Yutaka Takei

Factors associated with quality of bystander CPR: The presence of multiple rescuers and bystander-initiated CPR without instruction

AIMS To identify the factors associated with good-quality bystander cardiopulmonary resuscitation (BCPR). METHODS Data were prospectively collected from 553 out-of-hospital cardiac arrests (OHCAs) managed with BCPR in the absence of emergency medical technicians (EMT) during 2012. The quality of BCPR was evaluated by EMTs at the scene and was assessed according to the standard recommendations for chest compressions, including proper hand positions, rates and depths. RESULTS Good-quality BCPR was more frequently confirmed in OHCAs that occurred in the central/urban region (56.3% [251/446] vs. 39.3% [42/107], p=0.0015), had multiple rescuers (31.8% [142/446] vs. 11.2% [12/107], p<0.0001) and received bystander-initiated BCPR (22.0% [98/446] vs. 5.6% [6/107], p<0.0001). Good-quality BCPR was less frequently performed by family members (46.9% [209/446] vs. 67.3% [72/107], p=0.0001), elderly bystanders (13.5% [60/446] vs. 28.0% [30/107], p=0.0005) and in at-home OHCAs (51.1% [228/446] vs. 72.9% [78/107], p<0.0001). BCPR duration was significantly longer in the good-quality group (median, 8 vs. 6min, p=0.0015). Multiple logistic regression analysis indicated that multiple rescuers (odds ratio=2.8, 95% CI 1.5-5.6), bystander-initiated BCPR (2.7, 1.1-7.3), non-elderly bystanders (1.9, 1.1-3.2), occurrence in the central region (2.1, 1.3-3.3) and duration of BCPR (1.1, 1.0-1.1) were associated with good-quality BCPR. Moreover, good-quality BCPR was initiated earlier after recognition/witness of cardiac arrest compared with poor-quality BCPR (3 vs. 4min, p=0.0052). The rate of neurologically favourable survival at one year was 2.7 and 0% in the good-quality and poor-quality groups, respectively (p=0.1357). CONCLUSIONS The presence of multiple rescuers and bystander-initiated CPR are predominantly associated with good-quality BCPR.

Analysis of reasons for emergency call delays in Japan in relation to location: High incidence of correctable causes and the impact of delays on patient outcomes

REVIEW The interval between collapse and emergency call influences the prognosis of out-of-hospital cardiac arrest (OHCA). To reduce the interval, it is essential to identify the causes of delay. METHODS Basal data were collected prospectively by fire departments from 3746 OHCAs witnessed or recognised by citizens and in which resuscitation was attempted by emergency medical technicians (EMTs) between 1 April 2003 and 31 March 2008. EMTs identified the reasons for call delay by interview. RESULTS The delay, defined as an interval exceeding 2 min (median value), was less frequent in the urban region, public places and for witnessed OHCAs. Delay was more frequent in care facilities and for elderly patients and OHCAs with longer response times. Multiple logistic regression analysis indicated that urban regions, care facilities and arrest witnesses are independent factors associated with delay. The ratio of correctable causes (human factors) was high at care facilities and at home, compared with other places. Calling others was a major reason for delay in all places. Performing cardiopulmonary resuscitation (CPR) and other treatments was another major reason at care facilities. Large delay, defined as an interval exceeding 5 min (upper-quartile value), was an independent factor associated with a low 1-year survival rate. CONCLUSION The incidence of correctable causes of delay is high in the community. Correction of emergency call manuals in care facilities and public relation efforts to facilitate an early emergency call may be necessary. Basic life support (BLS) education should be modified to minimise delays related to making an emergency call.

The effects of the new CPR guideline on attitude toward basic life support in Japan

BACKGROUND There is no study regarding the influence of cardiopulmonary resuscitation (CPR) guideline renewal on citizens attitude towards all basic life support (BLS) actions. METHODS AND RESULTS We conducted a questionnaire survey to new driver licence applicants who participated in the BLS course at driving schools either before (January 2007 to April 2007) or after (October 2007 to April 2008) the revision of the textbook. Upon completion of the course, participants were given a questionnaire concerning willingness to participate in CPR, early emergency call, telephone-assisted chest compression and use of an automated external defibrillator (AED). After the revision, the proportions of positive respondents to use of AED as well as to all the four scenarios significantly increased from 2331/3564 to 3693/5156 (odds ratio (OR)=1.34) and from 1889/3443 to 3028/5126 (OR=1.18), respectively. However, the new guideline slightly but significantly augmented the unwillingness to make an early call (236/3568 vs. 416/5283, OR=0.83). Approximately 95% of respondents were willing to follow the telephone-assisted instruction of chest compression, while approximately 85% were eager to perform CPR on their own initiative. Multiple logistic regression analysis confirmed the results of mono-variate analysis, and identified previous CPR training, sex, rural area and student as other significant factors relating to attitude. CONCLUSIONS Future guidelines should emphasise the significance and benefit of early call in relation to telephone-assisted instruction of CPR or chest compression. The course instructors should be aware of the backgrounds of participants as to how this may relate to their willingness to participate.

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.

Improper bystander-performed basic life support in cardiac arrests managed with public automated external defibrillators

AIM The aim of the study was to determine the quality of basic life support (BLS) in out-of-hospital cardiac arrests (OHCAs) receiving bystander cardiopulmonary resuscitation (CPR) and public automated external defibrillator (AED) application. METHODS From January 2006 to December 2012, data were prospectively collected from OHCA) and impending cardiac arrests treated with and without public AED before emergency medical technician (EMT) arrival. Basic life support actions and outcomes were compared between cases with and without public AED application. Interruptions of CPR were compared between 2 groups of AED users: health care provider (HCP) and non-HCP. RESULTS Public AEDs were applied in 10 and 273 cases of impending cardiac arrest and non-EMT-witnessed OHCAs, respectively (4.3% of 6407 non-EMT-witnessed OHCAs). Defibrillation was delivered to 33 (13.3%) cases. Public AED application significantly improved the rate of 1-year neurologically favorable survival in bystander CPR-performed cases with shockable initial rhythm but not in those with nonshockable rhythm. Emergency calls were significantly delayed compared with other OHCAs without public AED application (median: 3 and 2 minutes, respectively; P < .0001). Analysis of AED records obtained from 136 (54.6%) of the 249 cases with AED application revealed significantly lower rate of compressions delivered per minute and significantly greater proportion of CPR pause in the non-HCP group. Time interval between power on and the first electrocardiographic analysis widely varied in both groups and was significantly prolonged in the non-HCP group (P = .0137). CONCLUSIONS Improper BLS responses were common in OHCAs treated with public AEDs. Periodic training for proper BLS is necessary for both HCPs and non-HCPs.

Impact of bystander-performed ventilation on functional outcomes after cardiac arrest and factors associated with ventilation-only cardiopulmonary resuscitation: A large observational study

AIM To determine the effectiveness of ventilations in bystander cardiopulmonary resuscitation (BCPR) and to identify the factors associated with ventilation-only BCPR. METHODS From out-of-hospital cardiac arrest (OHCA) data prospectively collected from 2005 to 2011 in Japan, we extracted data for 210,134 bystander-witnessed OHCAs with complete datasets but no prehospital involvement of physician [no BCPR, 115,733; ventilation-only, 2093; compression-only, 61,075; and conventional (compressions+ventilations) BCPR, 31,233] and determined the factors associated with 1-month neurologically favourable survival using simple and multivariable logistic regression analyses. In 91,885 patients with known BCPR durations, we determined the factors associated with ventilation-only BCPR. RESULTS The rate of survival in the no BCPR, ventilation-only, compression-only and conventional group was 2.8%, 3.9%, 4.5% and 5.0%, respectively. After adjustment for other factors associated with outcomes, the survival rate in the ventilation-only group was higher than that in the no BCPR group (adjusted OR; 95% CI, 1.29; 1.01-1.63), but lower than that in the compression-only (0.76; 0.59-0.96) or conventional groups (0.70; 0.55-0.89). Conventional CPR had the highest OR for survival in almost all OHCA subgroups. The adjusted OR (95% CI) for survival after dividing BCPR into ventilation and compression components was 1.19 (1.11-1.27) and 1.60 (1.51-1.69), respectively. Older guidelines, female sex, younger patient age, bystander-initiated CPR without instruction, early BCPR and short BCPR duration were associated with ventilation-only BCPR. CONCLUSIONS Ventilation is a significant component of BCPR, but alone is less effective than compression in improving neurologically favourable survival after OHCAs.

Advantage of CPR-first over call-first actions for out-of-hospital cardiac arrests in nonelderly patients and of noncardiac aetiology

AIM To assess the benefit of immediate call or cardiopulmonary resuscitation (CPR) for survival from out-of-hospital cardiac arrests (OHCAs). METHODS Of 952,288 OHCAs in 2005-2012, 41,734 were bystander-witnessed cases without prehospital involvement of physicians but with bystander CPR (BCPR) on bystanders own initiative. From those OHCAs, we finally extracted the following three call/BCPR groups: immediate Call+CPR (N=10,195, emergency call/BCPR initiated at 0 or 1 min after witness, absolute call-BCPR time interval=0 or 1 min), immediate Call-First (N=1820, emergency call placed at 0 or 1 min after witness, call-to-BCPR interval=2-4 min), immediate CPR-First (N=5446, BCPR initiated at 0 or 1 min after witness, BCPR-to-call interval=2-4 min). One-month neurologically favourable survivals were compared among the groups. Critical comparisons between Call-First and CPR-First groups were made considering arrest aetiology, age, and bystander-patient relationship after confirming the interactions among variables. RESULTS The overall survival rates in immediate Call+CPR, Call-First, and CPR-First groups were 11.5, 12.4, and 11.5%, respectively without significant differences (p=0.543). Subgroup analyses by multivariate logistic regression following univariate analysis disclosed that CPR-first group is more likely to survive in subgroups of noncardiac aetiology (adjusted odds ratio; 95% confidence interval, 2.01; 1.39-2.98) and of nonelderly OHCAs (1.38; 1.09-1.76). CONCLUSIONS Immediate CPR-first action followed by an emergency call without a large delay may be recommended when a bystander with sufficient skills to perform CPR witnesses OHCAs in nonelderly people and of noncardiac aetiology.

Primary respiratory arrest recognised by emergency medical technicians and followed by cardiac arrest in Japan: Identification of a subgroup of EMT-witnessed cardiac arrests with an extremely poor outcome

REVIEW Some unconscious patients are found to be in primary respiratory arrest (PRA) by emergency medical technicians (EMTs). In contrast to citizens, EMTs manage PRA with artificial ventilation but not with cardiopulmonary resuscitation (CPR). This study aimed to investigate the characteristics and outcomes of PRA prior to EMT arrival and compare these data with those of a PRA-related group: patients with out-of-hospital cardiac arrests (OHCAs). METHODS Baseline data were prospectively collected by fire departments for their adult (16 years or older) OHCA and PRA patients from April 2003 through March 2010. We extracted those who had PRA prior to EMT arrival. The EMT- and bystander-witnessed OHCA patients who underwent CPR were also extracted as control groups. RESULTS There were 178 cases of PRA prior to EMT arrival. The majority (164/178) of these individuals were in a deep coma and met the criteria for the initiation of bystander CPR. Approximately 61% (108/178) of these PRAs were followed by cardiac arrests, which were classified as EMT-witnessed OHCAs by the Utstein template. The EMTs manually ventilated the patients until the cardiac arrest occurred. The 1-Y survival of this subgroup was the lowest of the PRA and PRA-related OHCA subgroups and was significantly lower than that of bystander-witnessed OHCAs with bystander CPR, when trauma and terminal illness cases were excluded (adjusted odds ratio=3.888 (1.103-24.827)). CONCLUSIONS We identified a subgroup of PRAs with unexpectedly poor outcomes. The BLS guidelines for healthcare providers including EMTs should be re-evaluated by a large prospective study.

Recruitments of trained citizen volunteering for conventional cardiopulmonary resuscitation are necessary to improve the outcome after out-of-hospital cardiac arrests in remote time-distance area: A nationwide population-based study

AIMS To compare the factors associated with survival after out-of-hospital cardiac arrests (OHCAs) among three time-distance areas (defined as interquartile range of time for emergency medical services response to patients side). METHODS From a nationwide, prospectively collected data on 716,608 OHCAs between 2007 and 2012, this study analyzed 193,914 bystander-witnessed OHCAs without pre-hospital physician involvement. RESULTS Overall neurologically favourable 1-month survival rates were 7.4%, 4.1% and 1.7% for close, intermediate and remote areas, respectively. We classified BCPR by type (compression-only vs. conventional) and by dispatcher-assisted CPR (DA-CPR) (with vs. without); the effects on time-distance area survival were analyzed by BCPR classification. Association of each BCPR classification with survival was affected by time-distance area and arrest aetiology (p<0.05). The survival rates in the remote area were much higher with conventional BCPR than with compression-only BCPR (odds ratio; 95% confidence interval, 1.26; 1.05-1.51) and with BCPR without DA-CPR than with BCPR with DA-CPR (1.54; 1.29-1.82). Accordingly, we classified BCPR into five groups (no BCPR, compression-only with DA-CPR, conventional with DA-CPR, compression-only without DA-CPR, and conventional without DA-CPR) and analyzed for associations with survival, both cardiac and non-cardiac related, in each time-distance area by multivariate logistic regression analysis. In the remote area, conventional BCPR without DA-CPR significantly improved survival after OHCAs of cardiac aetiology, compared with all the other BCPR groups. Other correctable factors associated with survival were short collapse-to-call and call-to-first CPR intervals. CONCLUSION Every effort to recruit trained citizens initiating conventional BCPR should be made in remote time-distance areas.

Misplaced links in the chain of survival due to an incorrect manual for the emergency call at public facilities

BackgroundThe incidence of delayed emergency calls and the outcome of out-of-hospital cardiac arrest (OHCA) may differ among public facilities when emergency calls are placed by institutional staff. The purpose of this study was to identify the actions prescribed in the rules and/or manuals of public facilities and to clarify whether the incidence of delayed emergency call placement and the outcome of OHCA differ among these facilities.MethodsWe performed a questionnaire-based survey regarding emergency calls in public facilities in our community and analyzed our regional Utstein-based OHCA database.ResultsOur questionnaire survey disclosed that the most common actions prescribed in the manuals or rules applied in care facilities and educational institutions are to report the situation when a cardiac arrest occurs and to follow the directions of a custodian or supervisor. The international web search disclosed that these actions are rarely prescribed in medical emergency manuals in other countries. Most of these manuals simply say that staff should make an emergency call immediately upon detecting a serious illness or medical emergency. Analysis of the Utstein-based database from our community revealed that the time interval between collapse and emergency call placement is prolonged and the outcome of cardiac arrest poor in care facilities. A prompt emergency call and cardiopulmonary resuscitation (CPR) after arrest are associated with improved 1-year survival following OHCA. Contrary to accepted wisdom, staff who recognize a cardiac arrest may consult their supervisor and then continue CPR until they receive instructions from him or her.ConclusionsManuals or rules for making emergency calls in our public facilities may contain incorrect information, and emergency calls may be delayed owing to correctable human factors. Such manuals should be checked and revised.