Optimal defibrillation response intervals for maximum out-of-hospital cardiac arrest survival rates.
OBJECTIVE
Many centers optimize their emergency medical services (EMS) systems to achieve a target defibrillation response interval of "call received by dispatch" to "arrival at scene by responder with defibrillator" in 8 minutes or less for at least 90% of cardiac arrest cases. The objective of this study was to analyze survival as a function of time to test the evidence for this standard.


METHODS
This prospective cohort study included all adult, cardiac etiology, out-of-hospital cardiac arrest cases from phases I and II of the Ontario Prehospital Advanced Life Support (OPALS) study. Patients in the 21 Ontario study communities received a basic life support level of care with defibrillation by ambulance and firefighters but no advanced life support. Survival was plotted as a function of the defibrillation response interval. The equation of the curve, generated by means of logistic regression, was used to estimate survival at various defibrillation response interval cutoff points.


RESULTS
From January 1, 1991, to December 31, 1997, there were 392 (4.2%) survivors overall among the 9,273 patients treated. The defibrillation response interval mean was 6.2 minutes, and the 90th percentile was 9.3 minutes. There was a steep decrease in the first 5 minutes of the survival curve, beyond which the slope gradually leveled off. Controlling for known covariates, the decrement in the odds of survival with increasing response interval was 0.77 per minute (95% confidence interval 0.74 to 0.83). The survival function predicts, for successive 90th percentile cutoff points, both survival rates and additional lives saved per year in the OPALS communities compared with the 8-minute standard: 9 minutes (4.6%; -18 lives), 8 minutes (5.9%; 0 lives), 7 minutes (7.5%; 23 lives), 6 minutes (9.5%; 51 lives), and 5 minutes (12.0%; 86 lives).


CONCLUSIONS
The 8-minute target established in many communities is not supported by our data as the optimal EMS defibrillation response interval for cardiac arrest. EMS system leaders should consider the effect of decreasing the 90th percentile defibrillation response interval to less than 8 minutes.
De Maio
Valerie J
VJ
Ottawa Health Research Institute, Ottawa, Ontario, Canada. vdemaio@med.unc.edu
Stiell
Ian G
IG
Wells
George A
GA
Spaite
Daniel W
DW
D000328:Adult; D000368:Aged; D004554:Electric Countershock / Q000379:methods* / Q000592:standards; D004632:Emergency Medical Services / Q000379:methods* / Q000592:standards; D005260:Female; D006323:Heart Arrest / Q000150:complications / Q000209:etiology / Q000401:mortality* / Q000628:therapy*; D006801:Humans; D008020:Life Support Care / Q000379:methods* / Q000592:standards; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D009864:Ontario / Q000453:epidemiology; D017410:Practice Guidelines as Topic; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012307:Risk Factors; D012621:Seasons; D015996:Survival Rate; D017180:Tachycardia, Ventricular / Q000150:complications; D013997:Time Factors; D016896:Treatment Outcome; D014693:Ventricular Fibrillation / Q000150:complications