Out-of-Hospital Cardiac Arrest: A Strategy for Scotland

TAKING ACTION

The chain of survival can only be as strong as the weakest link in the chain, so all components need to be addressed. In order to deliver improved OHCA outcomes a framework of seven themes has been identified.

A. Early Recognition

B. CPR (Cardio-Pulmonary Resuscitation)

C. Defibrillation

D. Pre-Hospital Advanced Life Support

E. Post Resuscitation Care

F. Rehabilitation and Aftercare

G. Culture and Context

Under these themes, a series of actions and improvement programmes across 21 dimensions are described The first 15 of these are the primary interventions, the others which are grouped under 'Culture and Context' are enabling interventions.

Figure 5: Improving Out-of-Hospital Cardiac Arrest (OHCA) in Scotland

*By Assets we mean the people, organisations and equipment which could be made available or used more effectively in order to deliver improvement.

A. Early Recognition

Cardiac arrest is a sudden, medical emergency in which a person is highly unlikely to survive unless immediate and effective action is taken. The response of those who happen to be present during an OHCA is crucial.

Aim: To ensure that those who witness an out-of-hospital cardiac arrest (OHCA) promptly call 999 and are enabled to carry out immediate Cardio-Pulmonary Resuscitation (CPR) and use a Public Access Defibrillator (PAD), where available, until support arrives.

1. Public

There is a need to raise awareness through education, campaigns and other initiatives in order to increase the likelihood that members of the public recognise sudden cardiac arrest and quickly call for help. The public can also be reassured that if they do call 999 they will receive expert help and advice from the call handlers.

2. Ambulance Control Centre

SAS call handlers need to reliably and rapidly recognise that a patient is in cardiac arrest in response to an emergency call from a member of the public and then efficiently and effectively manage the call to support those immediately at the scene and to ensure that the appropriate resources are dispatched. We require a system to measure the accuracy of ACC in identifying OHCA and a process of support, training and feedback to ensure optimal ACC performance.

3. Assets

SAS control rooms need to have access to up to date and accurate information about all available responding assets. These assets could be ambulances, fire and rescue personnel, community first responders, doctors (including BASICs) or other trained responders. The aim is to ensure the fastest possible response to sudden OHCA.

Box 4 Ambulance Control Centres The Ambulance Control Centre (ACC) is the centre of the co-ordination of all the resources involved in the pre-hospital care of out-of-hospital cardiac arrests. ACC call handlers need to be effectively trained and supported and then reliably use the best triage tools available so that they can: Rapidly identify cardiac arrest. Reliably and rapidly recognise that an individual is having a cardiac arrest in response to an emergency call from a member of the public, who may be feeling anxious or fearful. Initiate telephone CPR guidance (T-CPR). The call handler must try to ensure that the caller or bystander rapidly begins chest compression. This may mean persuading someone who has had no training in CPR. Task/dispatch appropriate resources. Map assets. Call handlers need access to up-to-date and accurate information about available resources including Scottish Ambulance Service (SAS) assets and other available first responders, and the locations of public access defibrillators.

B. CPR (Cardio-Pulmonary Resuscitation)

Evidence shows that the earlier chest compressions are started following cardiac arrest, the more likely it is that the person will survive. Evidence also shows that these compressions need to be uninterrupted and of best possible quality.

Aim: To increase the rate of bystander CPR.

Aim: To equip an additional 500,000 people with CPR skills by 2020 creating a nation of life savers.

4. Public

Our aim is to increase the incidence of bystander CPR, through a clear program of community engagement, information and education.^[19] This will require a wide range of organisations and stakeholders to play their part to raise awareness and provide good quality CPR training.

We know that knowledge and skills in CPR is not evenly distributed throughout the population which means that more effort will need to be directed towards more deprived communities. The section on 'Health Inequalities' explores these issues in more detail.

Our goal must be to shift public attitudes so that taking action in such situations becomes the norm and the knowledge that early and continuous chest compression is a vital and effective thing to do to save a life is generally understood. How this cultural shift might be achieved is described further in the 'Public attitudes' section.

As well as working to improve the capture and reporting of data on whether bystander CPR has been performed at OHCAs, we aim to measure the number of people undertaking CPR training and the percentage of the population who have had some training in CPR. The British Heart Foundation have agreed to help explore how we can gather robust data on these measures.

5. Scottish Ambulance Service

The first task is to ensure that the closest available CPR-trained responders are despatched to an OHCA to support the caller/bystander. Experience tells us that better results are achieved when three or more people are available to give CPR, and particularly where expert co-ordination can be quickly on scene.

6. Assets

There is scope to increase the availability and utilisation of relevant public services in the response to OHCAs, deployed by and working alongside the ambulance service. However, this development needs to be supported by a well-governed training package for public sector responders.

There is a need to capture and feedback the impact of these organisations' contribution to survival through the audit supporting the Registry.

In many countries the fire service plays an important role in the response to OHCA. Building a closer working relationship between SFRS and SAS could lead to a transformational change, bringing major benefit to those suffering OHCA and which could quickly make Scotland an area of best practice for joined-up public services in this area. The Scottish Government strongly encourages this major change in the relationship between SAS and SFRS for the benefit of the people of Scotland.

In Scotland, the HM Fire Service Inspectorate report on 'Emergency Medical Response and the Scottish Fire and Rescue Service',^[20] published in October 2014, highlighted the opportunities for the Scottish Fire and Rescue Service (SFRS) to work more closely with SAS and contribute to the provision of emergency medical response. As part of their normal working arrangements, it is expected that the Inspectorate will revisit their report in due course.

Some public services are already engaged in local resilience building, including in 'hard to reach' communities. There is scope for appropriate groups (such as SFRS) to test the potential to add CPR training to this work.

A number of third sector organisations are currently engaged in CPR training in Scotland. Standardisation and strategic coordination of these training endeavours would enhance their impact.

The British Heart Foundation have for a number of years sought to help and support schools to improve the teaching of CPR skills. In 2014, the BHF launched its 'Nation of Lifesavers' campaign with the aim of ensuring no young person leaves schools without knowing how to save a life.^[21] The BHF has committed to ensuring that by 2020, all secondary schools in Scotland will be equipped to teach CPR and public access defibrillator awareness.

Box 5 Community Resilience Community resilience is the ability of communities to help themselves and to do so as part of an integrated network of support and care appropriate to their needs. Central to community resilience for OHCA are community first responders - members of the public who volunteer to help their communities by responding to medical emergencies while the emergency services are on their way. Community first responders are trained in a wide variety of skills including CPR and defibrillation. For the Scottish Ambulance Service the focus of Community Resilience is on: Supporting and strengthening the 'Community First Responder' networks across Scotland. Currently, SAS has 128 Community First responder schemes across Scotland, involving over 1,200 individuals. Engaging with partner organisations to enhance education and training for co-responders and where necessary for the public. Developing systems to ensure that best use is made of Public Access Defibrillators. In order to reinforce the work of SAS, there is scope to increase the involvement of other emergency services (such as SFRS) and third sector groups. In addition, there are a wide range of organisations, initiatives and groups operating at different levels which have an interest supporting community resilience, through promoting individual awareness and resilient behaviours, encouraging and co-ordinating volunteering, and through community level emergency planning groups. For some of these groups, health issues and responding to the medical emergencies of individuals are not their core purpose. However, there are opportunities to improve communication and networking amongst these them in order to explore the potential for CPR skills to become more widely available through for example, the Local Authority Resilience Group Scotland (LARGS), local Community Planning Partnerships, Community Safety Partnerships and community led initiatives such as Neighbourhood Watch Scotland.

C. Defibrillation

Defibrillation works in synergy with CPR and is most effective the earlier it is performed. The goal of getting a defibrillator to someone as quickly as possible will be achieved by ensuring that paramedics and others equipped with a defibrillator are rapidly deployed and by making best use of Public Access Defibrillators (PADs).

Aim: To rapidly deploy available assets which routinely carry defibrillators - ambulances and others where appropriate such as Scottish Fire and Rescue Service (SFRS) and Community First Responders.

Aim: To put in place effective arrangements to ensure that Public Access Defibrillators (PADs) are mapped, maintained and accessible to the public.

7. Public

There is a need to increase public awareness of the existence and possible availability of Public Access Defibrillators (PADs) and then to increase the instance of bystander defibrillation as part of the earliest possible approach to resuscitation. An important part of the message to the public is that modern PADs are both easy and very safe to operate.

The value and likely use of defibrillators bought for and by the public can be significantly increased by involving SAS to provide information and advice about defibrillators (e.g. type of defibrillator, siting, maintenance, usage, mapping onto ACC).

Box 6 - Ambitions for 2020 Improved Public Response to OHCA Many more people who witness an out-of-hospital cardiac arrest possess the skills and confidence to know what to do. Training in the use of CPR is more readily available through schools, work places and voluntary groups. Public Access Defibrillators (PADs) are more easily accessible and more people have an understanding of what they are for and a greater willingness to use them. It is the norm for families, friends and even strangers to take prompt and effective action when faced with an OHCA.

8. Scottish Ambulance Service

It is crucial to get a defibrillator to the person having an OHCA as quickly as possible. Beyond SAS's own assets, SAS need good information about other trained responders who can attend with a defibrillator.

There are many thousands of defibrillators in place across Scotland. However, this information is not centrally held and importantly not consistently available to ACCs which would allow call handlers to direct a bystander to access an available PAD (which might be close by, but not immediately visible).

The British Heart Foundation is committed to supporting the Scottish Ambulance Service to map the location of public access defibrillators across Scotland and the charity is funding a study to identify the challenges associated with doing so and how to overcome them.

Box 7 - Our Commitment: Scottish Ambulance Service Public Access Defibrillators (PADs) In order to support and improve the effectiveness of the use of PADs in Scotland: We will ensure effective governance arrangements for the mapping and maintenance of PADs and consider how best to encourage owners, purchasers and suppliers of PADs to ensure that PADs placed in the community are regularly serviced and maintained and registered with SAS. We will ensure that a register of PADs - mapped to the ACC - is developed and kept up to date. We will review the public information available about PADs, (including purchase, maintenance, location, access and signage).

9. Assets

In order to make best use of all available defibrillators they need to be appropriately located, properly maintained and mapped to the ambulance control centre.^[19] Enhancing the governance arrangements operated by SAS will help to ensure that public access defibrillators remain safe and sustainable.

Box 8 - Our Commitment: Police Scotland OHCA Improvement Programme We will continue to ensure that all Police Officers attend an annual Scottish Police Emergency Lifesaving Saving (SPELS) Course, which includes training in CPR. We will increase the number of officers and staff trained in First Aid at Work, an enhanced course which also includes the use of defibrillators. We will introduce and pilot an online defibrillator awareness package. We will consider with SAS whether Police defibrillators can be mapped onto the SAS database. We will complete our review of the availability and use of defibrillators in Police custody areas and vehicles (including Roads Policing Units and Armed Response Vehicles) with the aim of enhancing the contribution of Police Officers in the response to OHCA calls. We will promote enhanced community resilience through our membership of local Community Planning Partnerships, Community Safety Partnerships.

Box 9 - Our Commitment: Scottish Fire and Rescue Service OHCA Improvement Programme We will integrate health awareness such as cardiac arrest risk factors and provision of CPR training within our prevention work including our Home Safety Visits. We will offer our network of Fire Stations as locations for training members of the public and voluntary groups in CPR and if appropriate will enable our staff to become CPR trainers. We will work closely with SAS to pilot a SFRS response to OHCA in agreed geographic areas, learn lessons from the pilot and expand as appropriate. We will work closely to ensure all our defibrillators are mapped on to the SAS database and are placed in locations where evidence suggests they can add most value. We will agree appropriate and validated training for SFRS responders with SAS under the ethos of shared clinical governance. We will work with SAS to assess how we can support Community First Responders and promote enhanced Community Resilience. We will ensure that our workforce and their representatives form part of the planning and implementation to support the OHCA strategy. We will aim to train 100% of our support staff in CPR.

D. Pre-Hospital Resuscitation

The principles of pre-hospital resuscitation are that CPR, defibrillation, airway management, appropriate drug therapies and other interventions will be delivered rapidly in accordance with established resuscitation guidelines for best practice.

Aim: To ensure high quality resuscitation is delivered consistently in the pre-hospital care environment.

Aim: To ensure that patients - either during or after cardiac arrest - are taken to a location with appropriate post cardiac arrest care.

After OHCA it is essential that timely pre-hospital resuscitation is carried out by a sufficient number of appropriately trained rescuers. Ideally, bystander CPR will be started immediately after OHCA in order to buy time until additional help can arrive.

Experience shows that a minimum of three rescuers are required to deliver optimal pre-hospital resuscitation after OHCA. In addition, team training in non-technical skills as well as excellent technical skills, improves performance. Skills atrophy is a problem and the use of real-time CPR quality feedback during resuscitation can help mitigate this. Regular refresher training is essential. Where appropriate, the addition of a specialist 'second-tier' OHCA emergency responder with additional training can improve outcomes.

Box 10 The Sandpiper - Wildcat Project Although the component parts of the Chain or Survival are always the same, the methods by which these parts can be delivered will vary depending on the nature of the community being served and the resources available. The Sandpiper-Wildcat project is a proposed regional quality improvement initiative in Grampian. The Sandpiper Trust are currently fundraising to support a project team harnessing the expertise of BASICS Scotland, SAS, and the Resuscitation Research Group in Edinburgh to develop the principles from the RRG's very successful Edinburgh 3RU project and apply them to rural Scotland. The aims are: Maximise community readiness to undertake bystander CPR by innovative community education in partnership with BHF. Timely identification of cardiac arrest, rapid deployment of appropriate resources and encouragement of earliest possible bystander CPR by Ambulance Control. Availability of pre-hospital resources will be augmented by development of trained and equipped first responders. Novel training and re-training techniques will allow the positioning of skilled first responders in the most strategic locations. Earliest possible defibrillation. Wildcat will feature the first regional deployment of 'smart' defibrillators, able to communicate wirelessly to ensure constant readiness and facilitate usage data collection (including resuscitation quality metrics). Advanced Resuscitation led by Scottish Ambulance Service. The goal of this proposed two-year project is to develop a system which will save up to 50 additional lives each year in Grampian.

10. At scene

Outcomes from OHCA are improved by ensuring that the right number of appropriately trained and equipped people are available to effectively carry out resuscitation. Real time CPR feedback is very useful for maintaining the quality of CPR performance. This requires audit data on resuscitation quality to be routinely collected and used to highlight training needs.

It is important to minimise inappropriate resuscitation. This requires the early identification of cases where an anticipatory DNACPR decision has been documented, or where people are 'obviously dead' and beyond help.

The goal is to improve the overall response to and outcomes for OHCA but at the same time to reduce the number of inappropriate resuscitation attempts. Figure 6 below illustrates the change in profile in survivors and resuscitation attempts of successfully implementing this approach. The Registry will allow the impact of these changes to be measured.

Figure 6: Improving outcomes and the appropriateness of resuscitation attempts ^[22]

Figure 6 shows patients suffering OHCA plotted on two axes. The 'Biology' axis represents the patient's pre-exiting state of health and includes factors such as advanced age and pre-existing life limiting diseases (e.g. severe heart failure, severe lung disease) at the bottom of the scale, to normally good health (with a sudden reversible cause for OHCA) at the top. Similarly the 'Resuscitation' axis runs from poor prognostic factors on the left (e.g. unwitnessed arrest, no bystander CPR), to optimal resuscitation on the right (e.g. prompt recognition and bystander CPR, early defibrillation). This quad matrix now divides patients into those expected to survive at the top right and those unlikely to survive in the bottom left.

Box 11 - Our Commitment: Scottish Ambulance Service Pre-hospital Resuscitation The Scottish Ambulance Service will work with partners to design and deliver appropriate pre-hospital resuscitation models, responding to the challenges of geography, demographics and resources of individual communities. We will work with partner agencies to deliver appropriate resuscitation models. We will design these models to incorporate the geographical challenges, demographics and the resources of individual communities. We will engage and work in partnership with individual communities and other partner agencies to develop and implement these models.

11. Destination decision

It is important that patients who are transported from the scene of their OHCA are taken to the most appropriate hospital for further care. Work is required to put in place effective pathways and protocols which promote consistent best practice, but which recognise and reflect local geography and circumstances.

Box 12 The Story of a Survivor: Getting the right help at the right time Patient P had a sudden collapse while out shopping in a busy department store in the centre of Edinburgh. Early recognition by fellow shoppers that she'd had a cardiac arrest resulted in a prompt 999 call. The Ambulance Control call taker coached bystanders to do CPR while at the same time Dispatchers mobilised the nearest available ambulance crew and the 3RU paramedic on duty. A paramedic/technician crew arrived quickly and began further treatment. The 3RU paramedic arrived shortly after the first crew and helped the team to resuscitate P successfully using a series of advanced pre-hospital resuscitation techniques, including the use of mechanical CPR. This case demonstrates that early recognition and CPR by bystanders will buy time until help arrives. In an urban setting the ambulance service respond very quickly. In this case a specialist resuscitation rapid response unit (3RU) was also able to attend to help lead the successful resuscitation attempt. It is important to ensure that the right number of appropriately skilled rescuers are dispatched to an OHCA as quickly as possible.

E. Post Resuscitation Care

After the initial resuscitation phase, a complex series of interventions is required to ensure the best chance of a patient's long-term survival. This care starts pre-hospital and continues as the patient is transported to the Emergency Department (ED). After initial stabilisation and investigations patients will be referred to cardiology, intensive care and other specialist services as required. Interventions at this stage (e.g. temperature management) have been shown to make a significant difference to survival. Audit work in Scotland shows that there is a wide variation in practice in the management of OHCA even within a single ICU. There is a need to rationalise and standardise pathways of post resuscitation care across Scotland.

Aim: To ensure that patients treated in hospital following OHCA receive optimal care.

12. Emergency Department

The goal is to ensure that Emergency Departments are enabled to seamlessly provide the best possible care to patients who have had an OHCA. This will include initial stabilisation and investigation followed by prompt referral to appropriate in-patient specialties.

13. Cardiology and Intensive Care

Building on the current clinical evidence base there is a need to improve pathways of care between the pre-hospital phase and in-hospital cardiology and intensive care systems. We will need to gather more information and answer some outstanding questions (e.g. the role of PCI post-cardiac arrest) in order to define and disseminate optimal care pathways for Scotland.

There are a number of groups will an interest in this area of care (such as the Resuscitation Research Group, the Scottish Intensive Care Society, the Major Trauma Implementation Group and the National Advisory Committee on Heart Disease) and we seek opportunities to facilitate collaboration in developing improved approaches.

F. Rehabilitation and Aftercare

The focus of OHCA is of course on the person who has the cardiac arrest, with the goal of seeing them discharged from hospital with their health restored. What happens after that, and what happens to those involved in the event and its aftermath has, to date, been given little attention. Although the available evidence about this area of care is limited, we are clear that we need to do better.

Aim: To ensure that post event care and support is available to patients and their families/carers after OHCA.

Aim: To ensure that bystanders and others impacted by OHCA are supported after the event.

14. Survivors and their families

The principal aim of any OHCA strategy must be to increase survival. However, the desire to preserve life must not outweigh the need to sustain the 'quality' of the life saved. An appreciation of the perspectives of survivors, their close family and friends and those who have lived through the loss of a loved one is essential to guide and shape the provision of care.

To inform the strategy, Chest Heart & Stroke Scotland (CHSS) brought together a small focus group to explore the needs of survivors. A literature review was also conducted and used to identify new areas of interest. The initial work has helped to define our ambitions for 2020, in relation to improving the care of survivors and their families.

Box 13 - Ambitions for 2020 Better Care for Survivors and Families People who have survived a cardiac arrest and their families are offered individually tailored high quality information about their underlying condition and the potential physiological, psychological and social impact of cardiac arrest. Timely and appropriate care and advice is made available to the families of those who do not survive to discharge. This should include where possible, an explanation of the underlying cause and referral of family members to screening services where necessary. All survivors are offered a formal systematic assessment of their needs, using validated and clinically appropriate methodology. Assessments are conducted within the early post-discharge phase, within an environment which is conducive to effective communication. Survivors are offered personalised support to meet their needs, including referral to specialist services, such as cardiac rehabilitation as appropriate. Survivors and their families are offered opportunities for peer support. Additional information and support is provided to those requiring further investigation and/or therapeutic interventions, e.g. implantable cardioverter defibrillator (ICD).

Achieving our ambitions set out in Box 13 will not be accomplished through a single intervention or service, but will require sustained, coordinated and collaborative working between public and voluntary organisations across Scotland.

15. Those affected by OHCA

An out-of-hospital cardiac arrest can have an impact on many people beyond the individual whose heart has stopped. Those who witness the event, those who resuscitate the individual and family members can all be profoundly affected.

G. Culture and Context

This section draws together requirements and actions from across the other elements of the 'augmented chain of survival' in order to ensure that implementation of the strategy maintains an appropriate focus on these issues.

16. Registry - Data and reporting

Comprehensive data collection is widely recognised as an essential foundation to the systematic improvement of OHCA outcomes.

Aim: To collect, analyse and report accurate and complete data on OHCA in order to inform decision making and improve outcomes after cardiac arrest.

An OHCA Registry will link existing datasets to form a longitudinal patient journey for each OHCA victim and allow analysis of the patient-specific and system-specific factors influencing survival. This is vital in order to benchmark the performance of our existing system of OHCA care, identify strategic areas for improvement and demonstrate the impact of system change. This type of database will require collaboration between ISD, SAS and academic partners. Annex A describes in more detail the component parts of the Registry.

The Registry will also provide the authoritative means by which Scotland will be able to publically report progress towards improved OHCA outcomes.

Box 14 Measuring the process and outcomes of OHCA There are a range of measures which we would want to report in order to support improvements in OHCA. The Registry will provide the mechanism to enable these data to be comprehensively and accurately collated and analysed. Measures to be developed and reported include: Percentage of ROSC (Return of Spontaneous Circulation) for all OHCAs where resuscitation was attempted and initial rhythm was VF (Ventricular Fibrillation) Number of PADs mapped onto SAS CAD system Number of Co and First Responders mapped onto SAS CAD system Number (and %) of OHCA where T-CPR offered Number (and %) of OHCA where bystander CPR recorded Number (and %) of OHCA where closest first or co-responder was dispatched Number (and %) where a PAD was used Number (and %) of OHCA where a paramedic was in attendance Number (and %) of OHCA where three or more responders were at scene Survival rate - Number (and %) of people having a OHCA where resuscitation was attempted who survive to discharge

17. Clinical data

The collection of high quality data about cardiac arrest is important both in terms of clinical care and for what can be derived from the data subsequently including audit, feedback, training, and research.

Aim: To improve and simplify the capture of data by SAS to support clinical care and contribute to the cardiac arrest registry.

Ambulance staff attending OHCAs are the people directly responsible for capturing the data on the processes and outcomes associated with OHCA performance. SAS recognise that more can be done to develop its capacity to capture, analyse, interpret and share data with their staff and with appropriate partners in order to drive improvements in performance and outcomes for patients. In order to achieve this, SAS is currently reviewing the accuracy and use of its 'OHCA dashboard' which includes:

• Number of crews and resources dispatched to OHCA
• Response times
• Numbers where bystander CPR and/or PADS are used
• Percentage of pre-hospital ROSC rates

The ease of use of data input, extraction and use are critical in order to help busy staff to consistently and accurately collect the necessary data. These are key considerations in any revisions or procurement of the Electronic Patient Report Form (ePRF) system and defibrillators.

18. Health Inequalities

It is known that people in deprived communities are more likely to suffer from cardiovascular diseases and OHCA but also less likely to survive than people from more affluent areas. It is essential that in improving OHCA outcomes there is a focus and commitment to addressing health inequalities so that the gap in OHCA outcomes between the most deprived and more affluent areas is narrowed.

Aim: To reduce inequalities in survival after OHCA.

Aim: To strive to ensure that communities in remote and rural locations have equity of treatment for OHCA.

There is need to consider the full spectrum of factors impacting on OHCA outcome inequality including deprivation, ethnicity, gender and geography. For example, significant numbers of the Scottish population live in areas where geography presents a significant challenge in terms of ambulance response times,^[23] therefore requiring the development and delivery of rural - and also remote - pathways.

There is scope for all the supporting partners of the OHCA strategy to explore opportunities to engage with disadvantaged communities to strengthen their awareness of and response to cardiac arrest and its causes.

Figure 7: Prevalence of OHCA, likelihood of receiving bystander CPR and level of deprivation, 2011/12

These graphs (based on unpublished data from the RRG) show OHCA across the whole of Scotland in 2011/12 and shows that the prevalence of OHCA increases with the level of deprivation, but the likelihood of receiving bystander CPR is inversely related.

The OHCA strategy presents an opportunity for both the SAS and SFRS to position themselves as a health promoting and health protecting organisation. An understanding of the crucial importance of addressing 'health inequalities' as part of this strategy is acknowledged by SAS and this will inform their plans to improve survival in the communities they serve.

19. Public attitudes

There is a need to engender and support a cultural shift in order to encourage and 'normalise' amongst the public the use of CPR and PADs when faced with an OHCA.

Aim: To encourage a greater public awareness of the 'right thing to do' and an increased willingness to help when present as a bystander at an OHCA.

The available evidence about changing attitudes and about social marketing has to date not been well applied in relation to responding to OHCA. Initial social research has been commissioned by the Scottish Government to better understand knowledge, attitudes and behaviour around responding to out-of-hospital cardiac arrest and help inform strategies to address barriers to implementing the new strategy.

Around 80% of cardiac arrests occur at home yet a survey carried out by the British Heart Foundation showed that the majority of people (61%) would not feel confident in performing CPR on a family member or a loved one.^[24] This is in part due to fear of doing more harm than good and a lack of knowledge and skills. The same survey found that over half (56%) tended to look to others to take the lead during a medical emergency.

It has been suggested that some people are deterred from intervening in an emergency, for example from initiating CPR, out of concern that they may cause harm, or be sued. Although we have not found any examples of anyone in Scotland facing legal action for negligence or causing harm after seeking to provide help in an emergency, there have been calls that Scotland should follow the Westminster Government which recently passed the Social Action, Responsibility and Heroism Act 2015 for England and Wales. The need and value of a 'Good Samaritan law' in Scotland should be considered.

There is also a need to continue to shift prevailing attitudes to health more generally to highlight the public health messages that encourage people to address the preventable risks factors which can contribute to a cardiac arrest.

20. Culture of excellence

OHCA is time critical and demands that paramedics and others involved are skilled and motivated to deliver high quality care. This objective in a high pressure situation can only be achieved by attention to training and education, skill-mix and deployment models and reflective use of high quality data.

Aim: To engender the belief amongst staff and members of the public that with effective action, OHCA can be a survivable event.

It is vital that clinicians and those responsible for planning services understand that, with better planning organisation and delivery of care to patients who experience OHCA, we can ensure that more people survive and continue to live a fulfilling life. One challenge to improving survival from OHCA is to change hearts and minds - ensuring a positive mindset and approach. One way of achieving this cultural change is to set clear ambitious targets and aspirations as set out in this strategy. By creating the right conditions many more patients will survive to lead normal lives. This cultural shift must accompany the implementation of any change in process.

There is a need for clear definition of best practice and feedback on performance for all staff involved in the chain of survival - from ACC to ICU - in order to drive improvement and foster a culture of excellence. Post resuscitation debrief and post-event support are also important to as part of the feedback process and as mechanisms to protect staff wellbeing.

Effective training is central to the development and sustainability of a culture of excellence and all those engaged in responding to OHCA need to be able to access high quality training. We therefore propose to set up the 'STAR academy' - Scottish Training in Advanced Resuscitation - to be developed by all of the partners involved in resuscitation across the Chain of Survival. The STAR Academy will develop, promote and deliver all aspects of education and training to support professionals, ACC staff and other partner agencies to deliver world class care for patients experiencing OHCA. Training will encompass skills, drills, non-technical performance and systems of care. Particular emphasis will be given to a whole system approach and high quality 'training for the trainers' of all types of responder involved in OHCA.

Box 15 - Our Commitment: Scottish Ambulance Service Staff Support and Welfare SAS and aligned staff often work under the most significant pressure, in all environments, to deliver care to people facing extremely difficult circumstances. It is a job that can take a physical, psychological and emotional toll. We will improve our processes to ensure that staff are supported through the challenging experiences they face. We will put in place feedback mechanisms for all staff involved in OHCA to inform them of outcomes, of their own performance and provide appropriate recognition and support.

21. Research and Innovation

Scotland needs to use - and add to - the science, research and innovation around OHCA. This will include ensuring that Scotland is equipped to recognise, assess, and where justified, implement the latest clinically proven and cost effective innovations.

Aim: To develop and maintain an environment which supports innovation and research leading to improved outcomes in OHCA.

The Scottish Ambulance Service aspires to be a world-leading organisation in research and development relating to pre-hospital care. The OHCA strategy offers an opportunity for SAS to develop the resources to provide international leadership in improving systems, processes and outcomes relating to OHCA for the benefit of the people of Scotland and beyond.

Technology around OHCA continues to evolve and it is important that Scotland can efficiently and effectively adopt and promote new technologies when it is appropriate, and cost effective to do so. As a keen participant in the national 'Innovation Champion's' network, SAS already seeks to utilise emerging technologies to improve processes in all areas of supporting the 'Chain of Survival'.

Research and innovation is required across the whole chain of survival as many important questions currently remain unanswered. Examples include - how do we increase the efficiency of interactions between the initial bystander and ACC, or understand better the impact of OHCA on patients, families and rescuers. Additionally, training teams for effective pre-hospital resuscitation is currently undergoing a renaissance with the increasing recognition of the importance of non-technical skills and the utilisation of novel approaches such as pre-hospital ultrasound scanning and mechanical CPR. The international Cardiology community acknowledges that further research is urgently required to answer important questions re the role of immediate PCI after OHCA. In addition, there is currently no evidence based international consensus on the optimum management of patients in the ICU after OHCA. This is particularly evident when attempting to identify which patients will benefit from prolonged ICU care and which will not.

Scotland has the opportunity to lead the international community by initiating work to answer these key questions in OHCA care and treatment.

In order to fulfil the ambition of becoming an international leader for OHCA outcomes Scotland will require a knowledge and improvement hub in order to build and sustain engagement and commitment as well as support and drive innovation.

International experience suggests that a successful model for this is the establishment of a 'Resuscitation Outcomes Consortium'. This would provide infrastructure and project support for clinical trials and other outcome-oriented clinical research in the area of out-of-hospital cardiac arrest. The OHCA registry provides the foundation to systematic improvement and would be a central component of such an enterprise which is described in more detail in 'BOX' 16 below.

Box 16 Scottish Resuscitation Outcomes Consortium: A vision for the future In order to ensure ongoing improvements in OHCA outcomes, there is a need for a collaborative hub in Scotland around which ideas can be developed, research progressed, data analysed, information shared and support and expertise offered. Based on the experience in other countries, it is proposed that a consortium - the Scottish Resuscitation Outcomes Consortium (or Scot-ROC) - should be developed. To work with key partners to put in place the ethical, data protection, statistical and IT frameworks required to assemble key datasets required to analyse systems of care, identify strategic research areas and drive quality improvement. To provide infrastructure and project support for clinical trials and other outcome-oriented research into cardiopulmonary arrest that will rapidly lead to evidence-based change in clinical practice and pathways of care in Scotland. To maintain a focus on pre-hospital and early hospital based emergency interventions recognising the critical importance of this time frame and the common challenges of data collection, research and service improvement in these clinical domains. Scot-ROC investigators could conduct collaborative trials and tests of change of variable size and duration leveraging the combined power of the member institutions and promoting the rapid translation of promising scientific and clinical advances for the public good. Scot-ROC would report regularly with information available to stakeholders, Scottish Government and the general public, present at relevant meetings and publish in the peer reviewed literature. The consortium could also act as an advisory group for Scottish Government and other organisations.