Out of hospital cardiac arrest: strategy 2021 to 2026

5. Bystander Action (Call 999, CPR and Defibrillation)

We will encourage an increased willingness to deliver CPR and defibrillation among people who witness an out-of-hospital cardiac arrest.

Aims:

1. To equip a total of 1 million people in Scotland with CPR skills

2. All school aged children will have the opportunity to be equipped with CPR skills.

3. Bystander CPR rates will be increased to 85%.

4. Public Access Defibrillators will be as accessible as possible.

5. 20% of all cardiac arrests will have a defibrillator applied before the ambulance service arrive.

6. Survival from OHCA will increase to 15%.

Prompt bystander action – calling 999, delivering CPR and defibrillation - are vital to improving a person's chance of survival from OHCA.

The first action taken by any bystander must be to call 999 and request an ambulance for an OHCA.

Cardiopulmonary resuscitation (CPR) is a series of actions which artificially circulates blood around the body, buying time before the emergency services arrive or until defibrillation can be attempted^[30].

Public Access Defibrillators (PADs) deliver an electric shock to the heart of someone in cardiac arrest, allowing the normal, organised, electrical rhythm of the heart to restart^[31].

Although these are two distinct actions, CPR and defibrillation work hand in hand to give people the best chance of survival after cardiac arrest.

Evidence shows that the use of CPR in the immediate aftermath of an out-of-hospital cardiac arrest can increase the likelihood of survival by 2-3 times^[32]. Where only one bystander is present at the scene, the most important thing they can do is call for help and do CPR as instructed by the Ambulance Service call handler.

In some circumstances defibrillation within 3 minutes of a cardiac arrest can increase the chance of survival to above 70%^[33].

If there is a publicly accessible defibrillator nearby, and it is possible to fetch it without interrupting CPR, the Ambulance Service will instruct a bystander to collect it. In Scotland, defibrillators are not often used before the arrival of the Ambulance Service^[34].

Working with communities to familiarise people with both CPR skills and the use of PADs, and ensuring that people who witness an OHCA feel confident in using both of these, is the foundation of ensuring that those who experience an OHCA have the best chance of survival.

Cardiopulmonary resuscitation (CPR)

The most obvious barrier to performing CPR is the knowledge of how to do it. Even though Ambulance Service call handlers will instruct bystanders at an OHCA in how to do chest compressions, it is those who have previously been equipped with CPR skills who are most willing to deliver this intervention^[35].

We want bystanders who witness an OHCA to feel able to take action, and to achieve this we aim to familiarise a total of 1 million people in Scotland with CPR skills.

We will make a concerted effort to target our approach to equipping people with CPR skills. This is to ensure that we reach communities who typically face barriers to accessing opportunities to learn CPR skills, or who experience inequities in outcomes from OHCA^[36].

Alongside equipping people with these lifesaving skills, we must also make sure that we continue to work to address common misconceptions about CPR. Fear of inadvertently doing harm or making the situation worse and fear of being sued are some of the reasons cited for inaction^[37].

Much good practice already exists. Public services and third sector organisations have played a vital role in engaging with communities and equipping 640,000 people across Scotland with CPR skills through the implementation of the 2015 OHCA Strategy.

Now we can build on that success. We will use this opportunity to increase the reach of our work to embed CPR skills in communities across Scotland, and ensure that the change is sustained over time.

Schools

The SALFS partnership is committed to supporting schools and youth organisations to equip young people with CPR skills. We will work with local authorities, education colleagues and partners, to make sure that all school age children have the opportunity to learn CPR skills.

We will work with youth organisations to support young people to become CPR ambassadors in their communities and schools.

Equipping young people with these lifesaving skills not only creates the basis of a strong long-lasting bystander culture but enables even primary school aged children to support their friends and family to learn these skills too^{[38],[39],[40]}.

Community-led engagement

As 80% of cardiac arrests occur at home^[41], it is vital that we continue to consider ways to increase engagement at community-level. Our partners are committed to working closely with communities and we will work together to continue this approach.

It is important that we continue to ensure that our initiatives are as accessible as possible. To do this, we will increase engagement with existing community organisations (e.g. sports hubs, local businesses and other community groups) to raise awareness of and offer opportunities to learn CPR.

We are not the only partners in Scotland who are working towards increasing survival rates after OHCA. We will seek out and work in collaboration with local community groups across Scotland who focus on CPR and defibrillation (both provision of equipment and training) to gather our collective experiences and support and amplify each other's work.

First Responders

The strategy partners know that while recognising the signs of a cardiac arrest may seem straightforward, bystanders are not always confident in their ability to do so. It is vital then, that Scottish Ambulance Service call handlers are able to quickly recognise bystander's description of an OHCA and encourage the caller to begin CPR.

Supporting bystander action will give those in need a fighting chance until the appropriate emergency resources arrive on scene.

Prompt arrival of community responders is also vital to improving the Chain of Survival. By utilising trained volunteer emergency responders we can increase the resources available to help at an OHCA, relieve the pressure on bystanders and increase the chances of survival for those in need.

People from a number of agencies can be or already are trained to respond to OHCA. This means there is more opportunity for a quick initial response, particularly in some rural and remote areas. The ability to do this is already enshrined in community planning policy^[42], giving partners the scope to support local first response solutions.

In recent years, smartphone applications such as GoodSAM have facilitated rapid community responder action in response to OHCA, alerting nearby off duty doctors, nurses and paramedics to an emergency. Scottish Ambulance Service has adopted GoodSAM for use and the SALFS partnership will work to support its effective usage.

End of Life decision making and anticipatory care planning

CPR is a treatment that could be attempted on any individual whose heart function stops. Such events are inevitable as part of dying and thus, theoretically, CPR could be given to every person when they die.

It is therefore essential that emergency responders can more easily identify people for whom cardiac arrest represents the terminal event in their illness and for whom CPR would be inappropriate because it will not be of benefit or they have recorded that they do not want to receive CPR. This helps them to ensure that action taken reflects the wishes of that person.

Guidance is already in place to support recording of such decisions but the visibility of this can often be difficult in the emergency situation. We will work with NHS and emergency response partners to ensure the systems are in place to make information recorded about such decisions more accessible to all responders, and so help to reduce unwanted or inappropriate resuscitation attempts.

Defibrillators

Public Access Defibrillators (PADs) are designed for use by members of the public without training. They come with written instructions and can give audible guidance to users.

PADs are automatic defibrillators, which means that they will only deliver a shock where it is required. Despite this, the public are often still reluctant to use them^{[43],[44],[45]}.

To address this, we will work to embed the use of PADs within our public awareness campaign outlined in the Getting Scotland OHCA Ready chapter. We will draw on examples of best practice from the partnership and other local community groups to develop our messaging in this regard.

Another barrier to prompt bystander defibrillation is a lack of accessibility of PADs. This can be a result of a combination of factors including; lack of registration limiting the ability for SAS call handlers to direct a bystander to a nearby PAD, or the lack of a PAD placed within an accessible distance to the location of the OHCA.

At the time of writing, PADs are only used by the public in around 8%of arrests in Scotland^[46].

There are many PADs installed in a variety of locations across Scotland, though not all are registered with the Scottish Ambulance Service. We will continue to encourage the accessible mounting, clear signposting and registration of PADs.

The Scottish Ambulance Service uses 'The Circuit', a UK-wide registry of defibrillators developed by the British Heart Foundation which allows 999 call handlers to quickly direct bystanders

to a registered PAD when it is nearby. We recommend that all PADs are registered to increase the opportunities for the ambulance service to be aware of their location and support bystanders to access and use them in instances of OHCA.

To support effective use of PADs, we published Out-of-Hospital Cardiac Arrest: guide to public access defibrillators in 2018. This provides practical advice to those considering a PAD for their local community.

We will update the guide during the lifetime of this strategy to provide the most up to date advice and encourage communication between potential PAD guardians and SALFS partners.

PAD location work

Mathematical modelling can be used to help ensure that PADs are placed in locations that maximise their usefulness. Using our knowledge of where OHCAs are most likely to happen we are able to build a tool to show where PADs are most likely to be required.

We are working to make this type of tool readily available to communities and organisations who wish to deploy PADs for greatest benefit.

Actions:

1. We will work with Local Authorities to give school aged children to opportunity to be equipped with CPR skills.

2. We will work with the Scottish Ambulance Service to optimise the interaction with call handlers as they assist bystanders in performing CPR and using PAD.

3. We will support the development and deployment of first responder networks. This will include

• ensuring first responders are trained in the delivery of high performance CPR.
• working with communities, statutory organisations and third sector organisations to support a coordinated first response to OHCA.

4. We will work with NHS and emergency response partners to make sure that systems are in place to make information recorded about end of life decisions is available and accessible to responders in instances of OHCA.

5. We will familiarise adults and children across Scotland with PAD usage.

6. We will analyse and publish data to provide members of the public with information as to the most effective location to place their defibrillator.

7. We will develop and implement evidence based national PAD guidelines, focusing on optimal placement and public engagement.

8. We will continue to encourage the accessible mounting, clear signposting and registration of PADs with the Scottish Ambulance Service.

"Brian keeps wanting to say thank you all the time, but seeing him here speaking to us today is the best thank you"

Brian Clarke

On February 15th 2015 Brian Clarke was leaving the gym in Anstruther when he had a cardiac arrest. He was found in his car by a passerby who alerted the staff inside the gym. Stuart Barton, who had spoken to Brian only moments ago was shocked as he ran outside to see him collapsed. With another member of the public, he checked for breathing, called 999 and sent for a defibrillator. He also began CPR.

"So there's me, never used a defibrillator before, panicking, but it was so simple and you have that horrible thing going in your mind, am I doing this right? But it was honestly so simple and speaks so clearly, "analysing patient, shock advised, shock given", and then away you go with your CPR again. And right as we had a pulse, a knight in shining armour, the first responder showed up."

Gillian Duncan from East Neuk First Responders was now on the scene and took over from Stuart. Shortly after that, a Scottish Ambulance paramedic arrived and took Brian to hospital. Brian was on a life support machine for 50 hours and his family really didn't know what was going to happen, but then, he woke up. He was still Brian. He survived his OHCA because of the early actions of these individuals including early defibrillation.