Physician's presence in pre-hospital setting improves one-month favorable neurological survival after out-of-hospital cardiac arrest: a propensity score matching analysis of the JAAM-OHCA Registry

Benefits of targeted deployment of physician-led interprofessional pre-hospital teams on the care of critically Ill and injured patients: a systematic review and meta-analysis

INTRODUCTION

Over the past three decades, more advanced pre-hospital systems have increasingly integrated physicians into targeted roles, forming interprofessional teams. These teams focus on providing early senior decision-making and advanced interventions while also ensuring rapid transport to hospitals based on individual patient needs. This paper aims to evaluate the benefits of an inter-professional care model compared to a model where care is delivered solely by paramedics.

METHODOLOGY

A meta-analysis and systematic review were conducted using the guidelines of PRISMA 2020. Articles were identified through a systematic search of three databases and snowballing references. A systematic review was conducted of articles that met the inclusion criteria, and a suitable subset was included in a meta-analysis. The survival and mortality outcomes from the studies were then pooled using the statistical software Review Manager (RevMan) Version 8.2.0.

RESULTS

Two thousand two hundred ninety-six articles were found from the online databases and 86 from other sources. However, only 23 articles met the inclusion criteria of our study. A pooled analysis of the outcomes reported in these studies indicated that the mortality risk was significantly reduced in patients who received pre-hospital care from interprofessional teams led by physicians compared with those who received care from paramedics alone (AOR 0.80; 95% CI [0.68, 0.91] p = 0.001). The survival rate of critically ill or injured patients who received pre-hospital care from interprofessional teams led by physicians was increased compared to those who received care from paramedics alone (AOR 1.49; 95% CI [1.31, 1.69] P < 0.00001).

CONCLUSIONS

The results of our analysis indicate that the targeted deployment of interprofessional teams led by physicians in the pre-hospital care of critically ill or injured patients improves patient outcomes.

Effect of prehospital physician presence on Out-of-Hospital cardiac arrest (OHCA) patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR): A secondary analysis of the SAVE-J II study

Introduction

Extracorporeal cardiopulmonary resuscitation (ECPR) has been increasingly utilized for patients with out-of-hospital cardiac arrest (OHCA). However, the impact of prehospital physician presence on the outcomes of ECPR-treated OHCA patients remains uncertain. This study aimed to evaluate whether the presence of prehospital physicians improves 30-day survival and favorable neurological outcomes in this population.

Methods

This retrospective study analyzed data from the SAVE-J II study, a nationwide multicenter cohort of OHCA patients treated with ECPR in Japan. Patients were divided into two groups: prehospital physician absence and prehospital physician presence. Propensity score matching (PSM) was performed using six covariates (age, sex, witness status, presence of bystander CPR, initial heart rhythm, and location of cardiac arrest) to adjust for baseline differences. Sensitivity analyses included PSM with additional covariates (prehospital time and Low flow time), inverse probability of treatment weighting (IPTW), and varying matching ratios. Primary and secondary outcomes were 30-day survival and favorable neurological outcome (Cerebral Performance Category [CPC] 1-2), respectively.

Results

Of the 1,641 patients included, 448 were in the prehospital physician presence group and 1,193 in the prehospital physician absence group. Before PSM, 30-day survival rates were 28.2% (prehospital physician presence) vs. 25.7% (prehospital physician absence) (p = 0.350). After 1:1 PSM (6 covariates), the 30-day survival rate was significantly higher in the prehospital physician presence group (29.6%) compared to the prehospital physician absence group (22.7%) (p = 0.028), while favorable neurological outcomes showed no significant difference (prehospital physician presence: 14.5% vs. prehospital physician absence: 11.0%, p = 0.092). Sensitivity analyses confirmed the robustness of the findings, with 30-day survival consistently higher in the prehospital physician presence group across models, including 7-covariate PSM (31.8% vs. 23.0%, p = 0.009) and IPTW with 8 covariates (35.6% vs. 25.1%, p = 0.026). However, the 8-covariate IPTW model exhibited residual imbalance (SMD > 0.1 in four covariates). Favorable neurological outcomes did not show significant differences in any analysis.

Conclusions

Prehospital physician presence was associated with improved 30-day survival in OHCA patients undergoing ECPR. However, favorable neurological outcomes did not show significant improvement. These findings highlight the need for strategies to optimize low-flow time and explore the potential role of prehospital ECPR initiation. Further prospective studies are required to validate these findings and improve outcomes in this critical population.

Prehospital critical care beyond advanced life support for out-of-hospital cardiac arrest: A systematic review

Aim

To assess the clinical outcomes of patients with out-of-hospital cardiac arrest attended by prehospital critical care teams compared to non-critical care teams.

Methods

This review was prospectively registered with PROSPERO and the eligibility criteria followed a PICOST framework for ILCOR systematic reviews. Prehospital critical care was defined as any provider with enhanced clinical competencies beyond standard advanced life support algorithms and dedicated dispatch to critically ill patients. MEDLINE, Embase and CINAHL databases were searched from inception to 20 April 2024. Risk of bias was assessed using the ROBINS-I tool and the certainty of evidence by the GRADE approach. Meta-analyses of pooled data from studies at moderate risk of bias were performed using a generic inverse-variance with random-effects.

Results

The search returned 6,444 results and 17 articles were included, reporting 1,192,158 patients. Three studies reported traumatic patients and one reported paediatric patients. All studies were non-randomised and 15 were at moderate risk of bias. Most studies included prehospital physicians (n = 16). For adult non-traumatic patients, the certainty of evidence was low and prehospital critical care was associated with improved survival to hospital admission (OR 1.95, 95% CI 1.35-2.82), survival to hospital discharge (OR 1.34, 95% CI 1.10-1.63), survival at 30 days (OR 1.56, 95% CI 1.38-1.75), and favourable neurological outcome at 30 days (OR 1.48, 95% CI 1.19-1.84). Prehospital critical care was also associated with improved outcomes for traumatic and paediatric patients and the certainty of evidence was very low.

Conclusion

Attendance of prehospital critical care teams to patients with out-of-hospital cardiac arrest is associated with improved outcomes.

Non-linear association between the time required to reaching temperature targets and the neurological outcome in patients undergoing targeted temperature management after out-of-hospital cardiac arrest: Observational multicentre cohort study

Purpose

We evaluated associations between outcomes and time to achieving temperature targets during targeted temperature management of out-of-hospital cardiac arrest.

Methods

Using Comprehensive Registry of Intensive Care for out-of-hospital cardiac arrest Survival (CRITICAL) study, we enrolled all patients transported to participating hospitals from 1 July 2012 through 31 December 2017 aged ≥ 18 years with out-of-hospital cardiac arrest of cardiac aetiology and who received targeted temperature management in Osaka, Japan. Primary outcome was Cerebral Performance Category scale of 1 or 2 one month after cardiac arrest, designated as "one-month favourable neurological outcome". Non-linear multivariable logistic regression analyses assessed the primary outcome based on time to reaching temperature targets. In patients subdivided into quintiles based on time to achieving temperature targets, multivariable logistic regression calculated adjusted odds ratios and 95% confidence intervals.

Results

We analysed 473 patients. In non-linear multivariable logistic regression analysis, p value for non-linearity was < 0.01. In the first quintile (< 26.7 minutes), second quintile (26.8-89.9 minutes), third quintile (90.0-175.1 minutes), fourth quintile (175.2-352.1 minutes), and fifth quintile (≥ 352.2 minutes), one-month favourable neurological outcome was 32.6% (31/95), 40.0% (36/90), 53.5% (53/99), 57.4% (54/94), and 37.9% (36/95), respectively. Adjusted odds ratios with 95% confidence intervals for one-month favourable neurological outcome in the first, second, third, and fifth quintiles compared with the fourth quintile were 0.38 (0.20 to 0.72), 0.43 (0.23 to 0.81), 0.77 (0.41 to 1.44), and 0.46 (0.25 to 0.87), respectively.

Conclusion

Non-linear multivariable logistic regression analysis could clearly describe the association between neurological outcome in patients with out-of-hospital cardiac arrest and the time from the introduction of targeted temperature management to reaching the temperature targets.

Novel and innovative resuscitation systems in Japan

Aim

Out-of-hospital cardiac arrest (OHCA) is a life-threatening emergency that requires rapid and efficient intervention. Recently, several novel approaches have emerged and have been incorporated into resuscitation systems in some local areas of Japan. This review describes innovative resuscitation systems and highlights their strengths.

Main text

First, we discuss the deployment of a physician-staffed ambulance, in which emergency physicians offer advanced resuscitation to patients with OHCA on site. In addition, we describe the experimental practice of extracorporeal membrane oxygenation (ECPR) in a prehospital setting. Second, we describe a physician-staffed helicopter, wherein a medical team provides advanced resuscitation at the scene. We also explain their initiative to provide early ECPR, even in remote areas. Finally, we provide an overview of the "hybrid ER" system which is a "one-fits-all" resuscitation bay equipped with computed tomography and fluoroscopy equipment. This system is expected to help swiftly identify and rule out irreversible causes of cardiac arrest, such as massive subarachnoid hemorrhage, and implement ECPR without delay.

Conclusion

Although these revolutionary approaches may improve the outcomes of patients with OHCA, evidence of their effectiveness remains limited. In addition, it is crucial to ensure cost-effectiveness and sustainability. We will continue to work diligently to assess the effectiveness of these systems and focus on the development of cost-effective and sustainable systems.

Bayesian network predicted variables for good neurological outcomes in patients with out-of-hospital cardiac arrest

Out-of-hospital cardiac arrest (OHCA) is linked to a poor prognosis and remains a public health concern. Several studies have predicted good neurological outcomes of OHCA. In this study, we used the Bayesian network to identify variables closely associated with good neurological survival outcomes in patients with OHCA. This was a retrospective observational study using the Japan Association for Acute Medicine OHCA registry. Fifteen explanatory variables were used, and the outcome was one-month survival with Glasgow-Pittsburgh cerebral performance category (CPC) 1-2. The 2014-2018 dataset was used as training data. The variables selected were identified and a sensitivity analysis was performed. The 2019 dataset was used for the validation analysis. Four variables were identified, including the motor response component of the Glasgow Coma Scale (GCS M), initial rhythm, age, and absence of epinephrine. Estimated probabilities were increased in the following order: GCS M score: 2-6; epinephrine: non-administered; initial rhythm: spontaneous rhythm and shockable; and age: <58 and 59-70 years. The validation showed a sensitivity of 75.4% and a specificity of 95.4%. We identified GCS M score of 2-6, initial rhythm (spontaneous rhythm and shockable), younger age, and absence of epinephrine as variables associated with one-month survival with CPC 1-2. These variables may help clinicians in the decision-making process while treating patients with OHCA.

Pre-hospital airway management and neurological status of patients with out-of-hospital cardiac arrest: A retrospective cohort study

Purpose

Little is known about whether pre-hospital advanced airway management (AAM) under the presence of a physician could improve outcome of patients with cardiac arrest, compared with pre-hospital AAM under the absence of a physician.

Methods

This retrospective multicentre-cohort study enrolled consecutive patients who were transported to participating hospitals after out-of-hospital cardiac arrest in Japan between 1 June 2014 and 31 December 2019. We included patients who underwent pre-hospital AAM and resuscitation after arrival at hospital, and who were ≥18 years of age, with medical aetiologies. The primary outcome was favourable neurological survival (Cerebral Performance Category score of 1 or 2) one month after cardiac arrest. The primary outcome was called one-month favourable neurological survival. The first confirmed cardiac rhythm was defined using 3-lead electrocardiogram monitor or an automated external defibrillator and by determining whether the carotid artery was pulsating. Previous research found that the presence of a pre-hospital physician was associated with improved patients' outcomes, after the type of first confirmed cardiac rhythm was considered. Therefore, the first confirmed cardiac rhythm in current study was subdivided into non-shockable or shockable groups. A multivariable logistic regression analysis was performed on propensity score-matched patients.

Results

We analysed 16,703 patients. Among the 2,346 patients in the non-shockable group, 1.2% (N = 29) achieved the primary outcome. The adjusted odds ratio of pre-hospital AAM with or without a physician for the primary outcome in the results of the non-shockable group was 4.64 (95% confidence interval: 1.81-14.4). Among the 826 patients in the shockable group, 16.9% (N = 140) achieved the primary outcome and the adjusted odds ratio of pre-hospital AAM with or without a physician for the primary outcome in the results of the shockable group was 1.05 (95% confidence interval: 0.67-1.63).

Conclusions

This retrospective multicentre-cohort study found that pre-hospital AAM under the presence of a physician was significantly associated with increased neurological outcome in specific patients with cardiac arrest, compared with pre-hospital AAM under the absence of a physician.

Out-of-hospital cardiac arrest: A data-driven visualization of collaboration, frontier identification, and future trends

One of the main causes of death is out-of-hospital cardiac arrest (OHCA), which has a poor prognosis and poor neurological outcomes. This phenomenon has attracted increasing attention. However, there is still no published bibliometric analysis of OHCA. This bibliometric analysis of publications on OHCA aimed to visualize the current status of research, determine the frontiers of research, and identify future trends. Publications on OHCA were downloaded from the web of science database. The data elements included year, countries/territories, institutions, authors, journals, research areas, citations of publications, etc. Joinpoint regression and exponential models were used to identify and predict the trend of publications, respectively. Knowledge domain maps were applied to conduct contribution and collaboration, cooccurrence, cocitation, and coupled analyses. Timeline and burst detection analysis were used to identify the frontiers in the field. A total of 3 219 publications on OHCA were found from 1998 to 2022 (average annual percentage change = 16.7; 95% CI 14.4, 19.1). It was estimated that 859 articles and reviews would be published in 2025. The following research hotpots were identified: statement, epidemiology, clinical care, factors influencing prognosis and emergency medical services. The research frontier identification revealed that 7 categories were classified, including therapeutic hypothermia, emergency medical services, airway management, myocardial infarction, extracorporeal cardiopulmonary resuscitation, stroke foundation and trial. The burst detection analysis revealed that percutaneous coronary intervention, neurologic outcome, COVID-19 and extracorporeal cardiopulmonary resuscitation are issues that should be given continual attention in the future. This bibliometric analysis may reflect the current status and future frontiers of OHCA research.

Association of Prehospital Physician Presence During Pediatric Out-of-Hospital Cardiac Arrest With Neurologic Outcomes

OBJECTIVES

To examine the association of prehospital physician presence with neurologic outcomes of pediatric patients with out-of-hospital cardiac arrest (OHCA).

DESIGN

Retrospective cohort study.

SETTING

Data from the Japanese Association for Acute Medicine-OHCA Registry.

INTERVENTIONS

None.

PATIENTS

Pediatric patients (age 17 yr old or younger) registered in the database between June 2014 and December 2019.

MEASUREMENT AND MAIN RESULTS

We used logistic regression models with stabilized inverse probability of treatment weighting (IPTW) to estimate the associated treatment effect of a prehospital physician with 1-month neurologically intact survival. Secondary outcomes included in-hospital return of spontaneous circulation (ROSC) and 1-month survival after OHCA. A total of 1,187 patients (276 in the physician presence group and 911 in the physician absence group) were included (median age 3 yr [interquartile range 0-14 yr]; 723 [61%] male). Comparison of the physician presence group, versus the physician absence, showed 1-month favorable neurologic outcomes of 8.3% (23/276) versus 3.6% (33/911). Physician presence was associated with greater odds of 1-month neurologically intact survival after stabilized IPTW adjustment (adjusted odds ratio [aOR] 1.98, 95% CI 1.08-3.66). We also found an association in the secondary outcome between physician presence, opposed to absence, and in-hospital ROSC (aOR 1.48, 95% CI 1.08-2.04). However, we failed to identify an association with 1-month survival (aOR 1.49, 95% CI 0.97-2.88).

CONCLUSIONS

Among pediatric patients with OHCA, prehospital physician presence, compared with absence, was associated almost two-fold greater odds of 1-month favorable neurologic outcomes.

Prehospital Physician Presence for Patients With out-of-Hospital Cardiac Arrest Undergoing Extracorporeal Cardiopulmonary Resuscitation: A Multicenter, Retrospective, Nationwide Observational Study in Japan (The JAAM-OHCA registry)

The effectiveness of the presence of a prehospital physician for patients with out-of-hospital cardiac arrest (OHCA) undergoing extracorporeal cardiopulmonary resuscitation (ECPR) remains unknown. In this multicenter, retrospective, observational study, we enrolled patients aged ≥18 years who developed OHCA and received ECPR. The primary outcome was the 1-month favorable neurological outcome. We estimated the impact of the presence of a prehospital physician on outcomes using a propensity score analysis with inverse probability weighting. We enrolled 1269 patients. Favorable neurological outcomes occurred in 25 of 316 (7.9%) patients with prehospital physicians and 94 of 953 (9.9%) patients without prehospital physicians. In the propensity score analysis, favorable neurological outcomes did not differ between 2 groups (odds ratio = 0.72; 95% confidence interval: 0.44-1.17). The 1-month favorable neurological outcome was not associated with the presence of a prehospital physician for patients with OHCA who underwent EPCR.

Urban-suburb disparities in pre-hospital emergency medical resources and response time among patients with out-of-hospital cardiac arrest: A mixed-method cross-sectional study

Aim

To investigate (1) the association between pre-hospital emergency medical resources and pre-hospital emergency medical system (EMS) response time among patients with Out-of-hospital cardiac arrest (OHCA); (2) whether the association differs between urban and suburbs.

Methods

Densities of ambulances and physicians were independent variables, respectively. Pre-hospital emergency medical system response time was dependent variable. Multivariate linear regression was used to investigate the roles of ambulance density and physician density in pre-hospital EMS response time. Qualitative data were collected and analyzed to explore reasons for the disparities in pre-hospital resources between urban areas and suburbs.

Results

Ambulance density and physician density were both negatively associated with call to ambulance dispatch time, with odds ratios (ORs) 0.98 (95% confidence interval [CI] 0.96-0.99; P = 0.001) and 0.97 (95% CI; 0.93-0.99; P < 0.001), respectively. ORs of ambulance density and physician density in association with total response time were 0.99 (95% CI: 0.97-0.99; P = 0.013) and 0.90 (95% CI: 0.86-0.99; P = 0.048). The effect of ambulance density on call to ambulance dispatch time in urban areas was 14% smaller than that in suburb areas and that on total response time in urban areas was 3% smaller than the effect in suburbs. Similar effects were identified for physician density on urban-suburb disparities in call to ambulance dispatch time and total response time. The main reasons summarized from stakeholders for a lack of physicians and ambulances in suburbs included low income, poor personal incentive mechanisms, and inequality in financial distribution of the healthcare system.

Conclusion

Improving pre-hospital emergency medical resources allocation can reduce system delay and narrow urban-suburb disparity in EMS response time for OHCA patients.

Prediction of return of spontaneous circulation in out-of-hospital cardiac arrest with non-shockable initial rhythm using point-of-care testing: a retrospective observational study

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is a public health concern, and many studies have been conducted on return of spontaneous circulation (ROSC) and its prognostic factors. Rotational thromboelastometry (ROTEM^®), a point-of-care testing (POCT) method, has been useful for predicting ROSC in patients with OHCA, but very few studies have focused on patients with non-shockable rhythm. We examined whether the parameters of POCT could predict ROSC in patients with OHCA and accompanying non-shockable rhythm.

METHODS

This is a single-center, retrospective observational study. Complete blood count, blood gas, and ROTEM POCT measurements were used. This study included patients with non-traumatic OHCA aged 18 years or older who were transported to the emergency department and evaluated using POCT between January 2013 and December 2021. The patients were divided into the ROSC and non-ROSC groups. Prehospital information and POCT parameters were compared using receiver operating characteristic (ROC) curve analysis, and further logistic regression analysis was performed.

RESULTS

Sixty-seven and 135 patients were in the ROSC and non-ROSC groups, respectively. The ROC curves showed a high area under the curve (AUC) for K⁺ of 0.77 (95% confidence interval [CI]: 0.71-0.83) and EXTEM amplitude 5 min after clotting time (A5) of 0.70 (95%CI: 0.62-0.77). The odds ratios for ROSC were as follows: female sex 3.67 (95%CI: 1.67-8.04); K⁺ 0.64 (95%CI: 0.48-0.84); and EXTEM A5 1.03 (95%CI: 1.01-1.06).

CONCLUSION

In OHCA patients with non-shockable rhythm, K⁺ level and the ROTEM parameter EXTEM A5 may be useful in predicting ROSC.

Accumulated Epinephrine Dose is Associated With Acute Kidney Injury Following Resuscitation in Adult Cardiac Arrest Patients

The goal of this study was to investigate the association between total epinephrine dosage during resuscitation and acute kidney injury after return of spontaneous circulation in patients with cardiac arrest. We performed a secondary analysis of previously published data on the resuscitation of cardiac arrest patients. Bivariate, multivariate logistic regression, and subgroup analyses were conducted to investigate the association between total epinephrine dosage during resuscitation and acute kidney injury after return of spontaneous circulation. A total of 312 eligible patients were included. The mean age of the patients was 60.8 ± 15.2 years. More than half of the patients were male (73.4%) and had an out-of-hospital cardiac arrest (61.9%). During resuscitation, 125, 81, and 106 patients received ≤2, 3 - 4, and ≥5 mg epinephrine, respectively. After return of spontaneous circulation, there were 165 patients (52.9%) and 147 patients (47.1%) with and without acute kidney injury, respectively. Both bivariate and multivariate analysis showed a statistically significant association between total epinephrine dosage and acute kidney injury. The subgroup analysis showed that the strength of the association between epinephrine dosage and acute kidney injury varied by location of cardiac arrest. Further multivariate regression analysis found that the association between epinephrine dosage and acute kidney injury was only observed in patients with in-hospital cardiac arrest after adjusting for multiple confounding factors. Compared with in-hospital cardiac arrest patients who received ≤2 mg of epinephrine, patients with 3–4 mg of epinephrine or ≥5 mg of epinephrine had adjusted odds ratios of 4.2 (95% confidence interval 1.0–18.4) and 11.3 (95% confidence interval 2.0–63.0), respectively, to develop acute kidney injury. Therefore, we concluded that a higher epinephrine dosage during resuscitation was associated with an increased incidence of acute kidney injury after return of spontaneous circulation in adult patients with in-hospital cardiac arrest.