ORIGINAL RESEARCH Open Access

First-response treatment after out-of-hospital cardiac arrest: a survey of currentpractices across 29 countries in EuropeIris Oving1, Siobhan Masterson2, Ingvild B.M. Tjelmeland3, Martin Jonsson4, Federico Semeraro5, Mattias Ringh4,Anatolij Truhlar6, Diana Cimpoesu7, Fredrik Folke8,9, Stefanie G. Beesems1, Rudolph W. Koster1, Hanno L. Tan1,10*,Marieke T. Blom1 and for the ESCAPE-NET Investigators

Abstract

Background: In Europe, survival rates after out-of-hospital cardiac arrest (OHCA) vary widely. Presence/absence anddifferences in implementation of systems dispatching First Responders (FR) in order to arrive before EmergencyMedical Services (EMS) may contribute to this variation. A comprehensive overview of the different types of FR-systems used across Europe is lacking.

Methods: A mixed-method survey and information retrieved from national resuscitation councils and national EMSservices were used as a basis for an inventory. The survey was sent to 51 OHCA experts across 29 Europeancountries.

Results: Forty-seven (92%) OHCA experts from 29 countries responded to the survey. More than half of Europeancountries had at least one region with a FR-system. Four categories of FR types were identified: (1) firefighters(professional/voluntary); (2) police officers; (3) citizen-responders; (4) others including off-duty EMS personnel(nurses, medical doctors), taxi drivers. Three main roles for FRs were identified: (a) complementary to EMS; (b) partof EMS; (c) instead of EMS. A wide variation in FR-systems was observed, both between and within countries.

Conclusions: Policies relating to FRs are commonly implemented on a regional level, leading to a wide variation inFR-systems between and within countries. Future research should focus on identifying the FR-systems that moststrongly influence survival. The large variation in local circumstances across regions suggests that it is unlikely thatthere will be a ‘one-size fits all’ FR-system for Europe, but examining the role of FRs in the Chain of Survival is likelyto become an increasingly important aspect of OHCA research.

Keywords: First responders, Out-of-hospital cardiac arrest, Cardiopulmonary resuscitation, Europe, ESCAPE-NET

IntroductionOut-of-hospital cardiac arrest (OHCA) is lethal withinminutes of collapse if left untreated, and the majority ofOHCA patients die before hospital admission [1, 2]. Ifearly cardiopulmonary resuscitation (CPR) is provided,survival rate increases [3, 4]. In particular, presence ofshockable rhythm is an important determinant of

survival, and OHCA patients who are found with ashockable initial rhythm are more likely to survive if theyare defibrillated with an automated external defibrillator(AED) [5]. However, many OHCA patients are notfound in a shockable rhythm due to prolonged emer-gency medical services (EMS) response times, particu-larly in residential areas where most OHCAs occur [6–8]. When CPR is started quickly after collapse, thelength of time that a shockable rhythm persists may beextended [9], thus prolonging the opportunity for suc-cessful defibrillation. Identifying and implementing sys-tems that increase the likelihood of immediate CPRprovision and rapid defibrillation are vital to improving

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

* Correspondence: h.l.tan@amc.nl1Department of Clinical and Experimental Cardiology, Heart Center,Amsterdam Cardiovascular Sciences, Amsterdam UMC, Department ofCardiology, Heart Center, Academic Medical Center, University ofAmsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands10Netherlands Heart Institute, Utrecht, The NetherlandsFull list of author information is available at the end of the article

Oving et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2019) 27:112 https://doi.org/10.1186/s13049-019-0689-0

survival. The deployment of First Responders (FRs) isone method that has been developed in order to meetthis challenge.FR-systems have been implemented differently across

Europe. Some countries have expanded the traditionalEMS response with dispatch of CPR trained firefightersand police officers equipped with AEDs. Research hasshown that the introduction of these types of dispatchedFRs led to shorter response times [10], and increased 30day survival [11, 12]. Dispatch of trained citizen-FRsmay also be successful in reducing response time [13],time to initiation of CPR [14, 15], time to defibrillation[16], and overall survival [17].Survival rates after OHCA vary widely between regions

across Europe [2] and the presence or absence of FR-systems, and differences in their implementation, maycontribute to this variation. For instance, FRs may be lesseffective when they are inefficiently deployed and/or timefrom collapse to initiation of CPR is prolonged when thetechnology used for FR dispatch is suboptimal [15]. Inaddition, differences in FR skill sets may contribute, e.g.,level of resuscitation training, available equipment, and ex-perience in coping with emergency situations.Survival rates after OHCA may increase across Europe

if FR-systems are optimized. Similarly, optimization effortsmay benefit from past experiences in FR implementationacross Europe. However, to date, no comprehensive in-ventory of the different types of dispatched FR-systemsused across Europe exists. Additionally, while the most re-cent European Resuscitation Guidelines emphasise theimportance of community response in saving lives [18],the extent to which establishment of FR-systems has beenadopted as national policy across Europe is unknown.Therefore, the aim of this paper is to create an inventoryof dispatched FR-systems across Europe, and to determinewhether countries have a national policy regarding FR-systems. This will serve as a basis to highlight key differ-ences in order to ultimately optimise FR-systems acrossEurope.

MethodsDesign and set upThis research was conducted as part of the ESCAPE-NET project that aims to discover the causes and besttreatments of OHCA [19]. A mixed-method survey wascombined with information retrieved from national re-suscitation councils and national EMS services as a basisfor an inventory.

Survey and information gatheringThe content of the survey was determined after severalmeetings with an expert panel, consisting of five expertsin the field of OHCA (three cardiologists, one EMS-consultant and one intensive care nurse; initials: IT, RK,

AT, FS, and MR) in Europe. The survey was built byDutch researchers and finalised after a pilot carried outby Amsterdam Resuscitation Studies (ARREST) [20]researchers.The survey was sent to 51 OHCA professionals across

29 European countries between August and November2018 (Additional file 1: Supplementary 1a). An OHCAprofessional was defined as a European ResuscitationCouncil (ERC) or ESCAPE-NET member with a longworking experience (≥5 years) in the field of OHCA and,in particular, in prehospital resuscitation strategies.OHCA professionals were recruited during the ESCAPE-NET [19] and EuReCa [2] sessions at the ERC Congressin Bologna, 2018 (additional file 1: Supplementary 1a).Informed consent for using the contact details of theparticipants was sought and provided. A second attemptwas made to get non-responding survey participants totake part within three weeks. All survey results were val-idated with the respondents before results were finalised.In addition, data on national policies regarding FRs

was sought from national resuscitation councils (or na-tional EMS services where no council existed). If no re-sponse from a national council was received within threeweeks, other national experts in the field of OHCA wereconsulted. Similar to the survey respondents, nationalexperts had a long working experience (≥5 years) in thefield of OHCA and were identified using the ERC orESCAPE-NET network. Where possible, answers fromsurvey respondents and national resuscitation councilswere cross checked.

DefinitionsFor the purposes of this study, EMS and FRs were de-fined as follows:

Emergency medical services (EMS)Emergency Medical Services included on-duty emer-gency medical personnel who were dispatched by adispatch centre to provide acute medical care and totransport the patient to a hospital equipped to provideacute care.

First responder (FR)First Responders were defined as all individuals whowere dispatched by a dispatch centre to attend OHCAevents and initiate early CPR. FRs potentially includedfirefighters and police officers (traditional FRs) [21, 22],off-duty EMS staff and citizen-responders. An extensivedescription of EMS and FRs is provided in Additionalfile 1: Supplementary 1b.

FR-systemThe availability of dispatched FRs was determined foreach country and/or region. A FR-system was defined as

Oving et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2019) 27:112 Page 2 of 20

nationwide when it covered ≥50% of the country. TheFR-system was described and characteristics wereassessed (by examining each individual type of FR, aspart of the FR-system). Characteristics included: recruit-ment and activation methods, role on scene, equipment,CPR training and frequency of training, registration,feedback, financial support, and emotional support. Anextensive description of all characteristics is provided inAdditional file 1: Supplementary 1c.

ResultsThe response rate to the survey was 92% (47/51); infor-mation was obtained from 29 countries. For the specificquestions on national policy, the response rate from na-tional resuscitation councils was 62% (16/26; in 26 of the29 studied countries, a national resuscitation councilexisted). This rate increased to 77% (20/26) after con-sulting other experts.

Types and roles of FRs in EuropeFirst responders were categorised post-hoc into fourmain types:

1) Firefighters (professional and/or voluntary) (Fig. 1a)2) Citizen-responders (Fig. 1b)3) Police officers (Fig. 1c)4) Others, i.e., all responders that could not be

categorized into firefighters, citizen-responders, po-lice officers, (e.g., off-duty EMS personnel, nurses ormedical doctors, and taxi drivers).

The survey identified three main roles for FRs in theevent of OHCA:

1) Complementary to the statutory EMS response;2) Part of the statutory EMS response;3) Instead of EMS.

More than half (19 of 29) of European countries or re-gions thereof had FR-systems (Fig. 2a). Such FR-systemswere implemented nationwide in 16 countries, and re-gionally in 3 countries. In 14 countries, the FR-systemsacted complementary to the statutory EMS response,while in one country FRs were part of the EMS response(France), and in another, FRs substituted the EMS (re-mote areas in Iceland). In 10 of 29 countries there wasno dispatched FR-system (Fig. 2b).

Variation in first responder-systems nationally andregionallyVariation in the type of FR-systems was observedboth between and within countries. FR-systems withone FR type existed nationwide in 8 countries and re-gionally in 9 countries. FR-systems with two FR typesexisted regionally in eight countries. FR-systems in-cluding three or four FR types existed nationwide in6 countries and regionally in 2 countries (Fig. 2a,Additional file 1: Supplementary 2).

Characteristics of first responder-systemsNext, we analysed the characteristics of the FR types inmore detail. Tables 1, 2 and 3 list the characteristics of fire-fighters, citizen-responders and police officers; Additionalfile 1: Table S1 lists the characteristics of the “other FRs”. Asummarised description is provided below.

Fig. 1 First responders per type and European region. a, fire fighters. b, citizen-responders. c, police officers

Oving et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2019) 27:112 Page 3 of 20

Response characteristics: availability and alertsDifferent methods were used to alert FRs. For fire-fighters and police officers, a standard communicationsystem is often used. A smaller proportion of regionsused a dedicated mobile phone alert (Tables 1 and 3).Citizen-responders are dispatched using a dedicated

mobile phone alert in all but one region (in which onlythe standard communication system is used). While fire-fighters and police officers tend to be available on a 24/7basis, this is not the case for all FR types (Table 2).In several countries, there is an age threshold to be

dispatched as a citizen-responder (e.g., ≥16 or ≥ 18years). Also, in a few countries there is no dispatch ofcitizen-responders to children (e.g., < 8 years).

EquipmentIn every country and region, FRs either carry an AED, orare directed by the dispatch centre to the nearest

publicly accessible AED. Safety jackets, pocket masks,mobile phones, and rescuer kits are generally part of theequipment.

Training and registrationIn most European regions, CPR training is required andchecked before FRs can be dispatched, except for citizen-responders in Denmark (in two regions: Capital regionand Central region) and Hungary. The frequency ofmandatory CPR training differed between countries, par-ticularly for citizen-responders (varying from monthlytraining to none). In Italy, untrained citizens are by lawnot allowed to use an AED, but can perform CPR.Citizen-responders are most commonly registered in

online databases such as HartslagNu (the Netherlands),MOMENTUM (Switzerland), O2 SOS (Czech Republic),DAE respondER (Italy). In some countries, includingIreland and Scotland, registration is managed by the

Fig. 2 Overview of first responder systems in Europe. a, overview of different types of dispatched first responder systems dispatched in the eventof an out-of-hospital cardiac arrest, in Europe. The number of first responder refers to the number of first responders dispatched complementaryto the statutory Emergency Medical Services. b, overview of regions/countries without dispatch of first responders after an out-of-hospital cardiacarrest, in Europe. Abbreviations: FRs, First responders, EMS, Emergency Medical Services

Oving et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2019) 27:112 Page 4 of 20

Table

1Characteristicsof

dispatched

firefig

hters

Cou

ntry,

Region

Activationby

Locatio

nde

term

ination

1.Respon

sene

eded

Roleon

scen

eEquipm

ent

Training

;Freq

uency

Feed

back

Financialassistance

(NOTinclud

ing:

salary)

2.Inform

ation

provided

bydispatcher

Austria

(N=8.220000)

Standard

commun

ication

system

GPS

1.Con

firmingthe

respon

se2.Locatio

nof

victim;

locatio

nof

AED

1.Get

alocalA

EDor

from

thevehicle;

2.Con

nect

abreathingmask;

3.Attachpads

and

follow

theAED

instructions;

4.Perfo

rmCPR

1.AED

;2.Safety

jacket;

3.Mob

ileph

one/page

r;4.Rescuerkit

Traine

dfor

CPR

includ

ing

useof

anAED

;Ann

ually

DesignatedEM

Sstaff

discusscalls

attend

edwith

firefighters

Paym

entof

equipm

ent;AED

relateddisposables

Czech

Repu

blic,

(N=10.521646)

Standard

commun

ication

system

Add

ressandGPS

1.Subsequent

callfro

mdispatcher

tofirefighter

orbackwards

2.Locationofvictim;

demographics;situational

inform

ation

1.Get

anAED

from

thevehicle;

2.Co

nnectabreathing

mask;

3.Attachpads

and

follow

theAED

instructions;

4.Perfo

rmCPR

1.AED

;2.Safety

jacket;

3.Mob

ileph

one/page

r;4.Rescuerkit;

5.BVM,

6.Oxyge

n

Traine

dfor

CPR

includ

ing

useof

anAED

;Ann

ually

DesignatedEM

Sstaff

discusscalls

attend

edwith

firefighters/

Firefig

htersparticipate

inade

briefw

ithEM

Sstaffim

med

iatelyafter

anOHCA/the

own

training

officerscan

also

take

part

No

Den

mark,

CapitalR

egion,

Region

Zealand,

Region

South

(N=3.879024)

Standard

commun

ication

system

GPS

1.Norespon

sefro

mthefirefighter

isrequ

ired

2.Locatio

nof

victim

1.Get

anAED

from

thevehicle;

2.Attachpads

and

follow

theAED

instructions;

3.Perfo

rmCPR

1.AED

Traine

dfor

CPR

includ

ing

useof

anAED

;Ann

ually

Non

eNo

Den

mark

Cen

tralRegion

,Region

North

(N=1.903148)

Standard

commun

ication

system

GPS

1.Con

firmingthe

respon

se2.Locatio

nof

victim

1.Get

anAED

from

thevehicle;

2.Attachpads

and

follow

theAED

instructions;

3.Perfo

rmCPR

1.AED

;2.Safety

jacket;

3.Mob

ileph

one/page

r;4.Rescuerkit

Traine

dfor

CPR

includ

ing

useof

anAED

;Introd

uced

low

dose,high

frequ

ency

training

Non

eNo

England

(N=55.980000)

SMSor

APP

Add

ress

1.Norespon

sefro

mthefirefighter

isrequ

ired

2.Locationofvictim,

demog

raph

ics

(victim

)&situationalinfo

1.Get

anAED

from

thevehicle;

2.Co

nnectabreathing

mask;

3.Attachpads

and

follow

theAED

instructions;

4.Perfo

rmCPR;

5.They

aretrainedin

airway

managem

ent

OPairways

1.AED

;2.Mob

ileph

one/page

r

Traine

dfor

CPR

includ

ing

useof

anAED

;Ann

ually

Firefighteractivity

isdescribed

intheannu

alrepo

rt/Firefightersreceive

aregu

larreporto

ftheir

activity/Firefightersreceive

writtenfeedback

onindivid

ualcallsfrom

theEM

S

No

Oving et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2019) 27:112 Page 5 of 20

Table

1Characteristicsof

dispatched

firefig

hters(Con

tinued)

Cou

ntry,

Region

Activationby

Locatio

nde

term

ination

1.Respon

sene

eded

Roleon

scen

eEquipm

ent

Training

;Freq

uency

Feed

back

Financialassistance

(NOTinclud

ing:

salary)

2.Inform

ation

provided

bydispatcher

Finland

(N=5.513000)

Standard

commun

ication

system

GPS

1.Con

firmingthe

respon

se2.Locatio

nof

victim

1.Get

anAED

from

thevehicle;

2.Con

nect

abreathingmask;

3.Attachpads

and

follow

theAED

instructions;

4.Perfo

rmCPR

1.AED

;2.Safety

jacket;

3.Mob

ileph

one/page

r;4.Rescuerkit

Traine

dfor

CPR

includ

ing

useof

anAED

;Ann

ually

Firefig

hter

activity

isde

scrib

edin

theannu

alrepo

rt

No

Ireland

(N=4.830000)

Standard

commun

ication

system

;SMS

Not

determ

ined

1.Followinglocalfire

and

rescue

dispatch

protocols

2.Locatio

nof

victim

;de

mog

raph

ics;

situationalinformation

1.Get

alocalA

EDor

from

thevehicle;

2.Con

nect

abreathingmask;

3.Attachpads

and

follow

theAED

instructions;

4.Perfo

rmCPR

1.AED

;2.Safety

jacket;

3.Mob

ileph

one/page

r;4.Resuscitatio

nkit

Traine

dfor

CPR

includ

ing

useof

anAED

;Bi-ann

ually

Firefig

hter

activity

isde

scrib

edin

theannu

alrepo

rt/Firefig

hters

participatein

ade

brief

with

EMSstaff

immed

iatelyafteran

OHCA

No

Italy,Emilia

Romagna

(N=4.453000)

APP

GPS

1.Con

firmingthe

respon

se2.Locatio

nof

victim

&locatio

nof

AED

1.Get

alocalA

EDor

from

thevehicle;

2.Con

nect

abreathingmask;

3.Attachpads

and

follow

theAED

instructions;

4.Perfo

rmCPR

1.AED

;2.Safety

jacket;

3.Mob

ileph

one/page

r;4.Rescuerkit

Traine

dfor

CPR

includ

ing

useof

anAED

;Bi-ann

ually

Therespon

dermanager

send

san

emailtocollect

feed

back

bymail(bu

tis

notaroutine)

Supp

ortedby

Emilia

Romagna

Health

care

Region

Fund

ingand

Fond

azione

del

Mon

tedi

Bologn

ae

Ravenn

afor

developm

ent.

Luxembo

urg

(N=6,020,050)

Standard

commun

ication

system

;SMS,

Page

r

Not

determ

ined

1.Followinglocal

fireandrescue

dispatch

protocols

2.Locatio

nof

victim;

demog

raph

ics;

situational

inform

ation

1.Get

anAED

from

thevehicle;

2.Attachpads

and

follow

theAED

instructions;

3.Perfo

rmCPR

1.AED

;2.Safety

jacket;

3.Mob

ileph

one/page

r;4.Rescuerkit

Trainedfor

CPRinclud

ing

useof

anAED

;initialadvanced

training

infirst

aid(~

40h),

annu

ally8h

training

Non

eNo

The

Nethe

rland

s(N

=17.180000)

Standard

commun

ication

system

GPS

1.Con

firmingthe

respon

se2.Locatio

nof

victim

,de

mog

raph

ics(victim

)andsituational

inform

ation

1.Get

anAED

from

thevehicle;

2.Attachpads

and

follow

theAED

instructions;

3.Perfo

rmCPR;

4.Maintainasafe

situation

1.AED

;2.Safety

jacket;

3.Mob

ileph

one/page

r

Traine

dfor

CPR

includ

ing

useof

anAED

;Ann

ually

Non

eNo

Oving et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2019) 27:112 Page 6 of 20

Table

1Characteristicsof

dispatched

firefig

hters(Con

tinued)

Cou

ntry,

Region

Activationby

Locatio

nde

term

ination

1.Respon

sene

eded

Roleon

scen

eEquipm

ent

Training

;Freq

uency

Feed

back

Financialassistance

(NOTinclud

ing:

salary)

2.Inform

ation

provided

bydispatcher

Norway

(N=5.328212)

Standard

commun

ication

system

Throug

hcommun

ication

with

firefighter

dispatch

centre

1.Con

firmingthe

respon

se2.Locatio

nof

victim

;situational

inform

ation

1.Get

anAED

from

thevehicle;

2.Con

nect

abreathingmask;

3.Attachpads

and

follow

theAED

instructions;

4.Perfo

rmCPR

1.AED

;2.Safety

jacket;

3.Rescuerkit

Trainedfor

CPRinclud

ing

useof

anAED

;Firefightersare

motivated

totraineveryyear

Non

eNo

Poland

(N=37.980000)

Standard

commun

ication

system

Add

ress

1.Con

firmingthe

respon

se2.Locatio

nof

victim

1.Get

anAED

from

thevehicle;

2.Con

nect

abreathingmask;

3.Attachpads

and

follow

theAED

instructions;

4.Perfo

rmCPR

1.AED

;2.Mob

ileph

one/page

r;3.Rescuerkit

Traine

dfor

CPR

includ

ing

useof

anAED

;3years

NR

No

Portug

al(N

=10.290000)

Standard

commun

ication

system

Add

ress

1.Using

theradio

2.Locatio

nof

victim

;de

mog

raph

ics;

situationalinformation

1.Get

anAED

from

thevehicle;

2.Con

nect

abreathingmask;

3.Attachpads

and

follow

theAED

instructions;

4.Perfo

rmCPR

1.AED

;2.Safety

jacket;

3.Mob

ileph

one/page

r;4.Rescuerkit

Training

isno

tnatio

nally

organized,

only

inafew

corporations

firefightersare

traine

dto

use

AED

NR

No

Romania

(N=19.530000)

Standard

commun

ication

system

;SMS;

Page

r

GPS;A

ddress

1.Radioor

phon

erepo

rtprovideto

the

dispatch

with

physicianon

coordinatio

n2.Locatio

nof

victim

;situationalinfo

1.Get

anAED

from

thevehicle;

2.Con

nect

abreathingmask;

3.Attachpads

and

follow

theAED

instructions;

4.Perfo

rmCPR;

5.IV

line;

6.Com

bi-tub

e

1.AED

;2.Safety

jacket;

3.Mob

ileph

one/page

r;4.Rescuerkit;

5.Valvemask;

6.IV;

7.Oxyge

n

Traine

dforCPR

includ

inguseof

anAED

;Every

twoyears

Firefig

htersreceivea

regu

larrepo

rtof

their

activity/Designated

EMSstaffdiscusscalls

attend

edwith

firefighters

Med

icalsupp

lies,all

materialsfor

interven

tions;sup

port

fortraining

andsome

equipm

ent.

Sloven

ia(N

=2.084000)

Standard

commun

ication

system

Locatio

nisno

tde

term

ined

ortracked-they

are

activated

iftheETA

ofthefirstrespon

ders

isfaster

than

theETA

oftheEM

Steam

-we

expe

ctthem

tobe

with

inthelocated

district

1.Con

firmingthe

respon

se2.Locatio

nof

victim

1.One

person

intheteam

hasthe

AED

/orAED

atthestation;

2.Con

nect

abreathingmask;

3.Attachpads

and

follow

theAED

instructions;

4.Perfo

rmCPR

1.AED

;2.Mob

ileph

one/page

r;3.Rescuerkit

Traine

dforCPR

includ

inguseof

anAED

;Ann

ually

Inform

ally,e.g.rep

orts

ontheresults

Yes,no

tfro

mtheEM

Sbu

tfro

mthelocal

mun

icipality

Oving et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2019) 27:112 Page 7 of 20

Table

1Characteristicsof

dispatched

firefig

hters(Con

tinued)

Cou

ntry,

Region

Activationby

Locatio

nde

term

ination

1.Respon

sene

eded

Roleon

scen

eEquipm

ent

Training

;Freq

uency

Feed

back

Financialassistance

(NOTinclud

ing:

salary)

2.Inform

ation

provided

bydispatcher

Swed

en,

Norbo

tten

Cou

nty

(N=251,295)

Standard

commun

ication

system

;SMS

GPS

1.Con

firmingthe

respon

se2.Locatio

nof

victim

,de

mog

raph

ics

(victim

)

1.Get

anAED

from

thevehicle;

2.Attachpads

and

follow

theAED

instructions;

3.Perfo

rmCPR

1.AED

;2.Mob

ileph

one/page

r;3.Rescuerkit

Traine

dforCPR

includ

inguseof

anAED

;Ann

ually

NR

No

Swed

en,

Region

Western

Swed

en(N

=2.016000)

Standard

commun

ication

system

GPS

1.Con

firmingthe

respon

se2.Locatio

nof

victim

,de

mog

raph

ics

(victim

)

1.Get

anAED

from

thevehicle;

2.Con

nect

abreathingmask;

3.Attachpads

and

follow

theAED

instructions;

4.Perfo

rmCPR

1.AED

;2.Mob

ileph

one/page

r;3.Rescuerkit

Traine

dforCPR

includ

inguseof

anAED

;Ann

ually

Meetin

gbe

tweenEM

Sandfirefig

htersdiffers

depe

ndingon

mun

icipality/sub

region

No

Swed

en,

Stockholm

(N=965,232)

Standard

commun

ication

system

GPS

1.Thecallis

conn

ectedto

theow

ndispatch

centre

whe

reby

they

confirm

their

respon

se.

2.Locatio

nof

victim

&de

mog

raph

ics

(victim

)

1.Get

anAED

from

thevehicle;

2.Attachpads

and

follow

theAED

instructions;

3.Perfo

rmCPR

1.AED

;2.Mob

ileph

one/page

r;3.Rescuerkit

Traine

dforCPR

includ

inguseof

anAED

;Ann

ually

Meetin

gacoup

leof

times

each

year

todiscussthecollabo

ratio

n

No

Switzerland

,Ticino

Canton)

(N=353,709)

SMSor

APP

Not

determ

ined

1.Con

firmingthe

respon

se2.Locatio

nof

victim,

Locatio

nof

AED

,de

mog

raph

ics

(victim

)&situatio

nal

inform

ation

1.Get

anAED

from

thevehicle;

2.Con

nect

abreathingmask;

3.Attachpads

and

follow

theAED

instructions;

4.Perfo

rmCPR;

5.Assistanceto

bystande

rs;

6.Integrationin

advanced

resuscitatio

n(with

ambu

lance

team

)

1.AED

;2.Safety

jacket;

3.Mob

ileph

one/page

r;4.Rescuerkit

Traine

dforCPR

includ

inguseof

anAED

;Bi-

annu

ally

DesignatedEM

Sstaff

discusscalls

attend

edwith

firefighters/

Firefig

htersparticipate

inade

briefw

ithEM

Sstaffim

med

iatelyafter

anOHCA/Firefig

hters

receivefeed

back

basedon

AED

data

from

theop

erational

andclinicalmanager.

They

areinvitedto

theannu

alceremon

y,whe

resurvivorsmeet

firstrespon

ders

AED

andrescue

kit

donatedfro

mFond

azione

Ticino

Cuo

re

Iffirefig

htersareconsidered

tobe

implem

entedin

thetotalcou

ntry,d

ifferen

cesin

density

andcharacteristics,from

city

tocity,m

ayexist

AED

Autom

aticExternal

Defibrillator,APP

(mob

ile)ap

plication,

BVM

BagVa

lveMask,CP

RCardiop

ulmon

aryresuscita

tion,

EMSEm

erge

ncyMed

ical

Services,ETA

Estim

ated

Timeof

Arrival,G

PSGloba

lPosition

ingSystem

,OHCA

outof

hospita

lcardiac

arrest,N

RNot

repo

rted

;SMS,text

message

Oving et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2019) 27:112 Page 8 of 20

Table

2Characteristicsof

dispatched

citizen

-respo

nders

Cou

ntry,

Region

Activesystem

Metho

dto

activate

Location

determ

ination

1.Respon

sene

eded

Roleon

scen

eEquipm

ent

Training

;Freq

uency

Registratio

nFeed

back

Financial

assistance

Emotional

supp

ort

Other

requ

irements

tobecomea

citizen-re

spon

der

2.Inform

ation

provided

bydispatcher

Austria

(N=8.220.000)

24h/7

Standard

commun

ication

system

;SMS;

Page

r;APP

GPS

1.Co

nfirm

ingthe

respon

se2.Locatio

nof

victim;

locationof

AED

1.AED

(privateuse);

2.Attachpads

andfollow

AED

instructions;

3.Perfo

rmCPR

1.AED

;2.Safety

jacket;

3.RescuerK

it

Yestraine

dfor

CPR

includ

ing

useof

anAED

;Ann

ually

Inan

online

system

:Online

App

(forEM

S,Paramed

ics,

Med

ical

Stud

ents,

Physicians)or

asde

sign

ated

First

Respon

ders

(EMS/

Paramed

ics)

that

areon

call(during

theirfre

etim

e)

Citizen-re

spon

ders

receivearegu

lar

repo

rtof

their

activity/Designated

EMSstaffd

iscuss

calls

attend

edwith

citizen-re

spon

ders

Yes:

equipm

ent

andAED

related

disposables

Yes

Aminimum

of18

yearsforthe

citizen-re

spon

ders

isrequ

ired

Czech

Repu

blic

Hrade

cKralove

Region

(N=550.804)

24h/7

SMS;APP

GPS

1.Con

firmingthe

respon

se2.Locatio

nof

victim;

locationof

AED

;situatio

nal

inform

ation

(Possib

ilityto

call

dispatch

centre

foradd

ition

alinform

ation)

1.Get

alocalA

ED;

conn

ecta

breathingmask;

2.Attachpads

and

followAED

instructions;

3.Perfo

rmCP

ROfn

ote:

Citizen-re

spon

ders

usually

dono

tbringAED

sto

the

victim

(densityof

localA

EDsislow).

They

usually

replacebystanders

orrelatives

indo

inghigh

-quality

CPR

1.Safety

jacket;

2.Po

cket

mask,

3.Sm

artphone

Yestraine

dfor

CPR

includ

ing

useof

anAED

;Any

valid

ERC

course

certificate

isne

eded

Inan

online

system

:SW

KISS

SHARP

(new

name:

O2SO

S),

registratio

nand

inform

ationat

fr.zzskhk.cz

Letter

ofthanks

Yes:safety

vest,p

ocket

mask,un

til2017

also

smartpho

ne

Yes,critical

incident

stress

managem

ent

availableon

requ

est

Aminimum

of18

yearsforthe

citizen-re

spon

ders

isrequ

iredand

they

mustd

eclare

tohave

nocriminalhistory.

Thismustbe

proven

byan

officialdocum

ent

issuedby

the

state-wideregistry.

Den

mark,Capital

region

,Cen

tral

Region

(N=3.137.000)

24h/7

APP

GPS

1.Con

firmingthe

respon

se2.Locatio

nof

victim;

locationof

nearest

accessibleAED

1.Get

alocal

AED

;2.Attachpads

andfollow

AED

instructions;

3.Perfo

rmCPR

1.AED

Not

requ

ired

butstrong

lyrecommen

ded

Inan

online

system

:Inthe

appserver

Viamailand

social

mediawhenasked

for

No

Yes,critical

incident

stress

managem

ent

availableon

requ

est

Aminimum

of18

yearsforthe

citizen-re

spon

ders

isrequ

ired

Den

mark,Region

Zealand,

Region

South

(N=2.056.025)

24h/7

APP

GPS

1.Con

firmingthe

respon

se2.Locatio

nof

victim;

locationof

AED

1.Get

alocal

AED

;2.Attachpads

andfollow

AED

instructions;

3.Perfo

rmCPR;

4.Ifthecitizen

respon

der

wants:guide

the

ambu

lanceto

theright

address

andassistthe

ambu

lance

1.AED

Yestraine

dfor

CPR

includ

ing

useof

anAED

;at

leasta4h

CPR

training

course

Inan

online

system

:Inthe

appserver

Viamailand

social

mediawhenasked

for

No

Yes,critical

incident

stress

managem

ent

availableon

requ

est

Aminimum

of18

yearsforthe

citizen-re

spon

ders

isrequ

iredand

absenceof

acriminalhistory

regardingchild

abuse

Oving et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2019) 27:112 Page 9 of 20

Table

2Characteristicsof

dispatched

citizen

-respo

nders(Con

tinued)

Cou

ntry,

Region

Activesystem

Metho

dto

activate

Location

determ

ination

1.Respon

sene

eded

Roleon

scen

eEquipm

ent

Training

;Freq

uency

Registratio

nFeed

back

Financial

assistance

Emotional

supp

ort

Other

requ

irements

tobecomea

citizen-re

spon

der

2.Inform

ation

provided

bydispatcher

person

nel.

Englanda

(N=55.980000)

24h/7

APP

GPS

and

Add

ress

1.Con

firmingthe

respon

se2.Locatio

nof

victim;

demog

raph

ics

(victim

)and

situatio

nal

inform

ation

1.Get

anAED

out

ofthevehicle;

2.Con

nect

abreathingmask;

3.Attachpads

andfollow

AED

instructions;

4.Perfo

rmCPR;

5.They

are

traine

din

airw

aymanagem

ent

1.AED

;2.RescuerK

itYestraine

dfor

CPR

includ

ing

useof

anAED

;Ann

ually

Inan

online

system

:In

house

database

Citizen-re

spon

seactivity

isdescrib

edintheannu

alrepo

rt/Citizen-

respon

dersreceive

aregu

larreportof

theiractivity/

Citizen-re

spon

ders

receivewritten

feedback

onindividu

alcalls

from

theEM

S

No

Yes

Each

Trustsetsits

ownparameters.

Mostrequ

irea

minimum

of16

or18

yearsforthe

citizen-re

spon

ders.

Also

,the

criminal

record

ischecked.

Germanyb,

Marbu

rg-Biedenkop

f,Güterslo

h,Freibu

rg,

Neckar-O

denw

ald-Kreis,

Greifswald,

Schleswig-Holstein

(N=3.661.774)

24/7

SMS;APP

GPS

1.Con

firmingthe

respon

se2.Locatio

nof

victim;

locationof

AED

1.Get

alocal

AED

;2.Con

nect

abreathingmask;

3.Attachpads

andfollow

AED

instructions;

4.Perfo

rmCPR

1.AED

;2.Safety

jacket;

3.RescuerK

it

Yestraine

dfor

CPR

includ

ing

useof

anAED

;Ann

ually

Inan

online

system

:Inthe

appserver/

German

Red

Cross

No

No

Yes,they

can

choo

seto

contacta

specialteam

ford

ebriefing

Aminimum

age

of18

yearsforthe

respon

dersis

requ

ired

Ireland

(N=4.830.000)

24h/7

SMS

Not

determ

ined

1.Con

firmingthe

respon

se2.Locatio

nof

victim;

locationof

AED

;demog

raph

ics

(victim

)and

situatio

nal

inform

ation

1.Get

alocalA

EDor

getan

AED

outof

the

vehicle;

2.Con

nect

abreathingmask;

3.Attachpads

andfollow

AED

instructions;

4.Perfo

rmCPR

1.AED

;2.Safety

jacket;

3.Resuscitation

kitbag

Yestraine

dfor

CPR

includ

ing

useof

anAED

;Mon

thly

Autho

risation

grantedby

Ambu

lance

Officer

Citizen-re

spon

seactivity

isdescribed

inthe

annu

alrepo

rt/

Citizen-re

spon

ders

receivearegu

lar

repo

rtof

their

activity/Designated

EMSstaffd

iscuss

calls

attend

edwith

citizen-re

spon

ders

Replacem

ent

of consum

able

equipm

ent

Yes

Aminimum

age

of18

yearsforthe

citizen-re

spon

ders

isrequ

iredand

they

mustg

etGarda

Clearance,

i.e.,confirm

ation

mustbe

received

from

theIrish

policethatthe

person

does

not

have

acriminal

convictio

nof

significance

Italy

EmiliaRo

magna

(N=4.453.000)

24h/7

APP

GPS

1.Con

firmingthe

respon

se2.Locatio

nof

victim;

locationof

AED

1.Get

alocalA

ED;

conn

ecta

breathingmask;

2.Attachpads

and

followAED

instructions;

3.Perfo

rmCPR

Non

eYestraine

dfor

CPR

includ

ing

useof

anAED

;Bi-ann

ually

Inan

online

system

:https://

www.118er.it/

dae/

Therespon

der

manager

send

san

emailtocollect

feedback

bymail

(but

isno

ta

routine)

No

No

Norequ

iremen

ts

Hun

gary

(N=9.800.000)

24h/7

Standard

commun

ication

system

;APP

GPS

1.One

person

from

thedispatch

centre

callsthecitizen

tocheckwhether

she/he

isableto

goto

thevictim

2.Locatio

nof

victim;

locationof

AED

1.Get

alocalA

ED;

2.Attachpads

and

followAED

instructions;

3.Perfo

rmCPR

1.AED

Not

requ

ired;

Thereisno

tanytraining

forthem

,it

depe

ndson

thecitizen

.

Inan

online

system

:Szív

city

(szivcity.hu)

Non

eNo

No

Norequ

iremen

ts

Oving et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2019) 27:112 Page 10 of 20

Table

2Characteristicsof

dispatched

citizen

-respo

nders(Con

tinued)

Cou

ntry,

Region

Activesystem

Metho

dto

activate

Location

determ

ination

1.Respon

sene

eded

Roleon

scen

eEquipm

ent

Training

;Freq

uency

Registratio

nFeed

back

Financial

assistance

Emotional

supp

ort

Other

requ

irements

tobecomea

citizen-re

spon

der

2.Inform

ation

provided

bydispatcher

TheNetherland

sExcept

Amsterdam

(N=15.835350)

24h/7

SMS;APP

GPS;A

ddress

1.Norespon

seis

requ

ired

2.Locatio

nof

victim;

locationof

AED

1.GetalocalAED

orgetanAED

outo

fthe

vehicle;

2.Attachpads

andfollow

AED

instructions;

3.Perfo

rmCPR

1.AED

Yestraine

dfor

CPR

includ

ing

useof

anAED

;Ann

ually

Inan

online

system

:Hartslag.nu

Non

eNo

Hartslag.nu

asks

foranevaluation

afterthe

event

Aminimum

age

of18

yearsis

requ

iredandno

dispatch

toOHCA

scaused

byatraumaor

inchildren<8years

Romania,Bucharest

(N=1.828.000)

NR

SMS

GPS

1.Norespon

seis

requ

ired

2.Locatio

nof

victim;

locationof

AED

1.Get

alocalA

ED;

2.Attachpads

and

followAED

instructions;

3.Perfo

rmCPR

1.AED

Yestraine

dfor

CPR

includ

ing

useof

anAED

;Onlytraine

don

ce

NR

Activity

isdescribed

intheannu

alrepo

rtNo

Inform

alem

otional

supp

ortfro

mAmbu

lance

ServiceStaff

Aminimum

age

of16

yearsforthe

citizen-re

spon

ders

isrequ

ired

Sweden,

NorrbottenCo

unty

(N=251.295)

24h/7

SMS

Triang

ulation

byteleph

one

towers

1.Norespon

seis

requ

ired

2.Locatio

nof

victim

1.Perfo

rmCPR

Non

eYestraine

dfor

CPR

includ

ing

useof

anAED

;Respon

ders

shou

ldbe

educated

but

nospecific

follow

upis

done

Inan

online

system

:https://w

ww.

mob

ilraddare.

se/

NR

Yes,please

describ

ethetype

ofassistance

given:

not

specified

Yes,if

requestedthey

cancontact

theprojectvia

email/telepho

ne

Aminimum

age

of18

yearsis

requ

iredandno

dispatch

tochildren<8years

Sweden,Region

western

Sweden

(N=2.016.000)

Duringdaytime:

07:00–22:59

SMS

GPS

1.Con

firmingthe

respon

se2.Locatio

nof

victim;

locationof

AED

1.Get

alocalA

EDor

getan

AED

outof

the

vehicle;

2.Attachpads

and

followAED

instructions;

3.Perfo

rmCPR

Non

eYestraine

dfor

CPR

includ

ing

useof

anAED

;Allshou

ldbe

traine

don

ce.

Therepe

titions

coursesdiffers

betw

een

individu

als

Directlyin

the

APP

Non

eNo

Yes,crisis

consultatio

nifrequ

ested.

Aminimum

age

of18

yearsfor

thecitizen-

respon

ders

isrequ

iredand

nodispatch

tochildren<8years

Sweden,Stockho

lm(N

=965.232)

Duringdaytime:

07:00–22:59

SMS;APP

GPS

1.Con

firmingthe

respon

se2.Locatio

nof

victim

;locatio

nof

AED

and

situational

inform

ation

1.Get

alocal

AED

;2.Attachpads

andfollow

AED

instructions;

3.Perfo

rmCPR

Non

eYestraine

dfor

CPR

includ

ing

useof

anAED

;Onlytraine

don

ce

Inan

online

system

:Register

directlyvia

application

Viamailand

social

mediawhenasked

for

No

Yes,de

briefing

ifne

eded

(ifrequ

estedcrisis

coun

selling

isgivenup

to10

visits)

Aminim

umage

of18

yearsis

requ

iredandno

dispatch

tochildren<8years

Scotland

(N=543.800)

Book

onwith

thecontrol

centre

whe

navailable.

Therefore,their

coverage

varies

across

the

coun

tryat

any

giventim

e

Standard

commun

ication

system

GPS

1.Con

firmingthe

respon

se2.Locatio

nof

victim

;situational

inform

ation

1.Get

anAED

out

ofthevehicle;

2.Co

nnecta

breathingmask;

3.Attachpads

and

followAED

instructions;

4.Perfo

rmCPR;

5.Insertairw

ayif

requ

ired

1.AED

;2.Safety

jacket;

3.RescuerKit

Yestraine

dfor

CPR

includ

ing

useof

anAED

;Com

mun

ityFirst

Respon

dersgo

throug

han

initial4day

training

course

andthen

are

expe

cted

toattend

mon

thly

training

sessions

with

intheirgrou

ps,

Inan

online

system

:After

training

and

suitability

checks

have

been

completed

they

arepu

ton

adatabase

andclassedas

anactive

respon

der)

andthen

whe

navailablethey

book

onand

Citizen-re

spon

seactivity

isdescrib

edintheannu

alrepo

rt;D

esignated

EMSstaffd

iscuss

calls

attend

edwith

citizen-re

spon

ders/

Citizen-re

spon

ders

receivewritten

feedback

onindividu

alcalls

from

theEM

S/Wehave

anetworkof

Commun

ityResilience

Facilitatorswho

Yes:thecan

claim

mileagecosts

ifthey

have

used

their

ownvehicle.

Scottish

Ambu

lance

Servicealso

replaces

any

consum

able

itemsused

duringthe

course

ofthe

first

responders

Yes

Aminimum

age

of18

yearsforthe

citizen-respon

ders

isrequ

iredand

dispatch

toadults

only;allcitizen-

respon

ders

undergoa

protectionof

vulnerablegroups

(PVG

)check

and,

depend

ingon

feedback,a

judg

ementis

madeon

the

suitabilityto

bea

Oving et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2019) 27:112 Page 11 of 20

Table

2Characteristicsof

dispatched

citizen

-respo

nders(Con

tinued)

Cou

ntry,

Region

Activesystem

Metho

dto

activate

Location

determ

ination

1.Respon

sene

eded

Roleon

scen

eEquipm

ent

Training

;Freq

uency

Registratio

nFeed

back

Financial

assistance

Emotional

supp

ort

Other

requ

irements

tobecomea

citizen-re

spon

der

2.Inform

ation

provided

bydispatcher

which

follow

astructured

prog

ramme

ACC

colleaguescan

deploy

them

meetw

ithCo

mmun

ityFirst

Respon

der

grou

psperio

dically

andareavailable

tosupp

ortthem

attendance

citizen-respon

der.

Switzerland

,Ticino

Canton

(N=353.709)

24h/7

APP

Not

determ

ined

1.Con

firmingthe

respon

se2.Locatio

nof

victim

;locatio

nof

AED

;de

mog

raph

icand

situational

inform

ation

1.Get

alocal

AED

;2.C

onne

cta

breathing

mask

1.Safety

jacket

Yestraine

dfor

CPR

includ

ing

useof

anAED

;Bi-ann

ually

Inan

online

system

:sm

artpho

neApp

lication

(MOMEN

TUM)

and

registratio

nprog

ram

createdby

us(fr.ticino

cuore.

ch)

Receivewritten

feed

back

onindividu

alcalls

from

theEM

S/Participatein

ade

briefwith

EMS

staffimmed

iately

afteran

OHCA/

Receivefeed

back

basedon

AED

data

from

the

operationaland

clinicalmanager/

Are

invitedto

the

annu

alceremon

y,whe

resurvivors

meetfirst

respon

ders

No

Yes,24

h/7days

team

ofpsycho

logical

coun

sellors

Aminimum

age

of18

yearsis

requ

ired(ofn

ote:

citizensare

allowed

tousean

AED

from

age

14years).

Citizen-re

spon

ders

mustadhere

tothegeneral

cond

ition

s.They

need

toself-

declareabsence

ofacriminal

record,but

declarations

are

notchecked.

Switzerland

,Region

ofFribourg

(N=225.500)

24h/7

APP

GPS

1.Con

firmingthe

respon

se2.Locatio

nof

victim;

locationof

AED

;demog

raph

ics

(victim

)and

situatio

nal

inform

ation

1.Get

alocalA

ED1.Safety

jacket

Yestraine

dfor

CPR

includ

ing

useof

anAED

;Everytw

oyears

Inan

online

system

:Citizen

respon

ders

mustcreate

anaccoun

tin

theapp

Citizen-re

spon

der

mustcompletea

feedback

sheet.

Depende

ntof

the

answ

ers,the

foun

datio

nwill

contactthe

respon

derb

yph

one.Sometimes

citizen-re

spon

ders

canhave

immediately

feedback

from

the

EMSstaff.

Yes,the

foun

datio

npaythe

replacem

ent

ofAED

consum

able

after

interventio

n

Yes,citizen

-respon

ders

have

the

possibility

tocalla

psycho

logical

service

Aminimum

age

of18

yearsis

requ

ired(ofn

ote:

citizensare

allowed

tousean

AED

from

age

14years).

Citizen-re

spon

ders

mustadhere

tothegeneral

cond

ition

s.They

need

toself-

declareabsence

ofacriminal

record,but

declarations

are

notchecked.

Ifcitizen

-respo

ndersareconsidered

tobe

implem

entedin

thetotalcou

ntry,d

ifferen

cesin

density

andcharacteristics,from

city

tocity,m

ayexist

Abb

reviations:asin

Table1

a The

respon

dent

specifically

indicatedthat

APP

usag

eisno

tun

iversala

nd(m

ajor)differen

cesacross

thecoun

tryexist

bTh

erearefour

differen

tAPP

-systemsin

German

y.Cha

racteristicsap

plyto

region

Marbu

rg-Biede

nkop

fbu

tmay

differ

across

theothe

rregion

s

Oving et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2019) 27:112 Page 12 of 20

Table

3Characteristicsof

dispatched

policeofficers

Cou

ntry,Reg

ion

Activationby

Locatio

nde

term

ination

1.Respon

sene

eded

Roleon

scen

e(steps)

Equipm

ent

Training

,Freq

uency

Feed

back

Financial

assistance

(NOTinclud

ing:

salary)

Other

2.Inform

ationprovided

bydispatcher

Austria

(N=8.220000)

Standard

commun

ication

system

;SMS;

Page

r;App

GPS

1.Con

firmingthe

respon

se2.ocationof

victim

;locatio

nof

AED

(ifapplicable)

1.Get

alocalA

EDor

from

thevehicle;

2.Attachpads

and

follow

theAED

instructions;

3.Perfo

rmCPR

1.AED

;2.Safety

jacket;

3.Mob

ileph

one/Page

r;4.Rescuerkit

Yestraine

dfor

CPR

includ

ing

useof

anAED

;Ann

ually

Policeofficersreceive

aregu

larrepo

rtof

theiractivity

AED

equipm

ent

andrelated

disposables

Belgium,Brussels

(N=1.208500)

Standard

commun

ication

system

GPS

1.Con

firmingthe

respon

se2.Locatio

nof

victim

1.Get

anAED

from

thevehicle;

2.Attachpads

and

follow

theAED

instructions;

3.Perfo

rmCPR

1.AED

Yestraine

dfor

CPR

includ

ing

useof

anAED

;Variable

frequ

ency

(dep

ends

onpo

licedistrict)

Thereisno

feed

back

totheofficer’s

supe

riors,after

the

interven

tionthey

are

debriefedas

partof

theEM

Steam

,at

theirde

mand.

NR

Czech

Repu

blic,

(N=10.521646)

Standard

commun

ication

system

GPS

and

Add

ress

1.Subseq

uent

call

from

dispatcher

topo

liceofficer/

backwards

2.Locatio

nof

victim

;de

mog

raph

ics

(victim

)and

situational

inform

ation

1.Get

anAED

from

thevehicle;

2.Con

nect

abreathingmask;

3.Attachpads

and

follow

theAED

instructions;

4.Perfo

rmCPR

1.AED

;2.Safety

jacket;

3.Mob

ileph

one/Page

r;4.BVM

with

out

oxygen

Yestraine

dfor

CPR

includ

ing

useof

anAED

;Ann

ually

DesignatedEM

Sstaff

discusscalls

attend

edwith

firefighters/

Policeofficers

participatein

ade

briefw

ithEM

Sstaff

immed

iatelyafteran

OHCA/Regu

lar

meetin

gswith

police

represen

tatives/EM

Squ

ality

managerscan

take

partifurge

ntprob

lemsne

edto

besolved

AED

slocated

insomepo

lice

carsare

purchasedby

EMS

Policestations

areusually

locatedat

places

whe

reno

ambu

lance

stations

are

England

(N=55.980000)

APP

Add

ress

1.Con

firmingthe

respon

se2.Locatio

nof

victim

;de

mog

raph

ics

(victim

)and

situational

inform

ation

1.Get

anAED

from

thevehicle;

2.Con

nect

abreathingmask;

3.Attachpads

and

follow

theAED

instructions;

4.Perfo

rmCPR;

5.Traine

din

airw

aymanagem

ent

1.AED

;2.Mob

ileph

one/Page

r;3.Rescuerkit

Yestraine

dfor

CPR

includ

ing

useof

anAED

;Ann

ually

Policeofficer

activity

isdescribed

inthe

annu

alrepo

rt/Po

lice

officersreceivea

regu

larreportof

their

activity;Policeofficers

receivewritten

feedback

onindividu

alcalls

from

theEM

S/Po

liceofficers

participateinadebrief

with

EMSstaff

immediatelyafteran

OHCA

No

Oving et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2019) 27:112 Page 13 of 20

Table

3Characteristicsof

dispatched

policeofficers(Con

tinued)

Cou

ntry,Reg

ion

Activationby

Locatio

nde

term

ination

1.Respon

sene

eded

Roleon

scen

e(steps)

Equipm

ent

Training

,Freq

uency

Feed

back

Financial

assistance

(NOTinclud

ing:

salary)

Other

2.Inform

ationprovided

bydispatcher

Ireland

(N=4.830000)

SMS

Not

determ

ined

1.Con

firmingthe

respon

se2.Locatio

nof

victim

;locatio

nof

AED

;de

mog

raph

ics

(victim

)

1.Get

alocalA

EDor

from

thevehicle

orPA

D;

2.Con

nect

abreathingmask;

3.Attachpads

and

follow

theAED

instructions;

4.Perfo

rmCPR

1.AED

;2.Safety

jacket;

3.Mob

ileph

one/Page

r

Yestraine

dfor

CPR

includ

ing

useof

anAED

;Ann

ually

Policeofficer

activity

isdescribed

inthe

annu

alrepo

rt/Po

lice

officersreceivea

regu

larreportof

their

activity/Po

liceofficers

participateinadebrief

with

EMSstaff

immediatelyafteran

OHCA

Consum

able

equipm

ent

replacem

ent

Italy,Emilia

Romagna

(N=445,300)

App

GPS

1.Con

firmingthe

respon

se2.Locatio

nof

victim

;Locatio

nof

AED

(ifapplicable)

1.Get

alocalA

EDor

from

thevehicle;

2.Con

nect

abreathingmask;

3.Attachpads

and

follow

theAED

instructions;

4.Perfo

rmCPR

1.AED

;2.Safety

jacket;

3.Mob

ileph

one/Page

r;4.Rescuerkit

Yestraine

dforCPR

includ

ing

useof

anAED

;Bi-ann

ually

Therespon

der

manager

send

san

emailtocollect

feed

back

bymail

(but

isno

taroutine)

No

TheNethe

rland

s(N

=17.180000)

Standard

commun

ication

system

GPS

1.Con

firmingthe

respon

se2.Locatio

nof

victim

;de

mog

raph

ics

(victim

)

1.Get

anAED

from

thevehicle;

2.Attachpads

and

follow

theAED

instructions;

3.Perfo

rmCPR;

4.Dosafety

measuresand

provideasafe

workspace

for

peop

leinvolved

1.AED

;2.Safety

jacket;

Yestraine

dfor

CPR

includ

ing

useof

anAED

;Ann

ually

Non

eNo

Swed

en,Stockho

lm(N

=965,232)

Standard

commun

ication

system

GPS

1.Po

liceis

dispatched

bytheirow

ndispatch

centre.

Ifavailablethey

answ

erby

oral

commun

ication

2.Locatio

nof

victim

;de

mog

raph

ics

(victim

)

NR

1.AED

;2.Mob

ileph

one/Page

r

Yestraine

dfor

CPR

includ

ing

useof

anAED

Meetin

gsacoup

leof

times

each

year

whe

rethey

discuss

thecollabo

ratio

n

No

Oving et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2019) 27:112 Page 14 of 20

Table

3Characteristicsof

dispatched

policeofficers(Con

tinued)

Cou

ntry,Reg

ion

Activationby

Locatio

nde

term

ination

1.Respon

sene

eded

Roleon

scen

e(steps)

Equipm

ent

Training

,Freq

uency

Feed

back

Financial

assistance

(NOTinclud

ing:

salary)

Other

2.Inform

ationprovided

bydispatcher

Switzerland

,reg

ion

ofFribou

rg(N

=225,500)

App

;Incase

ofOCHA,EMS

dispatch

centre

calls

thepo

lice

dispatch

centre

togive

thealarm.

Policemen

can

receivealarms

from

thepo

lice

dispatch

orfro

mtheapp(like

othe

rfirst

respon

ders)

GPS

1.Con

firmingthe

respon

se2.Locatio

nof

victim

1.Get

anAED

from

thevehicle;

2.Attachpads

and

follow

theAED

instructions;

3.Perfo

rmCPR

1.AED

;2.Safety

jacket;

3.Mob

ileph

one/Page

r

Yestraine

dfor

CPR

includ

ing

useof

anAED

;Every3years

Policeofficersreceive

sometimes

feedback

butitisno

tsystem

atic

Yes:AED

Electrod

esare

paidby

thefirst

respon

ders

foun

datio

n

Switzerland

,Ticino

Canton

(N=353,709)

APP

Not

determ

ined

1.Con

firmingthe

respon

se2.Locatio

nof

victim

;locatio

nof

AED

;de

mog

raph

ics

(victim

)and

situational

inform

ation

1.Get

anAED

from

thevehicle;

2.Con

nect

abreathingmask;

3.Attachpads

and

follow

theAED

instructions;

4.Perfo

rmCPR;

assistance

tobystande

rs;

5.Integrationin

advanced

resuscitatio

n(with

ambu

lance

team

)

1.AED

;2.Safety

jacket;

3.Mob

ileph

one/Page

r;4.Rescuerkit

Yestraine

dfor

CPR

includ

ing

useof

anAED

;Bi-ann

ually

DesignatedEM

Sstaff

discusscalls

attend

edwith

policeofficer/

Policeofficersreceive

writtenfeedback

onindividu

alcalls

from

theEM

S/Po

lice

officersparticipatein

adebriefw

ithEM

Sstaffimmediatelyafter

anOHCA

/Po

lice

officersreceive

feedback

basedon

AED

datafro

mme.

they

areinvitedto

the

annu

alceremon

y,where

survivorsmeet

firstrespon

ders

Yes:AED

and

rescue

kit

donatedfree

from

Ticino

Cure

Foun

dation

Ifpo

liceofficersareconsidered

tobe

implem

entedin

thetotalcou

ntry,d

ifferen

cesin

density

andcharacteristics,from

city

tocity,m

ayexist

Abb

reviations:asin

Table1

Oving et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2019) 27:112 Page 15 of 20

ambulance service on an EMS-owned database. Severalcountries (Denmark: region Zealand and SouthernDenmark, Czech Republic, Ireland and Switzerland) re-quire absence of a criminal record (or of a criminal con-viction of significance) in order to be able to register asa citizen-responder.

National and regional policiesPolicies relating to the implementation of FR-systemsare described on national or regional level, or both(Table 4). National policies may apply to the total FR-system or may be limited to one FR type only (Add-itional file 1: Table S2).

Future implementations of FR-systems in EuropeAs shown in Fig. 2b, some countries did not dispatchFRs to attend an OHCA at the time of the survey. Re-spondents from Bosnia-Herzegovina, Croatia, Cyprus,Estonia, Greece, France, Iceland, and Serbia were notaware of plans to introduce FR-systems to their coun-tries in the short term. Specific reasons for this are de-scribed in Additional file 1: Table S2, and include: (1)implementation of FRs is not a subject of interest or notconsidered as a priority; (2) there is a lack of a legalbackground definition for FRs, and (3) there are somelocal unmapped AEDs, but the location of these AEDs isnot available to the dispatch centre.At the time of our survey, in Malta, government and

non-governmental organisations were negotiating to im-plement a FR-system. In Spain, at least two regionalEMS-systems were recruiting citizens to respond toOHCA. In Italy, there were indications that the Provinceof Pavia would begin implementing FR-systems within afew months (Additional file 1: Table S2).

DiscussionKey findingsOur study shows the variety of FR-systems that have de-veloped in Europe to expedite provision of good qualityCPR and defibrillation in case of an OHCA. These FR-systems have either been implemented nationwide or re-gionally, and development is primarily influenced bylocal initiatives, circumstances and opportunities. Pol-icies regarding FRs are commonly implemented on a re-gional level, even if a national policy exists. This hasresulted in a wide variety of FR-systems both betweenand within countries. Even in countries that do not haveFR-systems in place, local and national initiatives to im-plement FR-systems are being developed.

The need for FR-systemsThe evidence for the benefits of early defibrillation areclear, therefore it may be suggested that increasing thenumber of AEDs available should be sufficient to

improve OHCA survival. However, an increased numberof AEDs alone is unlikely to improve survival in a cost-effective manner, as demonstrated by an Irish HealthTechnology Assessment which calculated that an invest-ment of €105 million in AED purchase would yield – atbest – an additional 10 lives saved per year [23]. Rather,the strategic deployment of AEDs by CPR-competentFRs may be an important link in the Chain of Survival[12, 16, 17], as acknowledged in the most recent Euro-pean Resuscitation Guidelines [18].We observed that, even in countries with a national

FR-policy, the organisation of FR-systems is often man-aged by regional EMS. The design of FR-systems is thuscommonly influenced by local circumstances and bywhat is available. For instance, in Slovenia, a FR-systemwith voluntary firefighters was chosen because of the ex-tensive network of volunteer fire brigades across all vil-lages. Although there is interest from police officers tobe part of this FR-system, the network of police patrolsin Slovenia is less dense than that of fire fighters and,therefore, police are not included in the FR-system.

Important aspects of FR-systemsIt is unlikely that a “one size fits all” FR-system in Eur-ope can be implemented. However, by combining resultsfrom this study with previous studies, some importantaspects of FR-systems have been identified.First, FR type and number of dispatched FR types

within one FR-system may be important. In our study,firefighters featured highly as FR types and previous re-search has demonstrated their role in OHCA-survival[11, 12, 24, 25]. FR-systems involving police officers and/or dispatched citizen-responders are very promising, butmore research is needed [14, 26, 27]. In certain regions,multiple FR types in one FR-system exist. So far, onlylimited evidence towards the effectiveness of havingmultiple FR-types is available. A study performed in theNetherlands by Zijlstra and colleagues showed that,while the contribution of citizen-responders was limitedby the strong involvement of other FRs and their com-peting contribution to OHCA care, it was estimated that,without the citizen-responders, 7.3% of patients wouldnot have received a first shock within 6 min [16]. Also,in Sweden, a study comparing additional dispatch ofCPR trained firefighters and police officers equippedwith AEDs to a control group where only EMS was dis-patched showed that dispatching these two FRs was as-sociated with a significant increase in 30-day survival[27]. However, more research is needed.Second, the method of alerting FRs matters. Our re-

sults showed that firefighter and police FRs are com-monly alerted by their own standard dispatch system,and previous evidence highlighted the benefit of directcommunication between the EMS and firefighter and

Oving et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2019) 27:112 Page 16 of 20

Table 4 Analysis of national policies relating to First Responders, per country

Country Implementation:National orRegional

Short description of policy

Austria Regional Not reported

CzechRepublic

National andregional

There is a national policy related to professional FRs (firefighters/police officers). This policy is very general (e.g. CPRtraining requirement). All 14 regional EMS organizations in the country have been using professional FRs to someextent. They differ a little across the areas to optimise the best strategy per region. Only 1 EMS has also introduceda mobile app for alerting FRs, incl. Both off-duty EMS personnel and citizen FRs. Citizen FRs need to have a validBLS/AED course certificate.

Denmark National andregional

Denmark has a strategy of engaging the community in saving lives after OHCA and succeeded in tripling thebystander rate and the survival after OHCA within the last 15 years. New programs dispatching citizen-respondersthrough a smart phone application has been implemented within the last few years.The government of Denmark supports the 10 steps of increasing survival after OHCA defined by the GlobalResuscitation Alliance, GRA: https://www.globalresuscitationalliance.org/wp-content/pdf/acting_on_the_call.pdf andhas a national “Resuscitation Academy” program working to implement the 10 steps in the five Danish regional EMSorganizations.Denmark also has some experience including professional fire fighters and police at OHCA already and expects tostrengthen this collaboration within the next years.

Ireland National andregional

The National Ambulance Service has a history of FR involvement which predates the 2000s. General practitionershave been acting as FRs in selected parts of the country since the early 1990s. The first formal recommendation tosupport the development of first responders appears in the following national document which was produced byour Department of Health:“Reducing the Risk: A Strategic Approach. Report of the Task Force on Sudden Cardiac Death (2006)”.The National Ambulance Service has policy and procedure documents to support first responder involvement incardiac arrest response. Ireland is in the process of developing a national OHCA strategy, which will include furtherspecific recommendations to further the development of first response in Ireland.

Italy Regional Law in Italy: Citizen trained in BLS are allowed to start CPR and to use an AED; citizens not trained can start CPR anduse an AED accordingly to the law that regulates the “state of necessity” in emergency situations.The law in Italy for FRs and untrained lay people is a barrier to diffusion of bystander intervention.Some regions in Italy (Region of Emilia Romagna) implemented FRs. FRs will become more common in Italy inother regions (e.g., Province of Pavia).

Luxembourg Regional Since July 1, 2018 Luxembourg is completely reorganised in only one EMS organisation for the country.Luxembourg has a FR system working in 56 out of 102 municipalities. This service is provided exclusively byvolunteer firefighters because they are “in the system” and thus quite easily reachable. There are different modalitiesaccording to local circumstances. Either the FR get to the scene by their own means (when they have theequipment in their car) or they meet at the fire station to get their equipment before going to the scene.In Luxembourg, for the moment, there are only firefighters acting as “organized” FRs. Police is more reluctant toparticipate and there is no citizen-responder system.There is a mandatory training in CPR for school children since 2017 and the Luxembourg Resuscitation Councilstrives to train as many as possible persons in elementary CPR (hands-only) on a voluntary basis.

Netherlands National andregional

In the Netherlands, a national policy regarding citizen-responders was published, whereas the requirements for fire-fighters and police officers are described on regional level only.Regarding the implementation of AEDs and citizen-responders, the first policy was written in 2002. The reason toinvolve no citizen-responders in the capital Amsterdam is the proximity of police officers and firefighters (alwaysshorter than 6 min to OHCA victim).

Norway National andregional

The Directory of health is working on policies and guidelines for FRs, including what a FR is, who can be called a FRand legal implications and concerns.There are 16 dispatch centres in Norway and they are all relating to firefighters as FRs in different ways

Portugal Regional At the present moment, private investors are spreading AED programs with the main purpose to have a systemwith FRs in the event of an OHCA. In one region (21.000 people of 506.000) of Lisbon, police officers have beentrained in BLS and AED. Portugal is in a preliminary process regarding the start of FRs.

Slovenia National andregional

In Slovenia, only voluntary fire fighters are implemented as FRs. This is due to a very extended network offirefighters brigades in Slovenia (literally, every village in Slovenia has a voluntary firefighters brigade). At the presentmoment, 35.000 volunteer fire fighters are organized in approximately 1500 fire fighters brigades. This numberexceeds the number of policemen by six-times (approximately 5500 policemen). Voluntary firefighters in Sloveniaare well organized and equipped (vehicles, communication, rescue equipment, etc.).On the other hand there is no nationwide strategy “how to organize FRs”. The Slovenian government released thedocument/regulation which basic conditions must be fulfilled to become a FR (skills, equipment, etc.). But theorganization of FR is left to the local EMS. The local EMS firstly considers the need of first responders (especially inremote areas). Afterwards the local fire fighters brigade will be contacted to participate in a FR system (there is noobligation). Therefore, there are areas in Slovenia without FRs.Policemen patrol network is scarce compared to the fire fighters (there is interest by policemen to be also a part ofa FR system).

Oving et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2019) 27:112 Page 17 of 20

police FRs [28, 29]. A mobile phone alert is often usedto alert citizen-responders, but only a few regions use amobile phone alert to alert other FR types (i.e., fire-fighters and police officers). In a study carried out inSwitzerland, all FR types (firefighters, police, citizen-responders) were alerted by either an app or text-message system (both considered as a mobile phonealert) [15]. The app-system, when compared to a text-message system, was found to be highly efficient in thedeployment of FRs, significantly reducing the time toinitiation of CPR and increasing survival rates [15].Third, our study showed that the response capabilities

of FRs should be considered. In the Czech Republic, fire-fighters were dispatched only in rare cases because theyshare locations with the EMS. Another example regard-ing response capabilities includes: in several countriesthere is no dispatch to children < 8 years by citizen-responders. Although this applies to a minority of theOHCA population, it should be taken into account. Also,the distinction between volunteer and professional FRsmay have an impact on FR engagement and response.Another example includes Slovenia where the local EMSdetermines the need for FRs, and requests local volun-teer firefighters to become FRs. As this strategy dependson local firefighter interest, there are still areas inSlovenia without FRs.Fourth, our study showed that frequent CPR training is a

feature of most FR-systems, as would be expected. Previousresearch has highlighted the superiority of off-duty medicalprofessionals over laypersons [30] and more recent studieshave shown the positive impact of trained citizen-responders on neurological outcomes [31]. Some regionsallow citizen-responders to register as FRs without validat-ing CPR-training (e.g., Denmark: Capital region and Centralregion), whereas CPR training is mandatory in two otherregions in Denmark (Region Zealand and Region SouthernDenmark). However, in the two regions where CPR trainingis not mandatory, CPR training is strongly recommended.Also, in Denmark, large-scale population-based CPR

training is common, and the positive impact of population-based CPR training has most recently been demonstratedby Kobayashi and colleagues in Japan [32]. Finally, im-proved survival after implementation of FR-systems is un-likely to occur unless all links in the Chain of Survival areworking. Hence, improvements in bystander-CPR shouldreceive high priority.

Future implementation of FR-systemsWe hypothesise that the general tendency in Europe to-wards more widespread implementation of FR-systemswill increase OHCA survival rates. At present, FR-implementation may not be a priority for every countryand difficulties in the legal definition of FRs may con-tribute to this. However, lack of national policies maynot be an impediment to local development. For in-stance, in Greece, small local initiatives already exist inthe absence of a national policy. In Croatia, local initia-tives are developed, including nurses on motorbikes andCPR-trained firefighters and police officers equippedwith AEDs. However, these initiatives are not currentlyconnected to the EMS to be dispatched and this maylimit their rapid response. In other countries and re-gions, while there is interest, local AEDs are not regis-tered; this may also delay implementation of an effectiveFR-system. These developments highlight that FR-systems are strongly driven by local initiative and localcapabilities. The need to allow flexibility in how FR-systems are implemented locally is likely to be an im-portant consideration in ensuring the sustainability ofFR-systems into the future.

Strengths and limitationsTo the best of our knowledge, this study provides themost comprehensive overview of first response in Eur-ope to date. While heterogeneity in FR-systems is a keyfinding, common themes have been identified that pro-vide a basis for understanding the development of FR-systems at a European level. It is acknowledged that a

Table 4 Analysis of national policies relating to First Responders, per country (Continued)

Country Implementation:National orRegional

Short description of policy

England National andregional

In England, ambulance trusts are responsible for local implementation, but there is an overarching GovernanceFramework.

Sweden Regional based Strategies or policies recommending establishment or the development of FRs in Sweden is lacking. Policies areregional.

Switzerland Regional based In Switzerland all health issues (except the management of epidemics and disasters) are left to the cantons. Itfollows that with 26 cantons, there are 26 different health laws. Since the FR network is still considered ancillary tothe EMS, there is no health law that takes this into account. This is the reason why there are so many differentapproaches (even inside the cantons). Only a few cantons have created a structure for the purpose of uniformlymanaging the FRs. Leading position and pioneer is Canton Ticino (https://www.ticinocuore.ch/en).The Swiss Resuscitation Council is working on a national strategy against OHCA.

AED Automatic External Defibrillator, CPR Cardiopulmonary Resuscitation, EMS Emergency Medical Services, ERC European Resuscitation Council, FR First-responder, OHCA Out Of Hospital Cardiac Arrest

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convenience sampling method was used to recruit re-spondents, but the sample was drawn from participantsin well-established European networks that have an ac-tive interest in OHCA.A limitation of this study is that, in countries/regions

considered as being covered by a specific FR-system, itwas not feasible to estimate the density of FRs (and dif-ferences, from city to city, may exist). Also, it was notpossible to relate different FR-systems to differences insurvival rates. However, this study has highlighted aunique element of the Chain of Survival which shouldbe considered in any further studies of OHCAepidemiology.When a FR-system is being developed, it is important

to analyse response times in order to confirm that thesystem actually contributes to early CPR and early defib-rillation, using measured effects. Only then in the longrun, the cost and effort of maintaining such a FR-systemwill remain accepted in the community.

ConclusionsAt present, more than half of European countriesdispatch FRs after a suspected OHCA. Policies relatingto FRs are mostly managed by local EMS, leading to awide variation between and within countries. Even incountries that do not have existing FR-systems, manyhave local initiatives and future plans for FR-system im-plementation. The willingness of people to volunteertheir time and skills to provide a first response to OHCAhas led to the development of a variety of national andlocal solutions, and has created a new paradigm withinthe Chain of Survival that needs to be researched andevaluated more extensively. Areas for future research in-clude: identifying the most effective methods of FRdispatch; identifying FR-systems that most strongly in-fluence survival; assessing the effect of adding a FR typein an existing FR-system; and understanding what moti-vates a volunteer to become a FR and what sustains thatmotivation. The diverse findings of our study reflect thediversity in circumstances across various European re-gions and suggest that it is unlikely that there will be a‘one size fits all’ FR-system across Europe. Rather, anoverall European policy that advises on the critical re-quirements for effective FR may be of benefit.

Supplementary informationSupplementary information accompanies this paper at https://doi.org/10.1186/s13049-019-0689-0.

Additional file 1. Respondents and survey definitions.

AbbreviationsAED: automated external defibrillator; ARREST: Amsterdam ResuscitationStudies; CPR: Cardiopulmonary resuscitation; EMS: emergency medical

service; ERC: European Resuscitation Council; FR: first responder; OHCA: out-of-hospital cardiac arrest

AcknowledgementsWe greatly appreciate the contributions of Paulien Homma (MSc), RemyStieglis (MSc) and Sanne Brands (MSc) of the Academic Medical Center(Amsterdam, The Netherlands) for piloting the survey and to the datacollection. Also, we are greatly indebted to Patrick Sulzgruber (MD, PhD fromAustria), Stephanie Leckey (BSc, from Northern Ireland), Cristina Granja (MD,PhD) and Tiago Amaral (MSc) from Portugal), Ari Salo (MD, PhD fromFinland), Linn Andelius (MD, from Denmark), Mark Biancardia (MD, fromMalta), Veronika Reinhard (MD, from Estonia), Koen Monsieurs (MD, PhD),David Yansenne, Pierre Mols (MD, PhD) and Bernard Kreps (MD, PhD) (fromBelgium), Marios Ioannidis (MD, PhD, from Cyprus), Violetta Raffay (MD, PhD,from Serbia), Emma Scott and Nicola Dunbar (from the United Kingdom),Enrico Baldi (MSc, from Italy), Vidar Magnusson (MD, MBA) and HildigunnurSvavarsdottir (PhD) (from Iceland), Hajriz Alihodžić (MD, PhD, from BosniaHerzegovina), Fernando Rosell Ortiz (MD, PhD from Spain), Nagy Enikő (fromHungary), Pascal Stammet (MD, PhD from Luxembourg), Andrej Markota(MD, PhD) and Janez Strnad (MD, PhD) (from Slovenia), Craig Hunter (fromScotland), Grzegorz Cebula (MD, PhD from Poland), Michael Müller (MD,PhD), Dennis Rupp and Erich Wranze (MD, PhD) (from Germany) and XavierJouven (MD, PhD, from France) for their cooperation and data collection.Also, we would like to thank all other respondents and national resuscitationcouncils who so generously shared their expert opinion and knowledge tomake this study possible.

Authors’ contributionsIO: study protocol, data collection, data analyses, writing the manuscript. SM:data collection, data analyses, writing the manuscript. IT: data collection,revision of manuscript. MJ: data collection, revision of manuscript. FS: datacollection, revision of manuscript. MR: data collection, revision of manuscript.AT: data collection, revision of manuscript. DC: data collection, revision ofmanuscript. FF: data collection, revision of manuscript. SB: data collection,revision of manuscript. RK: data collection, revision of manuscript. HT:supervision, revision of manuscript. MB: study protocol, supervision, revisionof manuscript. “All authors read and approved the final manuscript”.

FundingThis project/work has received funding from the European Union’s Horizon2020 research and innovation programme under acronym ESCAPE-NET, reg-istered under grant agreement No 733381. Dr Tan and Dr Blom were sup-ported by Dutch Heart Foundation (CVON 2018-30 Predict2).

Availability of data and materialsThe datasets used and/or analysed during the current study are availablefrom the corresponding author on reasonable request.

Ethics approval and consent to participateInformed consent for using the contact details of the participants wassought and provided. This study is part of the ESCAPE-NET study which hasbeen approved by the Institutional Review Board of Amsterdam UMC.

Consent for publicationNot applicable.

Competing interestsThe authors declare that they have no competing interests.

Author details1Department of Clinical and Experimental Cardiology, Heart Center,Amsterdam Cardiovascular Sciences, Amsterdam UMC, Department ofCardiology, Heart Center, Academic Medical Center, University ofAmsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.2Department of General Practice, National University of Ireland Galway andNational Ambulance Service, Dublin, Ireland. 3Norwegian National AdvisoryUnit on Prehospital Emergency Medicine (NAKOS), Oslo, Norway. 4Centre forResuscitation Science, Department for Medicine, Karolinska Institutet,Stockholm, Sweden. 5Department of Anaesthesia, Intensive Care andEmergency Medical Services, Ospedale Maggiore, Bologna, Italy. 6EmergencyMedical Services of the Hradec Kralove Region, Czech Republic and

Oving et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2019) 27:112 Page 19 of 20

Department of Anaesthesiology and Intensive Care Medicine, UniversityHospital Hradec Králové, Hradec Králové, Czech Republic. 7Department ofEmergency Medicine, “Grigore T. Popa” University of Medicine and Pharmacy,Iasi, Romania. 8Department of Cardiology, Copenhagen University HospitalGentofte, Hellerup, Denmark. 9Emergency Medical Services Copenhagen,University of Copenhagen, København, Denmark. 10Netherlands HeartInstitute, Utrecht, The Netherlands.

Received: 2 August 2019 Accepted: 20 November 2019

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