Out-of-hospital cardiac arrest: incidence, process of care, and outcomes in an urban city, Korea

Effect of citywide enhancement of the chain of survival on good neurologic outcomes after out-of-hospital cardiac arrest from 2008 to 2017

Improving outcomes after out-of-hospital cardiac arrests (OHCAs) requires an integrated approach by strengthening the chain of survival and emergency care systems. This study aimed to identify the change in outcomes over a decade and effect of citywide intervention on good neurologic outcomes after OHCAs in Daegu. This is a before- and after-intervention study to examine the association between the citywide intervention to improve the chain of survival and outcomes after OHCA. The primary outcome was a good neurologic outcome, defined as a cerebral performance category score of 1 or 2. After dividing into 3 phases according to the citywide intervention, the trends in outcomes after OHCA by primary electrocardiogram rhythm were assessed. Logistic regression analysis was used to analyze the association between the phases and outcomes. Overall, 6203 patients with OHCA were eligible. For 10 years (2008–2017), the rate of survival to discharge and the good neurologic outcomes increased from 2.6% to 8.7% and from 1.5% to 6.6%, respectively. Especially for patients with an initial shockable rhythm, these changes in outcomes were more pronounced (survival to discharge: 23.3% in 2008 to 55.0% in 2017, good neurologic outcomes: 13.3% to 46.0%). Compared with phase 1, the adjusted odds ratio (AOR) and 95% confidence intervals (CI) for good neurologic outcomes was 1.20 (95% CI: 0.78–1.85) for phase 2 and 1.64 (1.09–2.46) for phase 3. For patients with an initial shockable rhythm, the AOR for good neurologic outcomes was 3.76 (1.88–7.52) for phase 2 and 5.51 (2.77–10.98) for phase 3. Citywide improvement was observed in the good neurologic outcomes after OHCAs of medical origin, and the citywide intervention was significantly associated with better outcomes, particularly in those with initial shockable rhythm.

Application of the “Plan-Do-Study-Act” Model to Improve Survival after Cardiac Arrest in Korea: A Case Study

Objective:

Low rates of bystander cardiopulmonary resuscitation (CPR) were identified as a shortcoming in the “chain of survival” for out-of-hospital cardiac arrest (OHCA) care in the Korean city of Ansan. This study sought to evaluate the effect of an initiative to increase bystander CPR and quality of out-of-hospital resuscitation on outcome from OHCA. The post-intervention data were used to determine the next quality improvement (QI) target as part of the “Plan-Do-Study-Act” (PDSA) model for QI.

Hypothesis:

The study hypothesis was that bystander CPR, return of spontaneous circulation (ROSC), and survival to discharge after OHCA would increase in the post-intervention period.

Methods:

This was a retrospective pre/post study. The data from the pre-intervention period were abstracted from 2008–2011 and the post-intervention period from 2012–2013. The effect of the intervention on the odds of ROSC and survival to hospital discharge was determined using a generalized estimating equation to account for confounders and the effect of clustering within medical centers. The analysis was then used to identify other factors associated with outcomes to determine the next targets for intervention in the chain of survival for cardiac arrest in this community.

Results:

Rates of documented bystander CPR increased from 13% in the pre-intervention period to 37% in the post-intervention period. The overall rate of ROSC decreased from 18.4% to 14.3% (risk difference −4.1%; 95% CI, −7.1%–1.0%), whereas survival to hospital discharge increased from 3.9% to 5.0% (risk difference 1.1%; 95% CI, −1.8%–3.8%), and survival with good neurologic outcome increased from 0.8% to 1.6% (risk difference 0.8%; 95% CI, −0.8%–2.4%). In multivariable analyses, there was no association between the intervention and the rate of ROSC or survival to hospital discharge. The designated level of the treating hospital was a significant predictor of both survival and ROSC.

Conclusion:

In this case study, there were no observed improvements in outcomes from OHCA after the targeted intervention to improve out-of-hospital CPR. However, utilizing the PDSA model for QI, the designated level of the treating hospital was found to be a significant predictor of survival in the post-period, identifying the next target for intervention.

Incidence of Adult In-Hospital Cardiac Arrest Using National Representative Patient Sample in Korea

OBJECTIVES

This study analyzed the incidence and characteristics of in-hospital cardiac arrest (IHCA) in Korea based on a sample group of patients that is representative of the population.

METHODS

The incidence of IHCA in adults was extracted from HIRA-NIS-2009, a sample of all patients using medical services in Korea. IHCA patients were analyzed according to gender, age, type of medical institute, and classification under the 6th revision of the Korean Standard Classification of Diseases (KCD-6). In addition, to assess the differences arising from the size of medical institutes, the IHCA incidence was analyzed in relation to the number of inpatient beds.

RESULTS

Based on the sample data, the total incidence of IHCA in Korea was found to be 2.46 per 1,000 admissions (95% confidence interval [CI], 2.37-2.55). A higher incidence was found among men at 3.18 (95% CI, 3.03-3.33), compared to women at 1.84 (95% CI, 1.74-1.94). The incidence of IHCA was also higher in hospitals that had more than 600 inpatients beds at 5.40 (95% CI, 5.16-5.66) in comparison to those that had less than 600 inpatients beds at 4.09 (95% CI, 3.76-4.36) (p < 0.001). By primary disease, the incidence was the highest for infectious diseases.

CONCLUSIONS

We demonstrated that the IHCA incidence based on gender, age, diagnostic group, and number of beds could be analyzed using the insurance claim data from a national representative sample.

Availability and use of public access defibrillators in Busan Metropolitan City, South Korea

Out-of-hospital cardiac arrest (OHCA) is considered an important health issue worldwide, and early defibrillation is a key element for a favourable prognosis. In South Korea, public access defibrillation (PAD) programmes were initiated in 2007. However, the impact of PAD programmes on OHCA survival rates remains unclear. This study evaluated the deployment and maintenance status of public automatic external defibrillators (AED), including how frequently they were used, in Busan Metropolitan City, South Korea. Managers of possible AED sites were first contacted by telephone and asked to confirm the possession of an AED. AED suppliers were contacted for AED sales records to identify missing AED sites. AEDs located in ambulances and medical institutions were not included. Investigators visited confirmed AED sites and completed a checklist on AED maintenance and use. In total, 206 AEDs were located, indicative of an AED density of 0.268 AED/km² and a prevalence of 6.07 per 100,000 in Busan Metropolitan City. We found that public AEDs had been used for resuscitation only 15 times, an average rate of use of once every 26.3 years. Our results indicate that AEDs in Busan Metropolitan City are underused according to the guidelines, and several are in low-priority locations. We believe that AED deployment based on cardiac arrest statistics is important to optimise layperson AED training and utilisation.

For how long can two emergency medical technicians perform high-quality cardiopulmonary resuscitation?

OBJECTIVE

To determine the duration and obstacles to prolonged on-scene cardiopulmonary resuscitation (CPR), and establish how long a pair of emergency medical technicians (EMTs) can provide high-quality CPR.

METHOD

Intermediate-level EMTs in Gyeonggi-do Province, Republic of Korea completed a survey regarding on-scene CPR. EMTs undergoing routine training took part in a simulation using mannequins. Parameters including compression depth, total number and rate of compressions; occurrence of incorrect hand position and incomplete chest recoil were collected over 16 2-min cycles of CPR (32 min total), with EMTs working in pairs.

RESULT

The simulation study included 43 EMTs. The median duration of on-scene CPR was 3.7 min. Fear of decrease in performance was the main obstacle to continued CPR (n = 188/254 [74.0%]). Standards for high-quality CPR were met at each of the 16 steps of the simulation. Compression rate increased significantly with time. There were no significant changes in any other parameter.

CONCLUSION

Pairs of EMTs maintained high-quality CPR for 16 cycles (32 min) with no decrease in performance. Our findings could provide evidence to recommend guidelines for duration of on-scene CPR for cardiac arrest, particularly in countries where the level and number of ambulance crews are limited.

Comparison Between 30:1 and 30:2 Compression-to-ventilation Ratios for Cardiopulmonary Resuscitation: Are Two Ventilations Necessary?

OBJECTIVES

Controversy is continuing over the need for ventilation and the optimal compression-ventilation (CV) ratio during cardiopulmonary resuscitation (CPR). The aim of this study was to comparatively elucidate the effect on hemodynamics and arterial oxygen saturation of a single ventilation relative to two consecutive ventilations during CPR in a dog model of cardiac arrest.

METHODS

Twenty mongrel dogs were divided into two groups. After 3 minutes of ventricular fibrillation (VF), the single-ventilation group received CPR with a 30:1 CV ratio, and the two-ventilation group received CPR with a 30:2 CV ratio, all with room air for 7 minutes. Thereafter, continuous chest compressions and intermittent ventilation at rate of 10 per minute were followed for both groups for 10 minutes. Hemodynamic parameters, arterial blood gas profiles, and variables from CPR were compared at baseline and at 5, 10, 15, and 20 minutes after induction of VF.

RESULTS

Hemodynamic parameters including aortic systolic and diastolic pressures, right atrial systolic and diastolic pressures, coronary perfusion pressure, end-tidal carbon dioxide tension, and arterial blood gas profiles including arterial oxygen tension, arterial oxygen saturation, and arterial carbon dioxide tension were not different between two groups during CPR. In the 30:1 group, the period of compression interruption was shorter and chest compression fraction was higher than that in the 30:2 group (6 sec/min vs. 10.9 sec/min, p < 0.001; 90.0% vs. 81.8%, p < 0.001).

CONCLUSIONS

CPR with a 30:1 CV ratio, compared to CPR with a 30:2 CV ratio, results in comparable arterial oxygenation saturation and hemodynamics.

Epidemiological and Survival Trends of Pediatric Cardiac Arrests in Emergency Departments in Korea: A Cross-sectional, Nationwide Report

Cardiac arrest (CA) in children is associated with high mortality rates. In Korea, cohort studies regarding the outcomes of pediatric CAs are lacking, especially in emergency departments (EDs) or in-hospital settings. This study was conducted to examine the trends in epidemiology and survival outcomes in children with resuscitation-attempted CAs using data from a cross-sectional, national, ED-based clinical registry. We extracted cases in which cardiopulmonary resuscitation and/or manual defibrillation were performed according to treatment codes using the National Emergency Department Information System (NEDIS) from 2008 to 2012. The total number of ED visits registered in the NEDIS during the 5-yr evaluation period was 20,424,530; among these, there were 2,970 resuscitation-attempted CAs in children. The annual rates of pediatric CAs per 1,000 ED visits showed an upward trend from 2.81 in 2009 to 3.62 in 2012 (P for trend = 0.045). The median number of estimated pediatric CAs at each ED was 7.8 (25th to 75th percentile, 4 to 13) per year. The overall rates for admission survival and discharge survival were 35.2% and 12.8%, respectively. The survival outcome of adults increased substantially over the past 5 yr (11.8% in 2008, 11.7% in 2010, and 13.6% in 2012; P for trend = 0.001); however, the results for children did not improve (13.6% in 2008, 11.4% in 2010, and 13.7% in 2012; P for trend = 0.870). Conclusively, we found that the overall incidence of pediatric CAs in EDs increased substantially over the past 5 yr, but without significantly higher survival outcomes.