Paramedic Out-of-Hospital Cardiac Arrest Case Volume Is a Predictor of Return of Spontaneous Circulation

Jenna E. Tuttle, MHS, NRP; Michael W. Hubble, PhD, NRP


Western J Emerg Med. 2018;19(4):654-659. 

In This Article

Abstract and Introduction


Introduction: Many factors contribute to the survival of out-of-hospital cardiac arrest (OHCA). One such factor is the quality of resuscitation efforts, which in turn may be a function of OHCA case volume. However, few studies have investigated the OHCA case volume-survival relationship. Consequently, we sought to develop a model describing the likelihood of return of spontaneous circulation (ROSC) as a function of paramedic cumulative OHCA experience.

Methods: We conducted a statewide retrospective study of cardiac arrest using the North Carolina Prehospital Care Reporting System. Adult patients suffering a witnessed, non-traumatic cardiac arrest between January 2012 and June 2014 were included. Using logistic regression, we calculated an adjusted odds ratio (OR) for the influence of the preceding five-year paramedic OHCA case volume on ROSC while controlling for the potentially confounding variables identified a priori as patient age, gender, and non-Caucasian race; shockable presenting rhythm; layperson/first responder cardiopulmonary resuscitation (CPR); and emergency medical services (EMS) response time.

Results: Of the 6,405 patients meeting inclusion criteria, 3,155 (49.3%) experienced ROSC. ROSC was more likely among patients treated by paramedics with ≥ 15 OHCA experiences during the preceding five years (OR [1.21], p<0.01). ROSC was also more likely among patients with shockable initial rhythms (OR [2.35], p<0.01) and who received layperson/first responder CPR (OR [1.77], p<0.01). Increasing patient age (OR [0.996], p=0.02), male gender (OR [0.742], p<0.01), and increasing EMS response time (OR [0.954], p<0.01) were associated with a decreased likelihood of ROSC. Non-Caucasian race was not an independent predictor of ROSC.

Conclusion: We found that a paramedic five-year OHCA case volume of ≥ 15 is significantly associated with ROSC. Further study is needed to determine the specific actions of these more experienced paramedics who are responsible for the increased likelihood of ROSC, as well as the influence of case volume on the longer-term outcome measures of hospital discharge and neurological function.


Sudden cardiac death accounts for more than half of all coronary heart disease deaths in the United States (U.S.), with approximately 326,200 cases of out-of-hospital cardiac arrest (OHCA) patients assessed by emergency medical services (EMS) each year.[1] The importance of bystander cardiopulmonary resuscitation (CPR), early defibrillation, and quality resuscitation and post-resuscitation care on favorable outcomes are well documented. However, other factors such as the quality and timing of paramedic interventions may also influence outcomes. Unfortunately, resuscitation skills are known to decline over time,[2] which may lower survival rates. Such skill decay may be the result of limited exposure to OHCA case volume, which has been observed to average less than two cases per year per paramedic in some areas.[3] Only one study has previously quantified the OHCA case volume-survival relationship among paramedics;[4] however, it is unclear if the findings of this international study can be extrapolated to EMS systems in the U.S.

Due to the lack of previous investigations among U.S. EMS systems, the influence of OHCA case volume on patient outcomes remains poorly quantified. Therefore, using a statewide dataset we sought to develop a model describing the likelihood of return of spontaneous circulation (ROSC) as a function of OHCA case volume. We hypothesized that the likelihood of ROSC increased with increasing paramedic OHCA case volume.