Yukihiro Wato

The continuous quality improvement project for telephone-assisted instruction of cardiopulmonary resuscitation increased the incidence of bystander CPR and improved the outcomes of out-of-hospital cardiac arrests.

REVIEW In 2007, the Ishikawa Medical Control Council initiated the continuous quality improvement (CQI) project for telephone-assisted cardiopulmonary resuscitation (telephone-CPR), which included instruction on chest-compression-only CPR, education on how to recognise out-of-hospital cardiac arrests (OHCAs) with agonal breathing, emesis and convulsion, recommendations for on-line or redialling instructions and feedback from emergency physicians. This study aimed to investigate the effect of this project on the incidence of bystander CPR and the outcomes of OHCAs. MATERIALS AND METHODS The baseline data were prospectively collected on 4995 resuscitation-attempted OHCAs, which were recognised or witnessed by citizens rather than emergency medical technicians during the period of February 2004 to March 2010. The incidence of telephone-CPR and bystander CPR, as well as the outcomes of the OHCAs, was compared before and after the project. RESULTS The incidence of telephone-CPR and bystander CPR significantly increased after the project (from 42% to 62% and from 41% to 56%, respectively). The incidence of failed telephone-CPR due to human factors significantly decreased from 30% to 16%. The outcomes of OHCAs significantly improved after the projects. A multiple logistic regression analysis revealed that the CQI project is one of the independent factors associated with one-year (1-Y) survival with favourable neurological outcomes (odds ratio=1.81, 95% confidence interval=1.20-2.76). CONCLUSIONS The CQI project for telephone-CPR increased the incidence of bystander CPR and improved the outcome of OHCAs. A CQI project appeared to be essential to augment the effects of telephone-CPR.

Survey of a Protocol to Increase Appropriate Implementation of Dispatcher-Assisted Cardiopulmonary Resuscitation for Out-of-Hospital Cardiac Arrest

Background— Dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) attempts to improve the management of out-of-hospital cardiac arrest by laypersons who are unable to recognize cardiac arrest and are unfamiliar with CPR. Therefore, we investigated the sensitivity and specificity of our new DA-CPR protocol for achieving implementation of bystander CPR in out-of-hospital cardiac arrest victims not already receiving bystander CPR. Methods and Results— Since 2007, we have applied a new DA-CPR protocol that uses supplementary key words. Fire departments prospectively collected baseline data on DA-CPR from January 2009 to December 2011. DA-CPR was attempted in 2747 patients; of these, 417 (15.2%) did not experience cardiac arrest. The sensitivity and specificity of the 2007 protocol versus estimated values of the previous standard protocol were 72.9% versus 50.3% and 99.6% versus 99.8%, respectively. We identified key words that may be useful for detecting out-of-hospital cardiac arrest. Multiple logistic regression analysis revealed that the occurrence of cardiac arrest after an emergency call (odds ratio, 16.85) and placing an emergency call away from the scene of the arrest (odds ratio, 11.04) were potentially associated with failure to provide DA-CPR. Furthermore, at-home cardiac arrest (odds ratio, 1.61) and family members as bystanders (odds ratio, 1.55) were associated with bystander noncompliance with DA-CPR. No complications were reported in the 417 patients who received DA-CPR but did not have cardiac arrest. Conclusions— Our 2007 protocol is safe and highly specific and may be more sensitive than the standard protocol. Understanding the factors associated with failure of bystanders to provide DA-CPR and implementing public education are necessary to increase the benefit of DA-CPR.

Do early emergency calls before patient collapse improve survival after out-of-hospital cardiac arrests?

AIM Some out-of-hospital cardiac arrests (OHCAs) are witnessed after emergency calls. This study aimed to confirm the benefit of early emergency calls before patient collapse on survival after OHCAs witnessed by bystanders and/or emergency medical technicians (EMTs). METHODS We analysed 278,310 witnessed OHCAs [EMT-witnessed cases (n=54,172), bystander-witnessed cases (n=224,138)] without pre-hospital physician involvement from all Japanese OHCA data prospectively collected between 2006 and 2012. The data were analysed for the correlation between neurologically favourable 1-month survival and the time interval between the emergency call and patient collapse. RESULTS When emergency calls were placed earlier before patient collapse, the proportion of EMT-witnessed cases and survival rate after OHCAs witnessed by bystanders and EMTs were higher. When analysed only for bystander-witnessed cases, for earlier emergency calls placed before patient collapse, survival rate and incidences of bystander cardiopulmonary resuscitation (CPR) and dispatcher-assisted CPR decreased: 2.9%, 33.6% and 24.4%, respectively, for emergency calls placed >6min before collapse and 5.5%, 48.8% and 48.5%, respectively, for those placed 1-2min after collapse. Multivariable logistic regression showed that call-to-collapse interval (adjusted odds ratio; 95% confidence interval) (0.92; 0.90-0.94) and EMT response time after collapse (0.84; 0.82-0.86) were associated with survival after bystander-witnessed OHCAs with emergency calls before collapse. CONCLUSION Early emergency calls before patient collapse efficiently increases the proportion of EMT-witnessed cases and promotes survival after witnessed OHCAs. However, early emergency call before collapse may worsen the outcome when the patients condition deteriorates to cardiac arrest before EMT arrival.

Augmented survival of out-of-hospital cardiac arrest victims with the use of mobile phones for emergency communication under the DA-CPR protocol getting information from callers beside the victim

PURPOSE To investigate the impacts of emergency calls made using mobile phones on the quality of dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) and survival from out-of-hospital cardiac arrests (OHCAs) that were not witnessed by emergency medical service (EMS). METHODS In this prospective study, we collected data for 2530 DA-CPR-attempted medical emergency cases (517 using mobile phones and 2013 using landline phones) and 2980 non-EMS-witnessed OHCAs (600 using mobile phones and 2380 using landline phones). Time factors and quality of DA-CPR, backgrounds of callers and outcomes of OHCAs were compared between mobile and landline phone groups. RESULTS Emergency calls are much more frequently placed beside the arrest victim in mobile phone group (52.7% vs. 17.2%). The positive predictive value and acceptance rate of DA-CPR in mobile phone group (84.7% and 80.6%, respectively) were significantly higher than those in landline group (79.2% and 70.9%). The proportion of good-quality bystander CPR in mobile phone group was significantly higher than that in landline group (53.5% vs. 45.0%). When analysed for all non-EMS-witnessed OHCAs, rates of 1-month survival and 1-year neurologically favourable survival in mobile phone group (7.8% and 3.5%, respectively) were higher than those in landline phone group (4.6% and 1.9%; p<0.05). Multiple logistic regression analysis, including other backgrounds, revealed that mobile phone calls were associated with increased 1-month survival in the subgroup of OHCAs receiving bystander CPR (adjusted odds ratio, 1.84; 95% CI, 1.15-2.92). CONCLUSION Emergency calls made using mobile phones are likely to augment the survival from OHCAs by improving DA-CPR.

Assessing the efficacy of the new protocol for chest compressions before definitive cardiac arrest in emergency medical service-witnessed adult out-of-hospital cardiac arrests

AIMS Japanese emergency medical services (EMS) personnel providing advance life support confirm the absence of a carotid pulse before initiating chest compressions (CCs) in adult out-of-hospital cardiac arrest (OHCA). This study aims to investigate the efficacy of a new protocol facilitating early CCs before definitive cardiac arrest in enhancing the outcomes of OHCA. METHODS The 2011 new protocol facilitated EMS to initiate CCs when the carotid pulse was weak and/or <50/min in comatose adult patients with respiratory arrest (apnoea or agonal breathing) and loss of the radial pulse. During 2008-2015, we compared the neurologically favourable 1-year survival rate of EMS-witnessed OHCA and EMS-confirmed out-of-hospital respiratory arrest (OHRA) in adults before (N = 257 and 34, respectively) and after (N = 255 and 54, respectively) the implementation of the new protocol. RESULTS After the new protocol, EMS initiated CCs >1.5 min before definitive cardiac arrest in 31% (80/255) and 33% (18/54) of EMS-witnessed OHCA and EMS-confirmed OHRA, respectively. While the new protocol was not significantly associated with survival of EMS-confirmed OHRA, it was significantly associated with survival of EMS-witnessed OHCA: 9.0% and 14.9%, before and after, P by univariate analysis <0.03; adjusted OR (95% CI) by multivariable logistic regression analysis, 2.01 (1.04-3.90). Neither early start of CCs nor the new protocol was associated with the progression to cardiac arrest in 212 cases with impending cardiac arrest. CONCLUSIONS A new EMS protocol facilitating early CCs before definitive cardiac arrest was associated with higher survival of EMS-witnessed OHCA.

Temporal variations in dispatcher-assisted and bystander-initiated resuscitation efforts

Purpose: To investigate temporal variations in dispatcher‐assisted and bystander‐initiated resuscitation efforts and their association with survival after bystander‐witnessed out‐of‐hospital cardiac arrests (OHCAs). Methods: We retrospectively analyzed the neurologically favorable 1‐month survival and the parameters related to dispatcher assisted cardiopulmonary resuscitation (DA‐CPR) and bystander CPR (BCPR) for 227,524 OHCA patients between 2007 and 2013 in Japan. DA‐CPR sensitivity for OHCAs, bystanders compliance to DA‐CPR assessed by the proportion of bystanders who follow DA‐CPR, and performance of BCPR measured by the rate of bystander‐initiated CPR in patients without DA‐CPR were calculated as indices of resuscitation efforts. Results: Performance of BCPR was only similar to temporal variations in the survival (correlation between hourly paired values, R2 = 0.263, P = 0.01): a lower survival rate (3.4% vs 4.2%) and performance of BCPR (23.1% vs 30.8%) during night‐time (22:00–5:59) than during non‐night‐time. In subgroup analyses based on interaction tests, all three indices deteriorated during night‐time when OHCAs were witnessed by non‐family (adjusted odds ratio, 0.73–0.82), particularly in non‐elderly patients. The rate of public access defibrillation for these OHCAs markedly decreased during night‐time (adjusted odds ratio, 0.49) with delayed emergency calls and BCPR initiation. Multivariable logistic regression analyses revealed that the survival rate of non‐family‐witnessed OHCAs was 1.83‐fold lower during night‐time than during non‐night‐time. Conclusions: Dispatcher‐assisted and bystander‐initiated resuscitation efforts are low during night‐time in OHCAs witnessed by non‐family. A divisional alert system to recruit well‐trained individuals is needed in order to improve the outcomes of night‐time OHCAs witnessed by non‐family bystanders.

The impact of prehospital assessment and EMS transport of acute aortic syndrome patients

Background: The quality of acute aortic syndrome (AAS) assessment by emergency medical service (EMS) and the incidence and prehospital factors associated with 1‐month survival remain unclear. Methods: We retrospectively analyzed the data collected for 94,468 patients with non‐traumatic medical emergency excluding out‐of‐hospital cardiac arrest during the period of 2011–2014. Results: Of these transported by EMS, 22,075 had any of the AAS‐related symptoms, and 330 had an EMS‐assessed risk for AAS; of these, 195 received an in‐hospital AAS diagnosis. Of the remaining 21,745 patients without EMS‐assessed risk, 166 were diagnosed with AAS. Therefore, the sensitivity and specificity of our EMS‐risk assessment for AAS was 54.0% (195/361) and 99.4% (21,579/21,714), respectively. EMS assessed the risk less frequently when patients were elderly and presented with dyspnea and syncope/faintness. Sign of upper extremity ischemia was rarely detected (6.9%) and absence of this sign was associated with lack of EMS‐assessed risk. The calculation of modified aortic dissection detection risk score revealed that rigorous assessment based on this score may increase the EMS sensitivity for AAS. The 1‐month survival rate was significantly higher in patients admitted to core hospitals with surgical teams for AAS than in those admitted to all other hospitals [87.5% (210/240) vs 69.4% (84/121); P < 0.01]. Multiple logistic regression analysis demonstrated that Stanford type A, Glasgow coma scale ≤ 14, and admission to core hospitals providing emergency cardiovascular surgery were associated with 1‐month survival. Conclusions: Improvement of AAS survival is likely to be affected by rapid admission to appropriate hospitals providing cardiovascular surgery.