Elsevier

Resuscitation

Volume 80, Issue 12, December 2009, Pages 1336-1341
Resuscitation

Clinical paper
Time needed for a regional emergency medical system to implement resuscitation Guidelines 2005—The Netherlands experience

https://doi.org/10.1016/j.resuscitation.2009.08.011Get rights and content

Abstract

Introduction

In December 2005, updated resuscitation Guidelines (G) were introduced worldwide and will be revised again in 2010. This study sought to elucidate how long it takes to implement new guidelines.

Methods

This was a prospective observational study. From July 2005 to January 2008, we included all patients with an out-of-hospital cardiac arrest of suspected cardiac cause. We analyzed Emergency Medical System (EMS) Guideline usage via defibrillator recordings of the continuous ECG and impedance signals. We excluded patients with missing or otherwise unusable ECGs. All shocks and CPR cycles were individually classified. The same Guideline needed to be applied for at least 75% of all shocks and CPR cycles. If no shocks had been given, continuous ECGs were classified by its CPR status only. Continuous ECGs were classified as G1992, G2000 or G2005. If at least 75% of the shocks were given according to G2000 and at least 75% of the CPR was according to G2005, the Guideline protocol was classified as intermediate. All analyses that did not fulfil any Guideline criteria were classified as indeterminate.

Results

Of 1672 analyzable resuscitations, 31 (2%) used G1992, 826 (49%) G2000, 608 (36%) G2005, and 125 (7%) intermediate Guidelines. The Guideline protocol could not be identified for the remaining 81 (5%) patients. It took 17 months (from publication) until EMS personnel applied GL2005 in over 80% of cases.

Conclusion

Our experience shows it took one-and-a-half years to effectively implement new resuscitation Guidelines. We believe improvements in implementation can shorten this to six months.

Introduction

The European Resuscitation Council was founded in August 1989, and published its first evidence based resuscitation Guidelines in 1992 in a cooperative venture with the American Heart Association.1, 2 Over subsequent years, there was a growing awareness of the importance of early defibrillation, as advised in the resuscitation Guidelines of 2000.3, 4 The most recent resuscitation Guidelines were published in 2005, and placed a renewed emphasis on the importance of high quality, minimally interrupted CPR.5 The Guidelines are scheduled to be revised again in 2010.

The publication of resuscitation Guidelines is the start of an implementation process that consists of several links. First, countries need to evaluate the ERC Guidelines for possible adaptation to national practical and legal requirements. Second, countries that do not have English as their native language need to translate the Guidelines. Third, training material needs to be developed in accordance with the new Guidelines. Fourth, trainers need to be trained, who in turn will be responsible for the training of thousands of paramedics. It obviously takes a lot of time to train this many people.

The purpose of this study was to elucidate how long it took for Emergency Medical System (EMS) personnel to implement the 2005 resuscitation Guidelines.

Section snippets

Setting

The Dutch province of North Holland has a population of 2.6 million people and covers approximately 2671 km2 including both urban and rural communities. Medical emergency calls are immediately transferred to the regional EMS dispatch centre. When suspecting a cardiac arrest, the EMS dispatcher sends out two ambulances of a single tier. All EMS personnel are qualified to perform Advanced Life Support (ALS) according to the guidelines of the European Resuscitation Council,6, 7 and are equipped

Characteristics of study subjects

During the study period of 30 months, 2115 patients suffered an OHCA of presumed cardiac cause and underwent attempted resuscitation by EMS paramedics. We excluded 154 patients due to lack of a continuous ECG recording. Another 289 patients were excluded for various reasons (Figure 2). The clinical and operational characteristics of the patients in our study are shown in Table 2.

Guidelines usage

Of the 1672 analyzable ECGs, we found that 31 (2%) had been treated according to G1992, 826 patients (49%) according

Discussion

The major finding of this study is that it took one-and-a-half years to implement the 2005 resuscitation Guidelines in the Dutch EMS system, and reach a point where at least 80% of patients were being treated according to the new Guidelines. Several factors influenced the duration of this time interval. First, the translation of the Guidelines into Dutch could only be initiated after they had been officially published in December 2005. Second, the training of EMS personnel could only start

Limitations

A relatively large number of cases (22%) could not be analyzed for various reasons. The baseline characteristics of patients whose ECG could not be analyzed were similar to the patients analyzed in this study (data not shown).

The four-month delay observed in our study due to the need for translation does not apply to countries with English as the native language. We therefore expect the implementation process to be quicker in English speaking countries.

Our analysis only evaluated whether shocks

Conclusion

It takes one-and-a-half years to implement new resuscitation Guidelines in the Dutch EMS system. The half-year it takes to train all personnel is unavoidable. However, a one-year delay is avoidable by abolishing the embargo on release of Guidelines changes to translators and policy makers, and adjusting the publication date of the national EMS protocols to the publication date of the new resuscitation Guidelines.

Acknowledgement

We greatly appreciate Michiel Hulleman, Esther Landman and Renate van der Meer for their contribution to the data collection and data entry. We are greatly indebted to the dispatch centres and ambulance paramedics of Amsterdam en Omstreken, Kennemerland and Noord-Holland Noord for their indispensable cooperation and support. This study is supported by a grant from Physio Control Inc. (Redmond, WA, USA).

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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2009.08.011.

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