Eui Jung Lee

A trend in epidemiology and outcomes of out-of-hospital cardiac arrest by urbanization level: a nationwide observational study from 2006 to 2010 in South Korea.

BACKGROUND The goal of this study is to better understand the trend in epidemiological features and the outcomes of emergency medical service (EMS)-assessed out-of-hospital cardiac arrest (OHCA) according to the community urbanization level: metropolitan, urban, and rural. METHODS This study was performed within a nationwide EMS system with a single-tiered basic-to-intermediate service level and approximately 900 destination hospitals for eligible OHCA cases in South Korea (with 48 million people). A nationwide OHCA database, which included information regarding demographics, Utstein criteria, EMS, and hospital factors and outcomes, was constructed using the EMS run sheets of eligible cases who were transported by 119 EMS ambulances and followed by a medical record review from 2006 to 2010. Cases with an unknown outcome were excluded. The community urbanization level was categorized according to population size, with metropolitan areas (more than 500,000 residents), urban areas (100,000-500,000 residents), and rural areas (<100,000 residents). The primary end point was the survival to discharge rate. Age- and sex-adjusted survival rates (ASRs) and standardized survival ratios (SSRs) with 95% confidence intervals (CIs) were calculated compared to a standard population. The adjusted odds ratios (AORs) and 95% CIs for survival were calculated and adjusted for potential risk factors using stratified multivariable logistic regression analysis. RESULTS There were 97,291 EMS-assessed OHCAs with 73,826 (75.9%) EMS-treated cases analyzed, after excluding the patients with unknown outcome (N=4172). The standardized incidence rate increased from 37.5 in 2006 to 46.8 in 2010 per 100,000 person-years for EMS-assessed OHCAs, and the survival rate was 3.0% for EMS-assessed OHCAs (3.3% for cardiac etiology and 2.3% for non-cardiac etiology) and 3.6% for EMS-treated OHCAs. Significantly different trends were found by urbanization level for bystander CPR, EMS performance, and the level of the destination hospital. The ASRs for survival were significantly improved by year in the metropolitan areas (3.6% in 2006 to 5.3% in 2010) but remained low in the urban areas (1.4% in 2006 to 2.3% in 2010) and very low in the rural areas (0.5 in 2006 and 0.8 in 2010). The SSRs (95% CIs) in the metropolitan areas were 1.19 (1.06-1.34) in 2006 and 1.77 (1.64-1.92) in 2010, whereas the SSRs were observed to be less than 1.00 during the five-year period in both urban and rural areas. The AORs (95% CIs) for survival significantly increased to 1.42 (1.22-1.66) in the metropolitan areas and to 1.58 (1.18-2.11) in the urban areas while not increasing in the rural areas, compared to the level of each group of areas in 2006. CONCLUSIONS In this nationwide cohort study from 2006 to 2010, the standardized incidence rate and survival to discharge rate of EMS-assessed OHCAs increased annually in metropolitan and urban communities but did not increase in rural communities. Further investigations should be undertaken to improve the performance and outcomes in rural communities.

Epidemiology and outcomes from non-traumatic out-of-hospital cardiac arrest in Korea: A nationwide observational study ☆

OBJECTIVES We aimed to describe the epidemiological features and to determine the predictors for survival to discharge of non-traumatic out-of-hospital cardiac arrest (OHCA) in Korea. SUBJECTS AND METHODS A nationwide Utstein style OHCA database (2006-2007) was constructed from ambulance records and hospital medical record review. Cases were enrolled when they were non-traumatic OHCA with presumed cardiac aetiology. Using the population census (2005), we calculated age-gender standardized incidence rates (SIR) and mortality (SMR). We modelled a multivariate logistic regression analysis to determine the effect of risk factors on hospital outcomes. RESULTS The total number of EMS-assessed non-traumatic OHCA patients was 19045. The SIR was 20.9 (2006) and 22.2 (2007) per 100000 and survival-to-discharge rate was 2.3% for EMS-assessed non-traumatic OHCA, and was 3.5% for the resuscitation-attempted group. From a multivariate logistic regression analysis, witnessed arrest, and shorter basic life support (BLS) and EMS intervals turned out to be significant predictors of good outcome in the resuscitation-attempted group. CONCLUSION From a nationwide OHCA cohort, the incidence of EMS-assessed non-traumatic OHCA was found to be low. Survival-to-discharge rate in the resuscitation-attempted group was 3.5%, which was significantly associated with witnessed arrest, and shorter BLS and EMS intervals.

Pediatric out-of-hospital cardiac arrest in Korea: A nationwide population-based study☆☆☆

STUDY OBJECTIVES Our objective was to describe the incidence and demographics of pediatric out-of-hospital cardiac arrest (OHCA) in Korea. METHODS We identified non-traumatic OHCA patients aged less than 20 years from a Korean nationwide OHCA registry (2006-2007). Data from emergency medical service (EMS) run-sheets and hospital records were reviewed. We excluded cases with unknown hospital outcomes. Patient characteristics, treatment by EMS, and outcomes were compared by age groups: infant (<1 year), children (1-11 years), and adolescents (12-19 years). RESULTS A total of 971 patients including infants (n=299, 30.8%), children (n=305, 31.4%), and adolescents (n=367, 37.8%) met inclusion criteria. The incidence of pediatric OHCA was 4.2 per 100,000 person-years (67.1 in infants, 2.5 in children, and 3.5 in adolescents). The rate of cardiopulmonary resuscitation administered was 82.1% (infants 80.6%, children 82.0%, and adolescent 83.4%). The rate of applying automated external defibrillators and advanced airway management (endotracheal intubation or laryngeal mask airway), was only 4.1% and 2.5%, respectively. 7.4% showed ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) in the initial ECG. Survival to hospital discharge for all pediatric OHCA was 4.9% (2.9% for infants, 4.7% for children, and 7.2% of adolescents). For EMS-treated pediatric OHCA or patients with VF or pulseless VT, the rate was 5.0% and 31.6%, respectively. CONCLUSION Incidence and hospital outcomes in pediatric OHCA in Korea were comparable to other population-based nationwide reports.

Comparison of clinical performance of cranial computed tomography rules in patients with minor head injury: a multicenter prospective study.

OBJECTIVES The objective was to compare the predictive performance of three previously derived cranial computed tomography (CT) rules, the Canadian CT Head Rule (CCHR), the New Orleans Criteria (NOC), and National Emergency X-Ray Utilization Study (NEXUS)-II, for detecting clinically important traumatic brain injury (TBI) and the need for neurosurgical intervention in patients with blunt head trauma. METHODS This was a prospective, multicenter, observational cohort study of patients with blunt head trauma from June 2008 to May 2009. The historical and physical examination components of the CCHR, NOC, and NEXUS-II were documented on a data collection form and the performance of each of the three rules was compared. Patient eligibility for each specific rule was defined exactly as previously described for each specific rule. To compare the three decision rules in terms of sensitivity and specificity, an intersection cohort satisfying inclusion criteria of all three decision rules was derived. The primary outcome was clinically important TBI, and the secondary outcome was neurosurgical intervention. The sensitivity and specificity of each rule were calculated with 95% confidence intervals (95% CIs). We also calculated the potential reduction rate in cranial CT scan utilization realized by theoretical implementation of these rules. RESULTS A total of 7,131 patients were prospectively enrolled, including 692 (9.7%) with clinical TBI. Among the enrolled population, patients eligible for CCHR, NOC, and NEXUS-II totaled 696, 677, and 2,951, respectively. The sensitivity and specificity for clinically important brain injury were as follows: CCHR, 112 of 144 (79.2%, 95% CI = 70.8% to 86.0%) and 228 of 552 (41.3%, 95% CI = 37.3% to 45.5%); NOC, 91 of 99 (91.9%, 95% CI = 84.7% to 96.5%) and 125 of 558 (22.4%, 95% CI = 19.0% to 26.1%); and NEXUS-II, 511 of 576 (88.7%, 95% CI = 85.8% to 91.2%) and 1,104 of 2,375 (46.5%, 95% CI = 44.5% to 48.5%). The sensitivity and specificity for neurosurgical intervention were as follows: CCHR, 100% (95% CI = 59.0% to 100.0%) and 38.3% (95% CI = 34.5% to 41.9%); NOC, 100% (95% CI = 54.1% to 100.0%) and 20.4% (95% CI = 17.4% to 23.7%); and NEXUS-II, 95.1% (95% CI = 90.1% to 98.0%) and 41.4% (95% CI = 39.5% to 43.2%). Among the enrolled population, intersection patients of CCHR, NOC, and NEXUS-II totaled 588. The sensitivity and specificity for clinically important brain injury were as follows: CCHR, 73 of 98 (74.5%, 95% CI = 64.7% to 82.8%) and 201 of 490 (41.0%, 95% CI = 36.6% to 45.5%); NOC, 89 of 98 (90.8%, 95% CI = 83.3% to 95.7%) and 112 of 490 (22.9%, 95% CI = 19.2% to 26.8%); and NEXUS-II, 82 of 98 (83.7%, 95% CI = 74.8% to 90.4%) and 172 of 490 (35.1%, 95% CI = 30.9% to 39.5%). The potential reduction in emergency CT scans by using these decision rules would have been higher with the NEXUS-II rule (39.6%, 95% CI = 37.8% to 41.4%) than with the CCHR rule (27.0%, 95% CI = 23.7% to 30.3%) or NOC rule (20.2%, 95% CI = 17.2% to 23.3%). CONCLUSIONS For clinically important TBI, the three cranial CT decision rules had much lower sensitivities in this population than the original published studies, while the specificities were comparable to those studies. The sensitivities for neurosurgical intervention, however, were comparable to the original studies. The NEXUS-II rule showed the highest reduction rate for CT scans compared to other rules, but failed to identify all undergoing neurosurgical intervention for their original inclusion cohort.

Post-resuscitation care and outcomes of out-of-hospital cardiac arrest: A nationwide propensity score-matching analysis

OBJECTIVE This study aimed to determine whether active post-resuscitation care (APRC) was associated with improved out-of-hospital cardiac arrest (OHCA) outcomes on a nationwide level. METHODS AND RESULTS We used a national OHCA cohort database consisting of hospital and ambulance data. We included all survivors of OHCA, excluding patients with non-cardiac etiology, younger than 15 years, and with unknown outcomes, from (2008 to 2010). The APRC was defined when the OHCA patients received mild therapeutic hypothermia (MTH) or active cardiac care (ACC), such as intravenous thrombolysis, percutaneous coronary intervention, coronary artery bypass surgery, and pacemaker/implantable cardioverter defibrillator insertion, as well as routine intensive care; patients receiving conservative post-resuscitation care (CPRC) served as the other group. The primary and secondary outcomes were survival to discharge and a good neurological outcome (cerebral performance category [CPC] 1-2), respectively. We extracted propensity-matched samples to control for selection bias. A multivariable logistic regression analysis was used to compare the APRC and CPRC groups adjusting for potential risks to calculate the adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs). Of total 64,155 patients, 4557 survived to admission and were included in the final analysis. Out of these patients, 1599 (35.1%) cases survived to discharge, and 499 (11.0%) cases were discharged with good neurological recoveries. Overall, 695 cases (15.3%) received any APRC, including MTH (n=377, 8.3%) and ACC (370, 8.1%). The outcomes was better in the APRC group than in the CPRC group for survival to discharge (58.7% vs. 30.8%, p<0.001) and good neurological outcome (27.2% vs. 8.0%, p<0.001), respectively. In the total cohort, the adjusted ORs of the APRC group compared to those the CPRC group were 2.15 (95% CI 1.78-2.59) for survival to discharge and 2.54 (95% CI 1.98-3.27) for a good neurological outcome. In the propensity score-matched cohort, the adjusted ORs for survival to discharge and good neurological outcome of APRC were significantly favorable. CONCLUSIONS Active post-resuscitation care resulted in significantly improved outcomes in adult OHCA patients with a presumed cardiac etiology in a nationwide, retrospective, observational study.

A comparison of outcomes of out-of-hospital cardiac arrest with non-cardiac etiology between emergency departments with low- and high-resuscitation case volume.

OBJECTIVES It is unclear whether outcome after out-of-hospital cardiac arrest (OHCA) of non-cardiac etiology (NCE) is associated with the volume of patients with OHCA received annually at the emergency department (ED) where they receive treatment. This study evaluated whether the volume of patients treated is associated with better outcomes for non-cardiac OHCA patients. METHODS This study was performed in an emergency medical service (EMS) system with a single-tiered basic-to-intermediate service level and approximately 410 destination hospitals for eligible OHCA cases. A nationwide OHCA database (2006-2008), constructed from EMS run sheets, and a hospital medical record review were used. OHCA was defined as pulseless and unresponsive in the field. Included in the study were cases treated with OHCA whose etiology was non-cardiac. Excluded were cases with unknown hospital outcome. The cutoff number for a high volume (HV) versus a low volume (LV) of cardiopulmonary resuscitation (CPR) cases was calculated using a threshold model. The primary end points were survival to admission and survival to discharge. The adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs) for the endpoints were calculated, adjusting for potential predictors. RESULTS There were 10,425 eligible patients (trauma 5735; drowning 98; poisoning 684; asphyxia 1413; and hanging 1605). The survival-to-admission and the survival-to-discharge rates of the study participants were 9.6% and 2.4%, respectively. The cutoff number for case volume was 38 per year. The rates of survival to admission and survival to discharge were significantly higher in the HV (18.6% and 5.1%, respectively) group when compared to the LV group (5.9% and 1.3%, respectively). For the treated, non-cardiac OHCA patients, the adjusted ORs in the HV group compared to the LV group were 2.16 for survival to admission (95% CI: 1.84-2.55) and 2.58 for survival to discharge (95% CI: 1.90-3.52). The survival-to-discharge rate was significantly higher in the HV group than in the LV group for each cause: trauma 2.1% vs. 0.6%, drowning 6.8% vs. 1.9%, poisoning 8.6% vs. 1.7%, asphyxia 13.5% vs. 3.8%, and hanging 5.2% vs. 1.3%, respectively. CONCLUSION This national cohort study suggests that greater survival to admission as well as discharge for patients with OHCA of NCE is associated with greater annual volume of patients with OHCA treated at that hospital.

Use of a Comprehensive Metabolic Panel Point-of-Care Test to Reduce Length of Stay in the Emergency Department: A Randomized Controlled Trial

STUDY OBJECTIVE Awaiting results from laboratory testing may sometimes be a rate-limiting step in emergency department (ED) throughput prolonging length of stay and contributing to crowding. We determine whether introduction of a comprehensive metabolic panel point-of-care test can reduce ED length of stay compared with traditional central laboratory testing. METHODS We performed a randomized, controlled trial among 10,244 noncritically ill ED patients aged 15 years and older whose physicians ordered a comprehensive metabolic panel at a single, large, academic, urban medical center. Participants were randomly assigned to performance of a comprehensive metabolic panel by a point-of-care test (n=5,154) or central laboratory testing (n=5,090). The primary outcome was length of stay in the ED. RESULTS A point-of-care test reduced median ED length of stay among all study patients by 22 minutes (median 350 minutes [interquartile range 206 to 1,002 minutes] with point-of-care test versus median 372 minutes [interquartile range 217 to 1,150 minutes] with central laboratory testing; median difference 22 minutes; 95% confidence interval [CI] 4 to 40 minutes). A point-of-care test also reduced ED length of stay in patients discharged to home (256 versus 268 minutes; median difference 12 minutes; 95% CI 2 to 22 minutes) and with an Emergency Severity Index triage level of 3 (333 versus 355 minutes; median difference 22 minutes; 95% CI 4 to 40 minutes). CONCLUSION Use of a point-of-care test for a comprehensive metabolic panel reduced ED length of stay compared with central laboratory testing in the adult ED of a single academic center.

A point-of-care chemistry test for reduction of turnaround and clinical decision time

PURPOSE Our study compared clinical decision time between patients managed with a point-of-care chemistry test (POCT) and patients managed with the traditional central laboratory test (CLT). BASIC PROCEDURE This was a randomized controlled multicenter trial in the emergency departments (EDs) of 5 academic teaching hospitals. We randomly assigned patients to POCT or CLT stratified by the Emergency Severity Index. A POCT chemistry analyzer (Piccolo; Abaxis, Inc, Union City, Calif), which is able to test liver panel, renal panel, pancreas enzymes, lipid panel, electrolytes, and blood gases, was set up in each ED. Primary and secondary end point was turnaround time and door-to-clinical-decision time. MAIN FINDINGS The total 2323 patients were randomly assigned to the POCT group (n = 1167) or to the CLT group (n = 1156). All of the basic characteristics were similar in the 2 groups. The turnaround time (median, interquartile range [IQR]) of the POCT group was shorter than that of the CLT group (14, 12-19 versus 55, 45-69 minutes; P < .0001). The median (IQR) door-to-clinical-decision time was also shorter in the POCT compared with the CLT group (46, 33-61 versus 86, 68-107 minutes; P < .0001). The proportion of patients who had new decisions within 60 minutes was 72.8% for the POCT group and 12.5% for the CLT group (P < .0001). CONCLUSIONS A POCT chemistry analyzer in the ED shortens the test turnaround and ED clinical decision times compared with CLT.

Extracorporeal life support and survival after out-of-hospital cardiac arrest in a nationwide registry: A propensity score-matched analysis.

BACKGROUND The benefit of extracorporeal life support (ECLS) in highly selective patients with out-of-hospital cardiac arrest (OHCA) is supported by previous studies; however, it is unclear whether the effects of ECLS are observed at a population level. This study aimed to determine whether ECLS is associated with improved survival outcomes compared to conventional CPR (cardiopulmonary resuscitation) at a national level. METHODS We used a Korean national OHCA cohort database from 2009 to 2013. The inclusion criteria were OHCA adults with presumed cardiac aetiology and resuscitation by emergency medical services (EMS). Patients were excluded if their information on prehospital time intervals or clinical outcomes at hospital discharge was incomplete or not captured. The primary outcome was neurologically favourable survival to discharge. We compared the primary outcomes between the ECLS and non-ECLS groups using a multivariable logistic regression and a propensity score matching analysis. RESULTS Of the 119,077 patients with OHCA, 36,547 were included in the analysis. There were 320 patients who received ECLS. There was no significant difference in neurologically favourable survival to discharge between the ECLS group and the non-ECLS group after adjusting for covariates (adjusted OR, 0.65; 95% CI, 0.41-1.04). In the propensity score-matched cohort, there was also no significant difference between the two groups (adjusted OR, 0.94; 95% CI, 0.41-2.14). CONCLUSIONS In this propensity score-matched cohort using a nationwide OHCA database, OHCA victims who received ECLS did not show better survival outcomes than those who did not receive ECLS.

Interaction effects between hypothermia and diabetes mellitus on survival outcomes after out-of-hospital cardiac arrest

OBJECTIVES Mild therapeutic hypothermia (MTH) is the core hospital intervention to enhance neurological outcome after out-of-hospital cardiac arrest (OHCA). Diabetes mellitus (DM) has been known to be a harmful risk factor on survival after OHCA. This study aimed to investigate whether the effect of MTH on brain recovery after OHCA differed between patients with or without DM. METHODS We used a Korean national OHCA database composed of hospital and ambulance data. We included adult OHCA patients who survived to admission with presumed cardiac etiology during the study period from 2009 to 2013. We excluded cases without hospital outcome data. The primary exposure was MTH, which included all kinds of cooling methods that had been initiated within 6h after return of spontaneous circulation. DM was coded positive when the patient had a clinical history diagnosed by a physician before an OHCA event. The endpoints were discharge with good neurological recovery (cerebral performance category 1 or 2) and survival to discharge. We compared outcomes between MTH vs. non-MTH groups using multivariable logistic regression with an interaction term between MTH and DM for calculating adjusted odds ratios (AORs) and 95% confidence intervals (CIs) after adjusting for potential confounders. RESULTS Among 9735 patients following OHCA survived to hospital admission with cardiac etiology, MTH was performed in 16.5%. History of DM was observed in 25.4% among MTH group and 27.4% in non-MTH group (p=0.09). MTH group showed better outcomes than non-MTH group; 23.6% vs. 15.7% for good neurological recovery (p<0.01). AOR (95% CI) of MTH for good neurological recovery for all study groups was 1.23 (1.03-1.47). In the interaction model, AOR (95% CI) of MTH for good neurological recovery was 1.40 (1.16-1.70) in patients without DM vs. 0.69 (0.46-1.04) in patients with DM. For survival to discharge, the effects of MTH were different in patients without DM (1.97 (1.70-2.29)) and patients with DM (1.23 (0.96-1.57)). CONCLUSION DM modified the effect of MTH on survival and neurological outcomes for OHCA survivors. MTH is significantly associated with good neurological recovery in patients without DM, but not in patients with DM.