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Focus on Improving Cardiac Arrest Survival The Danish Fairytale: more than doubling survival in a decade By Fredrik Folke, Associate Professor, Emergency Medical Services, University of Copenhagen, Denmark; Christian Torp-Pedersen, Professor, Aalborg University, Denmark; Mads Wissenberg, MD, PhD, Emergency Medical Services, University of Copenhagen, Denmark; Freddy K. Lippert, Chief Executive Director, Emergency Medical Services, University of Copenhagen, Denmark Out-of-hospital cardiac arrest (OHCA) is a major health problem in the Western World - not only in Denmark with 3500 arrests every year - but also on a worldwide level with more than 700,000 arrests in the United States and Europe with often only 5-8 % survival rate. Since 2001, Denmark has succeeded in raising bystander CPR from 19% to 65%. In the same period, survival has increased from 4% to 12%. Tripling both bystander cardiopulmonary resuscitation (CPR) and survival from OHCA in just a decade is an extraordinary improvement, and it is the result of targeted action from many stakeholders in Danish society and a number of important initiatives. A goal was set The Danish Cardiac Arrest Register documented that in 2001 bystanders provided CPR in only 19% of OHCA cases; defibrillation before ambulance arrival was anecdotal and the 30-day survival rate was merely 4%. The common culture was only to perform CPR if you had attended a first aid course, and laymen did not know what an automated external defibrillator (AED) was. It was an untenable situation. To save more lives, help from laypeople was needed. An ambitious goal was set in 2003: to get bystanders to provide CPR in more than 50% of cardiac arrests and improve cardiac arrest survival. These goals were to be achieved by several national initiatives to strengthen bystander resuscitation, public access defibrillation and advanced cardiac arrest care. Danish initiatives In 2005 resuscitation training became mandatory in Danish elementary schools and from 2006 CPR courses became mandatory when taking a driver’s license. Furthermore, approximately 150,000 CPR self-instruction kits were distributed between 2005 and 2010 along with an increase in CPR course certificates from 175,000 annually in 2001-2004 to 300,000 annually 2008-2010. The Danish AED network In 2008, the non-commercial Danish Foundation TrygFonden founded the Danish AED network where all private and public owners of an AED can register their devices and everybody can see where the nearest AED is located (www.hjertestarter.dk). Also, the Danish Resuscitation Council, The National Board of Health and TrygFonden hosted the first national AED conference. At the conference The National Board of Health launched important recommendations to all owners of AEDs. Significant recommendations are to register the AEDs in the national AED network (Hjertestarter. dk) and to place AEDs outdoors so that they are accessible 24/7. To further support bystander defibrillation, TrygFonden launched a smart-phone app in 2010 with online information on all available AEDs from the AED network (hjertestarter.dk) Role of the emergency dispatch centre The Danish emergency medical dispatch centres were given access to the AED register in 2011, allowing the dispatchers to help bystanders to the nearest available AED. In addition, the Danish emergency dispatch centres were staffed by medically trained health care professionals the same year (instead of firefighters or police officers), offering telephone assisted CPR, which increased bystander CPR even further. Post cardiac arrest treatment Along with the pre-hospital initiatives of improving OHCA resuscitation, there has been an increased focus on the in-hospital effort to improve cardiac arrest care according to the newest guidelines, including introduction of therapeutic hypothermia and early revascularization. Research as a cornerstone Four emergency medicine professors have been appointed to enhance research within the pre-hospital field. Numerous PhD-students are conducting research and winning international awards – including 2 x ERC Young Investigator Award and an AHA Young Investigator Award. Their research has been published in recognized journals like Journal of American Medical Association (JAMA), Circulation, The Journal of the American Heart Association, Resuscitation, and the journal of the European Resuscitation Council. Funding for research A main contributor to the massive change in the Danish public’s perception about CPR is TrygFonden. Only 15 years ago, the first-aidculture was articulated as something very serious and the perception in the general public was that you should only perform CPR if you had attended a first aid course; laymen did not know what an AED was. Since 2004, TrygFonden has continuously pushed these messages to the Danes: “Just do it. It is better to do something than not to do anything,” and: “you can’t do any more harm to a person who is already dead, so do your best.” 32 Spring 2016 | Ambulancetoday
Focus on Improving Cardiac Arrest Survival Source: M. Wissenberg et. al. in JAMA 2013, “Association of National Initiatives to Improve Cardiac Arrest Management With Rates of Bystander Intervention and Patient Survival After Out-of-Hospital Cardiac Arrest” http://jama.jamanetwork.com/article.aspx?articleid=1745678 The Danish experience In 2011 the ambitious goal from 2003 was reached. Bystanders provided CPR in 58% of all OHCA incidents. This result was presented to the Danish Public through extensive media coverage at the first ‘Restart a Heart Day’ in October 2012. In 2013, bystander CPR further increased to 65% and OHCA survival reached 12%. Furthermore, more than 13,000 publicly available AEDs across the nation - for a population of 5.7 million - were registered at the AED network at the beginning of 2016 and defibrillation by lay-first-responders before EMS arrival reached more than 12% in public locations. It is also documented that 75% of cardiac arrest survivors who were at work before their cardiac arrest returned back to work after successful resuscitation. The figure below shows the temporal increase of bystander CPR (green line), the 30-day survival rate (red bars) and the increase in defibrillation before EMS arrival (blue line) from 2001-2013 in Denmark. The ugly duckling turning into a beautiful swan The case of Denmark is a story about how far you can move societal behavior within a decade by combining a high level of research, by establishing nationwide systems including community programs, by motivating citizens through communication and by changing public policy through lobbying. Through all of these interventions, Denmark has tripled both bystander CPR and survival within a period of 12 years. New goals The new ambition for Denmark is to raise bystander CPR to 85%, to further improve defibrillation before EMS arrival and to improve 30-day OHCA survival to more than 15%. To achieve this, Denmark is hosting a prestigious Utstein meeting on cardiac arrest in May where a Global Resuscitation Alliance is to be established, aiming at increasing community cardiac arrest survival by an ambitious 50%. This meeting is followed by another new and prestigious event - the first international Emergency Medical Services congress in Europe. The Danish fairy tale, its results and experiences will be presented and discussed. TrygFonden and the Laerdal Foundation are key partners for the international Utstein meeting and for EMS2016. Source: Utstein paper on Global Resuscitation Alliance: www.resuscitationacademy.org/wp-content/ uploads/2016/03/A-Call-to-Establish-a-Global-Resuscitation-Alliance1.pdf You can read more about EMS2016 and about the Global Resuscitation Alliance in this edition of Ambulance Today. Spring 2016 | Ambulancetoday 33 3
Page 1 and 2: TODAY Spring 2016 - Issue 1 | Volum
Page 3 and 4: Guest Editor’s Comment Now is the
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Page 7 and 8: Some thoughts from EMS2016 keynote
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