Skip to main content

First-response treatment after out-of-hospital cardiac arrest: a survey of current practices across 29 countries in Europe



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


A mixed-method survey and information retrieved from national resuscitation councils and national EMS services were used as a basis for an inventory. The survey was sent to 51 OHCA experts across 29 European countries.


Forty-seven (92%) OHCA experts from 29 countries responded to the survey. More than half of European countries 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) part of EMS; (c) instead of EMS. A wide variation in FR-systems was observed, both between and within countries.


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


Out-of-hospital cardiac arrest (OHCA) is lethal within minutes of collapse if left untreated, and the majority of OHCA patients die before hospital admission [1, 2]. If early cardiopulmonary resuscitation (CPR) is provided, survival rate increases [3, 4]. In particular, presence of shockable rhythm is an important determinant of survival, and OHCA patients who are found with a shockable initial rhythm are more likely to survive if they are defibrillated with an automated external defibrillator (AED) [5]. However, many OHCA patients are not found in a shockable rhythm due to prolonged emergency medical services (EMS) response times, particularly in residential areas where most OHCAs occur [6,7,8]. When CPR is started quickly after collapse, the length of time that a shockable rhythm persists may be extended [9], thus prolonging the opportunity for successful defibrillation. Identifying and implementing systems that increase the likelihood of immediate CPR provision and rapid defibrillation are vital to improving survival. The deployment of First Responders (FRs) is one method that has been developed in order to meet this challenge.

FR-systems have been implemented differently across Europe. Some countries have expanded the traditional EMS response with dispatch of CPR trained firefighters and police officers equipped with AEDs. Research has shown that the introduction of these types of dispatched FRs led to shorter response times [10], and increased 30 day survival [11, 12]. Dispatch of trained citizen-FRs may 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, may contribute to this variation. For instance, FRs may be less effective when they are inefficiently deployed and/or time from collapse to initiation of CPR is prolonged when the technology used for FR dispatch is suboptimal [15]. In addition, differences in FR skill sets may contribute, e.g., level of resuscitation training, available equipment, and experience in coping with emergency situations.

Survival rates after OHCA may increase across Europe if FR-systems are optimized. Similarly, optimization efforts may benefit from past experiences in FR implementation across Europe. However, to date, no comprehensive inventory of the different types of dispatched FR-systems used across Europe exists. Additionally, while the most recent European Resuscitation Guidelines emphasise the importance of community response in saving lives [18], the extent to which establishment of FR-systems has been adopted as national policy across Europe is unknown. Therefore, the aim of this paper is to create an inventory of dispatched FR-systems across Europe, and to determine whether countries have a national policy regarding FR-systems. This will serve as a basis to highlight key differences in order to ultimately optimise FR-systems across Europe.


Design and set up

This research was conducted as part of the ESCAPE-NET project that aims to discover the causes and best treatments of OHCA [19]. A mixed-method survey was combined with information retrieved from national resuscitation councils and national EMS services as a basis for an inventory.

Survey and information gathering

The content of the survey was determined after several meetings with an expert panel, consisting of five experts in 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 by Dutch researchers and finalised after a pilot carried out by Amsterdam Resuscitation Studies (ARREST) [20] researchers.

The survey was sent to 51 OHCA professionals across 29 European countries between August and November 2018 (Additional file 1: Supplementary 1a). An OHCA professional was defined as a European Resuscitation Council (ERC) or ESCAPE-NET member with a long working 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 Congress in Bologna, 2018 (additional file 1: Supplementary 1a). Informed consent for using the contact details of the participants was sought and provided. A second attempt was made to get non-responding survey participants to take part within three weeks. All survey results were validated with the respondents before results were finalised.

In addition, data on national policies regarding FRs was sought from national resuscitation councils (or national EMS services where no council existed). If no response from a national council was received within three weeks, other national experts in the field of OHCA were consulted. Similar to the survey respondents, national experts had a long working experience (≥5 years) in the field of OHCA and were identified using the ERC or ESCAPE-NET network. Where possible, answers from survey respondents and national resuscitation councils were cross checked.


For the purposes of this study, EMS and FRs were defined as follows:

Emergency medical services (EMS)

Emergency Medical Services included on-duty emergency medical personnel who were dispatched by a dispatch centre to provide acute medical care and to transport the patient to a hospital equipped to provide acute care.

First responder (FR)

First Responders were defined as all individuals who were dispatched by a dispatch centre to attend OHCA events and initiate early CPR. FRs potentially included firefighters and police officers (traditional FRs) [21, 22], off-duty EMS staff and citizen-responders. An extensive description of EMS and FRs is provided in Additional file 1: Supplementary 1b.


The availability of dispatched FRs was determined for each country and/or region. A FR-system was defined as nationwide when it covered ≥50% of the country. The FR-system was described and characteristics were assessed (by examining each individual type of FR, as part of the FR-system). Characteristics included: recruitment and activation methods, role on scene, equipment, CPR training and frequency of training, registration, feedback, financial support, and emotional support. An extensive description of all characteristics is provided in Additional file 1: Supplementary 1c.


The response rate to the survey was 92% (47/51); information was obtained from 29 countries. For the specific questions on national policy, the response rate from national resuscitation councils was 62% (16/26; in 26 of the 29 studied countries, a national resuscitation council existed). This rate increased to 77% (20/26) after consulting other experts.

Types and roles of FRs in Europe

First responders were categorised post-hoc into four main types:

  1. 1)

    Firefighters (professional and/or voluntary) (Fig. 1a)

  2. 2)

    Citizen-responders (Fig. 1b)

  3. 3)

    Police officers (Fig. 1c)

  4. 4)

    Others, i.e., all responders that could not be categorized into firefighters, citizen-responders, police officers, (e.g., off-duty EMS personnel, nurses or medical doctors, and taxi drivers).

Fig. 1

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

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

  1. 1)

    Complementary to the statutory EMS response;

  2. 2)

    Part of the statutory EMS response;

  3. 3)

    Instead of EMS.

More than half (19 of 29) of European countries or regions thereof had FR-systems (Fig. 2a). Such FR-systems were implemented nationwide in 16 countries, and regionally in 3 countries. In 14 countries, the FR-systems acted 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 (remote areas in Iceland). In 10 of 29 countries there was no dispatched FR-system (Fig. 2b).

Fig. 2

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

Variation in first responder-systems nationally and regionally

Variation in the type of FR-systems was observed both between and within countries. FR-systems with one FR type existed nationwide in 8 countries and regionally in 9 countries. FR-systems with two FR types existed regionally in eight countries. FR-systems including three or four FR types existed nationwide in 6 countries and regionally in 2 countries (Fig. 2a, Additional file 1: Supplementary 2).

Characteristics of first responder-systems

Next, we analysed the characteristics of the FR types in more detail. Tables 1, 2 and 3 list the characteristics of firefighters, citizen-responders and police officers; Additional file 1: Table S1 lists the characteristics of the “other FRs”. A summarised description is provided below.

Table 1 Characteristics of dispatched fire fighters
Table 2 Characteristics of dispatched citizen-responders
Table 3 Characteristics of dispatched police officers

Response characteristics: availability and alerts

Different methods were used to alert FRs. For firefighters and police officers, a standard communication system is often used. A smaller proportion of regions used 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 only the standard communication system is used). While firefighters and police officers tend to be available on a 24/7 basis, 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 ≥ 18 years). Also, in a few countries there is no dispatch of citizen-responders to children (e.g., < 8 years).


In every country and region, FRs either carry an AED, or are directed by the dispatch centre to the nearest publicly accessible AED. Safety jackets, pocket masks, mobile phones, and rescuer kits are generally part of the equipment.

Training and registration

In most European regions, CPR training is required and checked before FRs can be dispatched, except for citizen-responders in Denmark (in two regions: Capital region and Central region) and Hungary. The frequency of mandatory CPR training differed between countries, particularly for citizen-responders (varying from monthly training to none). In Italy, untrained citizens are by law not 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, including Ireland and Scotland, registration is managed by the ambulance service on an EMS-owned database. Several countries (Denmark: region Zealand and Southern Denmark, Czech Republic, Ireland and Switzerland) require absence of a criminal record (or of a criminal conviction of significance) in order to be able to register as a citizen-responder.

National and regional policies

Policies relating to the implementation of FR-systems are 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 (Additional file 1: Table S2).

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

Future implementations of FR-systems in Europe

As shown in Fig. 2b, some countries did not dispatch FRs to attend an OHCA at the time of the survey. Respondents from Bosnia-Herzegovina, Croatia, Cyprus, Estonia, Greece, France, Iceland, and Serbia were not aware of plans to introduce FR-systems to their countries in the short term. Specific reasons for this are described in Additional file 1: Table S2, and include: (1) implementation of FRs is not a subject of interest or not considered as a priority; (2) there is a lack of a legal background definition for FRs, and (3) there are some local unmapped AEDs, but the location of these AEDs is not available to the dispatch centre.

At the time of our survey, in Malta, government and non-governmental organisations were negotiating to implement a FR-system. In Spain, at least two regional EMS-systems were recruiting citizens to respond to OHCA. In Italy, there were indications that the Province of Pavia would begin implementing FR-systems within a few months (Additional file 1: Table S2).


Key findings

Our study shows the variety of FR-systems that have developed in Europe to expedite provision of good quality CPR and defibrillation in case of an OHCA. These FR-systems have either been implemented nationwide or regionally, and development is primarily influenced by local initiatives, circumstances and opportunities. Policies regarding FRs are commonly implemented on a regional level, even if a national policy exists. This has resulted in a wide variety of FR-systems both between and within countries. Even in countries that do not have FR-systems in place, local and national initiatives to implement FR-systems are being developed.

The need for FR-systems

The evidence for the benefits of early defibrillation are clear, therefore it may be suggested that increasing the number of AEDs available should be sufficient to improve OHCA survival. However, an increased number of AEDs alone is unlikely to improve survival in a cost-effective manner, as demonstrated by an Irish Health Technology Assessment which calculated that an investment of €105 million in AED purchase would yield – at best – an additional 10 lives saved per year [23]. Rather, the strategic deployment of AEDs by CPR-competent FRs may be an important link in the Chain of Survival [12, 16, 17], as acknowledged in the most recent European Resuscitation Guidelines [18].

We observed that, even in countries with a national FR-policy, the organisation of FR-systems is often managed by regional EMS. The design of FR-systems is thus commonly influenced by local circumstances and by what is available. For instance, in Slovenia, a FR-system with voluntary firefighters was chosen because of the extensive network of volunteer fire brigades across all villages. Although there is interest from police officers to be part of this FR-system, the network of police patrols in Slovenia is less dense than that of fire fighters and, therefore, police are not included in the FR-system.

Important aspects of FR-systems

It is unlikely that a “one size fits all” FR-system in Europe can be implemented. However, by combining results from this study with previous studies, some important aspects 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 research has demonstrated their role in OHCA-survival [11, 12, 24, 25]. FR-systems involving police officers and/or dispatched citizen-responders are very promising, but more research is needed [14, 26, 27]. In certain regions, multiple FR types in one FR-system exist. So far, only limited evidence towards the effectiveness of having multiple FR-types is available. A study performed in the Netherlands by Zijlstra and colleagues showed that, while the contribution of citizen-responders was limited by the strong involvement of other FRs and their competing contribution to OHCA care, it was estimated that, without the citizen-responders, 7.3% of patients would not have received a first shock within 6 min [16]. Also, in Sweden, a study comparing additional dispatch of CPR trained firefighters and police officers equipped with AEDs to a control group where only EMS was dispatched showed that dispatching these two FRs was associated with a significant increase in 30-day survival [27]. However, more research is needed.

Second, the method of alerting FRs matters. Our results showed that firefighter and police FRs are commonly alerted by their own standard dispatch system, and previous evidence highlighted the benefit of direct communication between the EMS and firefighter and police FRs [28, 29]. A mobile phone alert is often used to alert citizen-responders, but only a few regions use a mobile phone alert to alert other FR types (i.e., firefighters and police officers). In a study carried out in Switzerland, all FR types (firefighters, police, citizen-responders) were alerted by either an app or text-message system (both considered as a mobile phone alert) [15]. The app-system, when compared to a text-message system, was found to be highly efficient in the deployment of FRs, significantly reducing the time to initiation of CPR and increasing survival rates [15].

Third, our study showed that the response capabilities of FRs should be considered. In the Czech Republic, firefighters were dispatched only in rare cases because they share locations with the EMS. Another example regarding response capabilities includes: in several countries there is no dispatch to children < 8 years by citizen-responders. Although this applies to a minority of the OHCA population, it should be taken into account. Also, the distinction between volunteer and professional FRs may have an impact on FR engagement and response. Another example includes Slovenia where the local EMS determines the need for FRs, and requests local volunteer firefighters to become FRs. As this strategy depends on local firefighter interest, there are still areas in Slovenia without FRs.

Fourth, our study showed that frequent CPR training is a feature of most FR-systems, as would be expected. Previous research has highlighted the superiority of off-duty medical professionals over laypersons [30] and more recent studies have shown the positive impact of trained citizen-responders on neurological outcomes [31]. Some regions allow citizen-responders to register as FRs without validating CPR-training (e.g., Denmark: Capital region and Central region), whereas CPR training is mandatory in two other regions in Denmark (Region Zealand and Region Southern Denmark). However, in the two regions where CPR training is 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 demonstrated by Kobayashi and colleagues in Japan [32]. Finally, improved survival after implementation of FR-systems is unlikely to occur unless all links in the Chain of Survival are working. Hence, improvements in bystander-CPR should receive high priority.

Future implementation of FR-systems

We hypothesise that the general tendency in Europe towards more widespread implementation of FR-systems will increase OHCA survival rates. At present, FR-implementation may not be a priority for every country and difficulties in the legal definition of FRs may contribute to this. However, lack of national policies may not be an impediment to local development. For instance, in Greece, small local initiatives already exist in the absence of a national policy. In Croatia, local initiatives are developed, including nurses on motorbikes and CPR-trained firefighters and police officers equipped with AEDs. However, these initiatives are not currently connected to the EMS to be dispatched and this may limit their rapid response. In other countries and regions, while there is interest, local AEDs are not registered; this may also delay implementation of an effective FR-system. These developments highlight that FR-systems are strongly driven by local initiative and local capabilities. The need to allow flexibility in how FR-systems are implemented locally is likely to be an important consideration in ensuring the sustainability of FR-systems into the future.

Strengths and limitations

To the best of our knowledge, this study provides the most comprehensive overview of first response in Europe to date. While heterogeneity in FR-systems is a key finding, common themes have been identified that provide a basis for understanding the development of FR-systems at a European level. It is acknowledged that a convenience sampling method was used to recruit respondents, but the sample was drawn from participants in well-established European networks that have an active interest in OHCA.

A limitation of this study is that, in countries/regions considered as being covered by a specific FR-system, it was not feasible to estimate the density of FRs (and differences, from city to city, may exist). Also, it was not possible to relate different FR-systems to differences in survival rates. However, this study has highlighted a unique element of the Chain of Survival which should be considered in any further studies of OHCA epidemiology.

When a FR-system is being developed, it is important to analyse response times in order to confirm that the system actually contributes to early CPR and early defibrillation, using measured effects. Only then in the long run, the cost and effort of maintaining such a FR-system will remain accepted in the community.


At present, more than half of European countries dispatch FRs after a suspected OHCA. Policies relating to FRs are mostly managed by local EMS, leading to a wide variation between and within countries. Even in countries that do not have existing FR-systems, many have local initiatives and future plans for FR-system implementation. The willingness of people to volunteer their time and skills to provide a first response to OHCA has led to the development of a variety of national and local solutions, and has created a new paradigm within the Chain of Survival that needs to be researched and evaluated more extensively. Areas for future research include: identifying the most effective methods of FR dispatch; identifying FR-systems that most strongly influence survival; assessing the effect of adding a FR type in an existing FR-system; and understanding what motivates a volunteer to become a FR and what sustains that motivation. The diverse findings of our study reflect the diversity in circumstances across various European regions and suggest that it is unlikely that there will be a ‘one size fits all’ FR-system across Europe. Rather, an overall European policy that advises on the critical requirements for effective FR may be of benefit.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.



automated external defibrillator


Amsterdam Resuscitation Studies


Cardiopulmonary resuscitation


emergency medical service


European Resuscitation Council


first responder


out-of-hospital cardiac arrest


  1. 1.

    Holmgren C, Bergfeldt L, Edvardsson N, et al. Analysis of initial rhythm, witnessed status and delay to treatment among survivors of out-of-hospital cardiac arrest in Sweden. Heart. 2010;96(22):1826–30.

    CAS  Article  Google Scholar 

  2. 2.

    Grasner JT, Lefering R, Koster RW, et al. EuReCa ONE-27 nations, ONE Europe, ONE registry: a prospective one month analysis of out-of-hospital cardiac arrest outcomes in 27 countries in Europe. Resuscitation. 2016;105:188–95.

    Article  Google Scholar 

  3. 3.

    Viereck S, Palsgaard Moller T, Kjaer Ersboll A, Folke F, Lippert F. Effect of bystander CPR initiation prior to the emergency call on ROSC and 30day survival-an evaluation of 548 emergency calls. Resuscitation. 2017;111:55–61.

    Article  Google Scholar 

  4. 4.

    Kragholm K, Wissenberg M, Mortensen RN, et al. Bystander efforts and 1-year outcomes in out-of-hospital cardiac arrest. N Engl J Med. 2017;376(18):1737–47.

    Article  Google Scholar 

  5. 5.

    Blom MT, Beesems SG, Homma PC, et al. Improved survival after out-of-hospital cardiac arrest and use of automated external defibrillators. Circulation. 2014;130(21):1868–75.

    Article  Google Scholar 

  6. 6.

    Hansen CM, Kragholm K, Granger CB, et al. The role of bystanders, first responders, and emergency medical service providers in timely defibrillation and related outcomes after out-of-hospital cardiac arrest: results from a statewide registry. Resuscitation. 2015;96:303–9.

    Article  Google Scholar 

  7. 7.

    Kiyohara K, Nishiyama C, Matsuyama T, et al. Out-of-hospital cardiac arrest at home in Japan. Am J Cardiol. 2019;123:1060–8.

    Article  Google Scholar 

  8. 8.

    Sondergaard KB, Wissenberg M, Gerds TA, et al. Bystander cardiopulmonary resuscitation and long-term outcomes in out-of-hospital cardiac arrest according to location of arrest. Eur Heart J. 2018;40(3):309–18.

    Article  Google Scholar 

  9. 9.

    Waalewijn RA, de Vos R, Tijssen JG, Koster RW. Survival models for out-of-hospital cardiopulmonary resuscitation from the perspectives of the bystander, the first responder, and the paramedic. Resuscitation. 2001;51(2):113–22.

    CAS  Article  Google Scholar 

  10. 10.

    Hollenberg J, Riva G, Bohm K, et al. Dual dispatch early defibrillation in out-of-hospital cardiac arrest: the SALSA-pilot. Eur Heart J. 2009;30(14):1781–9.

    Article  Google Scholar 

  11. 11.

    Hasselqvist-Ax I, Nordberg P, Herlitz J, et al. Dispatch of firefighters and police officers in out-of-hospital cardiac arrest: a Nationwide prospective cohort trial using propensity score analysis. J Am Heart Assoc. 2017;6(10):15.

    Article  Google Scholar 

  12. 12.

    Nordberg P, Hollenberg J, Rosenqvist M, et al. The implementation of a dual dispatch system in out-of-hospital cardiac arrest is associated with improved short and long term survival. Eur Heart J Acute Cardiovasc Care. 2014;3(4):293–303.

    Article  Google Scholar 

  13. 13.

    Moore MJ, Hamilton AJ, Cairns KJ, et al. The Northern Ireland public access defibrillation (NIPAD) study: effectiveness in urban and rural populations. Heart. 2008;94(12):1614–9.

    CAS  Article  Google Scholar 

  14. 14.

    Ringh M, Rosenqvist M, Hollenberg J, et al. Mobile-phone dispatch of laypersons for CPR in out-of-hospital cardiac arrest. N Engl J Med. 2015;372(24):2316–25.

    CAS  Article  Google Scholar 

  15. 15.

    Caputo ML, Muschietti S, Burkart R, et al. Lay persons alerted by mobile application system initiate earlier cardio-pulmonary resuscitation: a comparison with SMS-based system notification. Resuscitation. 2017;114:73–8.

    Article  Google Scholar 

  16. 16.

    Zijlstra JA, Stieglis R, Riedijk F, Smeekes M, van der Worp WE, Koster RW. Local lay rescuers with AEDs, alerted by text messages, contribute to early defibrillation in a Dutch out-of-hospital cardiac arrest dispatch system. Resuscitation. 2014;85(11):1444–9.

    Article  Google Scholar 

  17. 17.

    Pijls RW, Nelemans PJ, Rahel BM, Gorgels AP. A text message alert system for trained volunteers improves out-of-hospital cardiac arrest survival. Resuscitation. 2016;105:182–7.

    Article  Google Scholar 

  18. 18.

    Monsieurs KG, Nolan JP, Bossaert LL, et al. European resuscitation council guidelines for resuscitation 2015: section 1. Executive summary. Resuscitation. 2015;95:1–80.

    Article  Google Scholar 

  19. 19.

    Empana JP, Blom MT, Bttiger BW, et al. Determinants of occurrence and survival after sudden cardiac arrest-a European perspective: the ESCAPE-NET project. Resuscitation. 2018;124:7–13.

    Article  Google Scholar 

  20. 20.

    Blom MT, van Hoeijen DA, Bardai A, et al. Genetic, clinical and pharmacological determinants of out-of-hospital cardiac arrest: rationale and outline of the AmsteRdam resuscitation studies (ARREST) registry. Open Heart. 2014;1(1):e000112.

    CAS  Article  Google Scholar 

  21. 21.

    Ringh M, Hollenberg J, Palsgaard-Moeller T, et al. The challenges and possibilities of public access defibrillation. J Intern Med. 2018;283(3):238–56.

    CAS  Article  Google Scholar 

  22. 22.

    Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. Part 4: the automated external defibrillator: key link in the chain of survival. The American Heart Association in collaboration with the International Laison Committee on Resuscitation. Circulation. 2000;102(1 Suppl):102:I-60–I-76.

  23. 23.

    Moran P, Teljeur C, Masterson S, O'Neill M, Harrington P, Ryan M. Cost-effectiveness of a national public access defibrillation programme. Resuscitation. 2015;91:48–55.

    Article  Google Scholar 

  24. 24.

    Shuster M, Keller JL. Effect of fire department first-responder automated defibrillation. Ann Emerg Med. 1993;22(4):721–7.

    CAS  Article  Google Scholar 

  25. 25.

    Smith KL, Peeters A, McNeil JJ. Results from the first 12 months of a fire first-responder program in Australia. Resuscitation. 2001;49(2):143–50.

    CAS  Article  Google Scholar 

  26. 26.

    Baekgaard JS, Viereck S, Moller TP, Ersboll AK, Lippert F, Folke F. The effects of public access defibrillation on survival after out-of-hospital cardiac arrest: a systematic review of observational studies. Circulation. 2017;136(10):954–65.

    Article  Google Scholar 

  27. 27.

    Hasselqvist-Ax I, Nordberg P, Herlitz J, et al. Dispatch of firefighters and police officers in out-of-hospital cardiac arrest: a nationwide prospective cohort trial using propensity score analysis. J Am Heart Assoc. 2017;6(10):e005873.

    Article  Google Scholar 

  28. 28.

    White RD, Bunch TJ, Hankins DG. Evolution of a community-wide early defibrillation programme experience over 13 years using police/fire personnel and paramedics as responders. Resuscitation. 2005;65(3):279–83.

    Article  Google Scholar 

  29. 29.

    Myerburg RJ, Fenster J, Velez M, et al. Impact of community-wide police car deployment of automated external defibrillators on survival from out-of-hospital cardiac arrest. Circulation. 2002;106(9):1058–64.

    Article  Google Scholar 

  30. 30.

    Nord A, Svensson L, Karlsson T, Claesson A, Herlitz J, Nilsson L. Increased survival from out-of-hospital cardiac arrest when off duty medically educated personnel perform CPR compared with laymen. Resuscitation. 2017;120:88–94.

    Article  Google Scholar 

  31. 31.

    Ko SY, Ro YS, Shin SD, Song KJ, Hong KJ, Kong SY. Effect of a first responder on survival outcomes after out-of-hospital cardiac arrest occurs during a period of exercise in a public place. PLoS One. 2018;13(2):e0193361.

    Article  Google Scholar 

  32. 32.

    Kobayashi D, Kitamura T, Kiyohara K, et al. Cardiopulmonary resuscitation performed by off-duty medical professionals versus laypersons and survival from out-of-hospital cardiac arrest among adult patients. Resuscitation. 2019;135:66–72.

    Article  Google Scholar 

Download references


We greatly appreciate the contributions of Paulien Homma (MSc), Remy Stieglis (MSc) and Sanne Brands (MSc) of the Academic Medical Center (Amsterdam, The Netherlands) for piloting the survey and to the data collection. Also, we are greatly indebted to Patrick Sulzgruber (MD, PhD from Austria), Stephanie Leckey (BSc, from Northern Ireland), Cristina Granja (MD, PhD) and Tiago Amaral (MSc) from Portugal), Ari Salo (MD, PhD from Finland), Linn Andelius (MD, from Denmark), Mark Biancardia (MD, from Malta), Veronika Reinhard (MD, from Estonia), Koen Monsieurs (MD, PhD), David Yansenne, Pierre Mols (MD, PhD) and Bernard Kreps (MD, PhD) (from Belgium), 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 Hildigunnur Svavarsdottir (PhD) (from Iceland), Hajriz Alihodžić (MD, PhD, from Bosnia Herzegovina), Fernando Rosell Ortiz (MD, PhD from Spain), Nagy Enikő (from Hungary), Pascal Stammet (MD, PhD from Luxembourg), Andrej Markota (MD, PhD) and Janez Strnad (MD, PhD) (from Slovenia), Craig Hunter (from Scotland), Grzegorz Cebula (MD, PhD from Poland), Michael Müller (MD, PhD), Dennis Rupp and Erich Wranze (MD, PhD) (from Germany) and Xavier Jouven (MD, PhD, from France) for their cooperation and data collection. Also, we would like to thank all other respondents and national resuscitation councils who so generously shared their expert opinion and knowledge to make this study possible.


This project/work has received funding from the European Union’s Horizon 2020 research and innovation programme under acronym ESCAPE-NET, registered under grant agreement No 733381. Dr Tan and Dr Blom were supported by Dutch Heart Foundation (CVON 2018-30 Predict2).

Author information





IO: 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: data collection, revision of manuscript. MR: data collection, revision of manuscript. AT: data collection, revision of manuscript. DC: data collection, revision of manuscript. 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, revision of manuscript. “All authors read and approved the final manuscript”.

Corresponding author

Correspondence to Hanno L. Tan.

Ethics declarations

Ethics approval and consent to participate

Informed consent for using the contact details of the participants was sought and provided. This study is part of the ESCAPE-NET study which has been approved by the Institutional Review Board of Amsterdam UMC.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Oving, I., Masterson, S., Tjelmeland, I.B. et al. First-response treatment after out-of-hospital cardiac arrest: a survey of current practices across 29 countries in Europe. Scand J Trauma Resusc Emerg Med 27, 112 (2019).

Download citation


  • First responders
  • Out-of-hospital cardiac arrest
  • Cardiopulmonary resuscitation
  • Europe