key: cord-0822247-kg2iahho
authors: Andelius, Linn; Oving, Iris; Folke, Fredrik; de Graaf, Corina; Stieglis, Remy; Kjoelbye, Julie Samsoee; Hansen, Carolina Malta; Koster, Rudolph W.; L Tan, Hanno; Blom, Marieke T.
title: Management of first responder programmes for out-of-hospital cardiac arrest during the COVID-19 pandemic in Europe
date: 2021-01-02
journal: Resusc Plus
DOI: 10.1016/j.resplu.2020.100075
sha: 0e4fe32e5ce387b11293c0c60f98688c71df6243
doc_id: 822247
cord_uid: kg2iahho

Aim First responder (FR) programmes dispatch professional FRs (police and/or firefighters) or citizen responders to perform cardiopulmonary resuscitation (CPR) and use automated external defibrillators (AED) in out-of-hospital cardiac arrest (OHCA). We aimed to describe management of FR-programmes across Europe in response to the Coronavirus Disease 2019 (COVID-19) pandemic. Methods In June 2020, we conducted a cross-sectional survey sent to OHCA registry representatives in 17 European countries with active FR-programmes. The survey was administered by e-mail and included questions regarding management of both citizen responder and FR-programmes. A follow-up question was conducted in October 2020 assessing management during a potential “second wave” of COVID-19. Results All representatives responded (response rate = 100%). Fourteen regions dispatched citizen responders and 17 regions dispatched professional FRs (9 regions dispatched both). Responses were post-hoc divided into three categories: FR activation continued unchanged, FR activation continued with restrictions, or FR activation temporarily paused. For citizen responders, regions either temporarily paused activation (n = 7, 50.0%) or continued activation with restrictions (n = 7, 50.0%). The most common restriction was to omit rescue breaths and perform compression-only CPR. For professional FRs, nine regions continued activation with restrictions (52.9%) and five regions (29.4%) continued activation unchanged, but with personal protective equipment available for the professional FRs. In three regions (17.6%), activation of professional FRs temporarily paused. Conclusion Most regions changed management of FR-programmes in response to the COVID-19 pandemic. Studies are needed to investigate the consequences of pausing or restricting FR-programmes for bystander CPR and AED use, and how this may impact patient outcome.

First responder (FR) programmes are part of out-of-hospital cardiac arrest (OHCA) response in many regions in Europe 1 . They include activation of citizen responders and/or professional FRs (firefighters and/or police) to perform cardiopulmonary resuscitation (CPR) and/or use automated external defibrillators (AED) before arrival of the Emergency Medical Services (EMS). [2] [3] [4] [5] FRprogrammes can decrease time to resuscitation [6] [7] [8] and are therefore an important part of the system of care strategy "Chain of Survival" to increase survival following OHCA. 9 Regulation of FRprogrammes are often controlled by local EMS organisations and variations in management differ within countries and between countries in Europe. 1 The outbreak of the novel Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) causing Coronavirus Disease 19 was declared a pandemic by the World Health Organization on March 11, 2020. 10 The outbreak has led to changes in recommendations for management of OHCA patients in the prehospital setting to prevent transmission of the virus to the care provider. 11, 12 It is recommended that all FRs should wear personal protective equipment (PPE) 12 , but the high demand for PPE during the pandemic has led to a supply shortage in some regions 13, 14 , and providing PPE to citizen responders in particular is not feasible since they are often lay persons and some programmes include thousands of citizen responders. Since management of FR-programmes differs between regions in Europe 1 , it is likely to differ during the COVID-19 pandemic as well. Management needs to consider the balance of potential risk of exposing FRs to J o u r n a l P r e -p r o o f COVID-19 and increase the chance of improved outcome for the OHCA patient, strongly associated with bystander CPR and rapid defibrillation. 15, 16 We aimed to investigate differences in strategies for FR-programmes management during the COVID-19 pandemic across European regions. This can be used as basis for strategic management of FR-programmes during unpredictable changes in the prehospital setting such as a pandemic.

We identified regions through a previous study from 2019 describing dispatched FR-programmes in Europe 1 . We included 17 countries with active FR-programmes before the COVID-19 pandemic.

Nine of them dispatched both citizen responders and professional FRs, 3 dispatched only citizen responders, and six dispatched only professional FRs. The included countries and respective regions are described in Supplemental Table 1. A citizen responder is a person who volunteers to be dispatched to perform CPR and/or use an AED if located close to an OHCA. Citizen responder programmes can include lay persons or others such as off-duty healthcare professionals or taxi drivers. Citizen responders are activated by the emergency dispatch centre in case of a suspected OHCA. They are either alerted through smartphone applications or text-message systems. Professional FRs are defined as firefighters and/or police who are dispatched by the emergency dispatch centre. Professional FRs are often equipped with AEDs. This categorisation was defined when conducting the survey and accepted by the included regions. Details of each region's FR programme have been previously described. 1 We collected information from all countries by direct contact via e-mail in June 2020. All representatives for OHCA registries were asked a personalised open question with the possibility to J o u r n a l P r e -p r o o f respond with detailed information about how they managed their FR-programmes in response to the COVID-19 outbreak. A second attempt was made to get non-responding representatives to take part after approximately 7 days. Since the COVID-19 pandemic evolved in many countries after June 2020, regions could have experienced a second increase in number of persons with COVID-19 (a "second wave"). Therefore, a follow-up question was sent out in the end of October 2020 to assess how the included regions managed their FRs programmes during a potential second wave.

The response rate was 100% (17 out of 17 countries). Management of FR-programmes differed between regions. Responses for both citizen responders and professional FRs were categorised posthoc into three groups: 1) activation of FR-programmes remained unchanged, 2) FR activation continued with restrictions, or 3) FR activation temporarily paused.

Regions either paused activation of citizen responders temporarily (7 out of 14) or had their citizen responder programme active but with restrictions (7 out of 14) ( Figure 1A ). The most common restriction was informing citizen responders not to perform rescue breaths but to instead perform compression-only CPR (Table 1) . Only two regions changed management during the second wave of COVID-19. Switzerland activated their citizen responder programme, but the region had not experienced a second wave yet when the survey was conducted. Czech Republic also activated their citizen responder programme, but all citizen responders where instructed to follow ERC guidelines for resuscitation during COVID-19 (Table 1 ). 12

Half of the regions (9 out of 17) continued activation of professional FRs but with restrictions ( Figure 1B ). Like citizen responder programmes, the most common restriction was to omit rescue breaths and perform compression-only CPR ( Table 2) . Five regions (29.4%) continued activation unchanged, but the professional FRs were equipped with PPE to reduce risk of virus contamination.

Finally, in three regions (17.6%), activation of professional FRs temporarily paused. During the second wave of COVID-19, most regions continued with the same management. Slovenia restarted their professional FR programme but was not affected by a second wave when the survey was conducted.

In this study we described management of FR-programmes in 17 European countries during the outbreak of the COVID-19 pandemic. Most regions temporarily paused activation of citizen responders and professional FRs, or continued activation but with restrictions. The most common restriction was to omit rescue breaths and instead perform compression-only CPR. In regions where activation of professional FRs continued, they were equipped with PPE.

An increase in OHCA with a decrease in survival has been described in two meta-analyses during the COVID-19 pandemic. 17, 18 The decrease in survival is still unexplained but is likely dependent on multiple factors such as higher proportion of OHCAs in private homes, longer EMS response time due to increased workload, or a potential fear of starting CPR by bystanders because of risk of virus transmission. 15, 16, 19 Knowledge about the risk of coronavirus transmission during resuscitation is still undescribed. 20 Aerosol spreading during compression-only CPR has been described in a simulation and a cadaver model 21 transmission of 10% when performing compression-only CPR. They found that <10% of OHCA patients had COVID-19 which resulted in a theoretical risk of death for rescuers of 1 in 10,000

(with a mortality of 1% for COVID -19) . 15 Providing FRs with PPE is essential to prevent patientto-provider transmission but providing PPE to citizen responders is difficult. New guidelines suggest that bystander should place a cloth or use a face mask over the patients nose and mouth to prevent aerosol spread. 12 Table 1 

Pandemic AED, automated external defibrillator; COVID-19, coronavirus disease 2019; CPR, cardiopulmonary resuscitation; PPE, personal protective equipment. *Countries or regions where an increase in COVID-19 cases (a second wave) has not yet been detected. 

First-response treatment after out-of-hospital cardiac arrest: a survey of current practices across 29 countries in Europe

The role of bystanders, first responders, and emergency medical service providers in timely defibrillation and related outcomes after out-of-hospital cardiac arrest: Results from a statewide registry

Local lay rescuers with AEDs, alerted by text messages, contribute to early defibrillation in a Dutch out -of-hospital cardiac arrest dispatch system

Mobile-phone dispatch of laypersons for CPR in outof-hospital cardiac arrest

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WHO Director-General's opening remarks at the media briefing on COVID-19 -11

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European Resuscitation Council COVID-19 Guidelines Executive Summary

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a population-based, observational study. The Lancet Public health

Rupp (from Germany) for their cooperation and data collection. Also, we would like to thank all other respondents who so generously shared their expert opinion and knowledge to make this study possible.

Hradec Kralove Region Activation temporarily paused.Yes, activation was not paused, but dispatched citizens were instructed to follow the new ERC COVID-19 guidelines.

Compression-only CPR. Do not accept alarm if your daily work is essential for the community or you are in a risk group for COVID-19. Use glows and disinfect/wash hands before and after resuscitation.

Mandatory to use Level 3 PPE to perform airway procedure. Responders wear Level 2 and should therefore put cloth or similar over patient's mouth and nose when performing CPR and use AED.