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Emergency Medical Service Agency Practices and Cardiac Arrest Survival
Saket Girotra, MD, SM; Kimberly C. Dukes, PhD; Jessica Sperling, PhD; Kevin Kennedy, MS;
Marina Del Rios, MD, MS; Remle Crowe, PhD; Ashish R. Panchal, MD, PhD; Thomas Rea, MD, MPH;
Bryan F. McNally, MD, MPH; Paul S. Chan, MD, MSc
IMPORTANCE Survival for out-of-hospital cardiac arrest (OHCA) varies widely across
emergency medical service (EMS) agencies in the US. However, little is known about which
EMS practices are associated with higher agency-level survival.
OBJECTIVE To identify resuscitation practices associated with favorable neurological survival
for OHCA at EMS agencies.
DESIGN, SETTING, AND PARTICIPANTS This cohort study surveyed EMS agencies participating
in the Cardiac Arrest Registry to Enhance Survival (CARES) with 10 or more OHCAs annually
during January 2015 to December 2019; data analyses were performed from April to October
2023.
EXPOSURE Survey of resuscitation practices at EMS agencies.
MAIN OUTCOMES AND MEASURES Risk-standardized rates of favorable neurological survival
for OHCA at each EMS agency were estimated using hierarchical logistic regression.
Multivariable linear regression then examined the association of EMS practices with rates of
risk-standardized favorable neurological survival.
RESULTS Of 577 eligible EMS agencies, 470 agencies (81.5%) completed the survey. The mean
(SD) rate of risk-standardized favorable neurological survival was 8.1% (1.8%). A total of 7
EMS practices across 3 domains (training, cardiopulmonary resuscitation [CPR], and
transport) were associated with higher rates of risk-standardized favorable neurological
survival. EMS agencies with higher favorable neurological survival rates were more likely to
use simulation to assess CPR competency (β = 0.54; P = .05), perform frequent
reassessment (at least once every 6 months) of CPR competency in new staff (β = 0.51;
P = .04), use full multiperson scenario simulation for ongoing skills training (β = 0.48;
P = .01), perform simulation training at least every 6 months (β = 0.63; Pagency treatment
of OHCA, non-EMS stakeholder response to OHCA (dispatch-
ers, first responders, and law enforcement), and community fac-
tors affecting bystander response to OHCA. The survey was pi-
lot tested at 4 EMS agencies in Ohio and Missouri, and their
feedback was incorporated in refining the survey questions.
Each EMS agency identified a person most qualified to answer
questions related to resuscitation training, protocols, and poli-
cies, as well as first responder and dispatcher response. This was
most often the director of the EMS agency. The respondents were
required to answer each question on the survey. Survey re-
sponses from each EMS agency were not independently veri-
fied for accuracy.
Between September 28, 2022, and February 28, 2023, the
survey was sent to the liaisons at each eligible agency. We used
a multipronged approach to optimize the survey response rate
that included weekly email reminders, direct phone calls to
the EMS agency director, state coordinators at CARES contact-
ing sites by email or phone call, and twice-monthly drawings
Key Points
Question Which emergency medical services (EMS) agency
practices are associated with favorable neurological survival for
out-of-hospital cardiac arrest (OHCA)?
Findings This cohort study among 470 EMS agencies in the
Cardiac Arrest Registry to Enhance Survival (CARES) for OHCA
identified 7 practices related to training, cardiopulmonary
resuscitation, and transport that were associated with favorable
neurological survival. Adoption of more than half (�4) of these
practices was more common at EMS agencies in the highest
quartile of favorable neurological survival vs agencies in the lowest
quartile (59.3% vs 35.6%, respectively).
Meaning Given wide variability in EMS agency rates for OHCA
survival, these findings provide initial insights into EMS practices
associated with top-performing EMS agencies.
Research Original Investigation Emergency Medical Service Agency Practices and Cardiac Arrest Survival
684 JAMA Cardiology August 2024 Volume 9, Number 8 (Reprinted) jamacardiology.com
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of a free automated external defibrillator for eligible EMS agen-
cies during the last 3 months of the survey period.
Statistical Analysis
The primary outcome was an EMS agency’s rate of favorable
neurological survival, defined as survival to hospital dis-
charge with a cerebral performance category score of 1 or 2
(ie, without severe neurological disability). This outcome was
reported to CARES by the hospital caring for the patient. As a
secondary outcome, we also evaluated an EMS agency’s rate
of survival to hospital admission.
Since resuscitation practices at each EMS agency may be
correlated with one another, inclusion of multiple practices
in the same model can lead to multicollinearity, which can
potentially mask the association of important resuscitation
practices with survival. To avoid this, we used a 2-stage ap-
proach. First, we calculated risk-standardized rates of favor-
able neurological survival (primary outcome) for each EMS
agency using a multivariable hierarchical logistic regression
model that adjusted for differences in case mix across EMS
agencies. In this model, EMS agency was included as a ran-
dom effect, and the following variables were included as fixed
effects: age, sex, location of cardiac arrest (home, workplace,
street/highway, industrial building, recreational facility, or
other), whether the arrest was witnessed, initial cardiac ar-
rest rhythm, etiology of cardiac arrest (presumed cardiac, re-
spiratory, drug overdose, or other), whether bystander CPR was
initiated, and urbanicity of the OHCA location (US Census tract
classifications: urbanized, ≥50 000 residents; urban cluster,
nonurbanized areas with ≥2500 residents; or rural,survival was 8.1% (1.8%),
with large variation across EMS agencies (range, 1.8%-14.8%;
Figure, A). For the secondary outcome, the mean (SD; range)
rate of risk-standardized survival to hospital admission was
27.8% (3.6%; 16.6%-43.4%; Figure, B). We grouped EMS agen-
cies into quartiles of risk-standardized favorable neurologi-
cal survival rate by mean (SD) as follows: lowest quartile, 6.0%
(0.9%); middle 2 quartiles, 8.0% (0.6%); and highest quar-
tile, 12.0% (1.3%). There was a stepwise increase in survival
to hospital admission, survival to discharge, and favorable neu-
rological survival at the patient level across EMS quartile cat-
egories of risk-standardized favorable neurological survival
(eTable 2 in Supplement 1).
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Baseline characteristics of EMS agencies are reported in
eTable 3 in Supplement 1. A total of 251 of 470 total respond-
ing EMS agencies (53.4%) were based in a large town (75 000
to 149 999 residents) or a city (150 000 residents or more). A
total of 188 EMS agencies (40.1%) were fire-based EMS sys-
tems (representing an integrated response to medical and fire
emergencies) and 83.4% had a paid service model.
Table 1 and Table 2 summarize survey responses regard-
ing CPR training of staff and data review and EMS agency man-
agement of OHCA in the field, respectively. Nearly all agen-
cies (464 of 470 total EMS agencies [98.7%]) reported using
waveform capnography, 433 agencies (92.1%) reported use of
trained emergency medical dispatchers, and 388 agencies
(82.6%) reported using a mechanical CPR device for resusci-
tation in the field. Among the EMS agencies, a mean (SD) of
6.8 (20.0) hours of cardiac arrest training was provided to new
employees during orientation.
A total of 7 EMS agency practices across 3 domains (train-
ing, CPR, and transport) were significantly associated with EMS
agency rates of both outcomes when modeled as a continu-
ous variable (Table 3). EMS agencies with higher rates of risk-
standardized favorable neurological survival and survival to
hospital admission were more likely to use simulation to as-
sess competency in CPR in new staff and to conduct frequent
assessments of CPR competency in new staff (at least every 6
months). They were also more likely to perform full-scenario,
multiperson simulation training of all staff members and were
more likely to schedule simulation training at least every 6
months. EMS agencies with higher rates of risk-standardized
survival were more likely to have CPR feedback devices avail-
able for use during resuscitation, conduct training of staff in
the use of mechanical CPR devices at least once a year, and
transport patients with OHCA to a cardiac arrest center or a hos-
pital able to provide emergency coronary revascularization care
to patients with ST-elevation myocardial infarction (STEMI).
Lastly, the presence of a program to measure and improve CPR
quality was significantly associated with EMS agency rates of
survival to hospital admission, but not with favorable neuro-
logical survival (Table 3). There was no association between
the number of hours of cardiac arrest training for new employ-
ees, frequency of OHCA data review, use of waveform cap-
nography, and frequency of termination of resuscitation in the
field for patients meeting futility criteria with agency-level rates
of either survival outcome.
Of the 7 EMS practices that were significantly associated
with higher rates of risk-standardized favorable neurological
survival, EMS agencies in the highest quartile for survival
reported a mean (SD) of 3.9 (1.5) practices, compared with a
mean (SD) of 3.0 (1.5) practices at EMS agencies in the lowest
quartile (P0 0
What methods are used to teach resuscitation when
EMS staff are initially employed?
Online 144 (30.6) 36 (30.5) 71 (30.3) 37 (31.4)
In person 425 (90.4) 104 (88.1) 212 (90.6) 109 (92.4)
Simulation 295 (62.8) 69 (58.5) 143 (61.1) 83 (70.3)
How is EMS competency in CPR evaluated in new
staff?
Written examination 255 (54.3) 66 (55.9) 123 (52.6) 66 (55.9)
Oral examination 90 (19.1) 20 (16.9) 46 (19.7) 24 (20.3)
Simulation 401 (85.3) 95 (80.5) 200 (85.5) 106 (89.8)
How often is CPR competency assessed in new staff?
≥Twice a year 75 (18.0) 13 (12.9) 36 (17.5) 26 (23.6)
≤Annually 342 (82.0) 88 (87.1) 170 (82.5) 84 (76.4)
Missing, No. 53 17 28 8
Does your agency perform simulation training for
cardiac arrest care for all staff?
Yes 407 (86.8) 96 (81.4) 203 (87.1) 108 (91.5)
No 62 (13.2) 22 (18.6) 30 (12.9) 10 (8.5)
Missing, No. 1 0 1 0
What type of simulation is used for all staff?
BLS simulation with a manikin 181 (38.5) 42 (35.6) 93 (39.7) 46 (39.0)
Full-scenario simulation 359 (76.4) 83 (70.3) 177 (75.6) 99 (83.9)
Other 7 (1.5) 2 (1.7) 4 (1.7) 1 (0.8)
How often is simulation training performed by all
EMS agency members?
≥Every 6 mo 111 (23.6) 21 (17.8) 49 (20.9) 41 (34.7)
Infrequently or not at all 354 (75.3) 96 (81.4) 181 (77.4) 77 (65.3)
Unknown or missing 5 (1.1) 1 (0.8) 4 (1.7) 0
Does your agency have an ongoing quality
improvement program to measure CPR quality (eg,
data collection and feedback)?
370 (78.7) 98 (83.1) 175 (74.8) 97 (82.2)
How often is overall CPR quality at the agency
reviewed?
Never 100 (21.3) 20 (16.9) 59 (25.2) 21 (17.8)
Quarterly 137 (29.1) 37 (31.4) 67 (28.6) 33 (28.0)
Semiannually 22 (4.7) 4 (3.4) 10 (4.3) 8 (6.8)
Yearly 89 (18.9) 24 (20.3) 42 (17.9) 23 (19.5)
Other 122 (26.0) 33 (28.0) 56 (23.9) 33 (28.0) Abbreviations: BLS, basic life support;
CPR, cardiopulmonary resuscitation.
Emergency Medical Service Agency Practices and Cardiac Arrest Survival Original Investigation Research
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Table 2. Emergency Medical Services (EMS) Agency Practices Related to Resuscitation Treatment
Treatment of OHCA
No. (%)
Total (N = 470)
Risk-standardized favorable neurological survival
Quartile 1 (lowest)
(n = 118)
Quartiles 2 and 3
(n = 234)
Quartile 4 (highest)
(n = 118)
Does the emergency telephone number in your coverage
area use trained emergency medical dispatch?
433 (92.1) 103 (87.3) 223 (95.3) 107 (90.7)
Does your EMS agency have a standard clinical protocol
in responding to cardiac arrests?
463 (98.5) 118 (100) 229 (97.9) 116 (98.3)
Does your agency use quantitative waveform
capnography?
464 (98.7) 114 (96.6) 232 (99.1) 118 (100)
How often is quantitative waveform capnography used
in cardiac arrests at your agency?
75% of the Time 414 (88.1) 102 (86.4) 206 (88.0) 106 (89.8)
Unknown 12 (2.6) 3 (2.5) 6 (2.6) 3 (2.5)
How often is use of waveform capnography reviewed?
Never 6 (1.3) 4 (3.4) 2 (0.9) 0
Quarterly 136 (28.9) 34 (28.8) 65 (27.8) 37 (31.4)
Semiannually 26 (5.5) 6 (5.1) 11 (4.7) 9 (7.6)
Yearly 49 (10.4) 11 (9.3) 23 (9.8) 15 (12.7)
Other 188 (40.0) 49 (41.5) 95 (40.6) 44 (37.3)
None performed 65 (13.8) 14 (11.9) 38 (16.2) 13 (11.0)
Automated CPR feedback?
No 304 (64.7) 90 (76.3) 146 (62.4) 68 (57.6)
Yes 166 (35.3) 28 (23.7) 88 (37.6) 50 (42.4)
Are there instances when your agency uses a mechanical
CPR device during a cardiac arrest?
388 (82.6) 93 (78.8) 195 (83.3) 100 (84.7)
When does your agency use mechanical CPR device?
For all cardiac arrests 268 (57.0) 64 (54.2) 130 (55.6) 74 (62.7)
When short of staff in the field 45 (9.6) 12 (10.2) 24 (10.3) 9 (7.6)
To prevent infection risk 12 (2.6) 3 (2.5) 4 (1.7) 5 (4.2)
For prolonged resuscitations 66 (14.0) 21 (17.8) 29 (12.4) 16 (13.6)
While transporting patients without ROSC 83 (17.7) 24 (20.3) 38 (16.2) 21 (17.8)
Other 74 (15.7) 19 (16.1) 37 (15.8) 18 (15.3)
How often does your agency provide training for
the use of mechanical CPR devices?
≥Once a year 339 (72.1) 79 (66.9) 167 (71.4) 93 (78.8)
None performed 131 (27.9) 39 (33.1) 67 (28.6) 25 (21.2)
Are ECGs for suspected STEMI transmitted from the field
to a receiving hospital in real time?
Yes 381 (81.2) 95 (80.5) 187 (80.3) 99 (83.9)
No 88 (18.8) 23 (19.5) 46 (19.7) 19 (16.1)
Missing, No. 1 0 1 0
Does your EMS agency use a termination of resuscitation
protocol in the field?
458 (97.4) 114 (96.6) 228 (97.4) 116 (98.3)
How often is termination of resuscitation implemented
for patients meeting futility criteria?
0 12 (2.6) 4 (3.4) 6 (2.6) 2 (1.7)
or a STEMI center. Current
guidelines recommend regionalization of care of patients with
OHCA in cardiac arrest centers to ensure that multidisci-
plinary expertise is available to treat patients with OHCA.26
Since transport is usually initiated after achieving return of
spontaneous circulation, it is possible that EMS transport poli-
cies serve as a surrogate of other aspects of EMS quality.
Limitations
Our findings should be interpreted in the context of the fol-
lowing limitations. First, although we obtained survey re-
Table 3. Emergency Medical Services (EMS) Resuscitation Practices Associated With Agency-Level
Rates of Risk-Standardized Survivala
EMS resuscitation practice
Favorable neurological
survival Survival to hospital admission
β P valueb β P valueb
1. How is EMS competency in CPR evaluated in new
staff?
Written examination −0.08 .87 0.40 .24
Oral examination 0.17 .56 0.41 .33
Simulation 0.54 .05 1.28 .007
2. How often is CPR competency assessed in new staff?
≥Twice a year 0.51
.04
1.14
.04
≤Annually 1 [Reference] 1 [Reference]
3. What type of simulation is used for all staff?
BLS simulation with a manikin 0.03 .69 −0.18 .60
Full-scenario simulation 0.48 .01 1.24 .002
Other −0.31 .54 −1.58 .25
4. How often is simulation training performed by all EMS
agency members?
≥Once every 6 mo 0.63
40%) and because non-EMS first
responders (eg, law enforcement) arrive before EMS in more
than 40% of instances.27 Fourth, although our model to risk-
standardize EMS agency-level survival incorporated many of
the Utstein variables, data on all patient and care measures
known to predict short-term and long-term outcomes (ie,
patient comorbidities and EMS response intervals) were not
available. Fifth, it is important to emphasize that due to the
observational study design, we cannot determine a causal
relationship between the identified practices and EMS sur-
vival. Finally, although we found several practices across mul-
tiple domains that were associated with survival, granular de-
tails regarding how these practices were implemented were not
available. Our team is currently engaged in ongoing qualita-
tive research that includes on-site interviews with key stake-
holders at EMS agencies with the highest survival rates for
OHCA, and we hope to gain additional insights regarding best
practices for improving OHCA survival.
Conclusions
In a national registry for OHCA, we identified 7 EMS agency
practices associated with higher agency-level rates of favor-
able neurological survival. Given wide variability in OHCA sur-
vival among EMS agencies, our findings provide initial in-
sights into EMS practices that distinguish top-performing EMS
agencies. Future studies are needed to validate findings from
this study to identify best practices for EMS agencies.
ARTICLE INFORMATION
Accepted for Publication: April 5, 2025.
Published Online: June 5, 2024.
doi:10.1001/jamacardio.2024.1189
Author Affiliations: University of Texas
Southwestern Medical Center, Dallas (Girotra);
University of Iowa Carver College of Medicine, Iowa
City (Dukes, Del Rios); Social Science Research
Institute, Duke University, Durham, North Carolina
(Sperling); Saint Luke’s Mid America Heart Institute,
Kansas City, Missouri (Kennedy, Chan); ESO Inc,
Austin, Texas (Crowe); Department of Emergency
Medicine, The Ohio State University, Columbus
(Panchal); King County Medic One Emergency
Medical Services and Harborview Medical Center,
University of Washington, Seattle (Rea); Emory
University Rollins School of Public Health, Atlanta,
Georgia (McNally); Department of Emergency
Medicine, Emory University School of Medicine,
Atlanta, Georgia (McNally).
Author Contributions: Drs Girotra and Chan had
full access to all of the data in the study and take
responsibility for the integrity of the data and the
accuracy of the data analysis.
Concept and design: Girotra, Del Rios, Panchal,
Chan.
Acquisition, analysis, or interpretation of data:
All authors.
Drafting of the manuscript: Girotra, Crowe, Chan.
Critical review of the manuscript for important
intellectual content: All authors.
Statistical analysis: Kennedy.
Obtained funding: Girotra, Del Rios, Chan.
Administrative, technical, or material support:
Girotra, McNally, Chan.
Supervision: Girotra, Del Rios, Chan.
Table 4. Number of Practices Adopted by Emergency Medical Services Agencies in Each Quartile
Category of Risk-Standardized Favorable Neurological Survival
Practice
No. (%)
P value
Total
(N = 470)
Risk-standardized favorable neurological survival
Lowest (quartile 1)
(n = 118)
Middle (quartiles
2 and 3)
(n = 234)
Highest (quartile
4) (n = 118)
Adopted practices, No.
Mean (SD) 3.4 (1.5) 3.0 (1.5) 3.3 (1.4) 3.9 (1.5)
50% of
practices)
209 (44.5) 42 (35.6) 97 (41.5) 70 (59.3)5 (4.2) NA
Abbreviation: NA, not applicable.
a Kruskal-Wallis test.
b Continuous variables compared
using linear trend test.
Research Original Investigation Emergency Medical Service Agency Practices and Cardiac Arrest Survival
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© 2024 American Medical Association. All rights reserved.
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Conflict of Interest Disclosures: Dr Girotra
reported grants from the National Institutes of
Health (NIH) and personal fees from the American
Heart Association (AHA) for editorial work during
the conduct of the study. Dr Dukes reported grants
from the NIH and the National Heart, Lung, and
Blood Institute (NHLBI) during the conduct of the
study. Dr Del Rios reported grants from the NIH and
NHLBI and serves as the American Heart
Association Chair of the Emergency Cardiovascular
Care Committee, Science Subcommittee, during the
conduct of the study. Dr McNally reported grants
from the Centers for Disease Control and
Prevention Cardiac Arrest Registry to Enhance
Survival (CARES) during the conduct of the study.
Dr Chan reported grants from the NHLBI and the
AHA, and receives consulting fees from Optum
Consulting outside the submitted work. No other
disclosures were reported.
Funding/Support: Drs Girotra, Dukes, Sperling, Del
Rios, and Chan received research funding from the
National Heart, Lung, and Blood Institute
(R01HL160734). Dr Girotra is also supported by
funding from the National Heart, Lung, and Blood
Institute (R56HL158803, R01HL160734, and
R01HL166305). Dr Girotra also received funding
from the American Heart Association for editorial
work. Dr Chan receives funding from the American
Heart Association and the Missouri American
College of Cardiology. Dr McNally is the Executive
Director of Cardiac Arrest Registry to Enhance
Survival (CARES), which receives funding from the
American Red Cross and American Heart
Association.
Role of the Funder/Sponsor: The funders had no
role in the design and conduct of the study;
collection, management, analysis, and
interpretation of the data; preparation, review, or
approval of the manuscript; and decision to submit
the manuscript for publication.
Data Sharing Statement: See Supplement 2.
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