis group met the criteria for the primary outcome, with a cluster-adjusted difference of -0.2 percentage points (95% confidence interval, -1.1 to 0.7; P=0.59). Analyses of the data with adjustment for confounding factors, as well as subgroup analyses, also showed no survival benefit for either study group.Among patients who had an out-of-hospital cardiac arrest, we found no difference in the outcomes with a brief period, as compared with a longer period, of EMS-administered CPR before the first analysis of cardiac rhythm. (Funded by the National Heart, Lung, and Blood Institute and others; ROC PRIMED ClinicalTrials.gov number, NCT00394706.).

    View details for DOI 10.1056/NEJMoa1010076

    View details for Web of Science ID 000294405200005

    View details for PubMedID 21879896

    View details for PubMedCentralID PMC3181067

  • Mechanical versus manual chest compressions for cardiac arrest. The Cochrane database of systematic reviews Brooks, S. C., Bigham, B. L., Morrison, L. J. 2011: CD007260

    Abstract

    Mechanical chest compression devices have been proposed to improve the effectiveness of cardiopulmonary resuscitation (CPR).To assess the effectiveness of mechanical chest compressions versus standard manual chest compressions with respect to neurologically intact survival in patients who suffer cardiac arrest.We searched the Cochrane Central Register of Controlled Studies (CENTRAL) on The Cochrane Library, MEDLINE, EMBASE, Science Citation abstracts, Biotechnology and Bioengineering abstracts and Clinicaltrials.gov in November 2009. No language restrictions were applied. Experts in the field of mechanical chest compression devices and manufacturers were contacted.We included randomised controlled trials (RCTs), cluster RCTs and quasi-randomised studies comparing mechanical chest compressions to manual chest compressions during CPR for patients with atraumatic cardiac arrest.Two authors (SCB and LJM) abstracted data independently. Disagreement between reviewers was resolved by consensus and a third author (BB) if consensus could not be reached. The methodologies of selected studies were evaluated for risk of bias by a single author (SCB). The primary outcome was survival to hospital discharge with good neurologic outcome. We used the DerSimonian & Laird method (random-effects model) to provide a pooled estimate for relative risk with 95% confidence intervals.Four trials, including data from 868 patients, were included in the review. The overall quality of included studies was poor and significant clinical heterogeneity was observed. Only one study (N = 767) reported survival to hospital discharge with good neurologic function (as defined as a Cerebral Performance Category score of 1 or 2), demonstrating reduced survival with mechanical chest compressions when compared with manual chest compressions (RR 0.41 (95% CI 0.21- 0.79). Data from other studies included in this review were used to calculate relative risks for having a return of spontaneous circulation (2 studies, N = 51, pooled RR 2.81, 95% CI 0.96 to 8.22) and survival to hospital admission (1 study, N = 17, RR 4.13, 95% CI 0.19 to 88.71) in patients who received mechanical chest compressions versus those who received manual chest compressions.There is insufficient evidence from human RCTs to conclude that mechanical chest compressions during cardiopulmonary resuscitation for cardiac arrest is associated with benefit or harm. Widespread use of mechanical devices for chest compressions during cardiac is not supported by this review. More RCTs that measure and account for CPR process in both arms are needed to clarify the potential benefit from this intervention.

    View details for DOI 10.1002/14651858.CD007260.pub2

    View details for PubMedID 21249689

  • Ventricular tachyarrhythmias after cardiac arrest in public versus at home. The New England journal of medicine Weisfeldt, M. L., Everson-Stewart, S., Sitlani, C., Rea, T., Aufderheide, T. P., Atkins, D. L., Bigham, B., Brooks, S. C., Foerster, C., Gray, R., Ornato, J. P., Powell, J., Kudenchuk, P. J., Morrison, L. J. 2011; 364 (4): 313?21

    Abstract

    The incidence of ventricular fibrillation or pulseless ventricular tachycardia as the first recorded rhythm after out-of-hospital cardiac arrest has unexpectedly declined. The success of bystander-deployed automated external defibrillators (AEDs) in public settings suggests that this may be the more common initial rhythm when out-of-hospital cardiac arrest occurs in public. We conducted a study to determine whether the location of the arrest, the type of arrhythmia, and the probability of survival are associated.Between 2005 and 2007, we conducted a prospective cohort study of out-of-hospital cardiac arrest in adults in 10 North American communities. We assessed the frequencies of ventricular fibrillation or pulseless ventricular tachycardia and of survival to hospital discharge for arrests at home as compared with arrests in public.Of 12,930 evaluated out-of-hospital cardiac arrests, 2042 occurred in public and 9564 at home. For cardiac arrests at home, the incidence of ventricular fibrillation or pulseless ventricular tachycardia was 25% when the arrest was witnessed by emergency-medical-services (EMS) personnel, 35% when it was witnessed by a bystander, and 36% when a bystander applied an AED. For cardiac arrests in public, the corresponding rates were 38%, 60%, and 79%. The adjusted odds ratio for initial ventricular fibrillation or pulseless ventricular tachycardia in public versus at home was 2.28 (95% confidence interval [CI], 1.96 to 2.66; P < 0.001) for bystander-witnessed arrests and 4.48 (95% CI, 2.23 to 8.97; P<0.001) for arrests in which bystanders applied AEDs. The rate of survival to hospital discharge was 34% for arrests in public settings with AEDs applied by bystanders versus 12% for arrests at home (adjusted odds ratio, 2.49; 95% CI, 1.03 to 5.99; P = 0.04).Regardless of whether out-of-hospital cardiac arrests are witnessed by EMS personnel or bystanders and whether AEDs are applied by bystanders, the proportion of arrests with initial ventricular fibrillation or pulseless ventricular tachycardia is much greater in public settings than at home. The incremental value of resuscitation strategies, such as the ready availability of an AED, may be related to the place where the arrest occurs.

    View details for DOI 10.1056/NEJMoa1010663

    View details for PubMedID 21268723

    View details for PubMedCentralID PMC3062845

  • Patient safety in emergency medical services: executive summary and recommendations from the Niagara Summit. CJEM Bigham, B. L., Bull, E., Morrison, M., Burgess, R., Maher, J., Brooks, S. C., Morrison, L. J. 2011; 13 (1): 13?18

    Abstract

    Emergency medical services (EMS) personnel care for patients in challenging and dynamic environments that may contribute to an increased risk for adverse events. However, little is known about the risks to patient safety in the EMS setting. To address this knowledge gap, we conducted a systematic review of the literature, including nonrandomized, noncontrolled studies, conducted qualitative interviews of key informants, and, with the assistance of a pan-Canadian advisory board, hosted a 1-day summit of 52 experts in the field of EMS patient safety. The intent of the summit was to review available research, discuss the issues affecting prehospital patient safety, and discuss interventions that might improve the safety of the EMS industry. The primary objective was to define the strategic goals for improving patient safety in EMS. Participants represented all geographic regions of Canada and included administrators, educators, physicians, researchers, and patient safety experts. Data were collected through electronic voting and qualitative analysis of the discussions. The group reached consensus on nine recommendations to increase awareness, reduce adverse events, and suggest research and educational directions in EMS patient safety: increasing awareness of patient safety principles, improving adverse event reporting through creating nonpunitive reporting systems, supporting paramedic clinical decision making through improved research and education, policy changes, using flexible algorithms, adopting patient safety strategies from other disciplines, increasing funding for research in patient safety, salary support for paramedic researchers, and access to graduate training in prehospital research.

    View details for DOI 10.2310/8000.2011.100232

    View details for PubMedID 21324292

  • Trauma in the neighborhood: a geospatial analysis and assessment of social determinants of major injury in North America. American journal of public health Newgard, C. D., Schmicker, R. H., Sopko, G., Andrusiek, D., Bialkowski, W., Minei, J. P., Brasel, K., Bulger, E., Fleischman, R. J., Kerby, J. D., Bigham, B. L., Warden, C. R. 2011; 101 (4): 669?77

    Abstract

    We sought to identify and characterize areas with high rates of major trauma events in 9 diverse cities and counties in the United States and Canada.We analyzed a prospective, population-based cohort of injured individuals evaluated by 163 emergency medical service agencies transporting patients to 177 hospitals across the study sites between December 2005 and April 2007. Locations of injuries were geocoded, aggregated by census tract, assessed for geospatial clustering, and matched to sociodemographic measures. Negative binomial models were used to evaluate population measures.Emergency personnel evaluated 8786 major trauma patients, and data on 7326 of these patients were available for analysis. We identified 529 (13.7%) census tracts with a higher than expected incidence of major trauma events. In multivariable models, trauma events were associated with higher unemployment rates, larger percentages of non-White residents, smaller percentages of foreign-born residents, lower educational levels, smaller household sizes, younger age, and lower income levels.Major trauma events tend to cluster in census tracts with distinct population characteristics, suggesting that social and contextual factors may play a role in the occurrence of significant injury events.

    View details for DOI 10.2105/AJPH.2010.300063

    View details for PubMedID 21389292

    View details for PubMedCentralID PMC3052353

  • Cardiac arrest survival did not increase in the Resuscitation Outcomes Consortium after implementation of the 2005 AHA CPR and ECC guidelines. Resuscitation Bigham, B. L., Koprowicz, K., Rea, T., Dorian, P., Aufderheide, T. P., Davis, D. P., Powell, J., Morrison, L. J. 2011; 82 (8): 979?83

    Abstract

    We examined the effect of the 2005 American Heart Association guidelines on survival in the Resuscitation Outcomes Consortium (ROC) Cardiac Arrest Epistry.We surveyed 174 EMS agencies from 8 of 10 ROC sites to determine 2005 AHA guideline implementation, or crossover, date. Two sites with 2005 compatible treatment algorithms prior to guideline release, and agencies that did not adopt the new guidelines during the study period were excluded. Non-traumatic adult cardiac arrests that were not witnessed by EMS, and did not have do not resuscitate orders were included. A linear mixed effects model was applied for survival controlling for time and agency. The "crossover" date was added to the model to determine the effect of the 2005 guidelines.Of 174 agencies, 85 contributed cases to both cohorts during the 18 month period between 2005/12/01 and 2007/05/31. Of 7779 cases, 5054 occurred during the 13 month (median) interval before crossover and 2725 occurred in the five month (median) interval after crossover. The overall survival rate was 6.1%; 5.8% in the old cohort vs. 6.5%, p=0.23. For VF/VT patients, survival was 14.6% vs. 18.0%, p=0.063. Our model estimated no increase in survival over time (monthly OR 1.014, 95% CI 0.988, 1.041, p=0.28).This study found no significant change in survival rate over time in the early months after implementation. Further longitudinal study is needed to determine the full impact of the guidelines on survival and methods to translate knowledge quickly and effectively in EMS.

    View details for DOI 10.1016/j.resuscitation.2011.03.024

    View details for PubMedID 21497983

    View details for PubMedCentralID PMC3744665

  • EMS Provider and Patient Safety during Response and Transport: Proceedings of an Ambulance Safety Conference. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors Brice, J. H., Studnek, J. R., Bigham, B. L., Martin-Gill, C., Custalow, C. B., Hawkins, E., Morrison, L. J. 2011; 16 (1): 3?19

    Abstract

    Abstract The out-of-hospital setting is unique to health care and presents many challenges to providing safe, high-quality medical care in emergency situations. The challenges of the prehospital environment require thoughtful design of systems and processes of care. The unique challenges of ambulance safety may be met by analyzing systems and incorporating process improvements. The purposes of this paper are to 1) outline the nature of this problem, 2) introduce a framework for this discussion, 3) provide expert opinion from a two-day ambulance safety conference, and 4) propose a plan of action to address the safety issues identified in the literature and expert opinion at the conference. Utilizing the Haddon Matrix as a framework, we present the safety issues and proposed solutions for factors contributing to an injury event in the emergency medical services (EMS) transport environment: host, agent, physical environment, and social environment. Host refers to the person or persons at risk, in this case, the EMS personnel or the patient. The agent of injury refers to the energy exerted during the course of an injury, and may be modified to include unrestrained equipment that contributes to the injury. The physical environment refers to the characteristics of the setting in which the injury takes place, such as the roadway or the physical design of the ambulance. Finally, the social environment refers to the social, legal, and cultural norms and practices in the society, such as peer pressure and a culture that discourages the use of safety equipment.

    View details for DOI 10.3109/10903127.2011.626106

    View details for PubMedID 22023217

  • Perishock pause: an independent predictor of survival from out-of-hospital shockable cardiac arrest. Circulation Cheskes, S., Schmicker, R. H., Christenson, J., Salcido, D. D., Rea, T., Powell, J., Edelson, D. P., Sell, R., May, S., Menegazzi, J. J., Van Ottingham, L., Olsufka, M., Pennington, S., Simonini, J., Berg, R. A., Stiell, I., Idris, A., Bigham, B., Morrison, L. 2011; 124 (1): 58?66

    Abstract

    Perishock pauses are pauses in chest compressions before and after defibrillatory shock. We examined the relationship between perishock pauses and survival to hospital discharge.We included out-of-hospital cardiac arrest patients in the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest who suffered arrest between December 2005 and June 2007, presented with a shockable rhythm (ventricular fibrillation or pulseless ventricular tachycardia), and had cardiopulmonary resuscitation process data for at least 1 shock (n=815). We used multivariable logistic regression to determine the association between survival and perishock pauses. In an analysis adjusted for Utstein predictors of survival, the odds of survival were significantly lower for patients with preshock pause ?20 seconds (odds ratio, 0.47; 95% confidence interval, 0.27 to 0.82) and perishock pause ?40 seconds (odds ratio, 0.54; 95% confidence interval, 0.31 to 0.97) compared with patients with preshock pause <10 seconds and perishock pause <20 seconds. Postshock pause was not independently associated with a significant change in the odds of survival. Log-linear modeling depicted a decrease in survival to hospital discharge of 18% and 14% for every 5-second increase in both preshock and perishock pause interval (up to 40 and 50 seconds, respectively), with no significant association noted with changes in the postshock pause interval.In patients with cardiac arrest presenting in a shockable rhythm, longer perishock and preshock pauses were independently associated with a decrease in survival to hospital discharge. The impact of preshock pause on survival suggests that refinement of automatic defibrillator software and paramedic education to minimize preshock pause delays may have a significant impact on survival.

    View details for DOI 10.1161/CIRCULATIONAHA.110.010736

    View details for PubMedID 21690495

    View details for PubMedCentralID PMC3138806

  • Methodology for the development of a Canadian national EMS research agenda. BMC emergency medicine Jensen, J. L., Blanchard, I. E., Bigham, B. L., Dainty, K. N., Socha, D., Carter, A., Brown, L. H., Craig, A. M., Travers, A. H., Brown, R., Cain, E., Morrison, L. J. 2011; 11: 15

    Abstract

    Many health care disciplines use evidence-based decision making to improve patient care and system performance. While the amount and quality of emergency medical services (EMS) research in Canada has increased over the past two decades, there has not been a unified national plan to enable research, ensure efficient use of research resources, guide funding decisions and build capacity in EMS research. Other countries have used research agendas to identify barriers and opportunities in EMS research and define national research priorities. The objective of this project is to develop a national EMS research agenda for Canada that will: 1) explore what barriers to EMS research currently exist, 2) identify current strengths and opportunities that may be of benefit to advancing EMS research, 3) make recommendations to overcome barriers and capitalize on opportunities, and 4) identify national EMS research priorities.Paramedics, educators, EMS managers, medical directors, researchers and other key stakeholders from across Canada will be purposefully recruited to participate in this mixed methods study, which consists of three phases: 1) qualitative interviews with a selection of the study participants, who will be asked about their experience and opinions about the four study objectives, 2) a facilitated roundtable discussion, in which all participants will explore and discuss the study objectives, and 3) an online Delphi consensus survey, in which all participants will be asked to score the importance of each topic discovered during the interviews and roundtable as they relate to the study objectives. Results will be analyzed to determine the level of consensus achieved for each topic.A mixed methods approach will be used to address the four study objectives. We anticipate that the keys to success will be: 1) ensuring a representative sample of EMS stakeholders, 2) fostering an open and collaborative roundtable discussion, and 3) adhering to a predefined approach to measure consensus on each topic. Steps have been taken in the methodology to address each of these a priori concerns.

    View details for DOI 10.1186/1471-227X-11-15

    View details for PubMedID 21961624

    View details for PubMedCentralID PMC3203066

  • Effect of Gender on Outcome of Out of Hospital Cardiac Arrest in the Resuscitation Outcomes Consortium Rac, V. E., Schmicker, R. H., Weisfeldt, M. L., Bigham, B. L., Berg, R. A., Topjian, A., Abramson, B., Atkins, D. L., Morrison, L. J., ROC Investigators LIPPINCOTT WILLIAMS & WILKINS. 2010
  • Chest Compression Rates Used During Out-of-Hospital Cardiopulmonary Resuscitation in Nine Resuscitation Outcomes Consortium Regional Sites Idris, A. H., Nichols, P., Schroeder, D., Everson-Stewart, S., Powell, J. L., Callaway, C. W., Morrison, L., Aufderheide, T. P., Rea, T., Atkins, D., Berg, R., Bigham, B., Davis, D., Stiell, I., Sopko, G., Nichol, G., Resuscitation Outcomes Consortium LIPPINCOTT WILLIAMS & WILKINS. 2010
  • Peri-Shock Pause: an Independent Predictor of Survival From Out-of-Hospital Shockable Cardiac Arrest Cheskes, S., Schmicker, R. H., Christenson, J., Menegazzi, J. J., Rea, T., Powell, J., May, S., Salcido, D. D., Olsufka, M., Pennington, S., Simonini, J., Edelson, D., Stiell, I., Berg, R. A., Van Ottingham, L., Idris, A., Sell, R., Bigham, B., Morrison, L., ROC Investigators LIPPINCOTT WILLIAMS & WILKINS. 2010
  • Knowledge translation in emergency medical services: A qualitative survey of barriers to guideline implementation RESUSCITATION Bigham, B. L., Aufderheide, T. P., Davis, D. P., Powell, J., Donn, S., Suffoletto, B., Nafziger, S., Stouffer, J., Morrison, L. J., ROC Investigators 2010; 81 (7): 836?40

    Abstract

    The American Heart Association (AHA) released guidelines to improve survival rates from out-of-hospital cardiac arrest in 2005. We sought to identify what barriers delayed the implementation of these guidelines in EMS agencies.We surveyed 178 EMS agencies as part of a larger quantitative survey regarding guideline implementation and conducted a single-question semi-structured interview using the Grounded Theory method. We asked "What barriers if any, delayed implementation of the (2005 AHA) guidelines in your EMS agency?" Data were coded and member validation was employed to verify our findings.176/178 agencies completed the quantitative survey. Qualitative data collection ceased after reaching theoretical saturation with 34 interviews. Ten unique barriers were identified. We categorized these 10 barriers into three themes. The theme instruction delays (reported by 41% of respondents) included three barriers: booking/training instructors (9%), receiving training materials (15%), and scheduling staff for training (18%). The second theme, defibrillator delays (38%), included two barriers; reprogramming defibrillators (24%) and receiving new defibrillators to replace non-upgradeable units (15%). The third theme was decision-making (38%) and included five barriers; coordinating with allied agencies (9%), government regulators such as state and provincial health authorities (9%), medical direction and base hospitals (9%), ROC participation (9%), and internal crises (3%).Many barriers contributed to delays in the implementation of the 2005 AHA guidelines in EMS agencies. These identified barriers should be proactively addressed prior to the 2010 Guidelines to facilitate rapid translation of science into clinical practice.

    View details for DOI 10.1016/j.resuscitation.2010.03.012

    View details for Web of Science ID 000279758500014

    View details for PubMedID 20398994

    View details for PubMedCentralID PMC3209799

  • DELAYED PREHOSPITAL IMPLEMENTATION OF THE 2005 AMERICAN HEART ASSOCIATION GUIDELINES FOR CARDIOPULMONARY RESUSCITATION AND EMERGENCY CARDIAC CARE PREHOSPITAL EMERGENCY CARE Bigham, B. L., Koprowicz, K., Aufderheide, T. P., Davis, D. P., Donn, S., Powell, J., Suffoletto, B., Nafziger, S., Stouffer, J., Idris, A., Morrison, L. J., ROC Investigators 2010; 14 (3): 355?60

    Abstract

    In 2005, the American Heart Association (AHA) released guidelines to improve survival rates from out-of-hospital cardiac arrest (OHCA).To determine if, and when, emergency medical services (EMS) agencies participating in the Resuscitation Outcomes Consortium (ROC) implemented these guidelines.We contacted 178 EMS agencies and completed structured telephone interviews with 176 agencies. The survey collected data on specific treatment protocols before and after implementation of the 2005 guidelines as well as the date of implementation crossover (the "crossover date"). The crossover date was then linked to a database describing the size, type, and structure of each agency. Descriptive statistics and regression were used to examine patterns in time to crossover.The 2005 guidelines were implemented by 174 agencies (99%). The number of days from guideline release to implementation was as follows: mean 416 (standard deviation 172), median 415 (range 49-750). There was no difference in time to implementation in fire-based agencies (mean 432), nonfire municipal agencies (mean 365), and private agencies (mean 389, p = 0.31). Agencies not providing transport took longer to implement than agencies that transported patients (463 vs. 384 days, p = 0.004). Agencies providing only basic life support (BLS) care took longer to implement than agencies who provided advanced life support (ALS) care (mean 462 vs. 397 days, p = 0.03). Larger agencies (>10 vehicles) were able to implement the guidelines more quickly than smaller agencies (mean 386 vs. 442 days, p = 0.03). On average, it took 8.9 fewer days to implement the guidelines for every 50% increase in EMS-treated runs/year to which an agency responded.ROC EMS agencies required an average of 416 days to implement the 2005 AHA guidelines for OHCA. Small EMS agencies, BLS-only agencies, and nontransport agencies took longer than large agencies, agencies providing ALS care, and transport agencies, respectively, to implement the guidelines. Causes of delays to guideline implementation and effective methods for rapid EMS knowledge translation deserve investigation.

    View details for DOI 10.3109/10903121003770639

    View details for Web of Science ID 000283118400012

    View details for PubMedID 20388032

    View details for PubMedCentralID PMC3209500

  • A Critical Assessment of the Out-of-Hospital Trauma Triage Guidelines for Physiologic Abnormality JOURNAL OF TRAUMA-INJURY INFECTION AND CRITICAL CARE Newgard, C. D., Rudser, K., Hedges, J. R., Kerby, J. D., Stiell, I. G., Davis, D. P., Morrison, L. J., Bulger, E., Terndrup, T., Minei, J. P., Bardarson, B., Emerson, S., ROC Investigators 2010; 68 (2): 452?62

    Abstract

    It remains unclear whether the American College of Surgeons Committee on Trauma (ACSCOT) "step 1" field physiologic criteria could be further restricted without substantially sacrificing sensitivity. We assessed whether more restrictive physiologic criteria would improve the specificity of this triage step without missing high-risk patients.We analyzed an out-of-hospital, consecutive patient, prospective cohort of injured adults >or=15 years collected from December 1, 2005, to February 28, 2007, by 237 emergency medical service agencies transporting to 207 acute care hospitals in 11 sites across the United States and Canada. Patients were included based on ACSCOT field decision scheme physiologic criteria systolic blood pressure 29 breaths/min, Glasgow Coma Scale score 2 days.Of 7,127 injured persons, 6,259 had complete outcome information and were included in the analysis. There were 3,631 (58.0%) persons with death or LOS >2 days. Using only physiologic measures, the derived rule included advanced airway intervention, shock index >1.4, Glasgow Coma Scale <11, and pulse oximetry <93%. Rule validation demonstrated sensitivity 72% (95% confidence interval: 70%-74%) and specificity 69% (95% confidence interval: 67%-72%). Inclusion of demographic and mechanism variables did not significantly improve performance measures.We were unable to omit or further restrict any ACSCOT step 1 physiologic measures in a decision rule practical for field use without missing high-risk trauma patients.

    View details for DOI 10.1097/TA.0b013e3181ae20c9

    View details for Web of Science ID 000274492600043

    View details for PubMedID 20154558

    View details for PubMedCentralID PMC3785297

  • Predictors of adopting therapeutic hypothermia for post-cardiac arrest patients among Canadian emergency and critical care physicians. Resuscitation Bigham, B. L., Dainty, K. N., Scales, D. C., Morrison, L. J., Brooks, S. C. 2010; 81 (1): 20?24

    Abstract

    Therapeutic hypothermia improves outcomes in resuscitated cardiac arrest patients, but prior application rates are less than 30%. We sought to evaluate self-reported physician adoption, predictors of adoption, and barriers to use among Canadian emergency and critical care physicians. A web-based modified Dillman questionnaire asked all physicians on the membership lists of the Canadian Association of Emergency Physicians and the Canadian Critical Care Forum physicians to report their experience with therapeutic hypothermia using the Pathman framework of changing physician behaviour. We used logistic regression to explore the association between physician and practice variables and the adoption of therapeutic hypothermia. We surveyed 1264 physicians; 39% responded. Most (78%) were emergency physicians, 54% worked at tertiary care hospitals, 62% treated >10 arrests annually and 50% had standardized cooling protocols. Most respondents were aware of therapeutic hypothermia (99%) and agreed that it is beneficial (91%), but only two-thirds (68%) had used it in clinical practice. Predictors for adopting therapeutic hypothermia included critical care field of practice (OR 6.3, 95% CI 2.5-16.0), availability of a cooling protocol (OR 5.6, CI 3.1-10.0), being <10 years post-residency (OR 2.0, CI 1.2-3.3), and treating >10 cardiac arrests annually (OR 2.6, CI 1.6-4.1). Common barriers included: lack of awareness of recommended practice (31%), perceptions of poor prognosis (25%), too much work required to cool (20%) and staffing shortages (20%). Therapeutic hypothermia after cardiac arrest has not been universally adopted. Adoption might be improved through protocol implementation, education about benefits and prognosis, and strategies to make administration easier.

    View details for DOI 10.1016/j.resuscitation.2009.09.022

    View details for PubMedID 19913981

  • Increased survival after EMS witnessed cardiac arrest. Observations from the Resuscitation Outcomes Consortium (ROC) Epistry-Cardiac arrest. Resuscitation Hostler, D., Thomas, E. G., Emerson, S. S., Christenson, J., Stiell, I. G., Rittenberger, J. C., Gorman, K. R., Bigham, B. L., Callaway, C. W., Vilke, G. M., Beaudoin, T., Cheskes, S., Craig, A., Davis, D. P., Reed, A., Idris, A., Nichol, G. 2010; 81 (7): 826?30

    Abstract

    Out of hospital cardiac arrest (OHCA) is common and lethal. It has been suggested that OHCA witnessed by EMS providers is a predictor of survival because advanced help is immediately available. We examined EMS witnessed OHCA from the Resuscitation Outcomes Consortium (ROC) to determine the effect of EMS witnessed vs. bystander witnessed and unwitnessed OHCA.Data were analyzed from a prospective, population-based cohort study in 10 U.S. and Canadian ROC sites. Individuals with non-traumatic OHCA treated 04/01/06-03/31/07 by EMS providers with defibrillation or chest compressions were included. Cases were grouped into EMS-witnessed, bystander witnessed, and unwitnessed and further stratified for bystander CPR. Multiple logistic regressions evaluated the odds ratio (OR) for survival to discharge relative to the EMS-witnessed group after adjusting for age, sex, public/private location of collapse, ROC site, and initial ECG rhythm. Of 9991 OHCA, 1022 (10.2%) of EMS-witnessed, 3369 (33.7%) bystander witnessed, and 5600 (56.1%) unwitnessed.The most common initial rhythm in the EMS-witnessed group was PEA which was higher than in the bystander- and unwitnessed groups (p<0.001). The adjusted OR (95% CI) of survival compared to the EMS-witnessed group was 0.41, (0.36, 0.46) in bystander witnessed with bystander CPR, 0.37 (0.33, 0.43) in bystander witnessed without bystander CPR, 0.17 (0.14, 0.20) in unwitnessed with bystander CPR and 0.21 (0.18, 0.24) in unwitnessed cases without bystander CPR.Immediate application of prehospital care for OHCA may improve survival. Efforts should be made to educate patients to access 9-1-1 for prodromal symptoms.

    View details for DOI 10.1016/j.resuscitation.2010.02.005

    View details for PubMedID 20403656

    View details for PubMedCentralID PMC2893256

  • Paramedic-driven research. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne Bigham, B. L., Jensen, J. L., Blanchard, I. E. 2010; 182 (10): 1080

    View details for DOI 10.1503/cmaj.110-2079

    View details for PubMedID 20624883

    View details for PubMedCentralID PMC2900337

  • Predicting survival after out-of-hospital cardiac arrest: role of the Utstein data elements. Annals of emergency medicine Rea, T. D., Cook, A. J., Stiell, I. G., Powell, J., Bigham, B., Callaway, C. W., Chugh, S., Aufderheide, T. P., Morrison, L., Terndrup, T. E., Beaudoin, T., Wittwer, L., Davis, D., Idris, A., Nichol, G. 2010; 55 (3): 249?57

    Abstract

    Survival after out-of-hospital cardiac arrest depends on the links in the chain of survival. The Utstein elements are designed to assess these links and provide the basis for comparing outcomes within and across communities. We assess whether these measures sufficiently predict survival and explain outcome differences.We used an observational, prospective data collection, case-series of adult persons with nontraumatic out-of-hospital cardiac arrest from December 1, 2005, through March 1, 2007, from the multisite, population-based Resuscitation Outcomes Consortium Epistry-Cardiac Arrest. We used logistic regression, receiver operating curves, and measures of variance to estimate the extent to which the Utstein elements predicted survival to hospital discharge and explained outcome variability overall and between 7 Resuscitation Outcomes Consortium sites. Analyses were conducted for all emergency medical services-treated cardiac arrests and for the subset of bystander-witnessed patient arrests because of presumed cardiac cause presenting with ventricular fibrillation or ventricular tachycardia.Survival was 7.8% overall (n=833/10,681) and varied from 4.6% to 14.7% across Resuscitation Outcomes Consortium sites. Among bystander-witnessed ventricular fibrillation or ventricular tachycardia, survival was 22.1% overall (n=323/1459) and varied from 12.5% to 41.0% across sites. The Utstein elements collectively predicted 72% of survival variability among all arrests and 40% of survival variability among bystander-witnessed ventricular fibrillation. The Utstein elements accounted for 43.6% of the between-site survival difference among all arrests and 22.3% of the between-site difference among the bystander-witnessed ventricular fibrillation subset.The Utstein elements predict survival but account for only a modest portion of outcome variability overall and between Resuscitation Outcomes Consortium sites. The results underscore the need for ongoing investigation to better understand characteristics that influence cardiac arrest survival.

    View details for DOI 10.1016/j.annemergmed.2009.09.018

    View details for PubMedID 19944488

  • Barriers to Guideline Implementation: A Qualitative Survey of Emergency Medical Services Bigham, B. L., Aufderheide, T. P., Donn, S., Stouffer, J. A., Powell, J., Suffoletto, B., Davis, D. P., Nafziger, S., Idris, A., Helbock, M., Morrison, L. J. LIPPINCOTT WILLIAMS & WILKINS. 2008: S822
  • Survival Unchanged Five Months After Implementing The 2005 AHA CPR And ECC Guidelines For Out-of-hospital Cardiac Arrest Bigham, B. L., Koprowicz, K., Kiss, A., Dorian, P., Emerson, S., Zhan, C., Rea, T. D., Aufdarheide, T. P., Powell, J., Cheskes, S., Davis, D. P., Stouffer, J. A., Perry, J., Lees, M., Morrison, L. J. LIPPINCOTT WILLIAMS & WILKINS. 2008: S765
  • Patients with an AED Applied by a Bystander In a Public Setting have a Strikingly Higher Frequency of VT/VF Than Observed Cardiac Arrests in the Home Weisfeldt, M. L., Sitlani, C., Rea, T., Atkins, D., Aufderheide, T. P., Bigham, B., Brooks, S., Foerster, C., Ornato, J. P., Powell, J., Van Ottingham, L., Morrison, L. J. LIPPINCOTT WILLIAMS & WILKINS. 2008: S1481?S1482
  • What Is the Role of Chest Compression Depth during Out-of-Hospital CPR? Stiell, I. G., Everson-Stewart, S., Christenson, J., Cheskes, S., Powell, J., Bigham, B., Morrison, L., Larsen, J., Nichol, G., Hess, E., Valllancourt, C., Davis, D. P., Callaway, C. W., Resuscitation Outcomes Consortium LIPPINCOTT WILLIAMS & WILKINS. 2008: S1487
  • EMS Agencies Implemented the 2005 AHA Guidelines for CPR and ECC an Average of 416 Days after Their Release Bigham, B. L., Koprowicz, K., Stouffer, J. A., Aufderheide, T. P., Donn, S., Powell, J., Davis, D. P., Nafziger, S., Suffoletto, B., Idris, A., Helbock, M., Morrison, L. J. LIPPINCOTT WILLIAMS & WILKINS. 2008: S822
  • Termination of resuscitation: a guide to interpreting the literature. Resuscitation Morrison, L. J., Bigham, B. L., Kiss, A., Verbeek, P. R. 2008; 79 (3): 387?90

    Abstract

    Prehospital termination of resuscitation rules are used to decide on one of two actions: to continue resuscitation and transport to hospital or to terminate resuscitation. The literature is confusing as some rules are derived with survival as the outcome of interest (predicting when to transport and reporting sensitivity and negative predictive value) and other rules use death (predicting when to terminate resuscitation and reporting specificity and positive predictive value). Very few publish the EMS transport rate when the rule is applied; the outcome of interest to EMS services.We propose to review the test characteristics and transport rates of the decision rules published between 1966 and 2007.We identified 9 analyses of 6 termination of resuscitation rules; 1 inhospital, and 5 prehospital (2 advance and 3 basic life support providers). The inhospital and the basic life support rules were derived using survival whereas the advance life support rules were derived using death. The transport rate was published in two studies. When all the rules were reanalysed for death the specificity varied from 90.2% to 100%, the positive predictive value from 99.5% to 100% and the transport rate varied from 37% to 91%.We suggest that the diagnostic test characteristics of termination of resuscitation rules should be reported with death as the primary outcome which identifies for the paramedics futile resuscitations that should be terminated in the field. We also emphasize the need to report transport rates to provide the EMS services with an implementation benchmark.

    View details for DOI 10.1016/j.resuscitation.2008.07.009

    View details for PubMedID 18805621

  • Survival after EMS witnessed cardiac arrest. Observations from the resuscitation outcomes consortium (ROC)epistry all cardiac arrest Hostler, D., Thomas, E. G., Emerson, S., Christenson, J., Ritteriberger, J. C., Bigham, B., Callaway, C., Stiell, I. G., Vilke, G. M., Beaudoin, T., Cheskes, S., Craig, A., Davis, D. P., Gorman, K. R., Reed, A., Nichol, G. LIPPINCOTT WILLIAMS & WILKINS. 2007: 484
  • Predictors of out-of-hospital cardiac arrest survival: Influence of the Utstein measures Rea, T., Cook, A. J., Aufderheide, T. P., Beaudoin, T., Bigham, B., Callaway, C., Chugh, S., Davis, D., Diris, A., Morrison, L. J., Nichol, G., Powell, J. L., Stiell, I. G., Terndrup, T., Thiruganasambandamoorthy, V., Wittwer, L. LIPPINCOTT WILLIAMS & WILKINS. 2007: 435

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