An evaluation of the effectiveness of critical components of the chain of survival in out-of-hospital cardiopulmonary resuscitation in Nigeria

Abstract

ABSTRACT Background The ‘’Chain of Survival’’ (CoS), provides a structure to evaluate an emergency response system for out-of-hospital cardiac arrest (OHCA) in any community. This chain has not been previously evaluated in an African population. The aim of this study was to assess the effectiveness and efficiency of out-of-hospital CPR by evaluating the components of the CoS following sudden cardiac arrest in Nigeria. Methodology This was a prospective multicenter descriptive cross-sectional exploratory survey of epidemiology and outcome of sudden cardiac arrest (SCA) in adult Nigerians. The survey was conducted in six University teaching hospitals in the 6 geopolitical zones. Information concerning the patients were obtained from family member or an accompanying person, and hospital emergency department personnel. Exclusion criteria included age < 18 years, incomplete registered data, do not attempt resuscitation (DNAR) decision, and patients in whom resuscitation was not attempted. Primary outcome measures were return of spontaneous circulation (ROSC), survival to hospital admission and discharge. Results A total of 387 OHCA patients aged between 18 and 115 years met the inclusion criteria. They consisted of 62.5% males and 37.5% females, giving a male/female ratio of approximately 1.7:1, and the mean age was 49.9 ± 19.15 years. Most (55.6%) of the arrests occurred at home. Ninety-one-point seven percent (91.7%) of the arrests were witnessed. Calls were made to ambulance services but only in a third (34.6%) did ambulance arrive. The time taken for the ambulance to arrive at the call site ranged between 10 minutes and 60 minutes, with a mean time of arrival of 25.6 ±20.5 minutes. Only 14.3% of ambulances had facilities for both BLS interventions. Pre-hospital resuscitation was attempted in 15.2%. Pre-hospital ROSC was achieved in 3.6% of all the SCA events, but only 1.8% survived to hospital admission and were eventually discharged. Conclusion The emergency response service to OHCA in Nigeria is very poor due to weaknesses in the critical components of the CoS. There is a need for regular evaluation of the effectiveness of the CoS to identify weaknesses, and efforts made to improve performance in every component of the chain, through community wide BLS training. Clinical Perspective What is new? This is the first large scale multi-center study in Nigeria, and probably in Africa, to evaluate the effectiveness and efficiency of the components of chain of survival in out-of-hospital cardiopulmonary resuscitation, reflecting the complex interplay of resources, setting and bystander engagement on the clinical outcomes of cardiac arrest. The emergency response service system for OHCA in Nigeria is very poor. This study revealed the shortcomings related to cardiopulmonary resuscitation due to resource-limitation, which bellies the practical difficulties inherent in implementing the scientific recommendations on resuscitation formulated primarily from the perspective of a high-resource environment by the International Liaison Committee on Resuscitation. Clinical implications The shortcomings observed in cardiopulmonary resuscitation in this study calls for a well-organized, coordinated deliberate efforts to strengthen all parts of the chain of survival in a manner that emphasizes engagement from the community, and the development of locally implemented, strong pre-hospital chain of care, which is adaptable to the requirements of different cardiac emergencies. There should be a long-term, ongoing evaluation of the CoS to identify weaknesses and efforts made to improve performance in every community through a deliberate effort to ensure training on BLS for everyone (medical and non-medical), and from an early age.