The Pan-Asian Resuscitation Outcomes Study (PAROS) clinical research network: what, where, why and how

Survival and neurological outcomes among OHCA patients in middle- and high-income countries in the Asia-Pacific

BACKGROUND

Currently, there is a knowledge gap on how OHCA impacts lower-resourced areas, and how they fare compared to their higher-resourced counterparts. This study aims to explore the relationship between a country's income category and neurological outcomes after OHCA in the Asia-Pacific region.

METHODS

A multivariable logistic regression model was applied to the prospective Pan-Asian Resuscitation Outcomes Study (PAROS) dataset. The main exposure was country income status (defined by the World Bank), and the main outcome was neurological outcomes (measured by cerebral performance category score). Sensitivity analyses were run to evaluate the robustness of our findings.

RESULTS

Out of a total of 207,450 PAROS cases between 2009-2018, 168,967 OHCA cases were included in the study. 165,404 cases were from high-income countries and 3,563 cases were from middle-income countries. All pediatric, pronounced dead at scene, unknown on-scene survival status, no resuscitation attempted, and traumatic cases were excluded from the analysis. A larger proportion of OHCA patients in high-income countries survived with favorable neurological outcomes (3.65%) compared to middle-income countries (0.75%). High-income countries were associated with better neurological outcomes (AOR 9.05; 95% CI 6.27 to 13.72). Results remained consistent throughout sensitivity analyses.

CONCLUSION

In the PAROS cohort, high-income countries outperform middle income countries in post-OHCA neurological outcomes. Further research is needed to obtain better quality data in middle-income countries and expand reach into low-income countries.

Association between time taken to start Dispatch Assisted-Bystander Cardiopulmonary Resuscitation (DA-CPR) and outcomes for Out-of-Hospital Cardiac Arrest (OHCA)

BACKGROUND

We aimed to investigate the association between the time taken to start dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) and survival outcomes for OHCA.

METHODS

This was a retrospective analysis using the Singapore Pan-Asian Resuscitation Outcomes Study data between 2012 and 2021. We included all adult, witnessed, non-traumatic OHCA patients who received DA-CPR. The exposure of interest was time interval from emergency call to start of DA-CPR. Patients were divided into three groups based on previous studies. The outcome was defined as survival to 30-days with favorable neurological outcomes. Multivariable logistic regression analysis was performed. Restricted cubic spline curves were used to explore non-linear relationships.

RESULTS

3,861 OHCA patients were included in this analysis.　Patients were grouped as follows: short (0-179 seconds), medium (180-239 seconds), and long (≥240 seconds) to start DA-CPR. Adjusted odds ratios [95% CI] for survival to 30-days with favorable neurological outcomes were: medium 0.82 [0.52-1.28], long 0.63 [0.40-0.98]. The restricted cubic spline curve showed a monotonic decrease in the odds ratio for survival to 30-days with favorable neurological outcomes.

CONCLUSIONS

This study found that among non-traumatic, witnessed OHCA patients who received DA-CPR, a shorter time to start DA-CPR was associated with better 30-day survival with favorable neurological outcomes.

Establishing Core Elements for a Prehospital Emergency Care Systems Evaluation Tool (PECSET) for Systems in Early Stages of Development: A Delphi Consensus

OBJECTIVES

International Prehospital Emergency Care (PEC) standards have been primarily developed by and for high resource settings. Most PEC systems in Asia, which are still in the early stages of development, struggle to achieve these standards. There is a need for an evaluation tool which can define achievable basic building blocks for PEC systems in low resource settings to improve quality of PEC. We aimed to identify the core, basic elements (building blocks of a PEC system) for a Prehospital Emergency Care Systems Evaluation Tool (PECSET) for low resource settings in Asia.

METHODS

A 4-stage modified Delphi consensus method was used to engage 32 PEC experts from 12 Asian countries. Participants voted on 32 elements identified from a prior scoping review, focus group discussions, and survey. Each round of voting was conducted through an anonymous, web-based application and followed by face-to-face group discussions. The first two rounds aimed to answer, "Is the element important and feasible in a low resource setting?" The last two stages aimed to answer "Should this element be prioritized as core in the tool?" A thematic analysis of the recorded and transcribed discussions was used to identify participants' rationale for prioritization.

RESULTS

After four rounds of voting, 12 elements were identified as core elements: (1) dispatch assisted instructions, (2) protocols for screening, triage and destination, (3) medical direction, (4) standardized training programs, (5) minimum ambulance standards, (6) operational metrics, (7) quality assurance, (8) operational safety protools, (9) essential patient care documentation, (10) medical records management, (11) layperson awareness and education and (12) universal access emergency number. However, the participants decided to include all 32 elements in the tool grouped into broader categories by percent agreement for a tiered approach for early, intermediate, and advanced PEC systems. Rationales for prioritization included a need for focus on basic infrastructure and building resilience in resource-stretched systems.

CONCLUSIONS

Through a Delphi consensus process, stakeholders identified core elements for PEC systems in low resource settings. These findings will inform the development of a tool for quality assurance and monitoring in low resource settings in South and Southeast Asian countries.

The "invisible ceiling" of bystander CPR in three Asian countries: Descriptive study of national OHCA registry

BACKGROUND

Bystander cardiopulmonary resuscitation (CPR) for out-of-hospital cardiac arrest (OHCA) has increased in Singapore, Japan, and South Korea following the implementation of several public health, bystander-focused interventions, such as dispatcher-assisted CPR and community CPR training. It is unclear whether bystander CPR prevalence will continue on this trajectory over time. This study aimed to investigate the temporal trends of bystander CPR prevalence over a ten-year period in these three Asian countries.

METHOD

Using the national OHCA registries of Singapore, Japan and South Korea, we included witnessed, non-traumatic adult OHCA registered between 2010 and 2020 in Singapore and Japan, and between 2012 and 2020 in South Korea. We excluded those for whom resuscitation was not attempted or was terminated at scene. The study analysed the proportion of bystander CPR in the three countries, presenting the data annually and further breaking it down by age and gender.

RESULTS

This study included 491,067 patients in Japan [male 59 %, median, age 79 years (Q1-Q3, 69-87)], 13,143 patients in Singapore [male 66 %, median, age 69 years (Q1-Q3, 57-80)], and 87,997 patients in South Korea [male 64 %, median age 72 years (Q1-Q3, 59-81)]. The proportion of bystander CPR in each country had increased (Japan: 39 % in 2010 to 45 % in 2015, Singapore: 22 % in 2010 to 53 % in 2015, and South Korea: 37 % in 2012 to 56 % in 2015); however, these proportions have plateaued in 2020 (Japan: 46 %, Singapore: 54 %, and South Korea: 57 %) despite continued efforts. These trends were consistent across different age groups, gender and location.

CONCLUSION

This study investigated the trend of bystander CPR over 10 years in three Asian countries. Although the proportion of bystander CPR has increased, it has now plateaued between 50-60 %. Further research is necessary to identify the contributing factors and advance beyond this "invisible ceiling".

Performance of Universal TOR rule for out-of-hospital cardiac arrest in the Pan-Asian Resuscitation Outcomes Study

Aim

Out-of-hospital cardiac arrest (OHCA) is a public health problem. The Universal Termination of Resuscitation (TOR) rule attempts to reduce the rate of futile transports. The aim of this study was to examine and compare the performance of the TOR rule for OHCA cases in Japan, Korea, Singapore, and Taiwan, where the TOR rule has not been implemented.

Methods

This retrospective cohort study examined data from January 1, 2009, to June 30, 2018, reported to the Pan-Asian Resuscitation Outcomes Study. We included patients with nontraumatic OHCA in the four countries and compared the performance of the Universal TOR rule in these countries.

Results

The number of eligible cases was 173,629. The performance of the Universal TOR rule for cases of neurologically poor survival showed a positive predictive value of more than 0.99 in all four countries. However, specificity differed among them: Japan 0.938, 95% confidence interval (CI): 0.931-0.945; Korea 0.922, 95% CI: 0.901-0.939; Singapore 0.985, 95% CI: 0.964-0.993; and Taiwan 0.773, 95% CI: 0.736-0.807.

Conclusion

The positive predictive value of neurologically poor survival in cases meeting the Universal TOR rule among the four countries was greater than 99%. However, the specificity of these cases that met the Universal TOR rule differed among the four countries. Therefore, further refinement of the Universal TOR rule may be needed for local implementation. The quality of resuscitation in an out-of-hospital setting may also impact survival and neurological outcomes and needs to be considered in any implementation of TOR.

Cost-effectiveness analysis of a 'Termination of Resuscitation' protocol for the management of out-of-hospital cardiac arrest

BACKGROUND

Historically in Singapore, all out-of-hospital cardiac arrests (OHCA) were transported to hospital for pronouncement of death. A 'Termination of Resuscitation' (TOR) protocol, implemented from 2019 onwards, enables emergency responders to pronounce death at-scene in Singapore. This study aims to evaluate the cost-effectiveness of the TOR protocol for OHCA management.

METHODS

Adopting a healthcare provider's perspective, a Markov model was developed to evaluate three competing options: No TOR, Observed TOR reflecting existing practice, and Full TOR if TOR is exercised fully. The model had a cycle duration of 30 days after the initial state of having a cardiac arrest, and was evaluated over a 10-year time horizon. Probabilistic sensitivity analysis was performed to account for uncertainties. The costs per quality adjusted life years (QALY) was calculated.

RESULTS

A total of 3,695 OHCA cases eligible for the TOR protocol were analysed; mean age of 73.0 ± 15.5 years. For every 10,000 hypothetical patients, Observed TOR and Full TOR had more deaths by approximately 19 and 31 patients, respectively, compared to No TOR. Full TOR had the least costs and QALYs at $19,633,369 (95% Uncertainty Interval (UI) 19,469,973 to 19,796,764) and 0 QALYs. If TOR is exercised for every eligible case, it could expect to save approximately $400,440 per QALY loss compared to No TOR, and $821,151 per QALY loss compared to Observed TOR.

CONCLUSION

The application of the TOR protocol for the management of OHCA was found to be cost-effective within acceptable willingness-to-pay thresholds, providing some justification for sustainable adoption.

Bridging Real-World Data Gaps: Connecting Dots Across 10 Asian Countries

The economic trend and the health care landscape are rapidly evolving across Asia. Effective real-world data (RWD) for regulatory and clinical decision-making is a crucial milestone associated with this evolution. This necessitates a critical evaluation of RWD generation within distinct nations for the use of various RWD warehouses in the generation of real-world evidence (RWE). In this article, we outline the RWD generation trends for 2 contrasting nation archetypes: "Solo Scholars"-nations with relatively self-sufficient RWD research systems-and "Global Collaborators"-countries largely reliant on international infrastructures for RWD generation. The key trends and patterns in RWD generation, country-specific insights into the predominant databases used in each country to produce RWE, and insights into the broader landscape of RWD database use across these countries are discussed. Conclusively, the data point out the heterogeneous nature of RWD generation practices across 10 different Asian nations and advocate for strategic enhancements in data harmonization. The evidence highlights the imperative for improved database integration and the establishment of standardized protocols and infrastructure for leveraging electronic medical records (EMR) in streamlining RWD acquisition. The clinical data analysis and reporting system of Hong Kong is an excellent example of a successful EMR system that showcases the capacity of integrated robust EMR platforms to consolidate and produce diverse RWE. This, in turn, can potentially reduce the necessity for reliance on numerous condition-specific local and global registries or limited and largely unavailable medical insurance or claims databases in most Asian nations. Linking health technology assessment processes with open data initiatives such as the Observational Medical Outcomes Partnership Common Data Model and the Observational Health Data Sciences and Informatics could enable the leveraging of global data resources to inform local decision-making. Advancing such initiatives is crucial for reinforcing health care frameworks in resource-limited settings and advancing toward cohesive, evidence-driven health care policy and improved patient outcomes in the region.

Remarkable recovery following prolonged out-of-hospital cardiac arrest: hypoxic-ischemic encephalopathy (HIE) versus posterior reversible encephalopathy syndrome (PRES)-a case report

Background

Cardiac arrest is the most dramatic event that compromises the cerebral blood flow with fatal outcomes. Factors like the presence of bystander cardiopulmonary resuscitation, initial rhythm, and arrest time significantly influence outcomes. However, despite these known factors, there are still aspects of cardiac arrest-related neurological complications that remain less understood. As evidenced by limited case reports, the association between posterior reversible encephalopathy syndrome (PRES) and cardiac arrest is not widely known.

Case Description

We present a case study of out-of-hospital cardiac arrest (OHCA) involving a patient with multiple comorbidities and factors that could complicate her neurological outcome. Despite experiencing a delayed recovery following the cardiac arrest event and an initial insult to the brain, the patient exhibited remarkable neurological recovery. There has been a complex individualized targeted management that contributed to the favorable outcome.

Conclusions

This case study provides valuable insights into the complexities of managing OHCA patients, the factors influencing recovery, and the importance of a multidisciplinary team for early diagnosis and treatment of conditions like PRES to prevent permanent neurological damage. Further research into this area is necessary to better understand the mechanisms and implications of such associations for improving patient care and outcomes following cardiac arrest.

Impact of Bystander Cardiopulmonary Resuscitation on Out-of-Hospital Cardiac Arrest Outcome in Vietnam

Introduction

Patients experiencing an out-of-hospital cardiac arrest (OHCA) frequently do not receive bystander cardiopulmonary resuscitation (CPR), especially in low- and middle-income countries (LMIC). In this study we sought to determine the prevalence of OHCA patients in Vietnam who received bystander CPR and its effects on survival outcomes.

Methods

We performed a multicenter, retrospective observational study of patients (≥18 years) presenting with OHCA at three major hospitals in an LMIC from February 2014-December 2018. We collected data on the hospital and patient characteristics, the cardiac arrest events, the emergency medical services (EMS) system, the therapy methods, and the outcomes and compared these data, before and after pairwise 1:1 propensity score matching, between patients who received bystander CPR and those who did not. Upon admission, we assessed factors associated with good neurological survival at hospital discharge in univariable and multivariable logistic models.

Results

Of 521 patients, 388 (74.5%) were men, and the mean age was 56.7 years (SD 17.3). Although most cardiac arrests (68.7%, 358/521) occurred at home and 78.8% (410/520) were witnessed, a low proportion (22.1%, 115/521) of these patients received bystander CPR. Only half of the patients were brought by EMS (8.1%, 42/521) or private ambulance (42.8%, 223/521), 50.8% (133/262) of whom had resuscitation attempts. Before matching, there was a significant difference in good neurological survival between patients who received bystander CPR (12.2%, 14/115) and patients who did not (4.7%, 19/406; P < .001). After matching, good neurological survival was absent in all OHCA patients who did not receive CPR from a bystander. The multivariable analysis showed that bystander CPR (adjusted odds ratio: 3.624; 95% confidence interval 1.629-8.063) was an independent predictor of good neurological survival.

Conclusion

In our study, only 22.1% of total OHCA patients received bystander CPR, which contributed significantly to a low rate of good neurological survival in Vietnam. To improve the chances of survival with good neurological functions of OHCA patients, more people should be trained to perform bystander CPR and teach others as well. A standard program for emergency first-aid training is necessary for this purpose.

Call for a Singapore National Action Plan for Sepsis (SNAPS): Stop sepsis, save lives

Sepsis is a life-threatening organ dysfunction syndrome caused by a dysregulated host response to an infection.1 It affects up to 48.9 million people globally every year and causes 11 million sepsis-related deaths, accounting for 1 in every 5 deaths worldwide.2 The huge disease burden leads to significant consumption of healthcare resources due to longer hospitalisation and the need for intensive care.3 The resultant economic impact is tremendous; for instance, the 1-year incremental costs of sepsis to the healthcare system in Ontario, Canada approximates CAD 1 billion.3 In addition to the complexity of care required for sepsis, the higher healthcare costs incurred may be explained by the post-sepsis syndrome. Sequelae of sepsis include physical, psychological and medical complications.4

Comparing outcomes of out-of-hospital cardiac arrest patients with initial shockable rhythm in Singapore and Osaka using population-based databases

BACKGROUND

Previous research indicated outcomes among refractory out-of-hospital cardiac arrest (OHCA) patients with initial shockable rhythm were different in Singapore and Osaka, Japan, possibly due to the differences in access to extracorporeal cardiopulmonary resuscitation. However, this previous study had a risk of selection bias. To address this concern, this study aimed to evaluate the outcomes between Singapore and Osaka for OHCA patients with initial shockable rhythm using only population-based databases.

METHODS

This was a secondary analysis of two OHCA population-based databases in Osaka and Singapore, including adult OHCA patients with initial shockable rhythm. A machine-learning-based prediction model was derived from the Osaka data (n = 3088) and applied to the PAROS-SG data (n = 2905). We calculated the observed-expected ratio (OE ratio) for good neurological outcomes observed in Singapore and the expected derived from the data in Osaka by dividing subgroups with or without prehospital ROSC.

RESULTS

The one-month good neurological outcomes in Osaka and Singapore among patients with prehospital ROSC were 70% (791/1,125) and 57% (440/773), and among patients without prehospital ROSC were 10% (196/1963) and 2.8% (60/2,132). After adjusting patient characteristics, the outcome in Singapore was slightly better than expected from Osaka in patients with ROSC (OE ratio, 1.067 [95%CI 1.012 to 1.125]), conversely, it was worse than expected in patients without prehospital ROSC (OE ratio, 0.238 [95%CI 0.173 to 0.294]).

CONCLUSION

This study showed the outcomes of OHCA patients without prehospital ROSC in Singapore were worse than expected derived from Osaka data even using population-based databases. (249/250 words).

Machine learning pre-hospital real-time cardiac arrest outcome prediction (PReCAP) using time-adaptive cohort model based on the Pan-Asian Resuscitation Outcome Study

To save time during transport, where resuscitation quality can degrade in a moving ambulance, it would be prudent to continue the resuscitation on scene if there is a high likelihood of ROSC occurring at the scene. We developed the pre-hospital real-time cardiac arrest outcome prediction (PReCAP) model to predict ROSC at the scene using prehospital input variables with time-adaptive cohort. The patient survival at discharge from the emergency department (ED), the 30-day survival rate, and the final Cerebral Performance Category (CPC) were secondary prediction outcomes in this study. The Pan-Asian Resuscitation Outcome Study (PAROS) database, which includes out-of-hospital cardiac arrest (OHCA) patients transferred by emergency medical service in Asia between 2009 and 2018, was utilized for this study. From the variables available in the PAROS database, we selected relevant variables to predict OHCA outcomes. Light gradient-boosting machine (LightGBM) was used to build the PReCAP model. Between 2009 and 2018, 157,654 patients in the PAROS database were enrolled in our study. In terms of prediction of ROSC on scene, the PReCAP had an AUROC score between 0.85 and 0.87. The PReCAP had an AUROC score between 0.91 and 0.93 for predicting survived to discharge from ED, and an AUROC score between 0.80 and 0.86 for predicting the 30-day survival. The PReCAP predicted CPC with an AUROC score ranging from 0.84 to 0.91. The feature importance differed with time in the PReCAP model prediction of ROSC on scene. Using the PAROS database, PReCAP predicted ROSC on scene, survival to discharge from ED, 30-day survival, and CPC for each minute with an AUROC score ranging from 0.8 to 0.93. As this model used a multi-national database, it might be applicable for a variety of environments and populations.

Predicting Survival Outcomes in Post-Cardiac Arrest Syndrome: The Impact of Combined Sequential Organ Failure Assessment Score and Serum Lactate Measurement

BACKGROUND Post-cardiac arrest syndrome (PCAS) is a major concern and shares pathophysiology with sepsis. Sequential organ failure assessment (SOFA) scores and serum lactate levels, as suggested in the Survival Sepsis Guidelines, have shown significant predictive value for prognosis in patients with sepsis. This retrospective study aimed to evaluate combined use of the SOFA score and serum lactate measurement on survival prognosis in PCAS. MATERIAL AND METHODS Our study included patients with return of spontaneous circulation after cardiac arrest who were age >18 years and underwent targeted temperature management. The 438 patients were allocated to a surviving group and a deceased group at discharge. Multivariable regression models were used to evaluate any association with SOFA scores, serum lactate levels, and survival. To evaluate the predictive value of regression models, the area under the receiver operating characteristic curve (AUROC) was assessed. RESULTS Lower SOFA score and serum lactate level were associated with better survival rates in the post-cardiac arrest patients (SOFA score: odds ratio (OR), 0.77; 95% confidence interval (CI), 0.67-0.88; P<0.001; lactate level: OR, 0.85; 95% CI, 0.81-0.94; P<0.001). The combined model of the SOFA score and serum lactate level was superior to models including either SOFA score or serum lactate level alone in predicting survival (AUROC, 0.86 vs 0.83, P=0.028, 0.86 vs 0.81, P=0.004). CONCLUSIONS Because of the superiority of the combined model of SOFA score and serum lactate level, combining these 2 factors could improve prediction of prognosis and survival outcomes in PCAS.

Outcome assessment for out-of-hospital cardiac arrest patients in Singapore and Japan with initial shockable rhythm

BACKGROUND

Singapore and Osaka in Japan have comparable population sizes and prehospital management; however, the frequency of ECPR differs greatly for out-of-hospital cardiac arrest (OHCA) patients with initial shockable rhythm. Given this disparity, we hypothesized that the outcomes among the OHCA patients with initial shockable rhythm in Singapore were different from those in Osaka. The aim of this study was to evaluate the outcomes of OHCA patients with initial shockable rhythm in Singapore compared to the expected outcomes derived from Osaka data using machine learning-based prediction models.

METHODS

This was a secondary analysis of two OHCA databases: the Singapore PAROS database (SG-PAROS) and the Osaka-CRITICAL database from Osaka, Japan. This study included adult (18-74 years) OHCA patients with initial shockable rhythm. A machine learning-based prediction model was derived and validated using data from the Osaka-CRITICAL database (derivation data 2012-2017, validation data 2018-2019), and applied to the SG-PAROS database (2010-2016 data), to predict the risk-adjusted probability of favorable neurological outcomes. The observed and expected outcomes were compared using the observed-expected ratio (OE ratio) with 95% confidence intervals (CI).

RESULTS

From the SG-PAROS database, 1,789 patients were included in the analysis. For OHCA patients who achieved return of spontaneous circulation (ROSC) on hospital arrival, the observed favorable neurological outcome was at the same level as expected (OE ratio: 0.905 [95%CI: 0.784-1.036]). On the other hand, for those who had continued cardiac arrest on hospital arrival, the outcomes were lower than expected (shockable rhythm on hospital arrival, OE ratio: 0.369 [95%CI: 0.258-0.499], and nonshockable rhythm, OE ratio: 0.137 [95%CI: 0.065-0.235]).

CONCLUSION

This observational study found that the outcomes for patients with initial shockable rhythm but who did not obtain ROSC on hospital arrival in Singapore were lower than expected from Osaka. We hypothesize this is mainly due to differences in the use of ECPR.

The comparison of emergency medical service responses to and outcomes of out-of-hospital cardiac arrest before and during the COVID-19 pandemic in Thailand: a cross-sectional study

BACKGROUND

During the coronavirus disease 2019 (COVID-19) pandemic, the format of patients with out-of-hospital cardiac arrest (OHCA) management was modified. Therefore, this study compared the response time and survival at the scene of patients with OHCA managed by emergency medical services (EMS) before and during the COVID-19 pandemic in Thailand.

METHODS

This retrospective, observational study used EMS patient care reports to collect data on adult patients with OHCA coded with cardiac arrest. Before and during the COVID-19 pandemic was defined as the periods of January 1, 2018-December 31, 2019, and January 1, 2020-December 31, 2021, respectively.

RESULTS

A total of 513 and 482 patients were treated for OHCA before and during the COVID-19 pandemic, respectively, showing a decrease of 6% (% change difference =- 6.0, 95% confidence interval [CI] - 4.1, - 8.5). However, the average number of patients treated per week did not differ (4.83 ± 2.49 vs. 4.65 ± 2.06; p value = 0.700). While the mean response times did not significantly differ (11.87 ± 6.31 vs. 12.21 ± 6.50 min; p value = 0.400), the mean on-scene and hospital arrival times were significantly higher during the COVID-19 pandemic compared with before by 6.32 min (95% CI 4.36-8.27; p value < 0.001), and 6.88 min (95% CI 4.55-9.22; p value < 0.001), respectively. Multivariable analysis revealed that patients with OHCA had a 2.27 times higher rate of return of spontaneous circulation (ROSC) (adjusted odds ratio = 2.27, 95% CI 1.50-3.42, p value < 0.001), and a 0.84 times lower mortality rate (adjusted odds ratio = 0.84, 95% CI: 0.58-1.22, p value = 0.362) during the COVID-19 pandemic period compared with that before the pandemic.

CONCLUSIONS

In the present study, there was no significant difference between the response time of patients with OHCA managed by EMS before and during COVID-19 pandemic period; however, markedly longer on-scene and hospital arrival times and higher ROSC rates were observed during the COVID-19 pandemic than those in the period before the pandemic.

Global disparities in arrhythmia care: Mind the gap

Delivery of comprehensive arrhythmia care requires the simultaneous presence of many resources. These include complex hospital infrastructure, expensive implantable equipment, and expert personnel. In many low- and middle-income countries (LMICs), at least 1 of these components is often missing, resulting in a gap between the demand for arrhythmia care and the capacity to supply care. In addition to this treatment gap, there exists a training gap, as many clinicians in LMICs have limited access to formal training in cardiac electrophysiology. Given the progressive increase in the burden of cardiovascular diseases in LMICs, these patient care and clinical training gaps will widen unless further actions are taken to build capacity. Several strategies for building arrhythmia care capacity in LMICs have been described. Medical missions can provide donations of both equipment and clinical expertise but are only intermittently present and therefore are not optimized to provide the longitudinal support needed to create self-sustaining infrastructure. Use of donated or reprocessed equipment (eg, cardiac implantable electronic devices) can reduce procedural costs but does not address the need for infrastructure, including diagnostics and expert personnel. Collaborative efforts involving multiple stakeholders (eg, professional organizations, government agencies, hospitals, and educational institutions) have the potential to provide longitudinal support of both patient care and clinician education in LMICs.

Out of hospital cardiac arrest: experience of a bystander CPR training program in Karachi, Pakistan

Background

Nearly 90% of out-of-hospital cardiac arrest (OHCA) patients are witnessed, yet only 2.3% received bystander cardiopulmonary resuscitation (CPR) in Pakistan. This study aimed to determine retention of knowledge and skills of Hands-Only CPR among community participants in early recognition of OHCA and initiation of CPR in Karachi, Pakistan.

Methods

Pre and post-tests were conducted among CPR training participants from diverse non-health-related backgrounds from July 2018 to October 2019. Participants were tested for knowledge and skills of CPR before training (pre-test), immediately after training (post-test), and 6 months after training (re-test). All the participants received CPR training through video and scenario-based demonstration using manikins. Post-training CPR skills of the participants were assessed using a pre-defined performance checklist. The facilitator read out numerous case scenarios to the participants, such as drowning, poisoning, and road traffic injuries, etc., and then asked them to perform the critical steps of CPR identified in the scenario on manikins. The primary outcome was the mean difference in the knowledge score and skills of the participants related to the recognition of OHCA and initiation of CPR.

Results

The pre and post-tests were completed by 652 participants, whereas the retention test after 6 months was completed by 322 participants. The mean knowledge score related to the recognition of OHCA, and initiation of CPR improved significantly (p < 0.001) from pre-test [47.8/100, Standard Deviation (SD) ±13.4] to post-test (70.2/100, SD ±12.1). Mean CPR knowledge after 6 months (retention) reduced slightly from (70.2/100, ±12.1) to (66.5/100, ±10.8). CPR skill retention for various components (check for scene safety, check for response, check for breathing and correct placement of the heel of hands) deteriorated significantly (p < 0.001) from 77.9% in the post-test to 72.8% in re-test. Participants performed slightly better on achieving an adequate rate of chest compressions from 73.1% in post-test to 76.7% in re-test (p 0.27).

Conclusion

Community members with non-health backgrounds can learn and retain CPR skills, allowing them to be effective bystander CPR providers in OHCA situations. We recommend mass population training in Pakistan for CPR to increase survival from OHCA.

The Psychological Well-Being of Southeast Asian Frontline Healthcare Workers during COVID-19: A Multi-Country Study

Objectives: This study examined the prevalence of anxiety, depression, and job burnout among frontline healthcare workers (HCWs) across six Southeast Asian countries (Indonesia, Malaysia, Philippines, Singapore, Thailand, Vietnam) during the COVID-19 pandemic in 2021. We also investigated the associated risk and protective factors. Methods: Frontline HCWs (N = 1381) from the participating countries participated between 4 January and 14 June 2021. The participants completed self-reported surveys on anxiety (GAD-7), depression (PHQ-8), and job burnout (PWLS). Multivariate logistic regressions were performed with anxiety, depression, and job burnout as outcomes and sociodemographic and job characteristics and HCW perceptions as predictors. Results: The average proportion of HCWs reporting moderate anxiety, moderately severe depression, and job burnout across all countries were 10%, 4%, and 20%, respectively. Working longer hours than usual (Odds ratio [OR] = 1.82; 3.51), perceived high job risk (1.98; 2.22), and inadequate personal protective equipment (1.89; 2.11) were associated with increased odds of anxiety and job burnout while working night shifts was associated with increased risk of depression (3.23). Perceived good teamwork was associated with lower odds of anxiety (0.46), depression (0.43), and job burnout (0.39). Conclusion: Job burnout remains a foremost issue among HCWs. Potential opportunities to improve HCW wellness are discussed.

Mode of transportation of out-of-hospital cardiac arrest patients, the role of community actions and interventions

The Emergency Medical Services constitutes a critical component in treating patients with out-of-hospital cardiac arrest (OHCA). Activating the EMS system is the first important step in deploying resources, but community involvement in the care of emergent patients is multifaceted and complex. How does the public access EMS services versus other modes of transport remains under investigated; and if the public opts for a different mode of transport to the hospital, how does this affect outcomes?

Prevalence of anxiety, depression, and post-traumatic stress disorder after cardiac arrest: A systematic review and meta-analysis

AIM

Quality of life after surviving out-of-hospital cardiac arrest (OHCA) is poorly understood, and the risk to mental health is not well understood. We aimed to estimate the prevalence of anxiety, depression, and post-traumatic stress disorder (PTSD) following OHCA.

METHODS

In this systematic review and meta-analysis, databases (MEDLINE, EMBASE, and PsycINFO) were searched from inception to July 3, 2021, for studies reporting the prevalence of depression, anxiety, and PTSD among OHCA survivors. Data abstraction and quality assessment were conducted by two authors independently, and a third resolved discrepancies. A single-arm meta-analysis of proportions was conducted to pool the proportion of patients with these conditions at the earliest follow-up time point in each study and at predefined time points. Meta-regression was performed to identify significant moderators that contributed to between-study heterogeneity.

RESULTS

The search yielded 15,366 articles. 13 articles were included for analysis, which comprised 186,160 patients. The pooled overall prevalence at the earliest time point of follow-up was 19.0% (11 studies; 95% confidence interval [CI] = 11.0-30.0%) for depression, 26.0% (nine studies; 95% CI = 16.0-39.0%) for anxiety, and 20.0% (three studies; 95% CI = 3.0-65.0%) for PTSD. Meta-regression showed that the age of patients and proportion of female sex were non-significant moderators.

CONCLUSION

The burden of mental health disorders is high among survivors of OHCA. There is an urgent need to understand the predisposing risk factors and develop preventive strategies.

Accessibilité aux soins en situation d’urgence : des déterminants complexes, un besoin d’outils novateurs

Les délais d’accès aux soins sont directement associés au pronostic de nombreuses situations et pathologies urgentes telles que l’arrêt cardiaque extrahospitalier, l’accident vasculaire cérébral, l’infarctus du myocarde ou le traumatisme grave. Ils représentent ainsi un critère de qualité et d’efficacité du système préhospitalier. Or, les déterminants de l’accessibilité aux soins urgents, donc des délais de prise en charge préhospitalière jusqu’au soin définitif, sont multiples, intriquant notamment des dimensions organisationnelles, géographiques et socioéconomiques, captées par différentes définitions de l’accessibilité aux soins. La mesure de l’accessibilité aux soins urgents est donc complexe et nécessite l’emploi de méthodes spécifiques. Ses déterminants sont sujets à d’importantes disparités territoriales, tant sur le plan national que local, qui conduisent à de fortes inégalités de santé en situation urgente. L’organisation du système de soins préhospitaliers doit ainsi prendre en compte l’ensemble des définitions de l’accessibilité en vie réelle, afin de répondre à des objectifs de performance ajustés aux enjeux particuliers des pathologies traceuses les plus urgentes. Les prochaines évolutions organisationnelles et technologiques en médecine d’urgence devraient permettre de mieux appréhender les déterminants de l’accessibilité à toutes les phases de la prise en charge préhospitalière, vers un rééquilibrage de l’inadéquation entre les besoins réels et l’offre possible de soins urgents.

Survival after traumatic out-of-hospital cardiac arrest in Vietnam: a multicenter prospective cohort study

BACKGROUND

Pre-hospital services are not well developed in Vietnam, especially the lack of a trauma system of care. Thus, the prognosis of traumatic out-of-hospital cardiac arrest (OHCA) might differ from that of other countries. Although the outcome in cardiac arrest following trauma is dismal, pre-hospital resuscitation efforts are not futile and seem worthwhile. Understanding the country-specific causes, risk, and prognosis of traumatic OHCA is important to reduce mortality in Vietnam. Therefore, this study aimed to investigate the survival rate from traumatic OHCA and to measure the critical components of the chain of survival following a traumatic OHCA in the country.

METHODS

We performed a multicenter prospective observational study of patients (> 16 years) presenting with traumatic OHCA to three central hospitals throughout Vietnam from February 2014 to December 2018. We collected data on characteristics, management, and outcomes of patients, and compared these data between patients who died before hospital discharge and patients who survived to discharge from the hospital.

RESULTS

Of 111 eligible patients with traumatic OHCA, 92 (82.9%) were male and the mean age was 39.27 years (standard deviation: 16.38). Only 5.4% (6/111) survived to discharge from the hospital. Most cardiac arrests (62.2%; 69/111) occurred on the street or highway, 31.2% (29/93) were witnessed by bystanders, and 33.7% (32/95) were given cardiopulmonary resuscitation (CPR) by a bystander. Only 29 of 111 patients (26.1%) were taken by the emergency medical services (EMS), 27 of 30 patients (90%) received pre-hospital advanced airway management, and 29 of 53 patients (54.7%) were given resuscitation attempts by EMS or private ambulance. No significant difference between patients who died before hospital discharge and patients who survived to discharge from the hospital was found for bystander CPR (33.7%, 30/89 and 33.3%, 2/6, P > 0.999; respectively) and resuscitation attempts (56.3%, 27/48, and 40.0%, 2/5, P = 0.649; respectively).

CONCLUSION

In this study, patients with traumatic OHCA presented to the ED with a low rate of EMS utilization and low survival rates. The poor outcomes emphasize the need for increasing bystander first-aid, developing an organized trauma system of care, and developing a standard emergency first-aid program for both healthcare personnel and the community.

Incidence, characteristics and complications of dispatcher-assisted cardiopulmonary resuscitation initiated in patients not in cardiac arrest

AIM

Dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) can increase bystander CPR rates and improve outcomes in out-of-hospital cardiac arrest (OHCA). Despite the use of protocols, dispatchers may falsely recognise some cases to be in cardiac arrest. Hence, this study aimed to find the incidence of DA-CPR initiated for non-OHCA cases, its characteristics and clinical outcomes in the Singapore population.

METHODS

This was a multi-centre, observational study of all dispatcher-recognised cardiac arrests cases between January to December 2017 involving three tertiary hospitals in Singapore. Data was obtained from the Pan-Asian Resuscitation Outcomes Study cohort. Audio review of dispatch calls from the national emergency ambulance service were conducted and information about patients' clinical outcomes were prospectively collected from health records. Univariate analysis was performed to determine factors associated with in-hospital mortality among non-OHCA patients who received DA-CPR.

RESULTS

Of the 821 patients recognised as having OHCA 328 (40.0%) were not in cardiac arrest and 173 (52.7%) of these received DA-CPR. No complications from chest compressions were found from hospital records. The top diagnoses of non-OHCA patients were cerebrovascular accidents (CVA), syncope and infection. Only final diagnoses of CVA (aOR 20.68), infection (aOR 17.34) and myocardial infarction (aOR 32.19) were significantly associated with in-hospital mortality.

CONCLUSION

In this study, chest compressions initiated on patients not in cardiac arrest by dispatchers did not result in any reported complications and was not associated with in-hospital mortality. This provides reassurance for the continued implementation of DA-CPR.

Brain injury in extracorporeal cardiopulmonary resuscitation: translational to clinical research

The addition of extracorporeal membrane oxygenation (ECMO) to conventional cardiopulmonary resuscitation (CPR), termed extracorporeal cardiopulmonary resuscitation (ECPR), has significantly improved survival in selected patient populations. Despite this advancement, significant neurological impairment persists in approximately half of survivors. ECPR represents a potential advancement for patients who experience refractory cardiac arrest (CA) due to a reversible etiology and do not regain spontaneous circulation. Important risk factors for acute brain injury (ABI) in ECPR include lack of perfusion, reperfusion, and altered cerebral autoregulation. The initial hypoxic-ischemic injury caused by no-flow and low-flow states after CA and during CPR is compounded by reperfusion, hyperoxia during ECMO support, and nonpulsatile blood flow. Additionally, ECPR patients are at risk for Harlequin syndrome with peripheral cannulation, which can lead to preferential perfusion of cerebral vessels with deoxygenated blood. Lastly, the oxygenator membrane is prothrombotic and requires systemic anticoagulation. The two competing phenomena result in thrombus formation, hemolysis, and thrombocytopenia, increasing the risk of ischemic and hemorrhagic ABI. In addition to clinical studies, we assessed available ECPR animal models to identify the mechanisms underlying ABI at the cellular level. Standardized multimodal neurological monitoring may facilitate early detection of and intervention for ABI. With the increasing use of ECPR, it is critical to understand the pathophysiology of ABI, its prevention, and the management strategies for improving the outcomes of ECPR. Translational and clinical research focusing on acute ABI immediately after ECMO cannulation and its short- and long-term neurological outcomes are warranted.

Rationale, development and implementation of the ReACanROC registry for out-of-hospital cardiac arrests in France and Canada

France and Canada prehospital systems and care delivery in out-of-hospital cardiac arrests (OHCAs) show substantial differences. This article aims to describe the rationale, design, implementation and expected research implications of the international, population-based, France-Canada registry for OHCAs, namely ReACanROC, which is built from the merging of two nation-wide, population-based, Utstein-style prospectively implemented registries for OHCAs attended to by emergency medical services. Under the supervision of an international steering committee and research network, the ReACanROC dataset will be used to run in-depth analyses on the differences in organisational, practical and geographic predictors of survival after OHCA between France and Canada. ReACanROC is the first Europe-North America registry ever created to meet this goal. To date, it covers close to 80 million people over the two countries, and includes approximately 200 000 cases over a 10-year period.

A hypothetical implementation of 'Termination of Resuscitation' protocol for out-of-hospital cardiac arrest

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A proportion of out of hospital cardiac arrests are associated with poor prognoses.

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Prolonged resuscitation on medically futile cases results in financial burden for the health system and distress for health care workers.

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‘Termination of Resuscitation’ protocols enable ceasing resuscitation efforts for certain cases.

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Successfully adopting a protocol over existing practices demonstrates fewer cases transported to hospital, fewer emergency treatments and fewer inpatient bed days used.

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The protocol can lead to reduced costs and fewer non-beneficial hospital admissions.

Background

Out-of-hospital cardiac arrests with negligible chance of survival are routinely transported to hospital and many are pronounced dead thereafter. This leads to some potentially avoidable costs. The ‘Termination of Resuscitation’ protocol allows paramedics to terminate resuscitation efforts onsite for medically futile cases. This study estimates the changes in frequency of costly events that might occur when the protocol is applied to out-of-hospital cardiac arrests, as compared to existing practice.

Methods

We used Singapore data from the Pan-Asian Resuscitation Outcomes Study, from 1 Jan 2014 to 31 Dec 2017. A Markov model was developed to summarise the events that would occur in two scenarios, existing practice and the implementation of a Termination of Resuscitation protocol. The model was evaluated for 10,000 hypothetical patients with a cycle duration of 30 days after having a cardiac arrest. Probabilistic sensitivity analysis accounted for uncertainties in the outcomes: number of urgent transports and emergency treatments, inpatient bed days, and total number of deaths.

Results

For every 10,000 patients, existing practice resulted in 1118 (95% Uncertainty Interval 1117 to 1119) additional urgent transports to hospital and subsequent emergency treatments. There were 93 (95% Uncertainty Interval 66 to 120) extra inpatient bed days used, and 3 fewer deaths (95% Uncertainty Interval 2 to 4) in comparison to using the protocol.

Conclusion

The findings provide some evidence for adopting the Termination of Resuscitation protocol. This policy could lead to a reduction in costs and non-beneficial hospital admissions, however there may be a small increase in the number of avoidable deaths.

Survival after out-of-hospital cardiac arrest, Viet Nam: multicentre prospective cohort study

Objective

To investigate factors associated with survival after out-of-hospital cardiac arrest in Viet Nam.

Methods

We did a multicentre prospective observational study of people (> 18 years) presenting with out-of-hospital cardiac arrest (not caused by trauma) to three tertiary hospitals in Viet Nam from February 2014 to December 2018. We collected data on characteristics, management and outcomes of patients with out-of-hospital cardiac arrest and compared these data by type of transportation to hospital and survival to hospital admission. We assessed factors associated with survival to admission to and discharge from hospital using logistic regression analysis.

Findings

Of 590 eligible people with out-of-hospital cardiac arrest, 440 (74.6%) were male and the mean age was 56.1 years (standard deviation: 17.2). Only 24.2% (143/590) of these people survived to hospital admission and 14.1% (83/590) survived to hospital discharge. Most cardiac arrests (67.8%; 400/590) occurred at home, 79.4% (444/559) were witnessed by bystanders and 22.3% (124/555) were given cardiopulmonary resuscitation by a bystander. Only 8.6% (51/590) of the people were taken to hospital by the emergency medical services and 32.2% (49/152) received pre-hospital defibrillation. Pre-hospital defibrillation (odds ratio, OR: 3.90; 95% confidence interval, CI: 1.54-9.90) and return of spontaneous circulation in the emergency department (OR: 2.89; 95% CI: 1.03-8.12) were associated with survival to hospital admission. Hypothermia therapy during post-resuscitation care was associated with survival to discharge (OR: 5.44; 95% CI: 2.33-12.74).

Conclusion

Improvements are needed in the emergency medical services in Viet Nam such as increasing bystander cardiopulmonary resuscitation and public access defibrillation, and improving ambulance and post-resuscitation care.

Public knowledge and attitudes towards bystander cardiopulmonary resuscitation (CPR) in Ghana, West Africa

BACKGROUND AND OBJECTIVES

Early bystander cardiopulmonary resuscitation (CPR) is one of the most important predictors of out-of-hospital cardiac arrests (OHCA) survival. There is a dearth of literature on CPR engagement in countries such as Ghana, where cardiovascular events are increasingly prevalent. In this study, we sought to evaluate Ghanaians' knowledge of and attitudes towards bystander CPR, in the context of the country's nascent emergency medicine network.

METHODS

Capitalizing on the growing ubiquity and use of social media across the country, we used a novel social media sampling strategy for this study. We created, pre-tested, and distributed an online survey, using the two most utilized social media platforms in Ghana: WhatsApp and Facebook. An airtime data incentive of 5 US dollars, worth between 5 and 10 GB of cellular data based on mobile phone carrier, was provided as incentive. Inclusion criteria were (1) ≥ 18 years of age, (2) living in Ghana. Survey participants were encouraged to distribute the survey within their own networks to expand its reach. We stratified participants' responses by healthcare affiliation, and further grouped healthcare workers into ambulance and non-ambulance personnel. We used chi-square (χ2)/Fisher's Exact tests to compare differences in responses between the groups. Based on the question "have you ever heard of CPR?", an alpha of 0.05 and a 95% confidence interval, we expected to have 80% power to detect a 15% difference in responses between lay and healthcare providers with an estimated sample size of 246 study participants.

RESULTS

The survey was launched on 8 July 2019 and closed approximately 51 h post-launch. With a 64% completion rate and 479 unique survey completions, the study was overpowered at 96% power, to detect differences in responses between the groups. There was geographic representation across all 10 historic regions of Ghana. Over half (57.8%, n = 277) of the respondents were non-medically affiliated, and 71.9% were women. Healthcare workers were more aware of CPR than lay respondents (96.5% vs 68.1%; p < 0.001). Eighty-five percent of respondents were aware that CPR involves chest compressions, and almost 70% indicated that "mouth to mouth" is a necessary component of CPR. Fewer than 10% were unwilling to administer CPR. Lack of skills (44.9%) and fear of causing harm (25.5%) were barriers noted by respondents for not administering CPR. Notably, a quarter of ambulance workers reported never having received CPR training. If they were to witness a collapse, 62.0% would call an ambulance, and 32.6% would hail a taxi.

CONCLUSION

The majority of participants are willing to perform CPR. Contextualized training that emphasizes hands-only CPR and builds participants' confidence may increase bystander willingness and engagement.

Nationwide trends in residential and non-residential out-of-hospital cardiac arrest and differences in bystander cardiopulmonary resuscitation

AIMS

Singapore is highly-urbanized, with >90% of the population living in high-rise apartments. She has implemented several city-wide interventions such as dispatcher-assisted CPR, community CPR training and smartphone activation of volunteers to increase bystander CPR (BCPR) rates for out-of-hospital cardiac arrest (OHCA). These may have different impact on residential and non-residential OHCA. We aimed to evaluate the characteristics, processes-of-care and outcome differences between residential and non-residential OHCA and study the differences in temporal trends of BCPR rates.

METHODS

This was a national, observational study in Singapore from 2010 to 2016, using data from the prospective Pan-Asian Resuscitation Outcomes Study. The primary outcome was survival (to-discharge or to-30-days). Multivariate logistic regression was performed to determine the effect of location-type on survival and a test of statistical interaction was performed to assess the difference in the temporal relationship of BCPR rates between location-type.

RESULTS

8397 cases qualified for analysis, of which 5990 (71.3%) were residential. BCPR and bystander automated external defibrillator (AED) rates were significantly lower in residential as compared to non-residential arrests (41.0% vs 53.6%, p < 0.01; 0.4% vs 10.8%, p < 0.01 respectively). Residential BCPR increased from 15.8% (2010) to 57.1% (2016). Residential cardiac arrests had lower survival-to-discharge (2.9% vs 10.1%, p < 0.01). Multivariate logistic regression analysis showed that location-type had an independent effect on survival, with residential arrests having poorer survival compared to non-residential cardiac arrests (adjusted OR 0.547 [0.435-0.688]). A test of statistical interaction showed a significant interaction effect between year and location-type for bystander CPR, with a narrowing of differences in bystander CPR between residential and non-residential cardiac arrests over the years.

CONCLUSION

Residential cardiac arrests had poorer bystander intervention and survival from 2010 to 2016 in Singapore. BCPR had improved more in residential arrests compared to non-residential arrests over a period of city-wide interventions to improve BCPR.

Cardiac arrest and sudden cardiac death registries: a systematic review of global coverage

Background

Sudden cardiac death (SCD) is a major global health problem, accounting for up to 20% of deaths in Western societies. Clinical quality registries have been shown in a range of disease conditions to improve clinical management, reduce variation in care and improve outcomes.

Aim

To identify existing cardiac arrest (CA) and SCD registries, characterising global coverage and methods of data capture and validation.

Methods

Biomedical and public search engines were searched with the terms 'registry cardio*'; 'sudden cardiac death registry' and 'cardiac arrest registry'. Registries were categorised as either CA, SCD registries or 'other' according to prespecified criteria. SCD registry coordinators were contacted for contemporaneous data regarding registry details.

Results

Our search strategy identified 49 CA registries, 15 SCD registries and 9 other registries (ie, epistries). Population coverage of contemporary CA and SCD registries is highly variable with registries densely concentrated in North America and Western Europe. Existing SCD registries (n=15) cover a variety of age ranges and subpopulations, with some enrolling surviving patients (n=8) and family members (n=5). Genetic data are collected by nine registries, with the majority of these (n=7) offering indefinite storage in a biorepository.

Conclusions

Many CA registries exist globally, although with inequitable population coverage. Comprehensive multisource surveillance SCD registries are fewer in number and more challenging to design and maintain. Challenges identified include maximising case identification and case verification.

Trial registration number

CRD42019118910.

Characteristics of Out of Hospital Cardiac Arrest in the United Arab Emirates

Background:

Out of hospital cardiac arrest is one of the leading causes of death globally. This study aimed to identify the characteristics of out of hospital cardiac arrest patients who were attended and treated by the National Ambulance crew. A lot of studies reported the importance of implementing chain of survival to increase survival rates from cardiac arrest. To be implemented in United Arab Emirates (UAE), it required a detailed study of the community engagement. The study aimed to explore the demography of the incidences, location, age, gender epidemiology of the patients who had their cardiac arrest witnessed along with their Bystander cardiopulmonary resuscitation (CPR) performed prior to the arrival of National Ambulance and public access to an automated external defibrillator. The return of spontaneous circulation was also explored prior to their arrival to the emergency department.

Methods:

The research is a prospective descriptive cohort study of out of hospital cardiac arrest patients attended by National Ambulance between July 2017 and June 2018. The National Ambulance provides emergency medical services for public and private hospitals in the Emirates of Sharjah, Ajman, Ras-al-Khaimah, Fujairah, and Umm Al-Quwain and its clients in Abu Dhabi in UAE. Data for the study were collected by the National Ambulance crew attending the OHCA patients, using a structured questionnaire.

Results:

In this 1-year period, a total of 715 out of hospital cardiac arrest cases were attended by the National Ambulance with higher percentage (77%) of male patients. Resuscitation and transportation were attempted for 95% whereas 5% were pronounced dead on the spot. In this study, the median age of the patients was 50 years. Majority of the patients were Asians 55% (n = 395) followed by Arabs non-UAE citizens 19.4% (n = 139) and UAE citizens 16% (n = 113). Patients facing sudden cardiac arrest in their homes or residences represented 69.9% (n = 500), street and public places 22.5% (n = 161), and workplace 6.8% (n = 49). The percentage of patients who had witnessed cardiac arrest was 51.7% (n = 370) only 197 had CPR performed on them prior to the arrival of National Ambulance. Low public access to AED was found in this population that is 1.8% (n = 13). A majority of the participants in this study had nonshockable rhythms 84.3% (n = 603) whereas shockable rhythms presented on 11% (n = 80). The percentage of patients who had ROSC at the scene or en route to the hospitals was found 9.2% (n = 66).

Conclusion:

In this 1-year study, the result showed that cardiac arrest was recognized and witnessed in about half of the cases, but low bystander CPR was performed. Low public access and use of AED were found. Data on hospitalized and discharged OHCA patients were not available and required further linkage and corporation between ambulance services and hospitals to ensure data continuity of OHCA cases. This study is essential for the implementation of proper chain of survival and reduction in mortality rates in UAE.

Predictors of Out of Hospital Cardiac Arrest Outcomes in Pre-Hospital Settings; a Retrospective Cross-sectional Study

INTRODUCTION

Different potential factors can affect the outcomes of Out of Hospital Cardiac Arrest (OHCA). The present study aimed to identify important factors contributing to the Return of Spontaneous Circulation (ROSC) and Survival to Hospital Discharge (SHD) in these patients.

METHODS

This cross-sectional study was conducted on all the OHCA patients who underwent Cardiopulmonary Resuscitation (CPR) in emergency medical service (EMS) of Hamedan province during 2016-2017. All the relevant data were retrieved from three sources, according to Utstein's style. In addition, univariate and multivariate logistic regressions were employed to identify predictive factors of ROSC and SHD using SPSS software, version 20.

RESULTS

Among the 3214 eligible patients whose data were collected, most OHCA patients were female (59.7%) with the mean age of 58 years. Moreover, the majority of OHCAs (77.8%) occurred at home during 8pm-8am (65.1%) and about 26.3% of OHCAs were witnessed, with only 5.1% bystander-initiated CPR. Furthermore, the median ambulance response time and CPR duration were 6.0 and 20 minutes, respectively. Overall, ROSC and SHD success rates were 8.3 and 4.1%, respectively. Bystander CPR was found to be the most effective predicting factor for the success rate of ROSC (AOR=3.26, P<0.001) and SHD (AOR=3.04, P<0.001) after adjusting for the Utstein variables including the patients' age, gender, cardiac disease history, arrest time, CPR duration, response time, being witnessed, bystander CPR, and endotracheal intubation (ETI).

CONCLUSION

The overall success rates of ROSC and SHD were 8.3% and 4.1%, respectively. The age, ambulance response time, CPR duration, and cardiac disease history were negatively associated with the outcomes of ROSC and SHD, while being witnessed, bystander CPR, ETI, and initial shockable rhythm were positively related to both of the above-mentioned outcomes.

The importance of developing global emergency medicine research network

Despite the fact that emergency care can impact health of populations, the global epidemiology of emergencies in children and adults is unknown and substantial variation exists in emergency infrastructure among different nations, especially among the low and middle income countries. Various research networks which are etiology specific or subspecialty specific, including emergency care based networks have positively impacted the health of populations. However, emergency departments (ED) in low and middle income counties are underrepresented in most international networks. Creation of a global ED based research network will help generate generalizable evidence that can then be translated into locally relevant evidence-based guidelines, nurture future researchers in emergency medicine, standardize training/education and improve patient outcomes by reducing variation in clinical care.