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. 2023 Aug 17;15:100453. doi: 10.1016/j.resplu.2023.100453

PULS – Austrian Cardiac Arrest Awareness Association: An overview of a multi-tiered and multi-facetted regional initiative to save lives

Sebastian Schnaubelt a,b,⁎, Mario Krammel a,c
PMCID: PMC10461014  PMID: 37645620

Abstract

Background

Out-of-hospital cardiac arrest with subsequent cardiopulmonary resuscitation (CPR) still leads to dismal outcomes worldwide. The crucial gap between cardiac arrest and advanced life support can only be filled by bystander-CPR. However, knowledge and willingness of the public towards basic life support (BLS) remain low. Global and national initiatives for awareness building and CPR training have produced promising improvements, but an additional focus on regional initiatives might be necessary to truly implement change.

Methods and results

In order to support other like-minded groups, we present a “coming of age” narrative review of PULS – Austrian Cardiac Arrest Awareness Association, along with a future outlook and “lessons learned”. Interviews with past and present employees, members, and functionaries were conducted by the authors. Additionally, the organization’s archives were assessed.

Conclusion

Following current guidelines and the Utstein formula of survival, building a system to save lives is essential to achieve progress concerning cardiac arrest survival and outcomes. As kinds of “regional offices” of global resuscitation efforts, a network of individual local initiatives and organizations such as PULS can carry the respective messages, engage with local key figures of implementation, and keep up perpetual work for cardiac arrest awareness and BLS education.

Keywords: Sudden cardiac death, Cardiac arrest, Basic-life support, Cardiopulmonary resuscitation, Awareness, Education, First responder, Non-governmental organization

Introduction

Out-of-hospital cardiac arrest (OHCA) with subsequent cardiopulmonary resuscitation (CPR) is a major worldwide health burden, not just because of survival rates still remaining low but especially due to neurological sequelae impacting on both people’s daily lives and the economy.1, 2, 3 Ethically challenging end-of-life decisions aside, one would hope that modern medicine could at least enable survival and subsequent convalescence for those who seen as “savable” cases, for instance a person in the prime of their life with sudden cardiac death due to malign dysrhythmia. However, advanced life support (ALS), intensive care medicine, and neurological rehabilitation all come too late if the first minutes of anoxia from cardiac arrest until the initiation of ALS by the emergency medical service (EMS) are not reconciled by basic life support (BLS).4 Since BLS in OHCA will almost always be carried out by witnessing or bywalking laypersons, BLS education for the public is the key to enable bystander CPR in the first place, and thus plays a major role in the so-called chain(mail) of survival.5, 6 Recognition of OHCA, the call for help, chest compressions of high quality, and the use of an automated external defibrillator (AED) can and must all be carried out by those laypersons, but these tasks are easily forgotten in stressful situations and if not rehearsed regularly. International guidelines thus strongly recommend not only CPR training but also creating awareness towards sudden cardiac death, creating “systems to save lives”.7 Global programs such as the World Restart a Heart day (WRAH) or the kids save lives project are widely known,8, 9 but in order to achieve real implementation, also regional and local initiatives are needed, converting campaigns into action endorsed by the local public. National programs were demonstrated to impact on citizens’ willingness to perform CPR and on improved OHCA outcomes.10, 11, 12, 13 On a community level, the implementation of CPR education has shown to increase CPR performance- and AED use rates before EMS arrival, thus bridging the afore-mentioned crucial gap,14 and there are many more worldwide examples of other successful campaigns.15, 16, 17, 18 Moreover, following the formula for survival and especially local implementation,19 so-called first responders – as a bridging element between laypersons witnessing a cardiac arrest by chance and professional help – has been effectively conducted in various parts of the world, and has led to improved CPR outcomes. First responders can, for instance, be laypersons trained in first aid and using alerting phone applications or members of the police or fire brigade.20, 21, 22, 23

In Austria, past data have shown an insufficient awareness and knowledge of OHCA and BLS,24 and a regional initiative attempting to educate the public achieved positive results concerning the dynamics in BLS knowledge over a span of four years on the one-, but still noted crucial gaps of knowledge on the other hand.17 Through this narrative review, we aim to present our regional Viennese version of such an awareness-creating and BLS-teaching non-governmental organization, and to list “lessons learned” in order to support other likeminded groups of people in building up similar initiatives.

Methods

In order to conduct this narrative review of the Austrian Cardiac Arrest Awareness Association, interviews with past and present employees, members, and functionaries were conducted by the authors. Additionally, the organization’s archives were assessed, and quantitative measurements were conducted, for instance on performed CPR courses.

Historical setting and development

First steps

Before the background of dismal survival rates and neurological outcomes of performed CPRs both out- and in-hospital, like-minded emergency-, cardiology-, and anesthesiology physicians of Austria’s largest university hospital in Vienna founded PULS in 2008. Within “classic”, long-standing non-governmental organisations, various endeavours towards introducing special CPR awareness and education campaigns had afore been met with skepticism, a lack of available resources, and generally the failure to see the necessity behind such a project. BLS courses as a business model were already well-introduced throughout the country, but CPR education for laypersons at a low threshold, without fees, and scientifically guided by academic personnel were a novel idea. Also, the involvement and education of children as catalysators and multiplicators for a lasting impact on society was already discussed. PULS thus proceeded point by point, organizing BLS courses, acquiring automated external defibrillators (AED), and placing them at selected locations (e.g., outside schools or pharmacies). However, those were always rather isolated acts, and the organization could not achieve overall public visibility and was thus not able to induce real change.

An idea gains momentum

Around three years later, and rather by chance, a high-ranking Viennese politician came by a public BLS course organized by PULS. As usual, the event was attended by a few locals, but suddenly the trainers found themselves surrounded by television (TV) and newspaper reporters coming along with the politician. Luckily, the press deemed people performing chest compressions on mannequins on the ground interesting, and the following local TV and printed news were full of it. Seizing this unique opportunity, PULS began talks with this politician about further involvement, and then – already being a long-term supporter of civil security initiatives – he agreed to become the organization’s representative president. From this moment onwards, many doors flew open that had previously remained shut: High-ranking contacts on both governmental and business levels were suddenly only a phone-call away, and first successes like AED placement in the Vienna airport or converting old telephone boxes into “emergency boxes” with AEDs quickly caught on. Other politicians saw that more and more people came to BLS training and awareness events, and themselves endorsed the organization, creating crucial momentum for the way ahead.

To outgrow infancy

With its new-found role of a publicly acclaimed organization, regular BLS courses and awareness information-stands at big Viennese markets, events, and concerts, and scheduled initiatives for fixed dates such as the world heart day or world restart a heart day, PULS grew too big too fast. Since now, there had been no office and no storage facility – everything had been coordinated by volunteers at their home offices, and mannequins and AED training devices had been piled up in an old garage.

One the one hand, intermittent grants from the local municipality could be acquired, but on the other hand, as important as these funds were to afford new equipment or repairs, they were a mere drop in the ocean compared to a steady financing allowing for a strong foundation of further professionalizing attempts.

It quickly became clear that PULS would either stay a small club of volunteers or had to start looking for a permanent office and employees if it wanted to meet the ever-growing demand towards BLS education.

Steps into adulthood

“Stuck” with occasional donations and non-financial support, PULS then joined a governmental campaign that granted companies the chance to hire people over the age of 50 who had fallen unemployed, with most of the costs covered by the state. From this moment on, a small PULS-office attached to a municipal service could be occupied during workhours, which made life extremely easier for the volunteers and which also led to a boost in professionalism that was noticed: It was around this time, when a large well-known advertising company approached PULS with the suggestion of providing a campaign every year, free of charge. Together with the ongoing activities of PULS, this created just the right stepping-stone for approaching the government regarding permanent funding.

Independent life

With the help of retired renowned financial experts providing their aid as charity work, an exact financial plan was conducted. After a meticulously-worked-out proposal and application process, an agreement was made between PULS, the city of Vienna, and the Austrian governmental healthcare insurance to provide yearly funding. This would have to meet set goals such as the mission trias of BLS education, awareness creation, and scientific work against sudden cardiac death, but was otherwise completely independent. Thus, it was now possible to rent a sufficiently dimensioned office including storage space, buy a car for transporting devices and trainers, and hire more personnel; a variety of conducted projects was the result (Table 1, Fig. 1).

Table 1.

Past and ongoing projects achieved by PULS – Austrian cardiac arrest awareness association, stratified into the five columns suggested in Fig. 1. BLS = basic life support; AED = automated external defibrillator; ERC = European Resuscitation Council; WRAH = world restart a heart. CPR = cardiopulmonary resuscitation; EMS = emergency medical service.

Project Details
Awareness
 Yearly awareness advertisement campaigns Together with a large advertisement creative agency, novel awareness campaigns are rolled-out every year, with the goal of creating awareness for sudden cardiac death and CPR. Executions can be very creative and sometimes also controversial in order to stay in people’s minds and evoke conversation. Another company provides advertisement space, for instance for posters, free of charge at key places such as public transport stations or along highways. See a video online for an example.34 An increase in knowledge after such campaigns was demonstrated before,17 and encouraging data from, for instance, Scandinavia showing an increase in resuscitation rates by laypersons from around 31% to around 82% in 30 years of advocating and executing CPR awareness should be the goal.35, 36
 Charity events Organization of, for instance, ice hockey matches between the teams of the EMS and the police force, with any earnings directly going to the acquisition of new AEDs to be placed in Vienna.
 Survivor campaigns Collaboration with photographers and survivors of sudden cardiac death (amongst them celebrities known to locals) to create “stories of survival” which are then presented via advertisement campaigns (e.g., posters), or public talks and interviews with the survivors. This could also serve to promote person-centered care.37
 Information stands and short BLS training for foot traffic Provided regularly at large Viennese events such as city celebrations, special days of other organisations like the fire brigade, city markets, concerts, educational and museal events, or open-air festivities. Encouraged and endorsed by the municipal government. A pop-up information stand is built-up, flyers and giveaways (e.g., heart-shaped candy or CPR-branded bags) are distributed, and passers-by are engaged to talk about sudden cardiac death and BLS and are encouraged to try out chest compressions and the use of an AED on site. SeeFig. 2.
 Events for World Heart Day38 and WRAH8, 39 For these fixed dates, annual pop-up CPR trainings are provided throughout the city, and the PULS-office invites people to expert talks. Internationally, WRAH alone already facilitated BLS training for over two million people, and over 300 million people could be reached by the campaign.39
BLS trainings
 Elective university subject Together with the Medical University of Vienna, PULS hosts an elective subject for medical students, through which they receive theoretical and practical “train-the-trainer” sessions, and then attend PULS-activities to teach BLS to others. This basic concept of medical students teaching CPR to others had been introduced in the early 2000s, and it had been suggested that students might have a longer-lasting benefit than from pure lectures or courses alone.40 Still up to now, over 100 students volunteer to take this elective each semester.
 BLS training in schools Following the international kids save lives campaign9 that recommends CPR education from the age of 12 and even suggests younger children as young as four years old to be receptive to BLS training,41 PULS advocates for mandatory BLS training in schools. Unfortunately, this is still only recommended in Austria, and so PULS collaborates with other organisations and the city of Vienna to provide comprehensive trainings for children. Currently, these are conducted in the 3rd and 6th year of school with two hours of education per year, reaching around 30.000 children per year.
 BLS training for various organisations or companies If inquired upon, PULS provides BLS courses for personnel of other organisations free of charge; this could be for social caregivers, university alumni clubs, etc.
 BLS training in large apartment blocks The large apartment blocks of social housing in Vienna with hundreds of residents are densely populated areas potentially profiting from nearby AEDs and BLS training. Special focus is given to the “block captains” who serve as primary contact person for residents.
 BLS training for migrants With Austria being a country of destination for refugees and other migrants from all over the world, BLS courses are held in respective camps and facilities together with translators. Such trainings were also evaluated, showing that coming from a low availability of BLS education in the migrants’ home countries, courses provided in their new environment induced an increased awareness towards cardiac arrest and willingness (25–99% after the courses) to help. As an additional effect, a positive impact on the integration into the new country was noted.42
 BLS training for senior citizens or persons with special needs A standard BLS course might not fit perfectly for everybody, especially if one is impaired in daily life. However, respective individuals largely still take part in public life and could therefore also be potential bystanders of cardiac arrest. Special needs such as, for example, reduced mobility or impaired hearing pose a special challenge for both trainers and course participants. Data on such tailored courses are still scarce; and reports from, for instance, BLS training for deaf individuals43 or general first aid courses for the elderly44 show room for improvement.
Public AEDs
 AED network The overall aim of the Viennese AED network is to place an AED where potentially needed most, service those AEDs already in place, and register and manage all available AEDs and respective data. An online map of AEDs is available. This is an ever-evolving process with potential future applications of artificial intelligence and optimized AED placement. Past successes include converting old phone boxes into “emergency boxes” with AEDs, introducing “AED columns” on busy shopping streets, putting up signposts to the nearest AED, fitting AEDs on the Vienna airport, public transport, pharmacies, police cars, fire trucks, car breakdown services, and apartment blocks.45 Ideally, this AED network should in the future also incorporate data from novel technologies such as mathematical models of ideal AED placement.32, 33
First Responder System
 Promoting a “culture of first responders” via a smartphone-app In a collaboration with another organization, a special app is promoted through which people with certified past BLS training can register and are then dispatched to a nearby CPR-case. This system is fully integrated into the EMS dispatch system.46 In other, similar, international systems, this has already been shown to improve survival rates.47
 BLS and first responder training for police and fire brigade All police patrol cars and fire trucks in Vienna have been equipped with AEDs by PULS, and regular CPR trainings are held in police stations. These first responder units are dispatched to CPR missions by the EMS dispatch. Evaluating this program in Vienna, the time to first shock was shown to be significantly shorter in cases attended to by the police (62, 3, 4, 5, 6, 7, 8, 9, 10 vs. 128, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 minutes, p < 0.001), and a more frequent survival until hospital discharge was observed (adjusted OR 1.85 [1.06–3.23], p = 0.030).21
Science
 Scientific studies PULS tries to conduct or take part in scientific studies on the topic of sudden cardiac death, CPR, and life-saving systems in general. This is made possible through collaborations with universities and the municipal EMS.21, 24, 42, 48, 49, 50, 51
 Distribution of novel CPR guidelines Organization of a national webinar with experts on the field of CPR to present and explain the novel ERC guidelines7 shortly after their publication.
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Fig. 1.

Fig. 1

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The foundation and five supporting pillars of a regional organization tackling unfavorable cardiac arrest outcomes in a community. OHCA = out-of-hospital cardiac arrest; BLS = basic life support; AED = automatic external defibrillator.

The way ahead

COVID-19 did not spare PULS, and all activities had to be paused for some time. Thereafter, the once-gained momentum of progress seemed somewhat lost – vanishing voluntariness throughout the country highlighted a lack of trainers for courses and events, rising rent and energy costs impacted on finances, and the office was in need of more structural guidance. From late 2022 onwards, a modernization process was therefore started, polishing-up old standard operating procedures, re-starting and intensifying scientific study work, expanding the corporate design (Fig. 3), and searching for new ways of involving people in the organization. Following recommendations from the resuscitation alliance18 or the Utstein formula of survival19 highlighting local implementation as a crucial step, future goals were developed: Collaborations with other regional likeminded Austrian initiatives25, 26, 27 should be established, and, as suggested,17 a standardized tool for OHCA awareness campaign evaluation could be developed together.

Fig. 2.

Fig. 2

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An example of work at a combined training- and awareness-building stand of PULS at a local event. © PULS – Austrian Cardiac Arrest Awareness Association.

Fig. 3.

Fig. 3

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English logo. © PULS – Austrian Cardiac Arrest Awareness Association.

With already thousands of provided overall work hours, held BLS courses, and a multitude of reached individuals, the overall aim is now to further professionalize the organization and, in parallel, to gain fresh wind in the sails of volunteer work, until PULS’s 15-year jubilee in 2023.

Lessons learned

We believe that systems to save lives should and can indeed be built in a variety of different circumstances in order to have an impact (no matter how big) on overall survival and outcomes after cardiac arrest. To raise awareness about CPR and defibrillation, to use technology to engage communities, and to join the kids save lives spirit are three of the five “top messages” of the European Resuscitation Council’s 2021 guidelines7 that PULS is currently upholding. Initiatives like kids save lives or WRAH day can ignite sparks, inspire ideas, and provide a starting point globally, but – along the chainmail of survival5 and the Utstein formula of survival19 – there have to be local or regional initiatives upholding the spirit and doing the perpetual “ground work” all year long that doesn’t usually stand in the grand spotlight. A strong network of like-minded initiatives sharing their “lessons learned” could profit from the victories and defeats the respective others have already seen. Key points from the development of PULS include:

  • •

    Find key players in the community such as celebrities, politicians holding goal-keeper positions.

  • •

    Always upholding a balance towards potential conflicts of interest, involve companies that want to do good on the one side and receive some publicity on the other side in your strategy, and concentrate on those that can facilitate a wide and lasting distribution of your messages; free advertisement space could be a start.

  • •

    Even when difficult, try to regularly search potential funding as this will enable you to professionalize on a new level. Cooperations with governmental agencies are often worth investigating.

  • •

    Engage the press early on and build a lasting relationship; have a media strategy. Teaching a large group of people without anyone else knowing is good, but maybe turning it into a picturesque event suitable for a newspaper article will additionally reach many more.16

  • •

    Use coherent language and content in your educational endeavours, and consider teaching hands-only CPR in order to simplify measures for laypersons and in turn increase willingness to perform CPR at all.15, 16

  • •

    Weave the emotional aspect of our work into your presentations and events: Individual stories of survivors or bringing together a survivor with their first responder or bystander may touch people’s hearts on top of their brains and have a long-standing impact on awareness for cardiac arrest and its potential reversibility.

  • •

    Cover the scientific aspect of your endeavours. If you don’t have the expertise yet, try to collaborate with an academic institution or experienced individuals. It is one thing to state international guidelines in terms of increasing survival rates or beneficial outcomes, but if you can back up your work with studies conducted by you, in your local area, this gives the people you want to reach a more personal level of relevance.

  • •

    If there is a possibility to “pair” with an academic institution such as a medical university or faculty, consider creating a joint program of students serving as motivated trainers and distributors15, 17, 28

  • •

    In terms of AEDs and their distribution, it is essential to not just randomly hang AEDs at provided spots, but to have an underlying system, that should ideally match AED locations with high cardiac arrest occurrence spots.29, 30, 31 If your organization is eligible to do so, try to introduce an AED network and distribution chart, and try to use new technology (e.g., mathematical methods32, 33 to find the perfect spots.

Conclusion

Following current guidelines, building a system to save lives is essential to achieve progress concerning cardiac arrest survival and outcomes. As kinds of “regional offices” of global resuscitation efforts, a network of individual local initiatives and organizations such as PULS can carry the respective messages, engage with local key figures of implementation, and keep up perpetual work for cardiac arrest awareness and BLS education.

Funding

None.

Authors’ contributions

SS and MK conducted the data acquisition. SS crafted the initial manuscript, and SS, PS, and MK critically revised it. All authors approved the final version.

CRediT authorship contribution statement

Sebastian Schnaubelt: Conceptualization, Investigation, Writing – original draft, Writing – review & editing, Visualization. Mario Krammel: Conceptualization, Validation, Writing – review & editing, Resources, Supervision, Project administration.

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.

Acknowledgements

We thank all past and current members of PULS – Austrian Cardiac Arrest Awareness Association for their tremendous and longstanding contributions. We especially acknowledge Roman Fleischhackl, Ronny Tekal-Teutscher, Harry Kopietz, Hans Wehsely, Wolfgang Schreiber, Gerhard Kubiczek, Marco Lumsden, Franz Solta, David Weidenauer, Andreas Zenker, Markus Winnisch, Dieter Winnisch, Anita Winnisch, Michaela Sramek, Renate Holzwarth, Georg Konrad, Christian Bader, Patrick Sulzgruber, Jürgen Novotny, Caroline Seitz, Florian Ettl, and Gerry Foitik.

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