Victorian Ambulance Cardiac Arrest Registry (VACAR) Dr Karen Smith (PhD) VACAR Chair Manager Research and Evaluation Ambulance Victoria Smith K, Bray J, Barnes V, Lodder M, Cameron P, Bernard S and Currell A on behalf of the VACAR Steering Committee
Victorian Ambulance Cardiac
Arrest Registry (VACAR)
Dr Karen Smith (PhD)
VACAR Chair
Manager Research and Evaluation Ambulance Victoria
Smith K, Bray J, Barnes V, Lodder M, Cameron P, Bernard S
and Currell A on behalf of the VACAR Steering Committee
Ambulance Victoria
• Provides EMS for state of Victoria (amalgamation of two services MAS and RAV in 2008) –pop of
5.4 million
• Operates a two-tiered emergency medical service (EMS) response for all suspected cardiac
arrests
– 2143 ALS paramedics who are authorised to provide defibrillation, laryngeal mask airway
insertion and intravenous administration of epinephrine.
– 416 intensive care paramedics are authorised to perform endotracheal intubation and
administer a range of additional cardiac drugs such as amiodarone and sodium
biacarbonate.
• Response to suspected cardiac arrests also includes fire first responders for inner Melbourne and
CERTS (29 teams) in rural areas
• Cardiac arrest protocols follow the recommendations of the Australian Resuscitation Council
• Patients with ROSC are transported to the nearest hospital with an emergency department.
VACAR
• Funded by Victorian Dept Health
• Classified as Quality Assurance
• Employs 5 staff including a Senior Research Fellow
• Overseen by Steering Committee including AV, Medical
Directors and Monash University
• Aims to collect data on all cardiac arrest patients
attended by ambulance in Victoria
• Data collection dates back to 1999
Value of Registry
• Benchmark patient outcomes and ambulance response intervals
• Describe the epidemiology of out-of-hospital cardiac arrest in Victoria
• Identify modifiable predictors of outcome and model impact of changes
• Assist in the analysis of the sensitivity and specificity of the ambulance dispatch protocol
• Aid in the audit of ambulance patient care record compliance and quality assurance (provide feedback to teams)
• Monitor trends and impact of new treatment regimes and programs
• Base-line for clinical trials
• Aid in monitoring paramedic treatment experience.
Registry
Cases identified
• via data filter, manual PCR sort, Team Managers and clinical
audits
Registry
• Based on Utstein template and definitions
• Extracts clinical and operational data from PCRs (AV and Fire) and
operational databases
• Supplemented with hospital discharge data (date, direction,
diagnosis) (Ethics approvals from > 100 participating hospitals)
• Data entry lags 2-3 weeks post event
• Some coroners data (aetiology) included for discrete projects
Quality of Life
• VACAR has commenced a QOL follow-up on adult patients arresting
from Jan 2010 onwards
• Follow-up at 12-months post arrest
• Death registry checked prior to contact
• Built into ongoing DH funding
• Tools:
• Residential and work status question
• GOSE
• EQ5D
• SF-12
• Discharged patients sent a letter explaining intended follow-up
• Phoned – approx 30 minute interview
• Outsourced to Monash University- experience and align with VSTR
• For Jan- Mar 2010: QOL obtained for 84% of discharged adult
patients who are alive at 12-months
Quality Control
• Mandatory fields
• Validation of field combinations
• Range validations
• Rhythm confirmation from ECG
• Monthly retrospective audit (10% cases-random)
• Targeted retrospective reviews
• Senior paramedics audit all cases for:
• Defibrillated patients
• Death in AV care
Data Reasonably Complete
All cardiac arrests attended by AV 2000-2009 (n=46,388)
Key field Missing items (%)
Age 1939 (4.2%)
Gender 373 (0.8%)
Arrest location type 4
Witnessed status 600 (1.3%)
Bystander CPR 2719 (5.9%)
Outcome at scene 49 (0.1%)
Hospital discharge status 592 (1.3%)
EMS response time 1352 (2.9%)
Presenting rhythm 169 (0.4%)
Epidemiology
All arrests attended by AV over 10 years (2000-2009)
Item Number (%)
Total patients 46,399 (range 3,779 – 5,259 per year)
Presumed cardiac aetiology 33847 (73.0%)
Witnessed
By public
By paramedics
13,641 (29.4%)
3,065 (6.6%)
Male Gender 30,353 (65.6%)
Adult arrests (>15 years) 45,520 (98.1%)
Median age (IQR) 70 years (28)
Arrest at home 34, 125 (73.6%)
Resuscitation initiated by EMS 19,911 (42.9%)
EMS response time (call to scene):
Median
90th percentile
8
16
Metropolitan location 34335 (74%)
Precipitating event
Proportion with resuscitation attempted by EMS (adult patients)
Cardiac
Trauma
Respiratory
Overdose
Drowning
Hanging
Other
Age cohorts (all OHCA 2000-2010)
Series1, <2 years, 1.0% Series1, 3-17 years,
1.0%
Series1, 18-39 years, 11%
Series1, 40-59 years, 20%
Series1, 60-79 years, 38%
Series1, >80 years, 26%
Series1, Missing, 3%
Arrest Location (all OHCA 2000-2010)
Series1, Home , 73%
Series1, Public place, 16%
Series1, Nursing home /hostel, 7%
Series1, Work, 2% Series1, Medical
center, 2%
Survival influenced by usual predictors
Odds ratio P value 95% CI
VF/VT 5.76 <0.001 4.83 – 6.87
Witnessed 2.03 <0.001 1.70 – 2.43
Bystander CPR 1.34 <0.001 1.16 – 1.56
Female 1.20 0.028 1.02 – 1.42
Year of arrest 1.12 <0.001 1.09 – 1.15
Age 0.98 <0.001 0.97 – 0.98
EMS response time 0.90 <0.001 0.88 – 0.92
Arrest at home 0.62 <0.001 0.54 – 0.72
Adult, presumed cardiac, resuscitation attempted by EMS (n= 11,829)
Excludes EMS witnessed
Survival (adult all aetiologies)
Increased survival over the decade
Adult, presumed cardiac, resuscitation attempted by EMS
•Metro survival increased from 7% in 2000 to 13% in 2009, p<0.001
•Rural survival increased from 6% in 2000 to 7% in 2009
Survival increase predominantly in VF/VT patients
Adult, presumed cardiac, VF/VT, resuscitation attempted by EMS
•Metro survival increased from 14% in 2000 to 34% in 2009, p<0.001
VACAR Research
Epidemiology
• All patients1
• Traumatic 2
• Urban/rural3
• Age cohorts (paediatric4, young adult (inc
coroners findings), elderly5)
• Nursing homes, terminally ill
• EMS witnessed
• Paediatric hangings6
• Asystolic cardiac arrests7
Clinical Trials
• Therapeutic hypothermia by paramedics
following resuscitation from VF: RCT8
• Autopulse in rural areas
• The Rinse Trial. The Rapid Infusion of
Normal cold SalinE by paramedics during
CPR. NHMRC $678k
• AVOID- RCT on oxygen in STEMI
Treatment / programs
• Dispatcher CPR
• 2005 guidelines
• Fire First Responders9,10
• Sensitivity of AMPDS11
• Impact of hospitals (ICS)
• Impact of post ROSC BP
Environmental
• Impact of air pollution on OHCA incidence12
1. Fridman et al Resuscitation 2007
2. Ashour et al Emerg Med J 2007
3. Jennings et al MJA 2006
4. Deasy et al Resuscitation 2010
5. Deasy et al ResuscittaionJ2011
6. Deasy et al Emerg Med J In press
7. Meyer et al Emerg Med 2001
8. Bernard et al Circulation 2010
9. Smith et al Resuscitation2001
10. Smith et al MJA 2002
11. Flynn et al Prehosp Disaster Med 2006
12. Dennekamp et al Epidemiology 2010
Conclusion
• VACAR is one of the largest cardiac arrest registries in
the world (currently n>53,000).
• Data is collected from a single state-wide ambulance
service (two services prior to 2008) which reduces
heterogeneity.
• Despite increasing response times, significant
improvements in survival have been observed in the
metropolitan area of Victoria.
• Used to benchmark AV and monitor quality of care
• Currently a significant body of research using VACAR
data
Acknowledgements
• Acknowledge the VACAR team –
Janet Bray
Marian Lodder
Vanessa Barnes
Resmi Nair
Devina Vaughan