Background

The decision to initiate or continue advanced life support (ALS) in out-of-hospital cardiac arrest (OHCA) could be difficult due to the lack of information and contextual elements, especially in non-shockable rhythms. This study aims to explore factors associated with clinicians’ decision to initiate or continue ALS and the conditions associated with higher variability in asystolic patients.

Methods

This retrospective observational study enrolled 2653 asystolic patients on whom either ALS was attempted or not by the emergency medical services (EMS) physician. A multivariable logistic regression analysis was performed to find the factors associated with the decision to access ALS. A subgroup analysis was performed on patients with a predicted probability of ALS between 35% and 65%. The single physician’s behaviour was compared to that predicted by the model taking into account the entire agency.

Results

Age, location of event, bystander cardiopulmonary resuscitation and EMS-witnessed event were independent factors influencing physicians’ choices about ALS. Non-medical OHCA, younger patients, less experienced physicians, presence of breath activity at the emergency call and a longer time for ALS arrival were more frequent among cases with an expected higher variability in behaviours with ALS. Significant variability was detected between physicians.

Conclusions

Significant inter-physician variability in access to ALS could be present within the same EMS, especially among less experienced physicians, non-medical OHCA and in presence of signs of life during emergency call. This arbitrariness has been observed and should be properly addressed by EMS team members as it raises ethical issues regarding the disparity in treatment.

中文翻译：

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影响院前医生决定对院外心脏骤停患者进行高级复苏的因素

背景

由于缺乏信息和背景因素，特别是在非电击节律中，在院外心脏骤停 (OHCA) 中启动或继续高级生命支持 (ALS) 的决定可能很困难。本研究旨在探索与临床医生决定启动或继续 ALS 相关的因素，以及与心脏停搏患者较高变异性相关的条件。

方法

这项回顾性观察性研究招募了 2653 名心脏骤停患者，急诊医疗服务 (EMS) 医生对这些患者是否尝试过 ALS。进行了多变量逻辑回归分析，以找出与决定接受 ALS 相关的因素。对 ALS 预测概率在 35% 和 65% 之间的患者进行亚组分析。考虑到整个机构，将单个医生的行为与模型预测的行为进行比较。

结果

年龄、事件发生地点、旁观者心肺复苏和 EMS 目击事件是影响医生对 ALS 选择的独立因素。非医疗 OHCA、年轻患者、经验不足的医生、紧急呼叫时存在呼吸活动和 ALS 到达时间较长，在预期 ALS 行为变异性较高的病例中更为常见。在医生之间检测到显着的变异性。

结论

在同一个 EMS 中，医生之间接触 ALS 的显着差异可能存在，尤其是在经验不足的医生、非医疗 OHCA 和紧急呼叫期间存在生命迹象的情况下。这种任意性已经被观察到，应该由 EMS 团队成员适当解决，因为它会引发有关治疗差异的伦理问题。