Association of Public Health Initiatives With Outcomes for Out-of-Hospital Cardiac Arrest at Home and in Public Locations | Cardiology | JAMA Cardiology | JAMA Network
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Original Investigation
November 2017

Association of Public Health Initiatives With Outcomes for Out-of-Hospital Cardiac Arrest at Home and in Public Locations

Author Affiliations
  • 1Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, Canada
  • 2Duke Clinical Research Institute, Durham, North Carolina
  • 3Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
  • 4Department of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark
  • 5Department of Sociology, Duke University, Durham, North Carolina
  • 6Division of Cardiology, Department of Medicine, The University of North Carolina at Chapel Hill
  • 7Department of Emergency Medicine, Northwell Health, Hofstra Northwell School of Medicine at Hofstra University, Manhasset, New York
  • 8New Hanover Regional Medical Center, Wilmington, North Carolina
  • 9Wake Forest University Health Sciences, Winston-Salem, North Carolina
  • 10Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina
  • 11Department of Critical Care, University of Alberta, Edmonton, Alberta, Canada
  • 12Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
  • 13Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
JAMA Cardiol. 2017;2(11):1226-1235. doi:10.1001/jamacardio.2017.3471
Key Points

Question  Do comprehensive public health initiatives improve prehospital resuscitation efforts and outcomes for patients with out-of-hospital cardiac arrest at home, where outcomes are especially poor, and in public locations?

Findings  Among 8269 patients, this study demonstrates that resuscitation efforts and outcomes in those with out-of-hospital cardiac arrest at home and in public may be improved through coordinated, multifaceted public health initiatives targeting multiple personnel across the cardiac arrest “chain of survival,” including first-responder programs.

Meaning  Adopting some of these public health initiatives may be helpful for communities aiming to improve outcomes of out-of-hospital cardiac arrest, including at home.


Importance  Little is known about the influence of comprehensive public health initiatives according to out-of-hospital cardiac arrest (OHCA) location, particularly at home, where resuscitation efforts and outcomes have historically been poor.

Objective  To describe temporal trends in bystander cardiopulmonary resuscitation (CPR) and first-responder defibrillation for OHCAs stratified by home vs public location and their association with survival and neurological outcomes.

Design, Setting, and Participants  This observational study reviewed 8269 patients with OHCAs (5602 [67.7%] at home and 2667 [32.3%] in public) for whom resuscitation was attempted using data from the Cardiac Arrest Registry to Enhance Survival (CARES) from January 1, 2010, through December 31, 2014. The setting was 16 counties in North Carolina.

Exposures  Patients were stratified by home vs public OHCA. Public health initiatives to improve bystander and first-responder interventions included training members of the general population in CPR and in the use of automated external defibrillators, teaching first responders about team-based CPR (eg, automated external defibrillator use and high-performance CPR), and instructing dispatch centers on recognition of cardiac arrest.

Main Outcomes and Measures  Association of resuscitation efforts with survival and neurological outcomes from 2010 through 2014.

Results  Among home OHCA patients (n = 5602), the median age was 64 years, and 62.2% were male; among public OHCA patients (n = 2667), the median age was 68 years, and 61.5% were male. After comprehensive public health initiatives, the proportion of patients receiving bystander CPR increased at home (from 28.3% [275 of 973] to 41.3% [498 of 1206], P < .001) and in public (from 61.0% [275 of 451] to 70.5% [424 of 601], P = .01), while first-responder defibrillation increased at home (from 42.2% [132 of 313] to 50.8% [212 of 417], P = .02) but not significantly in public (from 33.1% [58 of 175] to 37.8% [93 of 246], P = .17). Survival to discharge improved for arrests at home (from 5.7% [60 of 1057] to 8.1% [100 of 1238], P = .047) and in public (from 10.8% [50 of 464] to 16.2% [98 of 604], P = .04). Compared with emergency medical services–initiated CPR and resuscitation, patients with home OHCA were significantly more likely to survive to hospital discharge if they received bystander-initiated CPR and first-responder defibrillation (odds ratio, 1.55; 95% CI, 1.01-2.38). Patients with arrests in public were most likely to survive if they received both bystander-initiated CPR and defibrillation (odds ratio, 4.33; 95% CI, 2.11-8.87).

Conclusions and Relevance  After coordinated and comprehensive public health initiatives, more patients received bystander CPR and first-responder defibrillation at home and in public, which was associated with improved survival.