Cardiac & Resuscitation, Communications & Dispatch, Exclusives, Heart of America, Top Story

Community Response to Cardiac Arrest in the Netherlands

In 1767, the Foundation of the Rescue of Drowned Persons was established in the Netherlands because of the high number of people who drowned in Amsterdam’s many canals. The foundation promoted rescue techniques, informing Amsterdam’s citizens that drowned persons could actually be saved by first-aid interventions. They also gave medals to rescuers.

The foundation exists and is still active today, and it illustrates the proactive Dutch attitude toward community participation to save lives.

Like drowning, the first few minutes of an out-of-hospital cardiac arrest (OHCA) are essential. This is especially true when the arrest is witnessed, caused by a shockable rhythm, and immediately recognized. BLS measures, including the use of an AED, must be implemented quickly.

This poses a great challenge in prehospital care, because most bystanders haven’t been trained to recognize and respond to cardiac arrests. It often takes approximately 10 minutes before the emergency dispatcher recognizes the arrest and an ambulance with trained responders can arrive to defibrillate the heart. These barriers of survival should be overcome to improve OHCA survival.

Today, the Netherlands has a nationwide response system that alerts trained citizens when they’re near someone who’s experiencing an out-of-hospital cardiac arrest (OHCA). The main elements of this system are available trained citizens, available AEDs and a system to alert them that’s used by the dispatch center.

This system has led to an increase in bystander CPR and placement of an AED prior to ambulance arrival. The average age of OHCA patients in the Netherlands is 66 years of age, with 72% being male. Cardiac arrests usually occur at home (69%) and are typically witnessed by at least one person (68%).

The median time from the emergency call to ambulance arrival is nine minutes. BLS is started before ambulance arrival in 84% of cases. An AED (either on-site or delivered on scene by a first responder) is placed before ambulance arrival in 65% of cases.

The overall survival to hospital discharge (of non-traumatic OHCA, all rhythms) is 23%, with a good neurological outcome (CPC1 or CPC2) in 95% of cases. The EuReCa study showed that the Netherlands, at 56% survival, has the highest survival rate in the Utstein comparator group (witnessed arrest with shockable rhythm) in all of Europe. The use of the nationwide OHCA response system is likely on one of the main reasons for this.

Figure 1: Survival after a witnessed v fib arrest are high in the Netherlands (NL) vs. the rest of Europe.

The Dutch Heart Foundation promotes so-called “six-minute zones”—the optimal response time frame to start BLS and apply an AED when someone suffers a cardiac arrest. To achieve this, there has to be a sufficient number of trained responders distributed throughout the community. This requires promotion of BLS training in the community and registering BLS-trained citizens so they’re an available resource for the dispatch center, which must have activation software to alert citizens. Furthermore, AEDs must be available 24/7, so they can be fetched by activated citizens, who are guided to the location by the activation system.

In the future, improved implementation of this system will save even more lives. We should involve logisticians to improve the activation system and ensure widespread AED distribution. Technological innovations may enable us to more immediately recognize a cardiac arrest call, improve the use of smartphone GPS, and may even allow the use drones to deliver an AED to the patient. Finally, we should aim to promote community response to OHCA by involving local organizations, government agencies and celebrities, and we should reward citizens who respond.

Resources

  • Berdowski J, Blom MT, Bardai A, et al. Impact of onsite or dispatched automated external defibrillator use on survival after out-of-hospital cardiac arrest. Circulation. 2011;124(20):2225–2232.
  • Blom MT, Beesems SG, Homma PC, et al. Improved survival after out-of-hospital cardiac arrest and use of automated external defibrillators. Circulation. 2014;130(21):1868–1875.
  • Gräsner JT, Lefering R, Koster RW, et al. EuReCa ONE-27 Nations, ONE Europe, ONE Registry: A prospective one month analysis of out-of-hospital cardiac arrest outcomes in 27 countries in Europe. Resuscitation. 2016;105:188–195.
  • Waalewijn RA, Tijssen JG, Koster RW. Bystander initiated actions in out-of-hospital cardiopulmonary resuscitation: Results from the Amsterdam Resuscitation Study (ARRESUST). Resuscitation. 2001;50(3):273-279.
  • Zijlstra JA, Koster RW, Blom MT, et al. Different defibrillation strategies in survivors after out-of-hospital cardiac arrest. Heart. 2018;104(23):1929–1936.
  • Zijlstra JA, Stieglis R, Riedijk F, et al. Local lay rescuers with AEDs, alerted by text messages, contribute to early defibrillation in a Dutch out-of-hospital cardiac arrest dispatch system. Resuscitation. 2014;85(11):1444–1999.