By Nick Sajko & Judah Goldstein
The out-of-hospital component of medical care begins with a 911 call and often ends on arrival to the Emergency Department. In this setting, a wide breadth of medical issues can be encountered, the most serious of which require out-of-hospital resuscitation (OHR). Although a broad category, OHR mainly involves two major conditions, both of which are associated with high mortality and morbidity rates. These conditions include: 1) out-of-hospital cardiac arrest (OHCA), and 2) major trauma. Taken together, they result in the deaths of 43,000 Canadians annually (1,2).
OHR takes place in a chaotic and often unpredictable environment. Paramedics have little control over where the resuscitation is initiated, the elements they encounter, or resources involved. With this in mind, implementation of new evidence-informed guidelines, specific to paramedic practice in these settings, will always be required to improve mortality and morbidity for sudden OHCA and major trauma patients. Unfortunately, there is currently no formal Canadian data collection and reporting platform to show whether current efforts are making a difference in patient outcomes on a national scale.
Three Canadian Universities (University of Toronto, Ottawa, and British Columbia) have played roles in out-of-hospital resuscitation data collection and research initiatives through their involvement in the joint U.S. / Canadian resuscitation outcomes consortium (ROC). This initiative led to the completion of a number of large, multi-center clinical trials on the paramedic management of OHCA and major trauma. With these efforts, there has been a doubling of survival rates for out-of-hospital resuscitation over the past 10 years at ROC sites (3–5). Unfortunately, funding for this joint venture has since ended, thus demanding a new approach to ongoing resuscitation research strategies in Canada. The opportunity now exists to expand the network beyond the current three Canadian sites so that continued improvements in resuscitation care can be realized throughout Canada.
Canadian Resuscitation Outcomes Consortium (CanROC)
The opportunity for a Canadian focused resuscitation research consortium has now presented itself. With the funding for the joint ROC venture ending in 2015, a national registry for OHCA and major trauma currently does not exist in Canada. Additionally, while it was proven to be a valuable endeavor, ROC did not provide a comprehensive picture of the Canadian out-of-hospital resuscitation landscape. The need for a national registry was highlighted by these prior efforts. Moreover, due to the practical realities of the Canadian geography, optimized paramedic care is even more important as patients are not always close to specialized care centers, and often have prolonged transport times.
A Canadian-focused initiative began in 2016. Titled “CanROC”, this initiative is a population-based registry that aims to capture data from all OHCA and major trauma patients assessed by paramedics from participating sites. This will allow for the production of high-quality population-based research using both observational and interventional data. CanROC will advance our knowledge and research within the field of OHR, while providing a unique Canadian context.
The CanROC Priorities
Paramedics in Canada should be aware of CanROC’s five key priorities:
1.New World-Class Science
CanROC aims to improve the science behind out of hospital resuscitation through improved data collection from paramedic services across Canada. This initiative also aims to look at opportunities for improved management strategies after the critically ill are transported to hospital thereby linking out-of-hospital care to in-hospital management and patient outcomes. It is often challenging for paramedic services to obtain patient outcomes, therefore this initiative will promote the bi-directional flow of information. In addition, data from the pediatric population will also be collected.
CanROC aims to increase the capacity of the resuscitation research community. In order to accomplish this, the initiative will build on the successes of the University of Toronto and Ottawa fellowship programs for resuscitation sciences and push to expand these opportunities to other centers across Canada. Paramedics interested in resuscitation research will have a network of mentors to draw from and opportunities for graduate level training at multiple sites across Canada.
3. National Scope
While the prior ROC initiative only involved 3 Canadian centers, CanROC aims to engage stakeholders from as many regions as possible across the nation. Expanding the scope to more regions nationwide will allow CanROC to produce data that is more representative of our Canadian landscape. Many provinces or cities have already committed to participating in this national initiative. Over the past three years, CanROC has aimed to be fully inclusive, recognizing the diversity of paramedic services across Canada including the unique challenges that they face as they move towards implementation of new evidence and practice.
4. Broad Community Involvement
CanROC’s plan is to continue to establish involvement and engagement from scientists, trainees, decision makers, and all health care providers – similar to what was done with ROC. However, unique to CanROC, is the plan for expanded public engagement. CanROC aims to engage survivors, bystanders, and the public in setting research priorities and building a support structure for those most affected by sudden OHCA or major trauma.
5. Knowledge Translation and Dissemination
The final and most crucial component to the CanROC initiative is effective knowledge translation and dissemination of research results. New evidence generated by the registry and associated research endeavors that could benefit OHCA and major trauma needs to be implemented into practice as soon as possible for maximum benefit. CanROC will consult and work alongside stakeholders and experts to develop effective means of knowledge translation and implementation through the network of involved paramedic agencies.
The CanROC Structure
CanROC is divided into numerous groups and committees in an effort to have focused work conducted in multiple facets of this initiative, at one time. Inter-committee communication will then allow for the functioning of CanROC as a whole. In brief, the structure of CanROC is as follows:
This represents the core decision-making body for CanROC. The group includes 11 voting members to decide on matters relevant to the initiative as a whole. Regular meetings are held and transparent communication is delivered to the entirety of the CanROC assembly using multiple methods of communication.
Support committees enable the effective division of work and responsibility under the steering committee’s leadership. The following support committees currently play vital roles in the CanROC system:
I)Publications and Protocol Review
II)EMS (including paramedics, first responders, medical directors)
III) Data Management
IV) Data Access
V) Cardiac Arrest
VIII) Trainees and Career Development
IX) Public Engagement
Annual CanROC Assembly
The CanROC group has met on an annually basis since its inception in 2016. The assembly has been held in Toronto, Ottawa and also in Vancouver. The purpose of the annual assembly is to discuss relevant issues regarding CanROC implementation, with a focus on new studies and initiatives. The assembly brings together all participating sites so that CanROC members can come together to share experiences.
Paramedic Services in CanROC – A Vital Partnership
Paramedic services across Canada are the backbone to the CanROC initiative, playing a major role in the generation of data, participation in committees, and the implementation of new evidence based practice as a result of the research conducted. All paramedics working within regions involved with the CanROC registry will have access to state-of-the-art reporting tools that provide a breakdown of performance metrics related to patient care, demographics, and outcomes. This data will allow agencies to better understand their current performance metrics and set benchmarks for continuous quality improvement against a national standard. Participating services will have access to state of the art reporting tools. CanROC will work with training and education departments to help guide education initiatives and identify gaps in care. In addition to quality improvement, this data collection is important to the generation of new research and future implementation of new practices to improve patient outcomes.
Adding to the roles in data generation and implementation, CanROC aims to allow for the networking of those healthcare professionals directly involved in out-of-hospital medicine (i.e. other paramedics, nurses, physicians) from all participating sites. This will foster strong connections and the effective dissemination of new standards of care.
Lastly, CanROC will provide a number of new research opportunities for paramedics interested in the resuscitation field. Opportunities to be directly involved will include a large spectrum of roles, ranging from: recruitment of patients, being part of study teams, training opportunities, graduate programs and principal investigators.
Interested paramedics can get involved through two major avenues: The application of an entire service to become or join an existing CanROC site OR the independent involvement of interested responders. Details on the process of getting involved via either these two avenues can be found here: http://canroc.org.
Moving Forward – Continued Canadian Excellence in Resuscitation Research
The design and implementation of CanROC, a Canadian registry for outcomes associated with out-of-hospital management of OHCA and major trauma, will allow for continued improvement in the management of patients with these time sensitive, life-threatening conditions.
Canadian investigators in resuscitation research have been at the forefront for 25 years, producing work and implementing system changes to prehospital management recognized on an international level. CanROC provides the opportunity to improve patient outcomes from sudden OHCA and major trauma, while fostering a community built around the production of high quality research and evidence based practices. Seeing these goals accomplished via CanROC will allow the continued participation of Canada as a world leader in resuscitation science.
1. Heart and Stroke Foundation. Heart and Stroke Foundation Statistics [Internet]. 2014 [cited 2014 Jul 23]. Available from: http://www.heartandstroke.com
2. Parachute. Ontario Injury Data Report 2018. Toronto; 2018.
3. Daya MR, Schmicker RH, Zive DM, Rea TD, Nichol G, Buick JE, et al. Out-of-hospital cardiac arrest survival improving over time: Results from the Resuscitation Outcomes Consortium (ROC). Resuscitation. 2015;
4. Buick JE, Drennan IR, Scales DC, Brooks SC, Byers A, Cheskes S, et al. Improving Temporal Trends in Survival and Neurological Outcomes after Out-of-Hospital Cardiac Arrest. Circ Cardiovasc Qual Outcomes. 2018;
5. Fordyce CB, Scheuermeyer FX, Barbic D, Schlamp R, Tallon J, Grunau B, et al. Trends in care processes and survival following prehospital resuscitation improvement initiatives for out-of-hospital cardiac arrest in British Columbia, 2006–2016. Resuscitation. 2018;125:118–25.