So Yeon Kong

Temporal trends in out-of-hospital cardiac arrest survival outcomes between two metropolitan communities: Seoul-Osaka resuscitation study.

Objectives The objective of this study was to compare the temporal trends in survival after out-of-hospital cardiac arrest (OHCA) between two large metropolitan communities in Asia and evaluate the factors affecting survival after OHCA. Design A population-based prospective observational study. Setting The Cardiovascular Disease Surveillance (CAVAS) project in Seoul and the Utstein Osaka Project in Osaka. Participants A total of 36 292 resuscitation-attempted OHCAs with cardiac aetiology from 2006 to 2011 in Seoul and Osaka (11 082 in Seoul and 25 210 in Osaka). Primary outcome measures The primary outcome was neurologically favourable survival. Trend analysis and multivariable Poisson regression models were conducted to evaluate the temporal trends in survival of two communities. Results During the study period, the overall neurologically favourable survival was 2.6% in Seoul and 4.6% in Osaka (p<0.01). In both communities, bystander cardiopulmonary resuscitation (CPR) rates increased significantly from 2006 to 2011 (from 0.1% to 13.1% in Seoul and from 33.3% to 41.7% in Osaka). OHCAs that occurred in public places increased in Seoul (12.5% to 20.1%, p for trend <0.01) and decreased in Osaka (13.5% to 10.5%, p for trend <0.01). The proportion of OHCAs defibrillated by emergency medical service (EMS) providers was only 0.4% in 2006 but increased to 17.5% in 2011 in Seoul, whereas the proportion in Osaka decreased from 17.7% to 13.7% (both p for trend <0.01). Age-adjusted and gender-adjusted rates of neurologically favourable survival increased significantly in Seoul from 1.4% in 2006 to 4.3% in 2011 (adjusted rate ratio per year, 1.17; p for trend <0.01), whereas no significant improvement was observed in Osaka (3.6% in 2006 and 5.1% in 2011; adjusted rate ratio per year, 1.03; p for trend=0.08). Conclusions Survivals after OHCA were increased in Seoul while remained constant in Osaka, which may have been affected by the differences and improvements of patient, community, and EMS system factors.

Dispatcher-assisted bystander cardiopulmonary resuscitation in rural and urban areas and survival outcomes after out-of-hospital cardiac arrest

OBJECTIVES We investigated the impact of dispatcher-assisted bystander cardiopulmonary resuscitation (DA-BCPR) on survival outcomes after out-of-hospital cardiac arrests (OHCAs) that occurred in rural and urban areas. METHODS This study was a cross-sectional study using nationwide emergency medical services (EMS)-based OHCA registry in Korea. All EMS-treated adults with OHCAs and with presumed cardiac etiology were enrolled between 2012 and 2015, excluding cases witnessed by an EMS provider. BCPR was categorized into 3 groups: BCPR-with-DA, BCPR-without-DA, and No-BCPR. The endpoint was good neurologic recovery at discharge. We compared the effects of BCPR on outcomes between rural and urban areas, using a multivariable logistic regression with an interaction term. RESULTS A total of 53,240 patients (36.3% BCPR-with-DA and 12.8% BCPR-without-DA) were included. Among OHCAs that occurred in rural areas (32.3% BCPR-with-DA and 14.0% BCPR-without-DA) and urban areas (36.9% BCPR-with-DA and 12.5% BCPR-without-DA), good neurological recovery was demonstrated in 1.6% and 6.8% of the patients in rural and urban areas, respectively (p < 0.01). The patients with OHCAs who received BCPR in both rural and urban areas were more likely to have good neurologic recovery than the No-BCPR group (AORs, 3.53 (1.84-6.77) BCPR-with-DA and 2.56 (1.23-5.32) BCPR-without-DA in rural; and 1.59 (1.41-1.79) BCPR-with-DA and 1.37 (1.18-1.60) BCPR-without-DA in urban). The effects of the measures of BCPR-with-DA on the outcome were more apparent in rural areas compared to urban areas. CONCLUSIONS BCPR, regardless of DA, was associated with improved neurologic recovery after OHCA in rural and urban areas. However, the effect of BCPR-with-DA was prominent for OHCA that occurred in rural areas.

Recognition of out-of-hospital cardiac arrest during emergency calls and public awareness of cardiopulmonary resuscitation in communities: A multilevel analysis

BACKGROUND For an effective dispatcher-assisted cardiopulmonary resuscitation (CPR) program, recognition of out-of-hospital cardiac arrest (OHCA) by a dispatcher is the first step in initiating bystander CPR. This study evaluated whether CPR awareness in the community is associated with recognition of arrest, dispatcher-provided CPR instructions, and bystander CPR. METHODS All emergency medical services (EMS)-treated adult OHCAs with cardiac etiology were enrolled between 2013 and 2015, excluding cases witnessed by EMS providers. Exposure was CPR awareness in the community where the OHCA occurred. Endpoints were recognition of arrest, dispatcher-provided CPR instructions, and bystander CPR. Multilevel logistic regression analysis was performed to calculate adjusted odds ratios (AORs) per 10% increment in community CPR awareness adjusting for potential confounders. RESULTS Of 44,185 eligible OHCAs, 20,255 (45.8%) cases were recognized by a dispatcher, 17,858 (40.4%) received dispatcher-provided CPR instructions, and 22,255 (50.4%) received bystander CPR (39.8% with dispatcher assistance and 10.6% without dispatcher assistance). Compared with OHCAs that occurred in the communities with low awareness, dispatchers were more likely to provide CPR instructions to the caller, and bystanders were more likely to perform CPR for OHCAs that occurred in the communities with high CPR awareness. AORs (95% CIs) per 10% increment in public awareness of CPR in the community were 1.05 (1.01-1.10) for recognition of arrest, 1.11 (1.06-1.16) for dispatcher-provided CPR instructions, and 1.07 (1.03-1.11) for bystander CPR. CONCLUSIONS Public CPR awareness of the communities where OHCAs occurred was associated with recognition of arrest during an emergency call, dispatcher-provided CPR instructions, and bystander CPR.

Association of dispatcher-assisted bystander cardiopulmonary resuscitation with survival outcomes after pediatric out-of-hospital cardiac arrest by community property value

OBJECTIVE We aimed to demonstrate the association of bystander cardiopulmonary resuscitation (BCPR) with survival outcomes after pediatric out-of-hospital cardiac arrest (OHCA) by community property value groups. METHODS This observational study enrolled all emergency medical services (EMS)-treated pediatric OHCAs in Korea between 2012 and 2015. Enrolled patients were divided into three groups: BCPR with dispatcher-assistance (DA), BCRP-without-DA, and no-BCPR. Patients were categorized based on tertiles for property tax per capita of community in which the cardiac arrest occurred. The endpoint was survival to discharge. To test the interactive effects between BCPR and community property value on study endpoints, a multilevel logistic regression model with an interaction term was used. RESULTS A total of 2020 patients were enrolled (37.0% BCPR-with-DA, 14.5% BCPR-without-DA, and 48.5% no-BCPR). BCPR-with-DA and BCPR-without-DA were more likely to have higher rates of survival to discharge compared to no-BCPR (8.6% and 13.0% vs. 3.5%; AORs (95% CIs): 2.23 (1.33-3.74) and 2.87 (1.57-5.25)). By interaction analysis with community property tax per capita, the AORs for survival in BCPR-with-DA and BCPR-without-DA groups were 2.56 (1.03-6.38) and 3.48 (1.10-10.9) for high value communities, 2.25 (0.95-5.31) and 3.76 (1.53-9.23) in middle communities, and 1.88 (0.88-3.99) and 1.54 (0.57-4.17) in low value communities (interaction, p = 0.68). CONCLUSION In pediatric OHCAs, BCRP was associated with improved survival outcomes. The survival benefits of BCPR did not differ significantly by community property value.

Cooling methods of targeted temperature management and neurological recovery after out-of-hospital cardiac arrest: A nationwide multicenter multi-level analysis

OBJECTIVE The purpose of this study was to determine whether the cooling method used for target temperature management (TTM) was associated with neurological recovery after out-of-hospital cardiac arrest (OHCA). METHODS From January 2008 to December 2016, adult OHCA patients who survived to hospitalization without any traumatic etiology and who received TTM were included. Patients who did not have information about neurological status at hospital discharge or who did not have information on target temperature management were excluded. Cooling methods were classified into four groups: (1) external device cooling (EDC) using a pad with cooling device, (2) external conventional cooling (ECC) such as ice water, fans, and simple blankets, (3) Intravascular cooling (IVC) using an intravascular cooling catheter, and (4) intracavitary cooling (ICC) using ice water for washing cavitary organ. The outcomes were good cerebral performance scale (CPC) score 1 or 2 and survival to discharge. In multivariate logistic regression analysis, the adjusted odds ratios (AORs) and the 95% confidence intervals (CIs) were calculated (reference = ECC). Finally, we used a GLIMMIX procedure with group-level variables (hospitals) to create a multilevel model for adjusting the clustering factor of patients being treated in the same hospital. RESULTS The final analysis included a total of 4246 eligible patients (ECC 1386, EDC 2107, IVC 376, ICC 377). Good neurologic recovery was 20.7% for all (ECC 17.4, EDC 23.1%, IVC 26.9%, and ICC 13.3%, p < .001). The survival rate was 46.4% for all (ECC 45.4%, EDC 48.5%, IVC 50.5%, ICC 34.2%, p < .001). There were no significant differences (AOR and 95% CI) in the multi-level analysis for good neurological recovery between cooling methods compared with ECC; EDC 1.20 (0.95-1.52), IVC 1.43 (0.90-2.27), and ICC 0.71 (0.46-1.10). The ICC group had a lower survival to discharge rate compared with ECC; EDC 0.97 (0.83-1.15), IVC 0.96 (0.78-1.19), and ICC 0.63 (0.43-0.85). CONCLUSION The cooling methods for TTM did not show any significant difference in neurological recovery in multi-level logistic regression analysis. Only intracavitary cooling resulted in a lower survival to discharge than external surface cooling.

Implementation of a bundle of Utstein cardiopulmonary resuscitation programs to improve survival outcomes after out-of-hospital cardiac arrest in a metropolis: A before and after study

INTRODUCTION The study aimed to determine the effect of community implementation of a bundles of cardiopulmonary resuscitation (CPR) programs on outcomes in out-of-hospital cardiac arrest (OHCA). METHODS A before- and after-intervention study was performed in a metropolis. Emergency medical services (EMS)-treated adults and cardiac OHCAs were included. Three new CPR programs was implemented in January 2015: 1) a high-quality dispatcher-assisted CPR program (DACPR), 2) a multi-tier response (MTR) program using fire engines or basic life support vehicles, and 3) a feedback CPR (FCPR) program with professional recording and feedback of CPR process. The outcomes (cerebral performance category 1 or 2, good CPC) and survival to discharge) were compared between study period (2015-2016) and control period (2013-2014). RESULTS Overall, 6201 and 6469 patients were included in the control period and the study period, respectively. During the post-intervention period, the proportion of OHCA patients who underwent three types of cardiopulmonary resuscitation programs increased significantly compared to those in the pre-intervention period. DACPR increased from 38.3% to 44.3%, MTR increased from 0.0% to 37.5%, and FCPR increased from 25.3% to 61.5%. (All p values <0.001). Good neurological recovery and survival to discharge were significantly increased from 5.4% to 6.8%, and from 9.6% to 10.9%. The adjusted odds ratio (95% confidence intervals) of the study period was 1.45 (1.12-1.87) for good CPC, and 1.31 (1.09-1.58) for survival to discharge. CONCLUSIONS The citywide implementation of a bundle of UTIS CPR programs was associated with significantly better OHCA outcomes.

Interactive Effect between On-Scene Hypoxia and Hypotension on Hospital Mortality and Disability in Severe Trauma

Abstract Background: It is unclear whether effect size of the hypoxia is different on in-hospital mortality and disability according to hypotension status in the field. Methods: Adult severe trauma (ST) patients during 2012–13 who were treated by emergency medical services (EMS) and had abnormal revised trauma scores in the field or who had positive trauma triage criteria were analyzed. Exposure was hypoxia (<94%) measured by EMS. End points were hospital mortality and disability defined as a Glasgow Outcome Scale that decreased by 2 points or more. Multivariable logistic regression with interaction model between hypoxia and hypotension was used for outcomes to calculate the adjusted odds ratios (AOR) with 95% confidence intervals (95% CIs) after adjusting for potential confounders. Results: A total of 17,406 EMS-ST patients were analyzed. Of those, 2,598 (14.9%) died, and 3,292 (21.5%) were considered disabled at discharge. The total hypoxia group showed higher mortality and disability indices (35.7 and 51.2%) than the non-hypoxia group (10.7 and 15.9%) (each p-value < 0.0001). The AOR of hypoxia was 2.15 (1.92–2.40) for mortality and was 1.97 (1.75–2.21) for disability. In the interaction model, AORs for mortality by hypoxia in the hypotensive and non-hypotensive groups were 2.66 (2.32–3.04) and 1.74 (1.61–1.87), respectively (P < 0.0001 for interaction). The AORs for disability in the hypotensive and non-hypotensive groups were 2.17 (1.87–2.53) and 1.55 (1.42–1.69), respectively (P < 0.0001 for interaction). Conclusions: The effect of hypoxia was much greater in the hypotensive group than in the non-hypotensive group both in terms of mortality and disability.

Effect of a first responder on survival outcomes after out-of-hospital cardiac arrest occurs during a period of exercise in a public place

Introduction The deployment of first responders in a public place is one of the interventions that is used for increasing bystander cardiopulmonary resuscitation (CPR) of out-of-hospital cardiac arrests (OHCA). We studied the association between the presence of a first responder and the survival of OHCA that occurred during a period of exercise in a public place. Methods All of the adult OHCAs of a presumed cardiac etiology that occurred during a period of exercise in a public place and that were witnessed by a bystander between 2013 and 2015 were analyzed. The main exposure of interest was the characteristics of the bystander (first responder vs. layperson). The endpoints were the provision of bystander CPR and good neurological recovery. Multivariable logistic regression analysis, adjusting for patient-environment and prehospital factors, was performed. Results A total of 870 patients had a cardiac arrest during a period of exercise in a public place, and 58 (6.7%) patients were witnessed by the first responder. The OHCAs witnessed by first responders were more likely to result in bystander CPR than those witnessed by laypersons (89.7% vs. 75.4%, p = 0.01, adjusted OR (95% CI): 3.51 (1.44–8.55)). In terms of good neurological recovery, the OHCAs witnessed by first responders had a higher likelihood than the patients witnessed by laypersons (37.9% vs, 24.0%, p = 0.02, adjusted OR (95% CI): 2.92 (1.33–6.40)). Conclusion The OHCAs occurred during a period of exercise in a public place and whom first responders witnessed were more likely to receive bystander CPR and to have a neurologically intact survival.

Epidemiology and outcomes of anaphylaxis-associated out-of-hospital cardiac arrest

Background Understanding the epidemiological characteristics of anaphylaxis-associated out-of-hospital cardiac arrest (OHCA) is the first step toward developing preventative strategies and optimizing care systems. We aimed to describe and compare epidemiological features and clinical outcomes among patients with anaphylaxis-associated OHCAs according to causative agent groups. Methods We identified emergency medical service (EMS)-treated anaphylaxis-associated OHCA patients from a nationwide OHCA registry between 2008 and 2015. We compared epidemiological characteristics and outcomes according to causal agents (a natural agents group and an iatrogenic agents group) and evaluated temporal variability in incidence. Multivariate logistic regression analysis was performed to compare survival to discharge between causative agent groups. Results During the study period (8 years), the total number of anaphylaxis-associated OHCAs was 233. A total of 224 eligible cases were included in the analysis. There were 192 patients (85.6%) in the natural agents group and 32 patients (14.3%) in the iatrogenic agents group. There was significant diurnal and seasonal variability in the frequency of anaphylaxis-associated OHCAs (p values<0.01 for both), with the highest incidences occurring during the day (7:01 am to 3 pm; 64.6%) and in summer (June to August, 48.7%). Compared with the natural agents group, the adjusted odds ratio (AOR) for survival to discharge in the iatrogenic agents group was statistically insignificant (AOR 3.61, 95% CI 0.86 to 15.06). Conclusion The incidence of anaphylaxis-associated OHCA is considerably low, and significant temporal variability, with a peak during the day and in summer, is evident. Anaphylaxis-associated OHCA is more common by natural agents than by iatrogenic agents, but no difference in the survival-to-discharge rate is evident.

34 Implementation of a bundle of utstein ten step recommendations from the global resuscitation alliance to improve survival outcomes after out-of-hospital cardiac arrest in a metropolis: a before and after study

Aim We aimed to evaluate whether implementation of a bundle of three programs of Utstein ten-step implementation strategy (UTIS) proposed by the Global Resuscitation Alliance improved outcomes after OHCAs. Method This study was a before-and-after study. All emergency medical services (EMS)-treated adults OHCAs with cardiac aetiology were included. Seoul implemented a bundle of three CPR programs among UTIS programs in 2015; Telephone–CPR (T–CPR) program: a monthly–based and individual dispatcher–targeted quality assurance protocol on telephone–CPR for every OHCA, Rapid CPR program: a multi–tier response, and Feedback CPR program: professional recording of EMS–CPR and feedback to individual team by medical director using high technology defibrillator devices. The EMS process and outcomes of OHCAs in the study period (2015–2016) were compared with control period (2013–2014). The primary outcome was a good neurological recovery (cerebral performance category 1 or 2). A mixed-effects logistic regression model including random intercepts for district EMS agency level was used to estimate the association between study period with outcomes, adjusted for potential confounders. Results Total 5968 and 6232 patients were included in the control and study period. T-CPR rate, Rapid CPR, and Feedback CPR in control versus study period were 48.1% versus 54.2%, 1.0% versus 35.8%, and 27.8% versus 63.8%, respectively (all p-values<0.001). Good neurological recovery rate was increased from 5.6% to 6.5%. In multivariable analyses, the adjusted OR of study period for good neurological recovery was 1.31 (95% CI: 1.11 to 1.55). Conclusion The citywide implementation of a bundle of UTIS programs was significantly associated with better OHCA outcomes. Conflict of interest None Funding None