Joo Yeong Kim

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.

Dispatcher-assisted bystander cardiopulmonary resuscitation in a metropolitan city: A before–after population-based study

BACKGROUND The goal of this study was to determine the effects of dispatcher-assisted bystander cardiopulmonary resuscitation (DA-CPR) on outcomes of out-of-hospital cardiac arrest (OHCA). METHODS All EMS in a metropolitan city with a population of 10 million are dispatched by a single, centralized, and physician-supervised center. Data on patients with adult OHCA with cardiac etiology were collected from the dispatch center registry and from EMS run sheets and hospital medical record review from 2009 to 2011. A standardized DA-CPR protocol (aligned with the 2010 AHA guidelines) we implemented as an intervention in January 2011. The end points were survival to discharge, good neurological outcome, and bystander CPR rate. Multivariate logistic analysis was used to compare between intervention group (2011) and historical control group (2009-2010). RESULTS Of 8.144 eligible patients, bystander CPR was performed for the patients in 5.7% (148/2600) of cases in 2009, 6.7% (190/2857) in 2010, and 12.4% (334/2686) in 2011 (p<0.001). The survival to discharge rates was 7.1% (2009), 7.1% (2010), and 9.4% (2011) (p=0.001). Good neurological outcomes occurred in 2.1% (2009), 2.0% (2010), and 3.6% (2011) of cases (p<0.001). The adjusted ORs (95% CIs) for survival to discharge compared with 2009 were 1.33 (1.07-1.66) in 2011 and 1.12 (0.89-1.41) in 2010. The adjusted ORs (95% CIs) for good neurological outcomes were 1.67 (1.13-2.45) in 2011 and 1.13 (0.74-1.72) in 2010. CONCLUSIONS An EMS intervention using the DA-CPR protocol was associated with a significant increase in bystander CPR and an improved survival and neurologic outcome after OHCA.

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.

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.

Risk of Diabetes Mellitus on Incidence of Out-of-Hospital Cardiac Arrests: A Case-Control Study

Background This study aimed to determine the risk of diabetes mellitus (DM) on incidence of out-of-hospital cardiac arrest (OHCA) and to investigate whether difference in effects of DM between therapeutic methods was observed. Methods This study was a case-control study using the Cardiac Arrest Pursuit Trial with Unique Registration and Epidemiologic Surveillance (CAPTURES) project database and 2013 Korean Community Health Survey (CHS). Cases were defined as EMS-treated adult (18 year old and older) OHCA patients with presumed cardiac etiology collected at 27 emergency departments from January to December 2014. OHCA patients whose arrest occurred at nursing homes or clinics and cases with unknown information on DM were excluded. Four controls were matched to one case with strata including age, gender, and county from the Korean CHS database. Multivariable conditional logistic regression analysis was conducted to estimate the risk of DM and treatment modality on incidence of OHCA. Results Total 1,386 OHCA patients and 5,544 community-based controls were analyzed. A total of 370 (26.7%) among cases and 860 (15.5%) among controls were diagnosed with DM. DM was associated with increasing risk of OHCA (AOR: 1.92 (1.65–2.24)). By DM treatment modality comparing with non-DM group, AOR (95% CI) was the highest in non-pharmacotherapy only group (4.65 (2.00–10.84)), followed by no treatment group (4.17 (2.91–5.96)), insulin group (2.69 (1.82–3.96)), and oral hypoglycemic agent group (1.55 (1.31–1.85)). Conclusion DM increased the risk of OHCA, which was the highest in the non-pharmacotherapy group and decreased in magnitude with pharmacotherapy.

Neurological prognostication by gender in out-of-hospital cardiac arrest patients receiving hypothermia treatment

OBJECTIVES This study examined whether the extent to which out-of-hospital cardiac arrest (OHCA) patients recover neurological function after therapeutic hypothermia (TH) is augmented in specific gender, age, and primary ECG group. METHODS A cross-sectional analysis was conducted using a nationwide database of OHCAs in Korea which was constructed from emergency medical services (EMS) run sheet and hospital medical record review between 2008 and 2012. Patients survived to admission were enrolled. Study endpoint was survival with neurological recovery (cerebral performance category 1 and 2). Main exposure was hypothermia. Gender, age group (<45, 45-65, and >65 years old) and primary ECG rhythm were considered as potential effect modifiers. Potential factors were accounted for adjustment using multivariable logistic regression. RESULTS Survival with good neurological recovery was 14.6% (9.3% in men and 17.2% in women). TH was performed in 15.5% (n=1140). Strata-specific crude analysis showed enhanced neurological recovery for women of childbearing ages compared to men counterparts (OR=4.38 (1.39, 13.74) vs. OR=1.73 (0.97, 3.10)). After adjusted for effect modifiers and covariates, the strongest effect of TH on neurological recovery was observed in men younger than 45 years of age with shockable rhythm (OR=2.00 (1.26, 3.19)), whereby no statistically significant associations were found in all women. In both genders, the magnitude of association decreased with age and having non-shockable cardiac rhythm. CONCLUSION TH was the strongest indicator for good neurological recovery in <45-year old men with shockable cardiac rhythm. Across all age groups, women were less likely to benefit from TH than men.

Specific Activity Types at the Time of Event and Outcomes of Out-of-Hospital Cardiac Arrest: A Nationwide Observational Study

This study aimed to describe the characteristics of out-of-hospital cardiac arrest (OHCA) according to specific activity types at the time of event and to determine the association between activities and outcomes according to activity type at the time of event occurrence of OHCA. A nationwide OHCA cohort database, compiled from January 2008 to December 2010 and consisting of hospital chart reviews and ambulance run sheet data, was used. Activity group was categorized as one of the following types: paid work activity (PWA), sports/leisure/education (SLE), routine life (RL), moving activity (MA), medical care (MC), other specific activity (OSA), and unknown activity. The main outcome was survival to discharge. Multivariate logistic analysis for outcomes was used adjusted for potential risk factors (reference = RL group). Of the 72,256 OHCAs, 44,537 cases were finally analyzed. The activities were RL (63.7%), PWA (3.1%), SLE (2.7%), MA (2.0%), MC (4.3%), OSA (2.2%), and unknown (21.9%). Survival to discharge rate for total patients was 3.5%. For survival to discharge, the adjusted odds ratios (95% confidence intervals) were 1.42 (1.06-1.90) in the SLE group and 1.62 (1.22-2.15) in PWA group compared with RL group. In conclusion, the SLE and PWA groups show higher survival to discharge rates than the routine life activity group.

Preventive Effects of Safety Helmets on Traumatic Brain Injury after Work-Related Falls

Introduction: Work-related traumatic brain injury (TBI) caused by falls is a catastrophic event that leads to disabilities and high socio-medical costs. This study aimed to measure the magnitude of the preventive effect of safety helmets on clinical outcomes and to compare the effect across different heights of fall. Methods: We collected a nationwide, prospective database of work-related injury patients who visited the 10 emergency departments between July 2010 and October 2012. All of the adult patients who experienced work-related fall injuries were eligible, excluding cases with unknown safety helmet use and height of fall. Primary and secondary endpoints were intracranial injury and in-hospital mortality. We calculated adjusted odds ratios (AORs) of safety helmet use and height of fall for study outcomes, and adjusted for any potential confounders. Results: A total of 1298 patients who suffered from work-related fall injuries were enrolled. The industrial or construction area was the most common place of fall injury occurrence, and 45.0% were wearing safety helmets at the time of fall injuries. The safety helmet group was less likely to have intracranial injury comparing with the no safety helmet group (the adjusted odds ratios (ORs) (95% confidence interval (CI)): 0.42 (0.24–0.73)), however, there was no statistical difference of in-hospital mortality between two groups (the adjusted ORs (95% CI): 0.83 (0.34–2.03). In the interaction analysis, preventive effects of safety helmet on intracranial injury were significant within 4 m height of fall. Conclusions: A safety helmet is associated with prevention of intracranial injury resulting from work-related fall and the effect is preserved within 4 m height of fall. Therefore, wearing a safety helmet can be an intervention for protecting fall-related intracranial injury in the workplace.

Age effects on case fatality rates of injury patients by mechanism

BACKGROUND Case fatality from injury increases exponentially with age. The objective of this study is to identify age effects on case fatality of injury patients by injury mechanism. METHODS This is an observational study using the Emergency Department-based Injury In-depth Surveillance data from 2007 to 2012. Eligibility was all injured patients, excluding those with unknown information for age, disposition after emergency department or admission, or injury mechanism. End point of this study was inhospital mortality. Injury mechanism was categorized into road transport injury (RTI), fall, collision, cut/pierce, burn, poisoning, and miscellaneous. Case fatality ratio was calculated to evaluate age effects on case fatality by injury mechanism and gender. RESULT Among 927011 injury patients, a total of 924755 patients were analyzed. Total case fatality rate was 0.9%, and rates by injury mechanisms were 4.4% in poisoning, 2.1% in RTI, and 0.8% in fall. By age and gender, the highest crude case fatality rate was 19.74% observed in older than 80-year-old men with poisoning. Case fatality ratios in both genders increased by age from 60- to 69-, 70- to 79-, to older than 80-year-old patients; ratios by injury mechanisms were 13.71, 20.76, and 22.29 (male) and 7.21, 11.18, and 13.05 (female) in poisoning; 5.46, 9.30, and 14.13 (male) and 3.90, 7.96, and 12.08 (female) in RTI; 1.22, 1.52, and 2.02 (male) and 1.14, 2.15, and 6.42 (female) in burn. CONCLUSIONS Case fatality rates of injury increased with age; however, the trends in increase differed by injury mechanisms and gender. Strategies for injury prevention and decreasing mortality should consider the age effects on case fatality of different injury mechanisms.

The Sewol Ferry Disaster: Experiences of a Community-Based Hospital in Ansan City.

The Sewol ferry disaster is one of the most tragic events in Koreas modern history. Among the 476 people on board, which included Danwon High School students (324) and teachers (14), 304 passengers died in the disaster (295 recovered corpses and 9 missing) and 172 survived. Of the rescued survivors, 72 were attending Danwon High School, located in Ansan City, and residing in a residence nearby. Because the students were young, emotionally susceptible adolescents, both the government and the parents requested the students be grouped together at a single hospital capable of appropriate psychiatric care. Korea University Ansan Hospital was the logical choice, as the only third-tier university-grade hospital with the necessary faculty and facilities within the residential area of the families of the students. We report the experiences and the lessons learned from the processes of preparing for and managing the surviving young students as a community-based hospital. (Disaster Med Public Health Preparedness. 2017;11:389-393).