Large urban center improves out-of-hospital cardiac arrest survival



      Large cities pose unique challenges that limit the effectiveness of system improvement interventions. Successful implementation of integrated cardiac resuscitation systems of care can serve as a model for other urban centers.


      This was a retrospective analysis of prospectively collected data of adult cases of non-traumatic cardiac arrest who received treatment by Chicago Fire Department EMS from September 1, 2013 through December 31, 2016. We measured temporal OHCA outcomes during implementation of system-wide initiatives including telephone-assisted and community CPR training programs; high performance CPR and team based simulation training; new post resuscitation care and destination protocols; and case review for EMS providers. Outcomes measured included bystander CPR rates, return of spontaneous circulation (ROSC), hospital admission and survival, and favorable neurologic outcomes (CPC 1–2). Relative risk was determined by logistic regression model where observed group-specific outcomes are expressed as odds ratios (OR).


      We included 6103 adult OHCA cases occurring outside of health care facilities from September 1, 2013 through December 31, 2016. Significantly improved outcomes (p < 0.05) were observed between 2013 and 2016 for bystander CPR (11.6% vs 19.4%), ROSC (28.6% vs 36.9%), hospital admission (22.5% vs 29.4%), survival (7.3% vs 9.9%), and CPC 1–2 (4.3% vs 6.4%). Utstein survival increased from 16.3%–35.4% and CPC 1–2 survival from 11.6%–29.1% (p < 0.05). After adjustment for OHCA characteristics, survival with CPC 1–2 increased over time (OR 1.15, p = 0.0277).


      Densely populated cities with low survival rates can overcome systematic challenges and improve OHCA survival.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Resuscitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Benjamin E.J.
        • Virani S.S.
        • Callaway C.W.
        • et al.
        Heart disease and stroke statistics–2018 update: a report from the american heart association.
        Circulation. 2018; 137: e67-e492
        • Girotra S.
        • van Diepen S.
        • Nallamothu B.K.
        • et al.
        Regional variation in out-of-hospital cardiac arrest survival in the United States.
        Circulation. 2016; 133: 2159-2168
        • Becker L.B.
        • Ostrander M.P.
        • Barrett J.
        • Kondos G.T.
        Outcome of CPR in a large metropolitan area—where are the survivors?.
        Ann Emerg Med. 1991; 20: 355-361
        • Nichol G.
        • Thomas E.
        • Callaway C.W.
        • et al.
        Regional variation in out-of-hospital cardiac arrest incidence and outcome.
        JAMA. 2008; 300: 1423-1431
        • Sasson C.
        • Cudnik M.T.
        • Nassel A.
        • et al.
        Identifying high-risk geographic areas for cardiac arrest using three methods for cluster analysis.
        Acad Emerg. 2012; 19: 139-146
        • Benjamin E.J.
        • Virani S.S.
        • Callaway C.W.
        • et al.
        Heart disease and stroke statistics—2018 update: a report from the American Heart Association.
        Circulation. 2018; 137: e67-e492
        • Eisenberg M.S.
        • Horwood B.T.
        • Cummins R.O.
        • Reynolds-Haertle R.
        • Hearne T.R.
        Cardiac arrest and resuscitation: a tale of 29 cities.
        Ann Emerg Med. 1990; 19: 179-186
        • Daya M.R.
        • Schmicker R.H.
        • Zive D.M.
        • et al.
        Out-of-hospital cardiac arrest survival improving over time: results from the Resuscitation Outcomes Consortium (ROC).
        Resuscitation. 2015; 91: 108-115
        • Hinchey P.R.
        • Myers J.B.
        • Lewis R.
        • et al.
        Improved out-of-hospital cardiac arrest survival after the sequential implementation of 2005 AHA guidelines for compressions, ventilations, and induced hypothermia: the Wake County experience.
        Ann Emerg Med. 2010; 56: 348-357
        • Mooney M.R.
        • Unger B.T.
        • Boland L.L.
        • et al.
        Therapeutic hypothermia after out-of-hospital cardiac arrest: evaluation of a regional system to increase access to cooling.
        Circulation. 2011; 124: 206-214
        • Fordyce C.B.
        • Hansen C.M.
        • Kragholm K.
        • et al.
        Association of public health initiatives with outcomes for out-of-hospital cardiac arrest at home and in public locations.
        JAMA Cardiol. 2017; 2: 1226-1235
        • Eckstein M.
        • Stratton S.J.
        • Chan L.S.
        Cardiac arrest resuscitation evaluation in Los Angeles: CARE-LA.
        Ann Emerg Med. 2005; 45: 504-509
        • Eisenberg M.S.
        Resuscitate! How your community can improve survival from sudden cardiac arrest.
        2nd ed. University of Washington Press, Seattle2013 ( Available only to UIC users)
      1. City of Chicago Facts and Statistics. (Accessed 8 August 2018, at

        • Tonna J.E.
        • Johnson N.J.
        • Greenwood J.
        • et al.
        Practice characteristics of Emergency Department extracorporeal cardiopulmonary resuscitation (eCPR) programs in the United States: the current state of the art of Emergency Department extracorporeal membrane oxygenation (ED ECMO).
        Resuscitation. 2016; 107: 38-46
      2. Sudden cardiac arrest: meeting the challenge.
        2011 (Accessed 18 November 2018)
        • Beck E.
        • Lazzara P.
        • Stein-Spencer L.
        Simulation station: Chicago Fire Department takes training to a new level.
        JEMS. 2011; 36 (61): 58-59
      3. Congress US Public Law 111-148. Government Printing Office, Washington DC, United States2010
        • Jermyn B.D.
        Response interval comparison between urban fire departments and ambulance services.
        Prehosp Emerg Care. 1999; 3: 15-18
        • Stout J.
        • Pepe P.E.
        • Mosesso Jr, V.N.
        All-advanced life support vs tiered-response ambulance systems.
        Prehosp Emerg Care. 2000; 4: 1-6
        • Consortium CEMD
        Cardiac Arrest Management: incident command for cardiac arrest (ICCA).
        • Gerber M.
        Improving resuscitation, Chicago style: HeartRescue Project focuses efforts to raise survival rates.
        • Bosson N.
        • Kaji A.H.
        • Niemann J.T.
        • et al.
        Survival and neurologic outcome after out-of-hospital cardiac arrest: results one year after regionalization of post-cardiac arrest care in a large metropolitan area.
        Prehosp Emerg Care. 2014; 18: 217-223
        • McNally B.
        • Stokes A.
        • Crouch A.
        • Kellermann A.L.
        • Group C.S.
        CARES: cardiac arrest registry to enhance survival.
        Ann Emerg Med. 2009; 54 (e672): 674-683
        • van Diepen S.
        • Girotra S.
        • Abella B.S.
        • et al.
        Multistate 5-year initiative to improve care for out-of-hospital cardiac arrest: primary results from the heartrescue project.
        J Am Heart Assoc. 2017; 6
        • Beck E.H.
        • Richards C.
        • Kiely M.
        • et al.
        Abstract 16267: identifying hot spots for EMS-treated acute cardiovascular events—stroke, STEMI, and cardiac arrest—in a large metropolitan city.
        Circulation. 2013; 128A16267
        • Del Ríos M.
        • Heinert S.
        • Foster E.
        • et al.
        Association of neighborhood characteristics with incidence and survival from out of hospital cardiac arrest in Chicago.
        Acad Emerg. 2015; 22A316
        • Del Rios M.
        • Han J.
        • Cano A.
        • et al.
        Pay it forward: high school video-based instruction can disseminate CPR knowledge in priority neighborhoods.
        West J Emerg Med. 2018; 19: 423-429
      4. Chicago: Geography and Climate. (Accessed 12 April 2018, at

        • McGrath B.P.
        Home monitoring of blood pressure.
        Aust Prescr. 2015; 38: 16-19
        • Harris P.A.
        • Taylor R.
        • Thielke R.
        • Payne J.
        • Gonzalez N.
        • Conde J.G.
        Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support.
        J Biomed Inform. 2009; 42: 377-381
        • Jennett B.
        • Bond M.
        Assessment of outcome after severe brain damage.
        Lancet. 1975; 1: 480-484
        • Grossestreuer A.V.
        • Abella B.S.
        • Sheak K.R.
        • et al.
        Inter-rater reliability of post-arrest cerebral performance category (CPC) scores.
        Resuscitation. 2016; 109: 21-24
        • Jacobs I.
        • Nadkarni V.
        • Bahr J.
        • et al.
        Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries: a statement for healthcare professionals from a task force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Councils of Southern Africa).
        Circulation. 2004; 110: 3385-3397
        • Pan W.
        Akaike’s information criterion in generalized estimating equations.
        Biometrics. 2001; 57: 120-125
        • Malta Hansen C.
        • Kragholm K.
        • Pearson D.A.
        • et al.
        Association of bystander and first-responder intervention with survival after out-of-hospital cardiac arrest in North Carolina, 2010-2013.
        JAMA. 2015; 314: 255-264
        • Bobrow B.J.
        • Spaite D.W.
        • Berg R.A.
        • et al.
        Chest compression-only CPR by lay rescuers and survival from out-of-hospital cardiac arrest.
        JAMA. 2010; 304: 1447-1454
        • Hasselqvist-Ax I.
        • Riva G.
        • Herlitz J.
        • et al.
        Early cardiopulmonary resuscitation in out-of-hospital cardiac arrest.
        N Engl J Med. 2015; 372: 2307-2315
        • Wissenberg M.
        • Lippert F.K.
        • Folke F.
        • et al.
        Association of national initiatives to improve cardiac arrest management with rates of bystander intervention and patient survival after out-of-hospital cardiac arrest.
        JAMA. 2013; 310: 1377-1384
        • Lick C.J.
        • Aufderheide T.P.
        • Niskanen R.A.
        • et al.
        Take heart America: a comprehensive, community-wide, systems-based approach to the treatment of cardiac arrest.
        Crit Care Med. 2011; 39: 26-33
        • Lombardi G.
        • Gallagher J.
        • Gennis P.
        Outcome of out-of-hospital cardiac arrest in New York City. the pre-hospital arrest survival evaluation (PHASE) study.
        JAMA. 1994; 271: 678-683
        • Gallagher E.J.
        • Lombardi G.
        • Gennis P.
        • Treiber M.
        Methodology—dependent variation in documentation of outcome predictors in out-of-hospital cardiac arrest.
        Acad Emerg Med. 1994; 1: 423-429
        • May S.
        • Zhang L.
        • Foley D.
        • et al.
        Improvement in non-traumatic, out-of-hospital cardiac arrest survival in detroit from 2014 to 2016.
        J Am Heart Assoc. 2018; 7e009831
        • Haywood K.
        • Whitehead L.
        • Nadkarni V.M.
        • et al.
        COSCA (core outcome set for cardiac arrest) in adults: an advisory statement from the international liaison committee on resuscitation.
        Circulation. 2018; 137: e783-e801