AHA 2026View all trials
Community and EMS Interventions to Improve Survival in Cardiac Arrest
Carolina Malta HansenKonstantin A. KrychtiukMonique A. StarksHussein R. Al‐KhalidiDaniel B. MarkLisa MonkLisa A. KaltenbachJames G. JollisSana M. Al‐KhatibHayden B. BosworthKimberly WardSarah SmithTyler CopeSteven VandeventerJyotsna GargAudrey L BlewerEdward SharpeThomas D. ReaR. Darrell NelsonBryan McNallyChristopher B. Granger
What happened
Community and EMS educational intervention fails to improve favorable neurological survival over standard care.
- adjusted OR 0.97
- 95% CI 0.75-1.26
- P=0.80
- n=22,459
Key points
- Context & question: To determine whether a multifaceted community and emergency medical services intervention improves survival with a favorable neurologic outcome in adults with out-of-hospital cardiac arrest.
- Methods & population: Registry-based, cluster-randomized trial in North Carolina assigning county clusters in a 1:1 ratio to a multifaceted intervention (28 clusters, N=11,615) or usual care (27 clusters, N=10,844); The intervention comprised 911 dispatcher training for rapid arrest recognition, dispatcher CPR coaching, community CPR training, and enhanced automated external defibrillator use by first responders and bystanders.
- Finding & limits: Survival to hospital discharge with a good neurologic outcome occurred in 9.0% of patients (1,048 of 11,608) in the intervention group versus 9.4% (1,017 of 10,839) in the usual-care group (adjusted;.75 to 1.26;). It is not clear whether the late rise in bystander CPR would eventually improve survival if community outreach were kept up longer.
Discussion
Expert perspectives 4
Expert perspective
Lisa Monk6d ago
Cross-Cutting Cardiology · Duke University
We want to gather information about how people do over the next year. We are following up with survivors at three and 12 months to assess their health status and quality of life.
RACE-CARS co-authorExpert perspective
Carolina Malta Hansen6d ago
Cross-Cutting Cardiology · Institut polytechnique de Grenoble
Changing how an entire community responds to cardiac arrest takes time, and our findings show just how challenging that can be. In the meantime, the message to the public remains simple: learn CPR, recognize the signs of cardiac arrest, call 9-1-1 immediately and follow the dispatcher's instructions. Everyone has the potential to save a life.
RACE-CARS co-authorExpert perspective
Christopher B. Granger6d ago
General Cardiology
The increase in bystander CPR toward the end of the study shows there was some effect and suggests that a sustained community outreach may be needed to show an improvement in survival. We have established an efficient, high-quality clinical trial network to continue this work.
RACE-CARS co-authorShow 1 more perspectivesShow fewer perspectives
Expert perspective
Critical Care Reviews5d ago
Community and EMS Interventions to Improve Survival in Cardiac Arrest - RACE-CARS RCT CCR Journal Watch CCR Summary & Critique
t.cot.cot.coRACE-CARSOutstanding questions
Open questions from this trial that would benefit from expert input.
Ask about this paper
Answers are grounded in this paper and cite their sources.
Full evidence
Why the trial, tables, limitations, PICO, abstract, media & sources
Full evidence
Why the trial, tables, limitations, PICO, abstract, media & sources
Why the trial?
Although early cardiopulmonary resuscitation and defibrillation are known to improve survival after out-of-hospital cardiac arrest, randomized trial evidence is lacking on whether community-based implementation strategies improve patient outcomes. The RACE-CARS trial was conducted to evaluate the effectiveness of a multifaceted community and emergency medical services intervention compared with usual care.
Does a multifaceted community and EMS intervention (telecommunicator training, community CPR training, and enhanced AED use) improve survival to hospital discharge with a good neurologic outcome compared with usual care in adults with out-of-hospital cardiac arrest?
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Structured PICO
Does a multifaceted community and EMS intervention (telecommunicator training, community CPR training, and enhanced AED use) improve survival to hospital discharge with a good neurologic outcome compared with usual care in adults with out-of-hospital cardiac arrest?
Population
22,459 adults with EMS-treated out-of-hospital cardiac arrest across 55 county clusters in North Carolina (median age 64.0 years, 36.7% women) from July 2022 to June 2026.
Intervention
Multifaceted community and EMS implementation strategy comprising four components: (1) training of 911 telecommunicators to improve rapid recognition of cardiac arrest, (2) training of 911 telecommunicators to improve delivery of CPR instructions to bystanders, (3) community CPR training, and (4) enhanced use of automated external defibrillators (AEDs) by first responders or bystanders before EMS arrival.
Comparator
Usual care
Outcome
Survival to hospital discharge with a good (favorable) neurologic outcomehard clinical endpoint
Main Result
Odds Ratio0.97 (95% CI 0.75–1.26)
Absolute Event Rate9% vs 9.4%
p-valuep=0.80
In this large cluster-randomized trial of over 22,000 patients with out-of-hospital cardiac arrest, a comprehensive community and 911/EMS training intervention failed to improve neurologically intact survival to hospital discharge compared with usual care.
Where experts stand
Experts read RACE-CARS as a null result: a broad community and EMS push did not improve survival with good brain function after cardiac arrest, though some see early signs that a longer effort might.
The trial is widely read as negative. The clinicians who interpret it argue that changing how a whole community responds to cardiac arrest takes time, and they point to more bystander CPR late in the study as a partial effect. The live question is whether a longer, sustained outreach effort would turn into better survival.
Agreement
Both clinicians who commented on the result say that changing a community's response to cardiac arrest is slow work. They suggest the intervention may need more time or sustained effort to show a survival benefit.
2 clinicians say this directly
2 takes classified by contention axis so far — the map appears as more land.
Still unclear
It is not clear whether the late rise in bystander CPR would eventually improve survival if community outreach were kept up longer.
Implication
No benefit on neurologically favorable survival with EMS-community education in OHCA; informs guidelines against implementation and directs future resuscitation trials.
Abstract
Background Early cardiopulmonary resuscitation (CPR) and defibrillation improve survival after out-of-hospital cardiac arrest, but evidence from randomized trials about whether community-based implementation strategies improve outcomes is lacking. Methods We conducted a registry-based, cluster-randomized trial involving adults with out-of-hospital cardiac arrest treated by emergency medical services (EMS) in North Carolina counties. The counties were grouped into clusters, which were then randomly assigned in a 1:1 ratio to implement a multifaceted intervention or administer usual care. The intervention included four components: training of 911 telecommunicators to improve rapid recognition of cardiac arrest, training of 911 telecommunicators to improve delivery of CPR instructions from telecommunicators to bystanders, community CPR training, and enhanced use of automated external defibrillators by first responders or bystanders before EMS arrival. Results From July 1, 2022, to June 30, 2026, a total of 28 clusters comprising 11,615 patients were assigned to the intervention group, and 27 clusters comprising 10,844 patients were assigned to the usual-care group. The median age of the patients was 64.0 years, and 36.7% were women. The percentage of patients who survived to hospital discharge with a good neurologic outcome was 9.0% (1048 of 11,608 patients) in the intervention group and 9.4% (1017 of 10,839 patients) in the usual-care group (adjusted odds ratio, 0.97; 95% confidence interval, 0.75 to 1.26; P=0.80). Conclusions Among adults with out-of-hospital cardiac arrest, implementation of a multifaceted strategy involving the community and EMS did not result in a greater percentage of patients who survived to hospital discharge with a favorable neurologic outcome than usual care.
Cite This Study
Hansen et al. (2026) conducted an RCT in Out-of-hospital cardiac arrest (n=22,459). Multifaceted community and EMS intervention (911 telecommunicator training for arrest recognition and CPR instructions, community CPR training, and enhanced AED use) vs. Usual care was evaluated on Survival to hospital discharge with a good neurologic outcome (adjusted OR 0.97, 95% CI 0.75-1.26, p=0.80). A multifaceted community and EMS strategy did not improve survival with good neurologic outcome vs usual care in out-of-hospital cardiac arrest.