Community first responders for out‐of‐hospital cardiac arrest in adults and children

Tomas Barry; Maeve C Doheny; Siobhán Masterson; Niall Conroy; Jan Klimas; Ricardo Segurado; Mary Codd; Gerard Bury

doi:10.1002/14651858.CD012764.pub2

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Figure 1

PRISMA study flow diagram.

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Summary of findings for the main comparison. Mobilization of community first responders (CFRs) in addition to routine emergency medical services (EMS) care compared to routine EMS care for out‐of‐hospital cardiac arrest (OHCA)

Mobilization of community first responders (CFRs) in addition to routine emergency medical services (EMS) care compared to routine EMS care for out‐of‐hospital cardiac arrest (OHCA)
Patient or population: adults and children more than 4 weeks old suffering from OHCA Setting: all community settings (Sweden and the Netherlands) Intervention: mobilization of CFRs in addition to routine EMS care Comparison: routine (usual) EMS care
Outcomes	Impact	№ of participants (studies)	Certainty of the evidence (GRADE)
Survival at hospital discharge	1 study (a cluster‐RCT) conducted in Amsterdam and surrounding areas considered mobilization of police and fire service CFRs equipped with AEDs. Study authors found no difference in survival at hospital discharge (OR 1.3, 95% CI 0.8 to 2.2)	469 (1 cluster‐RCT)	⊕⊕⊝⊝ Low^a
Survival at 30 days	1 study (an RCT) undertaken in Stockholm, Sweden, considered mobilization of nearby lay volunteers who were trained to perform CPR. Study authors found no difference in survival at 30 days (OR 1.34, 95% CI 0.79 to 2.29)	612 (1 RCT)	⊕⊕⊝⊝ Low^b
Neurological function at hospital discharge, measured by cerebral performance category (CPC)	No data were available	This outcome was not measured	‐
Neurological function at 30 days, measured by cerebral performance category (CPC)	No data were available	This outcome was not measured	‐
Cardiopulmonary resuscitation performed before EMS arrival	1 study (an RCT) undertaken in Stockholm, Sweden, considered mobilization of nearby lay volunteers who were trained to perform CPR. Study authors found an increase in CPR performed before EMS arrival in the intervention group (OR 1.49, 95% CI 1.09 to 2.03)	665 (1 RCT)	⊕⊕⊕⊝ Moderate^c
Defibrillation performed before EMS arrival	1 study (a cluster‐RCT) conducted in Amsterdam and surrounding areas considered mobilization of police and fire service CFRs equipped with AEDs. Study authors found that all 72 incidences of defibrillation performed before EMS arrival occurred in the intervention group	469 (1 cluster‐RCT)	⊕⊕⊕⊝ Moderate^d
Survival to hospital admission	1 study (a cluster‐RCT) conducted in Amsterdam and surrounding areas considered mobilization of police and fire service CFRs equipped with AEDs. Study authors found increased survival to hospital admission (OR 1.5, 95% CI 1.1 to 2.0)	469 (1 cluster‐RCT)	⊕⊕⊕⊝ Moderate^e

GRADE Working Group grades of evidence. High‐certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate‐certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low‐certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low‐certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect. AED = automatic external defibrillator; CI = confidence interval; CFR = community first responder; CPC = cerebral performance category; CPR = cardiopulmonary resuscitation; EMS = emergency medical services; OHCA = out‐of‐hospital cardiac arrest; OR = odds ratio; RCT = randomized controlled trial.
^aDowngraded two levels for very significant risk of bias (control group may have been exposed to an intervention effect; CPR before EMS arrival). ^bDowngraded two levels for very significant risk of bias (data missing for 55/667 participants for this outcome; 26% of eligible participants excluded from the trial; study not powered for this outcome). ^cDowngraded one level for significant risk of bias (26% of eligible participants excluded from the trial). ^dDowngraded one level for significant risk of bias (risk of both selection and detection bias; this outcome did not represent a primary or secondary outcome in this study). ^eDowngraded one level for significant risk of bias (control group may have been exposed to an intervention effect ‐ CPR before EMS arrival; however, this would be expected to reduce the chance of finding a difference between control and intervention groups for this outcome; risk of both selection and detection bias for this outcome).

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Table 1. van Alem 2003

	Intervention	Control
Included participants	243	226
Outcome			OR (95% CI)
Survival at hospital discharge	44/243	33/226	1.3 (0.8 to 2.2)
Neurological function at hospital discharge, measured by cerebral performance category (CPC)	not reported
Survival to hospital admission	103/243	74/226	1.5 (1.1 to 2.0)
CPR performed before EMS arrival	not reported
Defibrillation performed before EMS arrival	72/243	0/226	N/A
Survival at 30 days	not reported
Neurological function at 30 days, measured by CPC	not reported
Health‐related quality of life at 90 days	not reported
CI = confidence interval; CPC = cerebral performance category; EMS = emergency medical services; N/A =not applicable; OR = odds ratio.

Table 1. van Alem 2003

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Table 2. Ringh 2015

	Intervention	Control
Included participants	306	361
Outcome			OR (95% CI)*
Survival at hospital discharge	not reported
Neurological function at hospital discharge, measured by cerebral performance category (CPC).	not reported
Survival to hospital admission	not reported
CPR performed before EMS arrival	196/305	197/360	1.49 (1.09 to 2.03)
Defibrillation performed before EMS arrival	not reported
Survival at 30 days	32/286	28/326	1.34 (0.79 to 2.29)
Neurological function at 30 days, measured by CPC	not reported
Health‐related quality of life at 90 days	not reported
CI = confidence interval; CPC = cerebral performance category; EMS = emergency medical services; OR = odds ratio. *ORs and 95% CIs for this study were calculated by the review authors.

Table 2. Ringh 2015

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