
==== Front
Resusc Plus
Resusc Plus
Resuscitation Plus
2666-5204
Elsevier

S2666-5204(24)00204-2
10.1016/j.resplu.2024.100753
100753
Letter to the Editor
Incomplete prehospital documentation for Out-of-Hospital Cardiac Arrest (OHCA) in the United States
Shekhar Aditya C. shekhar.aditya.c@gmail.com
⁎
Kimbrell Joshua
Icahn School of Medicine at Mount Sinai, New York City, NY, United States
Pujar Sanjay V.
Department of Internal Medicine, Texas Health Resources, Denton, TX, United States
Stebel Jacob
Abbott Ethan E.
Icahn School of Medicine at Mount Sinai, New York City, NY, United States
⁎ Corresponding author. shekhar.aditya.c@gmail.com
29 8 2024
12 2024
29 8 2024
20 10075329 7 2024
10 8 2024
12 8 2024
© 2024 The Author(s)
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
==== Body
pmcEmergency medical services (EMS) data have proven extremely valuable in examining broad and local trends in out-of-hospital cardiac arrest (OHCA).1 However, profound data missingness may affect the generalizability of any conclusions drawn. Limited research has reported the extent to which data is missing from EMS documentation for OHCA at the national-level in the United States. The Utstein guidelines were developed in the early 1990s and have been revised multiple times to optimize OHCA reporting and research efforts.2, 3 In this study, we utilized a broad and nationally-representative EMS database to identify rates of missing data across key patient-level data elements emphasized by the Utstein guidelines.

We queried a nationally representative database of EMS activations in the United States (NEMSIS) to examine the rates of data missingness in OHCA; data are populated directly from EMS patient care reports, so any missingness in the database reflects missingness in documentation.4 Inclusion criteria were any OHCA prior to EMS arrival between January 2022 and December 2023 responded to by a 9-1-1 ground ambulance. Included cases were analyzed to identify rates of missingness for patient-level core data elements recommended by the 2024 Utstein guidelines. Utstein patient-level core data elements include: Age, Sex, Witnessed Status, Arrest Location, CPR prior to EMS arrival, AED use prior to EMS arrival, first-monitored arrest rhythm, and arrest etiology. Additionally, we identified rates of data missingness for race/ethnicity, which is not recommended as a patient-level core data element within the 2015 Utstein guidelines but is crucial to better understanding demographic disparities in OHCA.

Across 844,021 OHCAs, there was a wide range of missing data rates (0.75–33.1%) (Table 1). Patient race/ethnicity had the highest rates of data missingness (33.1%), followed by first monitored arrest rhythm (22.4%), CPR prior to EMS arrival (17.9%), and AED use prior to EMS arrival (13.3%). Patient sex had the lowest rate of missing data (0.75%), followed by patient age (1.2%), arrest location (2.7%), and etiology (4.8%).

Our analysis of a large and nationally representative database of EMS activations reveals varying levels of data missingness across eight key OHCA data elements. Our findings agree with prior research: for instance, race/ethnicity is missing within the Cardiac Arrest Registry to Enhance Survival (CARES) in 21.4% of cases.5 Some of the data missingness may be due to the information being unavailable (i.e. EMS not knowing the precise age of someone found down alone). Data missingness poses a challenge to researchers who use large-scale data to investigate health disparities. This is especially important considering quality improvement efforts aimed at achieving greater health equity in prehospital systems – a priority in recent years – rely on reliable data collection for measuring improvement. Our analysis is limited by the fact we cannot ascertain the overall accuracy of EMS documentation; rather, we merely present rates of data missingness. Further efforts are needed to improve prehospital documentation of OHCA from a research perspective and a public health surveillance perspective.Table 1 Rates of data missingness across key OHCA data elements.

Data Element	Percent Missing	
Age	1.2%	
Sex	0.75%	
Witnessed Status	5.0%	
Arrest Location	2.7%	
CPR Prior to EMS Arrival	17.9%	
AED Prior to EMS Arrival	13.3%	
First Monitored Arrest Rhythm	22.4%	
Arrest Etiology	4.8%	
Race/Ethnicity
(not an Utstein patient-level core data element)	33.1%	

Table 1 shows rates of data missingness in a large sample of OHCA in the United States across several key data elements.

Funding

None.

CRediT authorship contribution statement

Aditya C. Shekhar: Writing – review & editing, Writing – original draft, Supervision, Methodology, Formal analysis, Data curation, Conceptualization. Joshua Kimbrell: Writing – review & editing, Writing – original draft, Conceptualization. Sanjay V. Pujar: Writing – review & editing. Jacob Stebel: Writing – review & editing. Ethan E. Abbott: Writing – review & editing, Supervision.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
==== Refs
References

1 Sayre M.R. White L.J. Brown L.H. McHenry S.D. The national EMS research strategic plan Prehosp Emerg Care 9 2005 255 266 16147473
2 Chamberlain D. Cummins R.O. Abramson N. Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the ‘Utstein style’: prepared by a task force of representatives from the European Resuscitation Council, American Heart Association, Heart and Stroke Foundation of Canada, Australian Resuscitation Council Resuscitation 22 1991 1 26 1658890
3 Grasner J.T. Bray J.E. Nolan J.P. Cardiac arrest and cardiopulmonary resuscitation outcome reports: 2024 update of the Utstein Out-of-Hospital Cardiac Arrest Registry template Resuscitation 24 2024 110288
4 Ehlers J. Fisher B. Peterson S. Description of the 2020 NEMSIS public-release research dataset Prehosp Emerg Care 27 2023 473 481 35583482
5 Chan P.S. Merritt R. Chang A. Race and ethnicity data in the cardiac arrest registry to enhance survival: Insights from medicare self-reported data Resuscitation 1 2022 64 67
