Out-of-hospital cardiac arrests in the city of Cape Town, South Africa: a retrospective, descriptive analysis of prehospital patient records

The development history, current state, challenges, and future directions of the BASIC-OHCA registry in China: A narrative review

Out-of-hospital cardiac arrest is a major public health problem worldwide due to its high burden and poor outcomes. Despite progress in treatment, patient outcomes remain unsatisfactory, particularly in low-resource settings. The establishment of a registry is the first step towards gaining a comprehensive understanding of prevailing local conditions and identifying potential opportunities for improving patient survival. Here, we provide a narrative review of the BASeline Investigation of Out-of-hospital Cardiac Arrest (BASIC-OHCA), the first national OHCA registry in China, to introduce its development history, current state, challenges and future directions. We aim to enhance cross-cultural understanding by providing insights from China, while also serving as a reference for the implementation of large-scale registries in low-resource settings.

A resuscitation systems analysis for South Africa: A narrative review

With a growing incidence in cardiovascular diseases in Africa, including South Africa, and with it a greater incidence of out-of-hospital cardiac arrest (OHCA) there is a need to understand the readiness of these emergency care systems to support a response. Yet, OHCA is expensive and requires comprehensive development across an entire chain of survival in order to gain any benefit in mortality or morbidity. In this narrative review, we provide a resuscitation systems analysis using the Global Resuscitation Alliance's Frame of Survival. We provide evidence or commentary on the elements of the outer frame and inner frame, and make an assessment of the South African system's readiness to support OHCA care, and provide suggestions for priority areas that need to be developed. The South African resuscitation system demonstrates reasonable readiness to respond to OHCA but is characterised by considerable variation and fragmentation. Given the cost ineffectiveness of many interventions and the anticipated rise in OHCA incidence, there is a pressing need for context-specific strategies in South Africa. These strategies should focus on enhancing both outcomes and resource efficiency, while respecting community ethics and sociocultural dynamics.

The barriers and facilitators to initiation of telephone-assisted bystander cardiopulmonary resuscitation for patients experiencing out-of-hospital cardiac arrest in a private emergency dispatch centre in South Africa

Background

The incidence of cardiovascular diseases, and with it out-of-hospital cardiac arrest (OHCA), is on the increase in low- to middle-income countries (LMICs), like South Africa. Interventions such as mass public cardiopulmonary resuscitation (CPR) training campaigns and public access defibrillators are expensive and out of reach for many LMICs. Telephone-assisted CPR (tCPR) is a cost-effective, scalable alternative. This study explored the barriers and facilitators to tCPR uptake in OHCA in a private South African emergency dispatch centre.

Methods

This qualitative study applied inductive dominant content analysis to emergency call recordings of OHCA cases into a private emergency dispatch centre. Calls were analysed to the latent level to identify barriers and facilitators. Cases were sampled randomly, until data saturation.

Results

Saturation occurred after the analysis of 25 recordings. A further three recordings were analysed to confirm saturation of the facilitators; yielding a final sample size of 28 calls. Overall, t-CPR was offered in 23 (82.1%) cases, but only initiated in 8 (34.8%) of these calls. Five barriers ("Poor Communication"; "Lack of Support"; "Caller Hesitance or Uncertainty;" "Emotionality"; and "Practical Barriers") and three facilitators ("Caller Willingness"; "Support" and "CPR in Progress") were extracted.

Conclusion

Numerous barriers limit the initiation of tCPR in the South African private sector EMS. It is crucial to address these barriers and leverage the facilitators in order to improve tCPR uptake. This study highlights the importance of using specific language techniques and developing tailored tCPR algorithms to overcome these barriers, which is underpinned by standardised training of call-takers.

Incidence, process of care, and outcomes of out-of-hospital cardiac arrest in China: a prospective study of the BASIC-OHCA registry

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is an important global public health issue, but its epidemiology and outcomes in low-income and middle-income countries remain largely unknown. We aim to comprehensively describe the incidence, process of care, and outcomes of OHCA in China.

METHODS

In the prospective, multicentre, population-based Baseline Investigation of Out-of-hospital Cardiac Arrest (BASIC-OHCA) registry study, participating sites were selected from both urban and rural areas in all seven geographical regions across China. All patients with OHCA assessed by emergency medical service (EMS) staff were consecutively enrolled from Aug 1, 2019, to Dec 31, 2020. Patients with suspected cardiac arrest assessed by bystanders whose return of spontaneous circulation was achieved without the need for defibrillation or EMS personnel cardiopulmonary resuscitation were excluded. Patients with all key variables missing were excluded, including resuscitation attempt, age, sex, witnessed status, cause, all process of care indicators, and all outcome measures. In this analysis, we included data for EMS agencies serving 25 monitoring sites (20 urban and five rural) that included the entire serving population, data for the whole of 2020, and at least 50 OHCA patients in 2020. Data were collected and reported using the Utstein template. We calculated the crude incidence of EMS-assessed OHCA in 2020. We also report data on baseline characteristics (including sex, cause, location of OHCA, and presence of shockable rhythm), process of care (including EMS response time, cardiopulmonary resuscitation, defibrillation, and advanced life support), and outcomes of non-traumatic OHCA between Aug 1, 2019, and Dec 31, 2020, including survival and survival with favourable neurological outcomes at discharge or 30 days, and at 6 and 12 months.

FINDINGS

Of 115·1 million people served by the 25 participating sites, 132 262 EMS-assessed patients with OHCA were enrolled, and resuscitation was attempted for 42 054 (31·8%) patients between Aug 1, 2019, and Dec 31, 2020. The crude incidence of EMS-assessed OHCA was 95·7 per 100 000 population (95% CI 95·6-95·8) in 2020. Among 38 227 individuals with non-traumatic OHCA, 25 958 (67·9%) were male, 30 282 (79·2%) had a cardiac arrest at home, 32 523 (85·1%) had a presumed cardiac cause, and 2297 (6·0%) presented with an initial shockable rhythm. 4049 (11·5%) of 35 090 patients with an unwitnessed or bystander-witnessed OHCA received dispatcher-assisted cardiopulmonary resuscitation and 7121 (20·3%) received bystander cardiopulmonary resuscitation; only 14 (<0·1%) patients were assessed by bystanders with an automated external defibrillator. The median EMS response time was 12 min (IQR 9-16). At hospital discharge or 30 days, 441 (1·2%) of 38 227 survived, 304 (0·8%) survived up to 6 months, and 269 (0·7%) up to 12 months. At hospital discharge or 30 days, 309 (0·8%) survived with favourable neurological outcomes, 257 (0·7%) had favourable neurological outcomes at 6 months, and 236 (0·6%) at 12 months.

INTERPRETATION

Our findings revealed a high burden of EMS-assessed OHCA with a low proportion of resuscitation attempts. The suboptimal implementation of chain of survival and unsatisfactory prognosis call for national efforts to improve the care and outcomes of patients with OHCA in China.

FUNDING

The National Science & Technology Fundamental Resources Investigation Program of China, the State Key Program of the National Natural Science Foundation of China, Taishan Pandeng Scholar Program of Shandong Province, the Key Research & Development Program of Shandong Province, the Interdisciplinary Young Researcher Groups Program of Shandong University, the Clinical Research Center of Shandong University, the ECCM Program of Clinical Research Center of Shandong University, and the Natural Science Foundation of Shandong Province.

The understandability and quality of telephone-guided bystander cardiopulmonary resuscitation in the Western Cape province of South Africa: A manikin-based study

Background

The incidence of cardiovascular disease is on the increase in Africa and with it, an increase in the incidence of out-of-hospital cardiac arrest (OHCA). OHCA carries a high mortality, especially in low-resource settings. Interventions to treat OHCA, such as mass cardiopulmonary resuscitation (CPR) training campaigns are costly. One cost-effective and scalable intervention is telephone-guided bystander CPR (tCPR). Little data exists regarding the quality of tCPR. This study aimed to determine quality of tCPR in untrained members of the public. Participants were also asked to provide their views on the understandability of the tCPR instructions.

Methods

This study followed a prospective, simulation-based observational study design. Adult laypeople who have not had previous CPR training were recruited at public CPR training events and asked to perform CPR on a manikin. Quality was assessed in terms of hand placement, compression rate, compression depth, chest recoil, and chest exposure. tCPR instructions were provided by a trained medical provider, via loudspeaker. Participants were also asked to complete a short questionnaire afterwards, detailing the understandability of the tCPR instructions. Data were analysed descriptively and compared to recommended quality guidance.

Results

Fifty participants were enrolled. Hand placement was accurate in 74 % (n = 37) of participants, while compression depth and chest recoil only had compliance in 20 % (n = 10) and 24 % (n = 12) of participants, respectively. The mean compression rate was within guidelines in just under half (48 %, n = 24) of all participants. Only 20 (40 %) participants exposed the manikin's chest. Only 46 % (n = 23) of participants felt that the overall descriptions offered during the tCPR guidance were understandable, while 80 % (n = 40) and 36 % (n = 18) felt that the instructions on hand placement and compression rate were understandable, respectively. Lastly, 94 % (n = 47) of participants agreed that they would be more likely to perform bystander CPR if they were provided with tCPR.

Conclusion

The quality of CPR performed by laypersons is generally suboptimal and this may affect patient outcomes. There is an urgent need to develop more understandable tCPR algorithms that may encourage bystanders to start CPR and optimise its quality.

Cardiopulmonary resuscitation in low-resource settings: a statement by the International Liaison Committee on Resuscitation, supported by the AFEM, EUSEM, IFEM, and IFRC

Most recommendations on cardiopulmonary resuscitation were developed from the perspective of high-resource settings with the aim of applying them in these settings. These so-called international guidelines are often not applicable in low-resource settings. Organisations including the International Liaison Committee on Resuscitation (ILCOR) have not sufficiently addressed this problem. We formed a collaborative group of experts from various settings including low-income, middle-income, and high-income countries, and conducted a prospective, multiphase consensus process to formulate this ILCOR Task Force statement. We highlight the discrepancy between current cardiopulmonary resuscitation guidelines and their applicability in low-resource settings. Successful existing initiatives such as the Helping Babies Breathe programme and the WHO Emergency Care Systems Framework are acknowledged. The concept of the chainmail of survival as an adaptive approach towards a framework of resuscitation, the potential enablers of and barriers to this framework, and gaps in the knowledge are discussed, focusing on low-resource settings. Action points are proposed, which might be expanded into future recommendations and suggestions, addressing a large diversity of addressees from caregivers to stakeholders. This statement serves as a stepping-stone to developing a truly global approach to guide resuscitation care and science, including in health-care systems worldwide.

Knowledge, Attitudes, and Perceptions Regarding CPR Among Non-medical Staff at a Medical School in South Africa

Background Sudden cardiac arrest can occur unexpectedly in any person and at any place including at medical schools. Improved outcomes after cardiac arrest are dependent on the initiation of early first responder high-quality cardiopulmonary resuscitation (CPR) and rapid defibrillation. There is a lack of data pertaining to the knowledge, attitudes, and perceptions of non-medical staff at medical schools regarding CPR. The aim of this study was to determine the knowledge, attitudes, and perceptions of non-medical staff employed at a medical school in South Africa regarding CPR. Methods In this cross-sectional survey study, a paper-based questionnaire was administered to non-medical staff (i.e., all staff without a medical [MBBCh or equivalent] or nursing degree) employed at the medical school. Data were collected between August 1 and October 25, 2020. Results The final study sample comprised 150 participants. Of these, 103 (68.7%) were female, 109 (72.7%) were ≤ 40 years old, 62 (41.3%) had a postgraduate university degree, 72 (48.0%) had witnessed a medical emergency at the medical school premises and 46 (30.7%) had previously undertaken first aid or CPR training. The mean (SD) knowledge score was 4.4 ± 1.6 out of 10 with only 25 (16.7%) participants knowing what the first thing was to look out for during a medical emergency and 28 (18.7%) participants knowing the location of the automated external defibrillator. Most participants (n=136, 90.7%) indicated that CPR training should be mandatory for all employees. Conclusion Non-medical staff surveyed displayed suboptimal knowledge but positive attitudes and perceptions toward CPR. Although this was a single-center study, these results can be used to motivate CPR training of non-medical staff at all medical schools.

Effectiveness of school-based CPR training among adolescents to enhance knowledge and skills in CPR: A systematic review

BACKGROUND

 Cardiac arrest is responsible for 5% - 10% of all deaths among children age 5-19 years; therefore, strategies to prevent poor outcomes post cardiac arrest among children are critical within schools.

OBJECTIVES

 The purpose of this study was to systematically review the effectiveness of cardiopulmonary resuscitation (CPR) training on CPR knowledge and skills among adolescent school children.

METHOD

 This systematic review was conducted and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. The complete bibliographic databases of PubMed, Cochrane Library, CINAHL and Web of Science were searched from January 2012 to August 2021. Included studies met all the eligibility criteria. The Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies (EPHPP) and Mixed Method Appraisal tool were used to appraise the quality of the included studies.

RESULTS

 Fourteen studies were included in the review, and 5418 participants were found in the databases. The studies were mainly conducted during the last decade, which suggests that the public's attention has been directed toward training schoolchildren in CPR. The most common interventions were taught in video simulation training courses. They also used subjective assessments to evaluate the participants' knowledge and skills.

CONCLUSION

 Findings from this systematic review reveal that CPR training within school settings effectively promoted a change in CPR knowledge and skills among adolescents. Hence, continuous training of CPR among schoolchildren should be encouraged by policymakers, school authorities, parents and teachers to optimise the prompt usage of the skills in any cardiac event. However, a high-quality randomised controlled trial would enhance the strength of evidence in this area.

Out-of-hospital cardiac arrests in the city of Cape Town metropole of the Western Cape province of South Africa: a spatio-temporal analysis

BACKGROUND

The incidence of out-of-hospital cardiac arrest (OHCA) is expected to increase in sub-Saharan Africa along with the incidence of cardiovascular disease. In low-resource settings (LRS), OHCA carries a negligible survival rate. Interventions to improve OHCA survival might not be cost effective for many LRS, and therefore need to be targeted to areas of high incidence. The aim of this study was to describe the temporal and geographic distribution of OHCA in the City of Cape Town, South Africa, and their proximity to percutaneous coronary intervention (PCI) resources.

METHODS

In this retrospective study, OHCA data between 1 January and 31 December 2018 were extracted from public and one private emergency medical services in the Western Cape. For temporal analysis, distribution of OHCA according to time of day, day of the week and month of the year were subjected to chi-squared testing. For geospatial analysis, cluster and outlier, and hotspot analyses were performed. Proximity analysis was employed to determine the driving time from OHCA location to the closest PCI-capable facility.

RESULTS

A total of 929 patients with OHCA received an emergency medical services response in the City of Cape Town, corresponding to an annual prevalence of 23.2 per 100 000 persons. The distribution of OHCA incidence was not explained by month of the year (p = 0.08) or day of the week (p = 0.67). A statistically significant variation in OHCA incidence was explained by time of day (p < 0.01) with 30% (n = 279) of all OHCAs occurring from 05:00 to 09:59. Geospatial analysis yielded a large area of hotspots (99% confidence interval) over the centre of the metropole, Cape Flats and southern suburbs. The median (interquartile range) driving time from the incident to the closest PCI-capable facility was 10:22 (08:05) minutes.

CONCLUSIONS

Incidents of OHCA occurred predominantly at home during the mid-morning, with hotspots around the city centre and residential suburbs of Cape Town. While the incidents occurred close to PCI-capable facilities, some areas remained underserved and access to PCI for OHCA victims may be impossible due to socio-economic factors. With an increase in OHCA incidence expected, it is essential that contextual, cost-effective management interventions be developed and implemented.

A retrospective descriptive analysis of non-physician-performed prehospital endotracheal intubation practices and performance in South Africa

Introduction

Prehospital advanced airway management, including endotracheal intubation (ETI), is one of the most commonly performed advanced life support skills. In South Africa, prehospital ETI is performed by non-physician prehospital providers. This practice has recently come under scrutiny due to lower first pass (FPS) and overall success rates, a high incidence of adverse events (AEs), and limited evidence regarding the impact of ETI on mortality. The aim of this study was to describe non-physician ETI in a South African national sample in terms of patient demographics, indications for intubation, means of intubation and success rates. A secondary aim was to determine what factors were predictive of first pass success.

Methods

This study was a retrospective chart review of prehospital ETIs performed by non-physician prehospital providers, between 01 January 2017 and 31 December 2017. Two national private Emergency Medical Services (EMS) and one provincial public EMS were sampled. Data were analysed descriptively and summarised. Logistic regression was performed to evaluate factors that affect the likelihood of FPS.

Results

A total of 926 cases were included. The majority of cases were adults (n = 781, 84.3%) and male (n = 553, 57.6%). The most common pathologies requiring emergency treatment were head injury, including traumatic brain injury (n = 328, 35.4%), followed by cardiac arrest (n = 204, 22.0%). The mean time on scene was 46 minutes (SD = 28.3). The most cited indication for intubation was decreased level of consciousness (n = 515, 55.6%), followed by cardiac arrest (n = 242, 26.9%) and ineffective ventilation (n = 96, 10.4%). Rapid sequence intubation (RSI, n = 344, 37.2%) was the most common approach. The FPS rate was 75.3%, with an overall success rate of 95.7%. Intubation failed in 33 (3.6%) patients. The need for ventilation was inversely associated with FPS (OR = 0.42, 95% CI: 0.20–0.88, p = 0.02); while deep sedation (OR = 0.56, 95% CI: 0.36–0.88, p = 0.13) and no drugs (OR = 0.47, 95% CI: 0.25–0.90, p = 0.02) compared to RSI was less likely to result in FPS. Increased scene time (OR = 0.99, 95% CI: 0.985–0.997, p < 0.01) was inversely associated FPS.

Conclusion

This is one of the first and largest studies evaluating prehospital ETI in Africa. In this sample of ground-based EMS non-physician ETI, we found success rates similar to those reported in the literature. More research is needed to determine AE rates and the impact of ETI on patient outcome. There is an urgent need to standardise prehospital ETI reporting in South Africa to facilitate future research.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00688-4.