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A specialist, second-tier response to out-of-hospital cardiac arrest: setting up TOPCAT2
  1. Scott Clarke1,
  2. Richard M Lyon2,
  3. Steven Short1,
  4. Colin Crookston3,
  5. Gareth R Clegg2
  1. 1NHS Lothian, UK
  2. 2Emergency Department, The University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
  3. 3Scottish Ambulance Service, Edinburgh, UK
  1. Correspondence to Dr Richard M Lyon, Emergency Department, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh EH16 4SA, UK; richardlyon{at}


Background Out-of-hospital cardiac arrest (OHCA) is the most common, immediately life-threatening, medical emergency faced by ambulance crews. Survival from OHCA is largely dependent on quality of prehospital resuscitation. Non-technical skills, including resuscitation team leadership, communication and clinical decision-making are important in providing high quality prehospital resuscitation. We describe a pilot study (TOPCAT2, TC2) to establish a second tier, expert paramedic response to OHCA in Edinburgh, Scotland.

Methods Eight paramedics were selected to undergo advanced training in resuscitation and non-technical skills. Simulation and video feedback was used during training. The designated TC2 paramedic manned a regular ambulance service response car and attended emergency calls in the usual manner. Emergency medical dispatch centre dispatchers were instructed to call the TC2 paramedic directly on receipt of a possible OHCA call. Call and dispatch timings, quality of cardiopulmonary resuscitation and return-of-spontaneous circulation were all measured prospectively.

Results Establishing a specialist, second-tier paramedic response was feasible. There was no overall impact on ambulance response times. From the first 40 activations, the TC2 paramedic was activated in a median of 3.2 min (IQR 1.6–5.8) and on-scene in a median of 10.8 min (8.0–17.9). Bimonthly team debrief, case review and training sessions were successfully established. OHCA attended by TC2 showed an additional trend towards improved outcome with a rate of return of spontaneous circulation of 22.5%, compared with a national average of 16%.

Conclusions Establishing a specialist, second-tier response to OHCA is feasible, without impacting on overall ambulance response times. Improving non-technical skills, including prehospital resuscitation team leadership, has the potential to save lives and further research on the impact of the TOPCAT2 pilot programme is warranted.

  • Cardiac Care, Care Systems
  • Emergency Ambulance Systems
  • Prehospital Care, Clinical Management
  • Resuscitation

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Out-of-hospital cardiac arrest (OHCA) is a leading cause of mortality and serious neurological disability in Europe.1 ,2 Survival rates from OHCA are highly variable with reported survival-to-hospital discharge rates of <1% to over 20%.3 Improved outcome from OHCA has been reported by centres that have optimised the local ‘chain of survival’ in their area.4

Prehospital resuscitation is a vital part of the ‘chain of survival’.5 Studies have demonstrated that the quality of prehospital cardiopulmonary resuscitation (CPR) is a key determinant of outcome from OHCA.6 Prehospital resuscitation is complex and varied. High quality resuscitation requires good technical as well as non-technical skills.7 ,8

Key technical skills during cardiac arrest management are the ability to perform high quality CPR and defibrillation. Evidence suggests that the amount of time spent performing high quality chest compressions (hands-on-chest time) is a critical determinant of outcome from OHCA.6 Increased time-to-shock intervals, the interval between ceasing chest compressions and defibrillation, have been shown to decrease the chance of successful defibrillation.

Good teamwork, clear communication and effective leadership are vital non-technical skills during resuscitation.9 Recent studies have shown that good leadership skills are associated with better overall team performance during simulated cardiac arrest and have demonstrated specific improvements in the hands-on-chest time.10 Key leadership skills in resuscitation include critical decision-making and clear communication, especially with regard to task allocation and planning.

Previous research in our region suggested quality of prehospital resuscitation could be improved.11 ,12 During the TOPCAT study,13 an emergency medicine (EM) clinical research fellow attended OHCA resuscitation attempts as a secondary responder and provided resuscitation team leadership. He did not perform technical tasks, such as intubation or cannulation, other than those directly related to data collection for the study. Analysis of data from defibrillator downloads during the study period showed improved hands-on-chest time and compression rates when he attended with a trend towards an increased rate of return-of-spontaneous circulation.

We sought to improve quality of prehospital resuscitation in our area through a programme of audit, feedback, training and leadership. Initially we focused on technical skills, improving quality of CPR and defibrillation.12 Ambulance crews receive initial training in performing CPR and defibrillation but receive variable training updates. In our region, ambulance crews receive CPR training approximately once per year. Individual ambulance crews in our region are likely to encounter less than five OHCAs per year and skill retention can be problematic. We implemented regular training and education sessions combined with targeted feedback from defibrillator downloads after each prehospital resuscitation attempt. Following implementation, there was a significant improvement in hands-on-chest time and a significant reduction in time-to-shock intervals.12

The region within Edinburgh city bypass has a population of approximately 800 000. Approximately 350 OHCA occur annually. We describe a pilot study to establish a second tier, expert paramedic response to OHCA in Edinburgh, Scotland.


Selection and training

Following agreement from the Scottish Ambulance Service, an initial eight paramedics were selected for the programme, designated TOPCAT2 (TC2). Selection was based on regular attendance at voluntary OHCA education sessions and performance during simulated OHCA. Those selected underwent initial Advanced Life Support-style training with a hospital resuscitation officer to ensure their CPR and defibrillation skills were of a high standard. Further training concentrated on non-technical skills and was delivered by an EM consultant, an EM clinical research fellow, a resuscitation officer and a fellow in medical education. Training sessions used seminar-style teaching in addition to simulation with video recording to facilitate debriefing and evaluation. All of the paramedics attended during their off-duty and were unpaid. The pilot was registered with the Scottish Ambulance Service as a service improvement evaluation and formal ethical approval was waived.


Standard operating procedures were developed to ensure TC2 paramedics were preferentially tasked to suspected OHCA calls. A TC2 paramedic manning a Rapid Response Unit was identified for each shift and they were required to notify the Emergency Medical Dispatch Centre at the beginning and end of their shift. Dispatchers were required to task the TC2 paramedic in addition to the nearest available resource when OHCA was suspected. TC2 paramedics were authorised to leave non-urgent jobs for OHCA when contacted by the dispatcher. All of the paramedics in the programme agreed to be contacted during their breaks to respond to suspected OHCA. All ambulance crews were notified of the TC2 project via email and could request TC2 paramedic attendance at any time.


TC2 paramedics were required to complete an audit process for each shift. The standard operating procedure required them to complete a sign-on and sign-off form for each shift and an audit form for each time they were dispatched. Following each resuscitation attempt, they were required to complete our area's standard OHCA audit form, the ambulance service's electronic patient record (ePRF) and submit a defibrillator download for analysis.

Case review

TC2 paramedics were required to attend twice monthly review meetings. Data collected from audit forms and defibrillator downloads were used to review resuscitation attempts with input from the other TC2 paramedics and the clinical training team. Knowledge and skill gaps were identified to facilitate targeted education including simulations. Those paramedics on-duty attended when on standby and those on their off-duty attended unpaid.



There was no demonstrable impact on overall emergency medical services (EMS) performance in the region with no significant difference seen in response times to Category A (life-threatening) calls.

Resuscitation attempts

During the first 3 months of the project, TC2 paramedics attended 40 OHCA calls where resuscitation was attempted. Demographics for patients where a TC2 paramedic attended and a summary of the ambulance response are shown in table 1.

Table 1

Summary of first 40 out-of-hospital cardiac arrest calls attended by TOPCAT2 paramedics in Edinburgh


Initially, TC2 paramedics reported that ambulance crews were reluctant to accept guidance. With increased awareness, there was a feeling of greater acceptance among crews. Team debrief immediately after the resuscitation attempt and education sessions were vital for facilitating TC2 leadership on-scene.


This study describes a dedicated, second-tier paramedic response to OHCA. We found that by redeploying existing resources, we could provide a specialist response to OHCA without impacting overall ambulance performance in our region. Dispatch recognition and activation of TC2 was achievable in a timely fashion, although further work is required to shorten the activation and response time.

Several studies have described the impact of improving resuscitation non-technical skills and leadership.7 ,8 ,10 There appears to be a patient benefit in improving resuscitation non-technical skills and this pilot work translates the lessons learned from simulation into prehospital, clinical practice. Recent studies and guidelines have highlighted the need for good quality non-technical skills and leadership at OHCA14 but few studies have described how to implement a system, which provides trained, experienced leadership during prehospital resuscitation.

This study is limited by the initial small sample size; however future work aims to establish the impact of the TC2 project on patient outcome.


Establishing a specialist, second-tier response to OHCA is feasible, without impacting on overall ambulance response time. Initial results suggest that an expert, second-tier response to OHCA may improve quality of prehospital resuscitation. Improving non-technical skills, including prehospital resuscitation team leadership, has the potential to save lives and further research on the impact of the TOPCAT2 pilot programme is warranted.


The authors wish to thank the paramedics and technicians from the Scottish Ambulance Service for supporting the TOPCAT2 project.



  • Contributors All authors were directly involved with the study, contributed to data collection and manuscript writing.

  • Funding A small project grant from Chest, Heart and Stroke Scotland contributed to the TOPCAT2 pilot study.

  • Competing interests None.

  • Ethics approval Service evaluation.

  • Provenance and peer review Not commissioned; externally peer reviewed.