b'2021 CARES Annual Report 21 21 favorable survival was observed in 13.9% of arrests with CO-CPR, 17.3% with RB-CPR, and 6.8% with NO-CPR; p 0.001. In multivariable analysis, both RB-CPR and CO-CPR were associated with neurologically favorable survival compared to NO-CPR, and RB-CPR was associated with a higher odds of neurologically favorable survival compared to CO-CPR (adjusted OR: 2.73, 95% CI: 2.00-3.72, and adjusted OR: 1.94, 95% CI: 1.41-2.68, respectively). In adolescents, neurologically favorable survival was observed in 23.7% of arrests with CO-CPR, 25.7% with RB-CPR, and 10.3% with NO-CPR, p 0.001. In multivariable analysis, both RB-CPR and CO-CPR were associated with neurologically favorable survival compared to NO-CPR.Overall, the results of this study support current guidelines that recommend RB-CPR for pediatric OHCA. These results also support the use of RB-CPR and CO-CPR in children and adolescents with pediatric OHCA. However, CO-CPR was not associated with neurologically favorable survival in infants, therefore RB-CPR should continue to be the recommended modality. CO-CPR is associated with increased bystander CPR rates and survival in adults who experience OHCA, and CO-CPR has been the focus of public health campaigns including statewide educational efforts, high school education, and dispatcher assisted CPR.CO-CPR is currently the most common type of bystander CPR in pediatric OHCA. While public health efforts emphasizing CO-CPR have improved overall outcomes after OHCA in adults, it is possible that they have disadvantaged the pediatric population, especially infants and young children. The results of this study have important implications on bystander CPR education and training, which should continue to emphasize RB-CPR for infants in cardiac arrest and teach lay rescuers how to perform RB-CPR, concluded Dr. Naim.Understanding the Association of Survival, Length of Time on Scene, and Rate of Field Termination Using CARES Data By Douglas F. Kupas, MD, EMT-P, FAEMS, Professor of Emergency Medicine, Geisinger Commonwealth School of Medicine Christopher L. Berry, MD, Assistant Professor of Emergency Medicine, Geisinger Commonwealth School of Medicine Resuscitation of out-of-hospital-cardiac arrest (OHCA) has undergone a gradual paradigm shift from a scoop-and-run approach, focused on rapid transport to the emergency department, to on-scene resuscitation with a focus of achieving return-of-spontaneous-circulation (ROSC) where the patient lies. Delivering high-quality cardiopulmonary resuscitation (CPR) is a skill that is physically demanding and requires teamwork and attention to detail, and this quality deteriorates dramatically when done while a patient is being carried to or transported in a vehicle. As with most culture shifts in medicine, change is a gradual process and focused on-scene resuscitation has not been uniformly applied across all systems. A great strength of the CARES dataset is the heterogeneity of the EMS programs that contribute, allowing a comparison of the culture of resuscitation implemented by each agency.The challenge is how to quantify the resuscitation culture of an organization. To do this, our team evaluated 221,228 cases from the 380 CARES agencies with at least 100 cardiac arrest patients between 2013-2018 applying two different criteria: 1) average on-scene time an organization spends on OHCA patients and 2) the rate of field termination for an organization.8 It was hypothesized that organizations that spent more time on-scene resuscitating patients, applying high quality CPR and appropriate interventions where the patient lies, would therefore have improved outcomes than an agency focused on rapid transport. It was further hypothesized that programs that spent time on scene resuscitating may ultimately terminate resuscitation utilizing validated field termination of resuscitation (FTOR) rules on scene rather than transport those patients whose resuscitation was ultimately unsuccessful. Therefore, two analyses were run separately, with one comparing agencies average on-scene times against their outcomes and another comparing agencies rates of FTOR and their outcomes. To allow for the statistical analysis, agencies were divided into quartiles (containing 95 agencies each) based on their average on-scene times or FTOR rates and comparisons were made between quartile one (the quartile of agencies with the shortest on scene times or the least amount of FTOR) and quartile four (the quartile of agencies with the longest on scene times and highest rates of FTOR). FTOR rates were found to vary significantly among the agencies submitting to the CARES database, with some agencies not allowing for this practice at all and others terminating significantly more than 50% of their resuscitation attempts. Agencies may avoid FTOR due to a lack of compensation for care provided on scene with no transport or due to fear of leaving possible survivors behind. Figure 1 provides an unadjusted visualization of all four quartiles and their average rates of ROSC, survival to discharge and survival with good neurologic outcome. A trend is apparent: as rates of FTOR go up, the outcomes among OHCA victims appear to improve, suggesting that large numbers of potential survivors are not being left on scene due to the practice of FTOR. This is not to say that the act of field termination itself is a life-saving8Berry CL, Olaf MF, Kupas DF, Berger A, Knorr AC; CARES Surveillance Group. EMS agencies with high rates of field termination of resuscitation and longer scene times also have high rates of survival. Resuscitation. 2021 Dec; 169:205-213.'