Title: Exploring and improving resuscitation decisions in out of hospital cardiac arrest
Funder: Department of Health and Social Care

Abstract: Plain English summary_x000D_ _x000D_ Aim: To help NHS Paramedics make better decisions about when to continue and when to stop_x000D_ resuscitation._x000D_ _x000D_ Background: When the heart suddenly stops beating, treatment (known as resuscitation) must be_x000D_ started quickly. NHS Ambulance Services are called to help 30,000 people with this condition each_x000D_ year. Despite the best efforts of ambulance staff less than one in 10 people whose heart stops_x000D_ survive. This means that ambulance staff often have to make the difficult decision of when to stop_x000D_ resuscitation. They are helped by following guidelines, but they were written over 20 years ago and_x000D_ need updating._x000D_ _x000D_ The old guidelines no longer correctly guide paramedics when to stop treatment or when to carry on._x000D_ This means that treatment may be stopped too soon in some patients who might benefit from carrying_x000D_ on. In other patients, the guidelines suggest to move the patient to hospital despite the fact they have_x000D_ no chance of surviving. The knock-on effects of this are journeys with blue lights and sirens which put_x000D_ ambulance staff and other road users at risk of injury from crashes. Patients are separated from their_x000D_ families and taken to a busy hospital. At the hospital, it is difficult for staff to allow the family to spend_x000D_ quiet time with the patient. Hospitals also become overcrowded which can affect other patients._x000D_ This research will develop new guidelines based on the most up to date information available. It will_x000D_ consider how the new guidelines might work in real life. We will find out the views of ambulance and_x000D_ hospital staff, patients and relatives. This will help make sure the guidelines are acceptable to_x000D_ everyone._x000D_ _x000D_ Design: The project involves 5 pieces of work._x000D_ 1) Reviewing research undertaken by others and see how it can be used in the NHS_x000D_ 2) Finding out how ambulance services currently make decisions to stop or carry on with treatment_x000D_ 3) Seeing what the effects different guidelines may have on how ambulance staff treat patients and_x000D_ any knock-on effects for hospitals_x000D_ 4) Talking to ambulance and hospital staff, patients and relatives. This will help us find out what they_x000D_ think and what is important to them._x000D_ 5) Combining the information above to write new guidelines. This will be done in partnership with_x000D_ ambulance and hospital staff, patients and members of the public._x000D_ _x000D_ Patient and public involvement: We will work closely with patients and the public to ensure_x000D_ that their views are fully included in the project. One of our research team is a member of the public_x000D_ who has personal experience of loosing someone in the circumstances described here. He has_x000D_ worked with others patients over the years to help improve research in this area. He will work with our_x000D_ research team and a group of patients and members of the public to guide the research team to_x000D_ remain focused on the issues that are important to patients. This group will be involved in helping_x000D_ design, interpret and communicate the research. They will play an important role in developing the_x000D_ final recommendations for new guidelines._x000D_ _x000D_ Dissemination: We will publish our findings in medical journals and present them at meetings for_x000D_ doctors, nurses, paramedics and patients. We will send a copy of our final report to ambulance services and other interested groups. We will share the findings via the internet, our patient and public_x000D_ networks and through media teams, who has extensive experience of communicating such findings.

Lay abstract: Research question: In adult patients who sustain an out of hospital cardiac arrest and do not respond to treatment by paramedics, what is the best approach for deciding when and where to stop resuscitation attempts?_x000D_ _x000D_ Background: NHS Ambulance services treat » 30,000 cases of cardiac arrest annually. Paramedics_x000D_ terminate resuscitation in approximately 10,000 patients and transport 20,000 patients to hospital. Recent evidence has raised concerns that the current national guidelines which allow termination of resuscitation are no longer fit for purpose. This means that resuscitation may be stopped prematurely for some patients. For others, un-necessary, high risk transfers to hospital are undertaken with on-going cardiopulmonary resuscitation (CPR) despite negligible chances of survival. Concerns about the current guidelines has led to regional amendments to national guidelines which is creating variation and inconsistency between ambulance services._x000D_ _x000D_ Aim: To develop an evidence based guideline that assists paramedics, when making decisions during_x000D_ out of hospital cardiac arrest, that optimizes outcomes for patients and is sensitive to needs of relatives and demand on NHS services._x000D_ _x000D_ Objectives:_x000D_ i. Describe the content and performance characteristics of existing termination of resuscitation rules in adults who are treated for out of hospital cardiac arrest._x000D_ ii. Identify areas of consistency, variation and clinical risk associated with termination of resuscitation practices across UK ambulance services._x000D_ iii. Examine current NHS ambulance termination of resuscitation practice and model effects of alternative rules on patient flow and outcomes_x000D_ iv. Explore the perspectives of patients, relatives, paramedics and emergency medicine staff and consider the ethical aspects of termination of resuscitation rules_x000D_ v. Synthesise the information obtained above to develop evidence based, ethically grounded, consensus guidelines, that optimizes outcomes for patients and are sensitive to needs of relatives and demands on NHS services._x000D_ _x000D_ Methods: The study will comprise of 5 inter-related work packages._x000D_ Work package 1: Systematic review of the published evidence to describe the content and structure of_x000D_ existing termination of resuscitation rules and summarise their performance characteristics._x000D_ Work package 2: Documentary analysis and key-informant interviews to describe current NHS policies across NHS ambulance services, consistency and variation in approaches and the clinical risks / concerns linked to these policies amongst senior ambulance managers._x000D_ Work package 3: Analysis of the national out of hospital cardiac arrest registry to identify current practice and explore the effects on patient flow and outcomes, including cost-effectiveness outcomes, if other termination of resuscitation rules were used._x000D_ Work package 4: Interviews to explore the perspectives of patients / relatives, paramedics and_x000D_ emergency medicine staff and consider the ethical aspects of termination of resuscitation rules._x000D_ Work package 5: Presentation of research findings to a stakeholder group and using consensus_x000D_ methodology, develop recommendations for a termination of resuscitation guidelines._x000D_ _x000D_ Timeline for delivery: The study is planned to run for 36 months. Ethics and regulatory approvals will be obtained in the first 6 months. WP 1 (systematic review) months 1-12; WP 2 (ambulance policies) months 6-12; WP 3 (modelling) months 12-24; WP 4 (interviews and ethics analysis) – months 7-30, WP 5 (consensus conference) month 34. Final report submitted month 36._x000D_ _x000D_ Anticipated impact and dissemination: The output from this research will be an evidence informed,_x000D_ ethically grounded termination of resuscitation guideline, which is acceptable to NHS staff, patients and their relatives. It will change clinical practice through adoption by NHS Ambulance Services, through the Joint Royal College Ambulance Liaison Committee and Resuscitation Council (UK) leading to better decisions for patients, their relatives and the NHS.

Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING;8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: CARDIOVASCULAR