populations TFQO: Professor Judith Finn EVREVs: Dr Janet Bray and - PowerPoint PPT Presentation

Dallas 2015 BLS training for high risk populations TFQO: Professor Judith Finn EVREVs: Dr Janet Bray and Marion Leary #COI Taskforce: ETI

Dallas 2015 COI Disclosure (specific to this systematic review) Commercial/industry Leary co-ownership of Resuscor, LLC Potential intellectual conflicts Leary co-author on Blewer 2012

Dallas 2015 2010 CoSTR In lay providers requiring BLS training (P), does focusing training on high risk populations (I) compared with no such targeting (C) increase outcomes (eg. bystander CPR, survival etc) (O) 16 studies met criteria for review. Of these, 1 was published in Korean, with no English translation available. Overall, it seems as though CPR training in family members of high risk patients may improve the rate of bystander CPR seen when the bystanders are relatives of the victims, but it doesn’t improve it to beyond the levels seen by strangers. However, it may not be feasible to train the numbers of people potentially required to take CPR in order to effect an improvement in survival. In addition, there is very conflicting data on the potential effects (either positive or negative) on psychological adjustment in relatives of high-risk patients who take CPR training.

Dallas 2015 C2015 PICO Population : people at high-risk of OHCA Intervention : focused training of likely rescuers (eg family or care-givers) Comparison : no such targeting Outcomes: survival with favorable neurological outcome at discharge, ROSC, bystander CPR performance, number of people trained in CPR, willingness to provide CPR

Dallas 2015 Inclusion/Exclusion & Articles Found Inclusions: adults and children Excluded studies: that did not directly address the PICO question, only examined psychological outcomes, reviews, editorials, commentaries, abstracts only, duplicate data Reviewed 1563 abstracts with 29 articles included in the review (1 additional paper in Korean excluded –authors did not reply to contact and no English translation was available)

Dallas 2015 2015 Proposed Treatment Recommendations Based on moderate-low quality of evidence, we recommend training likely rescuers (e.g. family or care-givers) of high-risk populations in CPR – based on the willingness to be trained and the fact that there is low harm and high potential benefit. There is low to moderate quality of evidence in 29 studies related to CPR training in likely rescuers (e.g. family or care-givers) of high-risk OHCA groups, with no strong evidence of improved patients outcomes. The recommendation for providing training in this group places higher value on the potential benefits of patients receiving bystander CPR by a family-member or caregiver in the case of cardiac arrest, and the willingness of this group to be trained. We place lesser value on associated costs, and the potential that skills may not be retained without on-going CPR training. The cost of training are potentially reduced with CPR training self- instruction kits (e.g. DVD training).

Dallas 2015 Risk of Bias in studies RCTs Allocation: ¡Concealment Allocation: ¡Generation Blinding: ¡Participants Outcome: ¡Complete ¡ Outcome: ¡Selective Blinding: ¡Assessors Other ¡Bias Total ¡ Industry ¡ Study Year Design Patients Funding Blewer 2012 RCT 406 no Low Low Low Unclear Low High Low Brannon 2009 RCT 23 unclear High High Low Low Low Low Unclear Dracup ¡ 2000 RCT 335 no unclear High High Unclear High Unclear Low Dracup ¡ 1986 RCT 134 no unclear High High Unclear Low ¡ High Low Dracup ¡ 1998 RCT 480 no High High High Unclear Low unclear Low Greenberg ¡ 2012 RCT 162 no Low Low High Unclear Low Unclear Low Moser 1999 RCT 335 unclear unclear high high Unclear High High Low

Dallas 2015 Risk of Bias in studies Non-RCTs Exposure/Outcome Eligibility ¡Criteria Confounding Follow ¡up Total ¡ Industry ¡ Study Year Design Patients Funding Barr 2013 Non-­‑RCT 126 no high low high low Dracup 1989 Non-­‑RCT 83 unclear unclear low low low Dracup 1994 Non-­‑RCT 238 no low low unclear uncler Dracup 1998 Non-­‑RCT 94 no unclear unclear low low Haugk 2006 Non-­‑RCT 115 Yes, ¡partly unclear low unclear High Higgins 1998 Non-­‑RCT no low ¡ high unclear unclear Khan 2010 Non-­‑RCT 300 no low unclear unclear unclear Kliegal 2000 Non-­‑RCT 195 no unclear low unclear unclear Knight 2013 Non-­‑RCT 117 unclear low low low High Komelasky 1993 Non-­‑RCT 87 unclear Low low low unclear Komelasky 1990 Non-­‑RCT 55 No low low unclear Low McDaniel ¡ 1988 Non-­‑RCT 40 Yes, ¡partly Unclear High unclear unclear McLauchlan 1992 Non-­‑RCT 49 no unclear High high unclear Messmer 1993 Non-­‑RCT 30 no unclear unclear unclear low Moore 1997 Non-­‑RCT 34 Yes, ¡partly low Low unclear low Pane ¡ 1989 Non-­‑RCT 1388 no low low unclear low Pierick 2012 Non-­‑RCT 311 no low low low High Sanna 2006 Non-­‑RCT 89 unclear low low low High Schneider 2014 Non-­‑RCT 85 unclear low low low low Sharieff 2001 Non-­‑RCT 18 no low low unclear low Sigsbee 1990 Non-­‑RCT 50 no low low low low Wright ¡ 1989 Non-­‑RCT 41 no low low unclear low

Dallas 2015 Evidence profile table(s) Quality assessment № of patients Effect Quality Importance focussed Relative № of Risk of Other no such Absolute Study design Inconsistency Indirectness Imprecision CPR (95% studies bias considerations targeting (95% CI) training CI) survival with favourable neurologic outcome at discharge and ROSC 2 randomised serious 1 not serious not serious serious 2 none 3 see not see CRITICAL ⨁⨁ ◯◯ trials comment pooled comment LOW survival with favourable neurologic outcome at discharge and ROSC 7 observational very not serious serious 5 serious 2 none 6 see not see ⨁ ◯◯◯ CRITICAL studies serious 4 comment pooled comment VERY LOW bystander CPR performance (subsequent utilisation of skills) 2 randomised serious 1 not serious not serious serious 2 none 3 see not see ⨁⨁ ◯◯ IMPORTANT trials comment pooled comment LOW bystander CPR performance (subsequent utilisation of skills) 7 observational very not serious serious 5 serious 2 none 6 see not see IMPORTANT ⨁ ◯◯◯ studies serious 4 comment pooled comment VERY LOW ¡ 1 .Studies were not blinded, used temporal randomization, survival was self-reported, with large loss to follow up (Dracup 2000) or small sample size (Dracup 1986). 2. Large loss to follow-up and/or scant number of events. 3. The heterogeneous nature of RCT data prevents pooling. Dracup 1986 followed-up 65 adult cardiac patients six months after intervention. They did not report overall number of patients requiring CPR, but reported 4/65 patients died (2/24 control and 2/41 CPR groups) –none received CPR by trained individuals (unknown if present at time of arrest). Dracup 2000 conducted follow-up at 12-months in high-risk infants (with high rate of loss to follow up). They reported 13 arrests in this period (13 intervention arms and 0 in control), 100% were successfully resuscitated. 4. Most studies were subject to high loss to follow-up, did not adjust for confounders and used self-reported outcomes. Three studies did not provided adequate information about screening and eligibility (Dracup 1989, McDaniel 1988, McLauchlan 1992) and two studies were conducted on very small sample size McDaniel 1988, Mclauchlan 1992). Higgins 1998 unclear whether cardiac arrest case ascertainment was consistent across centres. 5. One study (Higgins 1998) examined whether hospitals provided CPR training and did not report the number of individuals trained 6. The heterogeneous nature of data prevents pooling. Follow-up periods varied from 3-months to 10 years. Dracup 1998 – at 6-months, 7/94 CPR-trained parents self-reported using CPR, with 100% survival. Dracup 1994 – at 21±6 months 11/172 adult cardiac patients died (1 out of hospital –no CPR, trained individual not present). Higgins 1998 –examined admission rates of pediatric cardiac arrests over 10-years in 41 centers. In centers teaching CPR to parents, CPR was attempted in 28/41 children with a 46% survival rate. In centers not teaching CPR 24 events occurred with no CPR attempt and no survivors. McDaniel 1988 at 3-months, 1/16 adult cardiac patients arrested out of hospital –no CPR attempted, trained individual not present. Mc Lauchlan 1992 at 24-months, 1/27 adult VT patients arrested, wife physically unable to perform CPR, patient died. Pierick 2012 at 12-months, 8/311 events occurred, seven parents performed CPR, one event was unknown; six infants survived with good or stable neurologic status (as reported by parents). Sanna 2006 –at 12-months, no events in 33 adult cardiac patients.