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Implementation of guidelines in communities

Question Type:
Intervention
Full Question:
Within organisations that provide care for patients in cardiac arrest in any setting (P), does implementation of resuscitation guidelines (I), compared with no such use (C), change survival to 180 days with good neurological outcome, survival to hospital discharge, bystander CPR performance, return of spontaneous circulation (O)?
Consensus on Science:
For the critical outcome of survival to 180 days with good neurologic outcome, we found no data. For the critical outcome of survival to hospital discharge, we identified very-low-quality evidence (downgraded for imprecision, risk of bias, and indirectness) from 11 observational studies. Seven studies showed that implementation of resuscitation guidelines improved survival (RR, 1.25; 95% CI, 1.16–1.35),(Rea 2006, 2760; Steinmetz 2008, 908; Garza 2009, 2597; Sayre 2009, 469; Aufderheide 2010, 1357; Deasy 2011, 984; Kudenchuk 2012, 1787) and 4 studies were neutral.(Olasveengen 2009, 407; Hung 2010, 569; Robinson 2010, 1648; Bigham 2011, 979) For the important outcome of ROSC, we identified very-low-quality evidence (downgraded for imprecision, risk of bias, and indirectness) from 10 observational studies. Seven studies showed that implementation of resuscitation guidelines improved ROSC (RR, 1.15; 95% CI, 1.11–1.20),(Rea 2006, 2760; Steinmetz 2008, 908; Garza 2009, 2597; Sayre 2009, 469; Aufderheide 2010, 1357; Deasy 2011, 984; Kudenchuk 2012, 1787) and 3 studies were neutral.(Olasveengen 2009, 407; Hung 2010, 569; Robinson 2010, 1648) For the important outcome of CPR performance, we identified very-low-quality evidence (downgraded for imprecision, risk of bias, and indirectness) from 4 observational studies that implementation of resuscitation guidelines improved the hands-off ratio of emergency medical services CPR performance (mean 0.28 versus 0.42).(Rea 2006, 2760; Olasveengen 2009, 407; Sayre 2009, 469; Kudenchuk 2012, 1787)
Treatment Recommendation:
We recommend implementation of resuscitation guidelines within organizations that provide care for patients in cardiac arrest in any setting (strong recommendation, very-low-quality evidence). Values, Preferences, and Task Force Insights In making this (discordant) recommendation, we placed a high value on the notion that cardiac arrest care requires coordination of time-sensitive interventions and often involves care providers who have not worked together before, potentially from multiple agencies or departments; guidelines may facilitate coordinated action. Despite the very low quality of evidence, the direction of effect is consistent, and pooled data are statistically significant and clinically meaningful. A discordant recommendation is justified because cardiac arrest is life threatening and the likelihood of benefit is high relative to possible harm.(Andrews 2013, 726) We recognize that most of the authors of the 2015 CoSTR are involved in writing resuscitation guidelines and that this should be considered a potential intellectual conflict of interest.
CoSTR Attachments:
641 Merged Worksheet 12.9.14 bigham_n.xlsx    
EIT 641 GRADE evidence table_n.docx    
EIT 641 GRADE recommendation table_n.docx    
EIT641 Bias Assessments JCR_n.xlsx    
EIT641 Bias Assessments Patrick Ko_n.xlsx    
EIT641 Bias Assessments TMO_n.xlsx    
EIT641 GRADE Data Collection Form JCR_n.xlsx    
EIT641 GRADE Data Collection Form Patrick Ko_n.xlsx    
EIT641 GRADE Data Collection Form Patrick Ko0117_FINAL_n.xlsx    
EIT641 GRADE Data Collection Form TMO_n.xlsx    

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