Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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More than just response time
- Ali Ajaj (15 June 2001)
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Ambulance response time improvements are not achievable or cost-effective
- David Dewar (21 June 2001)
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who pays?
- Dave Ryell (25 June 2001)
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Ali Ajaj, Specialist Registrar Walsall Manor Hospital, West Midlands, WS2 9XS
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EDITOR - Pell at al’s study showed ambulance response times to be independently associated with survival, and predicted an increased survival to 10-11% by decreasing target for response times to 90% of calls from 14 minutes to 5 minutes (1). In agreement with their study our population based retrospective study reviewed the ambulance and hospital records of patients sustaining out of hospital cardiac arrest and admitted to our hospital over a 12- month period. Of the 283 cardiac arrests 158 were randomly selected. 12 patients (7.7%) survived to hospital discharge, and the mean response time for these was 5.44 minutes compared to 6.43 minutes for non-survivors. Bottiger et al’s small study showed that use of rt-PA and heparin in patients in whom spontaneous circulation had not returned within 15 minutes of cardiopulmonary resuscitation following out of hospital cardiac arrest might improve patient outcome, and was safe with no bleeding complications related to CPR procedures (2). By reducing response time and in addition giving rt-PA after 15 minutes of CPR without return of spontaneous circulation we expect that survival will be further increased, and perhaps doubled. We accept that there will be ethical issues surrounding randomised prospective trials of rt-PA in out of hospital cardiac arrest, but we feel the potential benefits will be significant. Nearly 70% of patients discharged after out of hospital cardiac arrest are alive four years after the event (3). Although efforts to reduce response times are required administration of rt-PA by trained ambulance crews may prove to me more achievable than reducing target response times to less than five minutes. Ali Ajaj Salim Cheeroth 1. Pell JP, Sirel JM, Marsden AK, Ford I, Cobbe SM. Effect of reducing ambulance response times on deaths from out of hospital cardiac arrest: cohort study. BMJ 2001; 322:1385-1388 (9 June). 2. Bottiger BW, Bode C, Kern S, Gries A, Gust R, Glatzer R, Bauer H, Motsch J, Martin E. Lancet 2001; 357: 1583-1585 3. Cobbe SM, Dalziel K, Ford I, Marsden AK. Survival of 1476 patients initially resuscitated from out of hospital cardiac arrest. BMJ 1996; 312:1633-1637. |
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David Dewar, Specialist Registrar in Internal Medicine Kent and Sussex Hospital, Tunbridge Wells
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Dear Editor I was very interested in the recent statistical extrapolation by Pell et al1. This suggested that more rapid ambulance response times would improve survival from cardiac arrest. Might I commend the Scottish Ambulance Service for achieving 91% of responses within 14 minutes and 51% within 7 minutes. Predicted survival within their model was nearly doubled from 6 to 11% by increasing the target for 90% of ambulance responses to 5 minutes. There are approximately 3000 cardiac arrests attended each year in Scotland alone and at present ambulance calls are not prioritised in the majority of the UK. Therefore response targets represent the aim of all ambulance call-outs. Thus this would represent a massive, virtually incalculable and prohibitive cost. Approximately 90 extra patients would be discharged alive from hospital each year in Scotland, given that the figures represent 7 years of cumulative data. The final point is that the model assumes that all arrests are technically survivable and equivocal in success if defibrillation is applied earlier. This is clearly not the case. The rapid arrival of the medical SHO at an in-patient arrest has no influence of the vast majority of cardiac arrests. There is no doubt that rapid defibrillation saves lives but providing improvements will be expensive and difficult. In Canada there are now automated defibrillators in urban areas to allow the public to initiate advanced life support. I am not sure how the British public would respond to this advance. 1 Pell JP, Sirel JM, Marsden AK, Ford I, Cobbe SM. Effect of reducing ambulance response times on death from out of hospital cardiac arrest: cohort study. BMJ 2001;322:1385-1388. (9 June) I declare no competing interests in this article, letter or subject. Dr David H. Dewar
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Dave Ryell, state registered paramedic london ambulance service
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Evidence suggests little if any bystander cpr is performed pre the arrival of the paramedic. The dice is obviously loaded against survivability and given the often difficult egress to the patient 'top floor flat, behind the wardrobe oh and mind the vase'. NHS Ambulances are always financially capped and remain the underdog in the pre hospital cardiac arrest arena. whilst they hold the keys to thrombolysis,intubation, 12-lead ECG, defibrillation and cardiac drug therapies which are all of little benefit when traffic density dictates a slow response. As the study rightly demonstrates the key to success is reduction of attendance times which equates to more staff,vehicles ect which arm of the health service will relinquish more of their hard pressed budgets in the interests of survival. |
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