European Journal of Internal Medicine 22 (2011) 386–393

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European Journal of Internal Medicine

j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / e j i m

Original article

Emergency response time after out-of-hospital cardiac arrest

Andjelic Sladjana a,⁎, Panic Gordana b, Sijacki Ana c
a
Emergency Medical Care, Belgrade, Serbia
b
Clinic of Cardiology, Sremska Kamenica, Serbia
c
Institute for Research, Education and Development, Belgrade, Serbia

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: To investigate the emergency response time after out-of-hospital cardiac arrest (OHCA) in four
Received 6 October 2010 cities in Serbia.
Received in revised form 20 February 2011 Methods: A prospective, two-year, multicenter study was designed. Using the Utstein template we recorded
Accepted 8 April 2011 out-of-hospital CPR (OHCPR) and analyzed the time sequence segment of the variables in OHCA and CPR gold
Available online 17 May 2011
standards. Multivariable logistic regression models were developed using emergency response time as the
primary independent variable and survival to return of spontaneous circulation (ROSC), survival to hospital
Keywords:
Emergency response
discharge (HD), and one-year survival (1y) as the dependent variable. ROC curves represent cut off time
Time dependent survival data.
Out-of-hospital Results: During the study period, the median time of recognition OHCA was 5.5 min, call receipt was 1 min and
Cardiac arrest the call–response interval was 7 min. The median time required to verify OHCA and ALS onset was 10 min. ALS
Defibrillation was carried on for 30.5 min (SD = 21.3). Abandonment of further CPR/death occurred after 29 min. The first
CPR defibrillation shock was performed after 13.3 ± 9.0 min, endotracheal tube was placed after 16.8 ± 9.4 min and
the first adrenaline dose was injected after 18.9 ± 9.3 min. Higher survival (ROSC, HD, 1y) rate was found when
CPR is performed within the first 4 min after OHCA.
Conclusion: The emergency response time within 4 min was associated with improved survival to ROSC, HD and
1y after OHCA. Despite the fact that our results are in accordance with the findings published in other papers,
there is still a need to take all appropriate measures in order to decrease the emergency response time after OHCA.
© 2011 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

1. Introduction it is a matter of unwitnessed OHCA. The time of collapse can be

reported only by a witness to the event. However, in a state of
The time from out-of-hospital cardiac arrest (OHCA) to definitive panic, the witness can hardly remember to look at the watch and
outcome (survival or death) endlessly flows and is the most elusive memorize the time. The time of recognition is the time when a
variable. Precise determination of the timing of the situation course is person who did not witness OHCA is found by a third party.
needed for an accurate medical documentation and follow-up of the 2. Time of call receipt. Modern dispatch centers for EMS record this
outcome of recent advances in out-of-hospital cardiopulmonary time automatically, as well as the time at which the operator
resuscitation (OHCPR) [1]. The standard report Utstein template [2] forwarded the call to the team on the field. These data are me-
(Fig. 1), includes two major categories of variables for the record of morized within the listing at the dispatch center.
OHCPR: event variables and outcome variables. Time points and 3. Time of departure and arrival of vehicle at the scene. This is the time
event-to-event intervals were the least precise and the most sus- at which the vehicle stops at the resuscitation scene. Slow re-
ceptible to subjectiveness while completing the Utstein template. ception of relevant data from the caller, or a delayed activation of
Four subsequent time clocks activate from the moment of OHCA the emergency team can result in prolonged interval between the
and they represent the time of the emergency response [3] (Fig. 2). alarm and the departure of the EMS vehicle.
There are some points in time which should be recorded as com- 4. Time of confirmed OHCA.
pulsory criteria during OHCA. These are [2]: 5. Time of duration of CPR. ROSC is an intermediate outcome which can
be of a transient nature. Patients who never re-established
1. Time of collapse/time of recognition. Despite its importance, data
spontaneous circulation should also be noted.
regarding this time point are the most imprecise of all, especially if
6. Time of abandoning CPR attempts/death at the intervention site. The
time at which CPR efforts were terminated outside the hospital (in
⁎ Corresponding author at: City Institute for Emergency, Medical Care, Belgrade,
the field, during transport or in the ER) should be recorded as a
Street Aleksinackih rudara 25/4, 11070 New Belgrade, Serbia. Tel.: + 381 648243603. separate entity.
E-mail address: [email protected] (A. Sladjana). 7. Time of departure from the scene and arrival to ED.

0953-6205/$ – see front matter © 2011 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.ejim.2011.04.003
 A. Sladjana et al. / European Journal of Internal Medicine 22 (2011) 386–393 387

Fig. 1. Standard reporting of out-of-hospital cardiopulmonary resuscitation.

8. Time of awakening. These time points were deleted because of their interval should be used only for the time between two events. One of
imprecise definitions and the practical difficulties encountered in the most non-uniformed terms in CPR is the call–response interval
documenting the times accurately. (time of response) and represents the period from collection of the
call up to the moment of stopping the emergency vehicle. This
The inaccurate use of the term time and interval results in con- interval includes the time of calling the EMS, collection of the call,
fusion and false interpretation of OHCA in the available literature [2]. forwarding the call to the closest team, movement of the team from
Interval is not the same as time as it refers to a period between their base to the emergency vehicle, starting the vehicle and arri-
two events. Various jargon terms should be rejected and the term val at the intervention site. This interval is prolonged for time of
388 A. Sladjana et al. / European Journal of Internal Medicine 22 (2011) 386–393

Fig. 2. Four subsequent time clocks after OHCA.

approach to the patient or for the time needed to prepare the cardiogram. ALS resuscitation was performed in the following events:
defibrillator. when the attending physician diagnosed cardiac arrest upon arrival,
Four time intervals are the “gold standard” for CPR comparison: or when a hemodynamically unstable or critical patient experienced a
cardiac arrest in the presence of the ALS team. Exclusion criteria were
1. Interval from event onset to start of CPR. in accordance with the Utstein style JRCALC guidelines 1996.
2. Interval from event onset to first defibrillation. Early defibrilla-
tion is the milestone of successful treatment of lethal arrhythmia 3.3. Data collection
(VF/pulseness VT). The time interval between collapse and first
defibrillation is the key variable in the follow up of a number of The study instrument was the standard report on OHCA (Utstein
other elements of the emergency response. template) completed by EMS physicians. Its time sequence segment of
3. Interval from event onset to advanced airway management, is the variables in OHCA was analyzed. In order to decrease the subjectivity
critical, but it is one of the most demanding procedures for the EMS of the EMD and to decrease inconsistency of times among different
physicians during OHCPR. clocks (dispatcher's, doctor's, emergency vehicle and defibrillator
4. Interval from event onset to first administration of adrenaline. The display clocks), the clocks were synchronized at the start of each shift.
reports do not need to show the exact increase of the applied i.v. Using the Utstein template, we also analyzed outcome variables, such as
drug dose during OHCPR, but the application of these drugs is time immediate survival (ROSCN 20 min), short-term survival (to hospital
dependent [2]. New evidence suggests that an early defibrillation, discharge — HD), long-term survival (one year after discharge — 1y), or
not only shortens the time between collapse and defibrillation in death after the OHCPR.
patients in VF/pulseness VT, but analogously shortens the interval
between intubation and application of drugs [4]. 3.4. Data analysis

2. Objectives The collected data was coded and included in a special PC database.
Statistical analysis was performed using SPSS for Windows statistical
The aim of this study was to determine the emergency response software package, while graphic presentation was made using Har-
time after OHCA using Utstein style template for OHCPR carried out in vard Graphics software. Descriptive statistics were performed and
four cities in Serbia (Belgrade, Novi Sad, Niš and Kragujevac). continuous data are reported as medians with interquartile ranges
(IR). In order to test the differences of the observed individual risk
3. Study methods factors, χ²-test (Fisher's exact test) and Student's t-test (for numerical
values) at a significance level of p b 0.05 were used. The results of this
3.1. Study design prospective study represent a descriptive presentation of the data
obtained based on Utstein template and statistical results acquired by
The multi-centric (Belgrade, Novi Sad, Niš, and Kragujevac), univariate analysis of individual risk factors. Multivariable logistic
prospective study was conducted prospectively during the two-year regression models were developed using emergency response time as
period, from 1 January 2007 to 31 December 2008. The out-of-hospital the primary independent variable and survival to return of sponta-
CPR and their outcomes were recorded. The out-of-hospital emer- neous circulation (ROSC), survival to hospital discharge (HD), and
gency medical team (emergency medical doctor — EMD, nurse and one-year (1y) as the dependent variable. ROC curves represent cut off
driver) was providing the ALS (advanced life support) according to time dependent survival data. Categorical data are reported as
the CPR Guideline for 2005. percentages with 95% confidence intervals (CI).

3.2. Study subjects 3.5. Ethics

The study sample consisted of patients older than 18 years and The study was approved by the Ethical Committee of the Serbian
experiencing sudden OHCA, regardless of etiology or initial electro- Medical Society in Belgrade.
 A. Sladjana et al. / European Journal of Internal Medicine 22 (2011) 386–393 389

4. Results (median 1 h). Patients who survived to be dismissed from the hospital
were hospitalized for an average of 22.1 days (Table 1).
Using the Utstein template, the distribution of patients and the
events during the out-of-hospital CPR and the follow-up were analyzed 4.2. CPR gold standards
in a whole study sample, as well as for each city independently: BG
(Belgrade), NI (Nis), NS (Novi Sad) and KG (Kragujevac). The data are CPR was started 12.4 ± 9.1 min after the onset of CA and was
presented in Fig. 3[5]. During the investigation, 591 patients met the carried out for an average of 30.5 ± 21.3 min. The first defibrillation
inclusion criteria for study enrollment and OHCPR. shock (DC) was performed after 13.3 ± 9.0 min, ET was placed
successfully after 16.8 ± 9.4 min and the first adrenaline dose was
4.1. Times and time intervals related to OHCA injected after 18.9 ± 9.3 min (Table 2). Survival after OHCA was
studied and compared to the onset of CPR and cut-off value was 4 min.
The time of collapse/recognition by a lay-witness who started BLS In 27.2% of the patients (161/591) CPR was started within the first
was 7.8 min on average (median 5.5 min). Of these 591 patients with 4 min from the onset of OHCA. In 62.8% of the patients (430/591) CPR
OHCA, bystander CPR was initiated in 96 (16.2%) of them, either by a was started later than 4 min after the onset of OHCA.
family member or a friend (67/96) or medical person (29/96). The There was a statistically significant difference in times of the onset
time elapsed before the witness called the EMS was 2 min on average of CPR among the three analyzed time intervals (ROSC after OHCA,
(median 1 min) and the call–response interval was 9.2 min (median time of OHCA to discharge from hospital — HD, one-year after OHCA)
7 min). The average time required by the EMS to reach the patient was (ROSC: p b 0.001; HD: p b 0.001; 1y: p b 0.001). Higher survival rate
11.1 min (median 9 min), the time average required to verify OHCA was found within the patients with CPR performed within the first
and ALS onset was 11.8 min (median 10 min). ALS was carried on for 4 min (Fig. 4).
30.5 ± 21.3 min. Abandonment of further CPR/death at the interven-
tion site occurred after 31.1 min on average (median 29 min). Average 4.3. Reasons to discontinue CPR
time of departure from the scene and arrival to emergency depart-
ment (ED) was 9.8 min (median 7.7 min). The average time required The reason to discontinue CPR was ROSC in 30.3% (179/591) of the
by the patient to regain consciousness after successful CPR was 20.3 h cases, while ROSC was never achieved in 69.7% of the patients (412/

Fig. 3. The Utstein template data, total sample.

390 A. Sladjana et al. / European Journal of Internal Medicine 22 (2011) 386–393

Table 1 Table 2
Out-of-hospital cardiac arrest (OHCA) times. CPR gold standards.

Times Number Min Max Average SD IR Intervals of duration (min) Number of patients Mean (95% CI)
of patients median
Cardiac arrest-to-start CPR 591/591 10.0 9.1 12.4
Time of collapse/time of 96 0 60 7.8 9.9 Cardiac arrest-to-first defibrillation 281/591 13.3 9.0 17.3
recognition OHCA 5.5 8 Cardiac arrest-to-intubation 553/591 16.8 13.4 19.8
Time of call receipt 591 0 45 2 3.9 Cardiac arrest-to-first adrenaline 487/591 18.9 9.3 26.6
(minutes after OHCA) 1 2
Time of departure and arrival vehicle 591 0 57 9.2 7.6
at the scene (minutes after OHCA) 7 9
Time of confirmed OHCA (min) 591 0 61 11.8 9.1 worse was the situation in which the witness was a foreign visitor in a
10 10 country whose emergency phone EMS number was unknown to him.
Time of duration of CPR (min) 591 1 166 30.5 21.3 Currently, the implementation of a 112 system for emergency calls is
27 17
under way in Serbia. The time from recognition of OHCA to the
Time of departure from the scene 591 1 64 9.8 7.5
and arrival to ED (min) 7.7 17 emergency call for medical help was 2 min (median 1 min).
Time of abandoning CPR 348 7 102 31.1 12.4
attempts/death at the 29 12
intervention site 5.3. Time of departure and arrival of the vehicle at the scene
Awakening time (h) 76 0.03 396 20.3 53.4
1 19 The most critical component in early approach link is the time
Number of hospital days 74 1 129 22.2 23.0
needed to forward a medical team to the intervention site. After EMS
SD — standard deviation; IR — interquartile range 75%–25%, OHCA — out-of-hospital principles, this time period has to be less than 1 min. Einsenberg and
cardiac arrest, BLS — basic life support, ALS — advanced life support, EMS — emergency colleagues from Washington are developing CPR instructions which
medical system, ED — emergency department, h — hours.
the dispatcher forwards to the EMS caller [8]. Like these, the Index of
urgent care is available to dispatchers in Serbian emergency medical
care (EMC) [9]. In Belgrade EMC, successful resuscitation led by
591). In 62.1% of the patients, CPR was ineffective and was discontinued
physician's phone instructions was recorded [10]. In a Canadian study
at the site of the cardiac arrest. Duration of ROSC was analyzed in 105
(2006) the efficiency of BLS guided by the instructions from an EMS
patients across three time intervals: 0–20 min, 20 min–24 h and over
dispatcher was followed up for a period of time. In conclusion, the
24 h. ROSC lasting for up to 20 min was recorded in 5.7% of the patients
time needed for diagnosis was shortened by 2 min and 37 s[11].
(6/105), ROSC lasting from 20 min to 24 h in 50.5% (53/105), and for
From the moment of collection of the call, the EMS team must
over 24 h in 43.8% of the cases (46/105).
arrive as soon as possible to the site of the event. According to Spite,
the time for EMS arrival was less than 12 min only in a minor number
5. Discussion of OHCA (27%). The probability for ROSC and survival is greater if the
arrival of EMS is shorter, which is not always possible. Even in New
The emergency response time guideline has its origin in an article York [12], the EMS teams struggle with heavy traffic jams, hence the
published in 1979 that evaluated patient outcomes after out-of- time of arrival is on average 12 min, similar to Singapore (12.5
hospital nontraumatic cardiac arrest [6]. The investigators reported ± 4.61 min) [13]. Somewhat shorter time (10.1 ± 2.3 min) was
that survival decreased significantly if basic life support and advanced recorded in a French study [14].
life support were initiated in N.4 min and N.8 min, respectively. They In our study, the average time interval from the emergency call to
therefore suggested these times as recommended guidelines for the response was 9.2 min (median 7 min). The opinion that this time
emergency response of basic and advanced life support providers. interval is difficult to determine was changed by the study performed
The key variable for a successful OHCA treatment is time with by Campbell et al. which proves that when defined by a protocol, this
events: transformation from reversible to irreversible damage, from time period is not as elusive [15]. In many communities, attempts to
functionality to handicap, from life to death. The traditional belief that shorten this period with use of an automated external defibrillator
time is an ally changes into an attitude that time represents the (AED) have been carried out. During the period 1999–2001, in Miami
“mortal” enemy of successful OHCA treatment. County, the arrival time of the police equipped with AED to the OHCA
site and arrival time of EMS were compared. The average time of
5.1. Time of collapse/time of recognition arrival at the patient's site was lowered from 7.64 min (time needed
by the EMS to reach the patient) to 4.88 min which is the time needed
After OHCA, the first link in the survival chain is activated [7]the by the police to reach the site.
early approach which includes the events before the arrival of EMS.
The recognition of the early warning signs, such as chest pain or 5.4. Time of CPR onset
shortness of breath, motivate the witness to activate the EMS system,
this being the key link in the chain of events. In our investigation, we In our study, the average time of BLS onset was 7.8 min (median
had a total of 96 OHCA recognized by lay persons who immediately 5.5 min). It took our emergency medical teams an average of 11.8 min
started bystander BLS. (median 10 min) to confirm CA, whereas the average time from CA to
ALS was 12.4 min (median 11 min). In Hong Kong, the average time
5.2. Time of call receipt until onset of ALS was 9.8 min [16]. The survival rate of our patients
was analyzed relative to the CPR onset time with the cut-off time set
The first link in the chain, apart from recognition of OHCA, is a at 4 min. In 27.2% of the patients (161/591) CPR started within 4 min
prompt call for EMS. However, in a state of panic, many witnesses of OHCA, and in 62.8% of the cases (430/591) after more than 4 min
were unable to recall the phone number of the regional EMS. Even following the OHCA. Statistically significant difference was found in

Fig. 4. Time-dependent ROC curves for survival data (p b 0.001). OHCPR — out-of-hospital cardiopulmonary resuscitation, OHCA — out-of-hospital cardiac arrest, Group I — OHCPR
performed within 4 min after OHCA, Group II — OHCPR performed later than 4 min after OHCA, ROSC — survival to return of spontaneous circulation, HD — survival to hospital
discharge, 1y — one-year survival.
 A. Sladjana et al. / European Journal of Internal Medicine 22 (2011) 386–393 391

Survival Group I (cut-off time < 4 min) Group II (cut off time > 4 min)

Immediate

ROSC

Short-term

HD

Long-term

1y
392 A. Sladjana et al. / European Journal of Internal Medicine 22 (2011) 386–393

survival rates when observed in relation to the period of CPR after In our study, the average duration of CPR was 30.5 ± 21.3 min and
OHCA (Fig. 4). The survival rate (ROSC, HD, and 1y) increased when the time at which CPR was abandoned, i.e. the time of death, was on
CPR was started within 4min (p b 0.001). A significant obstacle for average 30.1 min (median 29 min). The reason for abandoning CPR
implementing reanimation measures is the complexity of CPR skills. A according to our EMS teams was ROSC in 30.3% of the cases (179/591),
number of studies clearly suggest poorly attained skills after attending similar to the New York study (32.2%) [11]. ROSC was never estab-
traditional CPR courses. Newly designed courses include maximum lished in 69.7% of our patients (412/591). The algorithm form of ROSC
simplification and practice by observing videos, and they confirmed duration was analyzed in 105 patients for three time intervals: a) 0–
their significance for attaining skills compared to traditional didactic 20 min registered in 5.7% of the patients (6/105), b) 20 min–24 h in
courses [17]. 50.5% (53/105), c) more than 24 h in 43.8% of the cases (46/105).
Papers on OHCPR have concluded that ROSC is a statistically signi-
5.5. Time of first DC shock ficant predictor of survival rate [11,25].

In our study, the first defibrillation was applied within the time 5.9. Time of departure from the scene and arrival to emergency
interval from 1 to 57 min, with a mean value of 13.3 min (SD = 9.0), department (ED)
which is slightly more than in Okayami (Japan) where it was
11.26 min. As previous studies have clearly shown that the time This level of the template refers to patients in whom return of
interval from collapse to fibrillation is decisive for the survival of the spontaneous circulation was sustained long enough to merit admis-
patient, De Maio et al. [18] have attempted to determine the survival sion to an intensive care unit. In our study this time was 9.8 min
rate in OHCA cases based upon time of delivery of the first DC shock. (median 7.7 min) but time required by the patient to regain
consciousness after successful CPR was 20.3 h (median 1 h).
5.6. Time needed for an effective airway management
5.10. The CPR gold standard
Our patients were successfully intubated within 16.8± 9.4 min after
OHCA. One study analyzed the average time needed for endotracheal – Interval from OHCA to the onset of CPR. In our study, the interval values
intubation (ET) by: paramedics (60.0 s), anesthesiologists (45.0 s), and for call-to-CPR were from 0 (CA occurred when the EMS team was
other specialists (60.0 s) [19]. The incidence of difficult ET was 8.9%. present) to 69 min, thus the average time was 12.4± 9.1 min, while
this time interval was 9.82 min on average in Hong Kong [16]. Door-
5.7. Time needed for first dose of adrenaline to-CPR interval in our sample was 1.3 min on average. Professor
Vukmir (USA) recorded different time intervals (min) depending on
In our study, the average time from OHCA to first application of different initial forms of CPR: lay bystanders (2.08 ± 2.77 min), BLS
adrenaline was 18.9 ± 9.3 min. In an Australian study [20], adrenaline (6.62 ± 5.73 min), and ALS (9.08± 6.31 min) [26]. In the same study,
did not result in improved immediate and long-term survival rates the survival rate after onset of ALS within the interval of 0–8 min and
compared to placebo. Clinical randomized study [21] carried out in 12 8 min after OHCA was compared. The survival ratio was 19.8
cities in France and Belgium compared high and standard doses of compared to 11.4, respectfully.
adrenaline applied during OHCPR in 3.327 patients during asystole and – Time interval from OHCA to first defibrillation is the key factor which
PEA. Despite some possible negative comments about the study design, determines the survival time. In our study the first DC shock was
the conclusion Gueugniaud et al. arrived at, that high adrenaline doses delivered after 13.3 ± 9.0 min on average. The OPALS study shows
(5 mg/every 3 min up to 15 mg max.) do not result in improved survival that by shortening this time interval, the one year survival time
rate compared to the standard adrenaline protocol (1 mg/every 3 min) after OHCA increases from 4.6% if the first DC shock is administered
can be clearly drawn. It is therefore very disappointing to know that a after 9 min, to 12.0% if the first DC shock was carried out after
drug that has been used for over 100 years for CPR is still controversial 5 min from OHCA onset.
concerning its efficiency and safety. While countries worldwide were – Time interval from OHCA to ET was 16.8 ± 9.4 min in our study. This
voting pro and contraregarding the use of vasopressin in OHCA, after is too long, bearing in mind that the Washington study [27]
guidelines were established in 2000, our EMS teams did not even have showed that ET within 12 min is related to survival rate of 46% and
this drug as an option. It seems we have just missed one more if this time is prolonged to 13 min, the survival rate is 23%. The
experience as in the CPR Guidelines 2005, adrenaline is once again set on explanation for this, in both Washington, and our study, is late
therapeutic pedestal. arrival of the EMS team.
– Time interval from OHCA to first drug administration. Whether our
5.8. Time of duration of CPR EMS teams were lacking experience, or the degree of presented
cardiovascular collapses was extremely severe, the described time
There is no agreement on optimal duration of CPR. According to interval in our study was 18.9 ± 9.3 min on average. However, we
Schulz [22], if ACA persists for less than 10 min, the survival rate is 48% compared our study with another one which showed OHCA to
and if ACA lasts for longer than 20 min, the survival rate is about 2%. drug application interval of 21.4 ± 8.3. Rittenberger and colleagues
Denton and Thomas [23] confirm that the larger number of noticed that this period was rarely considered to be a crucial
administered DC is a predictor of a poor outcome. Saklayan [24] variable. Therefore, they started an extensive 15 year meta-
reported that a shorter time of recognition is related to more favorable analysis and showed that the drug administration was too delayed
outcome, especially if OHCA has been witnessed by an EMC team. In to be efficient. An average time of 17.4 ± 10.3 min was described
majority of patients who survived to be dismissed from the hospital, [28] similar to that in our study.
BLS was started 4 min after OHCA, while ALS commenced within
8 min. The group of patients with an arrest-time shorter than 5 min 6. Conclusion
and CPR time less than 20 min had low mortality and modest
neurological deficit. The extrinsic factors are commonly decisive, due The most suitable time of emergency response in OHCA is still
to the “spectator” CPR lasting for up to 1 h, or the patient without unknown, as well as the intensity and duration of treatment by the
ROSC is “load and go” due to violent threats by the witnesses. The EMS. Our study points out the need for improvements in CPR ma-
majority of authors consider that the CPR should be abandoned in the nagement strategies, CPR data colection, resuscitation team manage-
absence of signs of efficiency after 30–60 min. ment, and basic and adult life support training programs. It also points
 A. Sladjana et al. / European Journal of Internal Medicine 22 (2011) 386–393 393

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