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Background The modifiable prehospital system factors, bystander cardiopulmonary resuscitation (CPR), emergency medical services (EMS), response time, and EMS physician attendance, may affect short- and long-term survival for both rural and urban out-of-hospital cardiac arrest (OHCA) patients. We studied how such factors influenced OHCA survival in a mixed urban/rural region with a high survival rate after OHCA. Methods We analyzed the association between modifiable prehospital factors and survival to different stages of care in 1138 medical OHCA patients from an Utstein template-based cardiac arrest registry, using Kaplan-Meier type survival curves, univariable and multivariable logistic regression and mortality hazard plots. Results We found a significantly higher probability for survival to hospital admission (OR: 1.84, 95% CI 1.43–2.36, p  < 0.001), to hospital discharge (OR: 1.51, 95% CI 1.08–2.11, p  = 0.017), and at 1 year (OR: 1.58, 95% CI 1.11–2.26, p  = 0.012) in the urban group versus the rural group. In patients receiving bystander CPR before EMS arrival, the odds of survival to hospital discharge increased more than threefold (OR: 3.05, 95% CI 2.00–4.65, p  < 0.001). However, bystander CPR was associated with increased patient survival to discharge only in urban areas (survival probability 0.26 with CPR vs. 0.08 without CPR, p  < 0.001). EMS response time ≥ 10 min was associated with decreased survival (OR: 0.61, 95% CI 0.45–0.83, p  = 0.002), however, only in urban areas (survival probability 0.15 ≥ 10 min vs. 0.25 < 10 min, p  < 0.001). In patients with prehospital EMS physician attendance, no significant differences were found in survival to hospital discharge (OR: 1.37, 95% CI 0.87–2.16, p  = 0.17). In rural areas, patients with EMS physician attendance had an overall better survival to hospital discharge (survival probability 0.17 with EMS physician vs. 0.05 without EMS physician, p  = 0.019). Adjusted for modifiable factors, the survival differences remained. Conclusions Overall, OHCA survival was higher in urban compared to rural areas, and the effect of bystander CPR, EMS response time and EMS physician attendance on survival differ between urban and rural areas. The effect of modifiable factors on survival was highest in the prehospital stage of care. In patients surviving to hospital admission, there was no significant difference in in-hospital mortality or in 1 year mortality between OHCA in rural versus urban areas.

ObjectiveCardiopulmonary resuscitation (CPR) provided by community citizens is of paramount importance for out-of-hospital cardiac arrest (OHCA) victims' survival. Fortunately, CPR rates by community citizens seem to be rising. However, the experience of providing CPR is rarely investigated. The aim of this study was to explore reactions and coping strategies in lay rescuers who have provided CPR to OHCA victims.Methods, participantsThis is a qualitative study of 20 lay rescuers who have provided CPR to 18 OHCA victims. We used a semistructured interview guide focusing on their experiences after providing CPR.SettingThe study was conducted in the Stavanger region of Norway, an area with very high bystander CPR rates.ResultsThree themes emerged from the interview analysis: concern, uncertainty and coping strategies. Providing CPR had been emotionally challenging for all lay rescuers and, for some, had consequences in terms of family and work life. Several lay rescuers experienced persistent mental recurrences of the OHCA incident and had concerns about the outcome for the cardiac arrest victim. Unknown or fatal outcomes often caused feelings of guilt and were particularly difficult to handle. Several reported the need to be acknowledged for their CPR attempts. Health-educated lay rescuers seemed to be less affected than others. A common coping strategy was confiding in close relations, preferably the health educated. However, some required professional help to cope with the OHCA incident.ConclusionsLay rescuers experience emotional and social challenges, and some struggle to cope in life after providing CPR in OHCA incidents. Experiencing a positive patient outcome and being a health-educated lay rescuer seem to mitigate concerns. Common coping strategies are attempts to reduce uncertainty towards patient outcome and own CPR quality. Further studies are needed to determine whether an organised professional follow-up can mitigate the concerns and uncertainty of lay rescuers.

Introduction Previous studies have suggested an effect of gender on outcome after out-of-hospital cardiac arrest (OHCA), but the results are conflicting. We aimed to investigate the association of gender to outcome, coronary angiography (CAG) and adverse events in OHCA survivors treated with mild induced hypothermia (MIH). Methods We performed a retrospective analysis of prospectively collected data from the International Cardiac Arrest Registry. Adult patients with a non-traumatic OHCA and treated with MIH were included. Good neurological outcome was defined as a cerebral performance category (CPC) of 1 or 2. Results A total of 1,667 patients, 472 women (28%) and 1,195 men (72%), met the inclusion criteria. Men were more likely to receive bystander cardiopulmonary resuscitation, have an initial shockable rhythm and to have a presumed cardiac cause of arrest. At hospital discharge, men had a higher survival rate (52% vs. 38%, P <0.001) and more often a good neurological outcome (43% vs. 32%, P <0.001) in the univariate analysis. When adjusting for baseline characteristics, male gender was associated with improved survival (OR 1.34, 95% CI 1.01 to 1.78) but no longer with neurological outcome (OR 1.24, 95% CI 0.92 to 1.67). Adverse events were common; women more often had hypokalemia, hypomagnesemia and bleeding requiring transfusion, while men had more pneumonia. In a subgroup analysis of patients with a presumed cardiac cause of arrest (n = 1,361), men more often had CAG performed on admission (58% vs. 50%, P  = 0.02) but this discrepancy disappeared in an adjusted analysis. Conclusions Gender differences exist regarding cause of arrest, adverse events and outcome. Male gender was independently associated with survival but not with neurological outcome.

Hypotension after cardiac arrest could aggravate prolonged hypoxic ischemic encephalopathy. The association of circulatory shock at hospital admission with outcome after cardiac arrest has not been well studied. The objective of this study was to investigate the independent association of circulatory shock at hospital admission with neurologic outcome, and to evaluate whether cardiovascular comorbidities interact with circulatory shock. 4004 adult patients with out-of-hospital cardiac arrest enrolled in the International Cardiac Arrest Registry 2006–2017 were included in analysis. Circulatory shock was defined as a systolic blood pressure below 90 mmHg and/or medical or mechanical supportive measures to maintain adequate perfusion during hospital admission. Primary outcome was cerebral performance category (CPC) dichotomized as good, (CPC 1–2) versus poor (CPC 3–5) outcome at hospital discharge. 38% of included patients were in circulatory shock at hospital admission, 32% had good neurologic outcome at hospital discharge. The adjusted odds ratio for good neurologic outcome in patients without preexisting cardiovascular disease with circulatory shock at hospital admission was 0.60 [0.46–0.79]. No significant interaction was detected with preexisting comorbidities in the main analysis. We conclude that circulatory shock at hospital admission after out-of-hospital cardiac arrest is independently associated with poor neurologic outcome.

Background The aim of this study was to explore the performance and outcomes for intravascular (IC) versus surface cooling devices (SFC) for targeted temperature management (TTM) after out-of-hospital cardiac arrest. Methods A retrospective analysis of data from the Time-differentiated Therapeutic Hypothermia (TTH48) trial (NCT01689077), which compared whether TTM at 33 °C for 48 h results in better neurologic outcomes compared with standard 24-h duration. Devices were assessed for the speed of cooling and rewarming rates. Precision was assessed by measuring temperature variability (TV), i.e., the standard deviation (SD) of all temperature measurements in the cooling phase. Main outcomes were overall mortality and poor neurological outcome, including death, severe disability, or vegetative status. Results A total of 352 patients had available data and were included in the analysis; of those, 218 (62%) were managed with IC. A total of 114/218 (53%) patients with IC and 61/134 (43%) with SFC were cooled for 48 h ( p  = 0.22). Time to target temperature (≤ 34 °C) was significantly shorter for patients treated with endovascular devices (2.2 [1.1–4.0] vs. 4.2 [2.7–6.0] h, p  < 0.001), but temperature was also lower on admission (35.0 [34.2–35.6] vs. 35.3 [34.5–35.8]°C; p  = 0.02) and cooling rate was similar (0.4 [0.2–0.8] vs. 0.4 [0.2–0.6]°C/h; p  = 0.14) when compared to SFC. Temperature variability was significantly lower in the endovascular device group when compared with SFC methods (0.6 [0.4–0.9] vs. 0.7 [0.5–1.0]°C; p  = 0.007), as was rewarming rate (0.31 [0.22–0.44] vs. 0.37 [0.29–0.49]°C/hour; p  = 0.02). There was no statistically significant difference in mortality (endovascular 65/218, 29% vs. others 43/134, 32%; p  = 0.72) or poor neurological outcome (endovascular 69/218, 32% vs. others 51/134, 38%; p  = 0.24) between type of devices. Conclusions Endovascular cooling devices were more precise than SFC methods in patients cooled at 33 °C after out-of-hospital cardiac arrest. Main outcomes were similar with regard to the cooling methods.

IntroductionIn surgery, serious adverse events have effects on the patient journey, the patient outcome and may constitute a burden to the surgeon involved. This study aims to investigate facilitators and barriers to transparency around, reporting of and learning from serious adverse events among surgeons.MethodsBased on a qualitative study design, we recruited 15 surgeons (4 females and 11 males) with 4 different surgical subspecialties from four Norwegian university hospitals. The participants underwent individual semistructured interviews and data were analysed according to principles of inductive qualitative content analysis.Results and discussionWe identified four overarching themes. All surgeons reported having experienced serious adverse events, describing these as part of ‘the nature of surgery’. Most surgeons reported that established strategies failed to combine facilitation of learning with taking care of the involved surgeons. Transparency about serious adverse events was by some felt as an extra burden, fearing that openness on technical-related errors could affect their future career negatively. Positive implications of transparency were linked with factors such as minimising the surgeon’s feeling of personal burden with positive impact on individual and collective learning. A lack of facilitation of individual and structural transparency factors could entail ‘collateral damage’. Our participants suggested that both the younger generation of surgeons in general, and the increasing number of women in surgical professions, might contribute to ‘maturing’ the culture of transparency.Conclusion and implicationsThis study suggests that transparency associated with serious adverse events is hampered by concerns at both personal and professional levels among surgeons. These results emphasise the importance of improved systemic learning and the need for structural changes; it is crucial to increase the focus on education and training curriculums and offer advice on coping strategies and establish arenas for safe discussions after serious adverse events.

Background Hospitals worldwide have implemented Rapid Response Systems (RRS) to facilitate early recognition and prompt response by trained personnel to deteriorating patients. A key concept of this system is that it should prevent ‘events of omission’, including failure to monitor patients’ vital signs, delayed detection, and treatment of deterioration and delayed transfer to an intensive care unit. Time matters when a patient deteriorates, and several in-hospital challenges may prevent the RRS from functioning adequately. Therefore, we must understand and address barriers for timely and adequate responses in cases of patient deterioration. Thus, this study aimed to investigate whether implementing (2012) and developing (2016) an RRS was associated with an overall temporal improvement and to identify needs for further improvement by studying; patient monitoring, omission event occurrences, documentation of limitation of medical treatment, unexpected death, and in-hospital- and 30-day mortality rates. Methods We performed an interprofessional mortality review to study the trajectory of the last hospital stay of patients dying in the study wards in three time periods (P1, P2, P3) from 2010 to 2019. We used non-parametric tests to test for differences between the periods. We also studied overall temporal trends in in-hospital- and 30-day mortality rates. Results Fewer patients experienced omission events (P1: 40%, P2: 20%, P3: 11%, P = 0.01). The number of documented complete vital sign sets, median (Q1,Q3) P1: 0 (0,0), P2: 2 (1,2), P3: 4 (3,5), P = 0.01) and intensive care consultations in the wards ( P1: 12%, P2: 30%, P3: 33%, P = 0.007) increased. Limitations of medical treatment were documented earlier (median days from admission were P1: 8, P2: 8, P3: 3, P = 0.01). In-hospital and 30-day mortality rates decreased during this decade (rate ratios 0.95 (95% CI: 0.92–0.98) and 0.97 (95% CI: 0.95–0.99)). Conclusion The RRS implementation and development during the last decade was associated with reduced omission events, earlier documentation of limitation of medical treatments, and a temporal reduction in the in-hospital- and 30-day mortality rates in the study wards. The mortality review is a suitable method to evaluate an RRS and provide a foundation for further improvement. Trial registration Retrospectively registered.

Purpose To evaluate the potential association between early dysnatremia and 6-month functional outcome after cardiac arrest. Methods We pooled data from four randomised clinical trials in post-cardiac-arrest patients admitted to the ICU with coma after stable return of spontaneous circulation (ROSC). Admission natremia was categorised as normal (135–145 mmol/L), low, or high. We analysed associations between natremia category and Cerebral Performance Category (CPC) 1 or 2 at 6 months, with and without adjustment on the modified Cardiac Arrest Hospital Prognosis Score (mCAHP). Results We included 1163 patients (581 from HYPERION, 352 from TTH48, 120 from COMACARE, and 110 from Xe-HYPOTHECA) with a mean age of 63 ± 13 years and a predominance of males (72.5%). A cardiac cause was identified in 63.6% of cases. Median time from collapse to ROSC was 20 [15–29] minutes. Overall, mean natremia on ICU admission was 137.5 ± 4.7 mmol/L; 211 (18.6%) and 31 (2.7%) patients had hyponatremia and hypernatremia, respectively. By univariate analysis, CPC 1 or 2 at 6 months was significantly less common in the group with hyponatremia (50/211 [24%] vs. 363/893 [41%]; P  = 0.001); the mCAHP-adjusted odds ratio was 0.45 (95%CI 0.26–0.79, p  = 0.005). The number of patients with hypernatremia was too small for a meaningful multivariable analysis. Conclusions Early hyponatremia was common in patients with ROSC after cardiac arrest and was associated with a poorer 6-month functional outcome. The mechanisms underlying this association remain to be elucidated in order to determine whether interventions targeting hyponatremia are worth investigating. Registration ClinicalTrial.gov, NCT01994772, November 2013, 21.

OBJECTIVESThere is little knowledge about which elements of health care simulation are most effective in improving patient safety. When empirical evidence is lacking, a consensus statement can help define priorities in, for example, education and research. A consensus process was therefore initiated to define priorities in health care simulation that contribute the most to improve patient safety. METHODSAn international group of experts took part in a 4-stage consensus process based on a modified nominal group technique. Stages 1 to 3 were based on electronic communication; stage 4 was a 2-day consensus meeting at the Utstein Abbey in Norway. The goals of stage 4 were to agree on the top 5 topics in health care simulation that contribute the most to patient safety, identify the patient safety problems they relate to, and suggest solutions with implementation strategies for these problems. RESULTSThe expert group agreed on the following topicstechnical skills, nontechnical skills, system probing, assessment, and effectiveness. For each topic, 5 patient safety problems were suggested that each topic might contribute to solve. Solutions to these problems and implementation strategies for these solutions were identified for technical skills, nontechnical skills, and system probing. In the case of assessment and effectiveness, the expert group found it difficult to suggest solutions and implementation strategies mainly because of lacking consensus on metrics and methodology. CONCLUSIONSThe expert group recommends that the 5 topics identified in this consensus process should be the main focus when health care simulation is implemented in patient safety curricula.

Background/aimIn the past decades, there has been an increasing focus on defining, identifying and reducing unwarranted variation in clinical practice. There have been several attempts to monitor and reduce unwarranted variation, but the experience so far is that these initiatives have failed to reach their goals. In this article, we present the initial process of developing a safety, quality and utilisation rate dashboard (‘clinical dashboard’) based on a selection of data routinely reported to executive boards and top-level leaders in Norwegian specialist healthcare.MethodsWe used a modified version of Wennberg’s categorisation of healthcare delivery to develop the dashboard, focusing on variation in (1) effective care and patient safety and (2) preference-sensitive and supply-sensitive care.ResultsEffective care and patient safety are monitored with outcome measures such as 30-day mortality after hospital admission and 5-year cancer survival, whereas utilisation rates for procedures selected on cost and volume are used to follow variations in preference-sensitive and supply-sensitive care.ConclusionWe argue that selecting quality indicators of patient safety, quality and utilisation rates and presenting them in a dashboard may help executive hospital boards and top-level leaders to focus on unwarranted variation.