Emergency Medical Services Arrival Research Articles

Early and prehospital trauma deaths: Who might benefit from advanced resuscitative care?

Recent civilian and military data from the United States and the United Kingdom suggest that further reductions in mortality will require prehospital or preoperating room hemorrhage control and blood product resuscitation. The aims of this study were to examine the potential preventability of prehospital and early in-hospital fatalities, and to consider the geographical location of such incidents, to contextualize how the use of advanced resuscitative techniques could be operationalized. Retrospective analysis of prehospital and early in-hospital trauma deaths from January to December 2017. Data were obtained from the Coroner/ME's Office. Each death was reviewed by a panel of two trauma surgeons and a forensic pathologist. Anatomical and physiological survivabilities were evaluated separately, and then combined, leading to a holistic assessment of preventability. Incident locations were mapped and analyzed using ArcGIS. Three hundred sixteen trauma deaths were identified. Two hundred thirty-one (73%) were deemed anatomically not survivable; 29 (9%) anatomically survivable, but only with hospital care; 43 (14%) anatomically survivable with advanced prehospital care; and 13 (4%) anatomically survivable with basic prehospital care. Physiologically, 114 (36%) of the patients had been dead for some time when found; 137 (43%) had no cardiorespiratory effort on arrival of Emergency Medical Services (EMS) at the scene; 24 (8%) had cardiorespiratory effort at the scene, but not on arrival at the emergency department; and 41 (13%) had cardiorespiratory effort on arrival at the emergency department, but died shortly after. Combining the assessments, 10 (3%) deaths were deemed probably not preventable, 38 (12%) possibly preventable, and the remaining 278 (85%) not preventable. Twelve percent of trauma deaths were potentially preventable and might be amenable to advanced resuscitative interventions. Operationalizing this type of care will be challenging and will require either prehospital doctors, or very highly trained paramedics, nurses, or physician assistants. Epidemiological, level III.

Evaluation of the intensity and management of pain before arrival in hospital among patients with suspected hip fractures

BackgroundPain management needs to be comprehensively investigated in patients with hip fractures, as it represents a fast-growing challenge to emergency care. The purpose of this study was to describe reported pain in patients with suspected hip fractures in a prehospital setting. MethodsIn this observational study, 1,426 patients with a suspected hip fracture were included. Dynamic and static pain were assessed on the arrival of the emergency medical services (EMS) and on hospital admission using the Numerical Rating Scale (NRS), if feasible, and the Behaviour Rating Scale (BRS), if not. ResultsOn EMS arrival, the median dynamic NRS pain score was eight and 84% of the patients had severe or moderate dynamic pain according to the BRS. On admission to hospital, the median dynamic NRS pain score was reduced to five and 45% of the patients had reduced dynamic pain according to the BRS. Among all patients, the NRS was judged to be feasible and was therefore used in 36%. Furthermore, there was an association between the decrease in pain and the increase in the number of administered medications, as well as the duration of prehospital care. ConclusionsPatients with suspected hip fractures suffered substantial pain on EMS arrival. Only half experienced a reduction in pain on hospital admission and only 75% received pain-relieving medication.

Getting R-AEDI to save lives in Singapore.

Early cardiopulmonary resuscitation (CPR) and defibrillation prior to the arrival of emergency medical services can improve survival from out-of-hospital cardiac arrest (OHCA) with good neurological outcome. However, the rate of local bystander CPR is only 24.3% and bystander defibrillation 2.1%. In 2015, the R-AEDI (Registry for AED Integration) initiative was started to improve OHCA survival rates. R-AEDI alerts volunteers to nearby OHCA cases via the myResponder mobile application. In 2015-2017, 7,682 AEDs were mapped and made accessible via this app. Comprehensive site inspections also resulted in fewer non-functional AEDs, as AED owners were educated on the importance of the maintenance of pads and batteries. The AED heat map allows us to identify areas that are lacking in or require improved public access AED coverage. The online AED registry found in the myResponder app is useful to locate AEDs rapidly during OHCAs. More community education would improve the rate of bystander defibrillation.

Abstract TP376: Director, Comprehensive Stroke Program

Background: Hospital system identified decline in Emergency Medical Services arrivals [EMS-A] and increased Private Vehicle arrivals [PVA]. Purpose: Understand community response and PVA for focused education to increase EMS-A in order to improve treatment rates and decrease disability. Methods: Retrospective chart review to evaluate age, gender, race, poverty levels, stroke type, severity, treatment rates, and outcomes of the Target Population [TP]. Results: Review of 4,264 records [2015-2018] identified 1,612 PVA and 2,652 EMS-A. The largest PVA age group, identified as TP, was age 46-65. The TP was 60% male. Hispanics comprised 59% PVA versus [v] 54% EMS-A. All other races had higher EMS-A. Those with PVA were more likely to have private insurance [39% PVA v 23% EMS-A] and more likely to have zip codes with less than 10% poverty [8% PVA v 1% EMS-A]. Those below poverty had lower PVA [6% PVA v 12% EMS-A]. Stroke type was 90% Ischemic. Eighty-nine percent of PVA had NIHSS 0-7 [NIHSS: 0=24%, 1-5=57%, 6-7=8%]. Time last known well [TLKW] for PVA NIHSS 0-7 was less than or equal to 3.5 hours in 15% and greater than 3.5 hours in 33%. Alteplase treatment rate for NIHSS 0-7 was 4% PVA v 9% EMS-A. Mechanical Endovascular Reperfusion [MER] treatment rate for NIHSS 0-7 was 0% PVA v 1% EMS-A. Discharge [DC] disposition for PVA NIHSS 0-7 showed 21% rehabilitation and 2% death or hospice. DC Modified Rankin Scale [mRS] for PVA NIHSS 0-7 was mRS 2-3 in 17% and mRS 4-5 in 10%. Conclusion: The majority of PVA were middle aged [46-65] and predominantly male. Hispanics were the only ethnic group with higher PVA v EMS-A. The TP majority lived in areas with less than 10% poverty, had private insurance, had ischemic strokes with milder deficits and presented outside the Alteplase treatment window. Treatment rates for Alteplase and MER were 50% greater for NIHSS 0-7 for EMS-A. At DC, 21% PVA with NIHSS 0-7 required rehabilitation and 27% had slight to severe disability. Identifying characteristics of the TP is helpful for focused public education to increase EMS-A and early presentation regardless of severity to increase treatment rates and decrease disability.

Exploratory Observational Study of Extracorporeal Cardiopulmonary Resuscitation for Nonshockable Out-Of-Hospital Cardiac Arrest Occurring After an Emergency Medical Services Arrival: SOS-KANTO 2012 Study Report.

The outcomes of patients with nonshockable out-of-hospital cardiac arrest (OHCA) are poor, but may be improved by extracorporeal cardiopulmonary resuscitation (E-CPR). To examine the effects of veno-arterial extracorporeal membranous oxygenation (ECMO) as E-CPR in patients with nonshockable OHCA after emergency medical services (EMS) arrival for whom satisfactory cardiopulmonary resuscitation (CPR) was immediately performed. Among 16,452 patients enrolled in the SOS-KANTO 2012 study, we examined data on 531 patients aged ≥ 18years who performed activities of daily living (ADL) well or had moderate disability before the onset of cardiac arrest (CA) and those with normal spontaneous respiration or pulse palpation upon EMS arrival. CPR was performed immediately after CA onset, and advanced life support was provided upon hospital arrival for these patients. We divided patients into ECMO and non-ECMO groups. We retrospectively analyzed background factors and clinical outcomes. E-CPR was performed on 38 (7.2%) patients. In the univariate analysis, the mean age of the ECMO group was lower, ADL function before onset was more favorable, mean body weight was higher, and the mean interval from onset until hospital arrival was shorter than those in the non-ECMO group. One-to 3-month survival or favorable cerebral function outcome rates were higher in the ECMO group than in the non-ECMO group. In the multivariate analysis, ECMO use and the interval from onset until hospital arrival were independent prognostic factors for favorable cerebral functional outcomes at 1 and 3months. E-CPR may be associated with favorable outcomes in carefully selected patients with nonshockable OHCA.

Comorbidity and bystander cardiopulmonary resuscitation in out-of-hospital cardiac arrest

​ObjectiveCardiopulmonary resuscitation (CPR) performed before the arrival of emergency medical services (EMS) is associated with increased survival after out-of-hospital cardiac arrest (OHCA). The aim of this study was to determine...

Thai family caregivers' experiences helping dependent elders during medical emergencies: a qualitative study

AimTo describe the experience of family caregivers of dependent elders during medical emergencies in rural settings in Thailand. MethodsThis was a descriptive qualitative research using in-depth interviews of 15 participants. Content analysis was applied to transcribed interviews, including data reduction as well as identification of key words, phrases, and themes. ResultsThe findings described the experience of caregivers of dependent older persons who faced emergency illness. Most of the family caregivers described their roles in unusual situations as practising assessment first and doing something that may relieve the symptoms experienced by the older persons before initiating and calling for help from relatives, neighbors, and, finally, the emergency medical services. The caregivers four main barriers to them feeling competent: (1) lack of home monitoring devices, (2) inexperienced caregivers in assessing warning signs to report during emergency care, (3) lack of information and understanding of patient rights in emergency health services, and (4) delayed arrival of emergency medical services. ConclusionsThere are barriers to the development of competency in caregiving skills, especially in assessing and recognizing warning signs and initiating first aid accurately before the arrival of the emergency health care team.

Epidemiological profile of emergency medical services in Japan: a population-based descriptive study in 2016.

AimThe aim of our study is to describe the characteristics of patients who use emergency medical services (EMS), EMS performance, and regional variations in Japan.MethodsWe undertook a nationwide, population‐based, descriptive review of anonymized ambulance transport records obtained from the Fire and Disaster Management Agency in Japan. All emergency patients transported to emergency medical institutions by EMS personnel from January to December 2016 were enrolled in this study, excluding patients who were not transported.ResultsDuring the study period, 5,097,838 patients were transported to a hospital. Their median age was 69 years, 51.4% were male, and 56.5% were over 65 years old. Median durations from EMS call to EMS arrival on scene were similar among the regions, ranging from 7 to 9 min. However, the longest median duration from EMS call to hospital arrival was 38 min, and the shortest was 31 min across the regions. Among all patients, 350,865 (6.9%) were assessed as being in a severe condition, 14,410 (0.3%) were in very severe condition, and 74,780 (1.5%) were confirmed to be dead at the time of initial medical examination in the emergency department.ConclusionsWe described the characteristics of emergency patients and EMS performance in Japan. This registry serves as a basis for providing relevant information to improve prehospital emergency medical systems.

Public-access defibrillation and neurological outcomes in patients with out-of-hospital cardiac arrest in Japan: a population-based cohort study

More than 80% of public-access defibrillation attempts do not result in sustained return of spontaneous circulation in patients who have had an out-of-hospital cardiac arrest (OHCA) and a shockable heart rhythm before arrival of emergency medical service (EMS) personnel. Neurological and survival outcomes in such patients have not been evaluated. We aimed to assess the neurological status and survival outcomes in such patients. This is a retropective analysis of a cohort study from a prospective, nationwide, population-based registry of 1 299 784 patients who had an OHCA event between Jan 1, 2005, and Dec 31, 2015 in Japan. The primary outcome was favourable neurological outcome (Cerebral Performance Category of 1 or 2) at 30 days after the OHCA and the secondary outcome was survival at 30 days following the OHCA. This study is registered with the University Hospital Medical Information Network Clinical Trials Registry, UMIN000009918. We identified 28 019 patients with bystander-witnessed OHCA and shockable heart rhythm who had received CPR from a bystander. Of these, 2242 (8·0%) patients did not achieve return of spontaneous circulation with CPR plus public-access defibrillation, and 25 087 (89·5%) patients did not achieve return of spontaneous circulation with CPR alone before EMS arrival. The proportion of patients with a favourable neurological outcome was significantly higher in those who received public-access defibrillation than those who did not (845 [37·7%] vs 5676 [22·6%]; adjusted odds ratio [OR] after propensity score-matching, 1·45 [95% CI 1·24-1·69], p<0·0001). The proportion of patients who survived at 30 days after the OHCA was also significantly higher in those who received public-access defibrillation than those who did not (987 [44·0%] vs 7976 [31·8%]; adjusted OR after propensity score-matching, 1·31 [95% CI 1·13-1·52], p<0·0001). Our findings support the benefits of public-access defibrillation and greater accessibility and availability of automated external defibrillators in the community. None.

Outcome, quality of life and direct costs after out-of-hospital cardiac arrest in an urban region of Switzerland

BackgroundConsidering the significant morbidity and mortality of out-of-hospital cardiac arrest, only little data on survival or quality of life after successful resuscitation is available in Europe. Additionally, economic aspects of such events are poorly studied. The purpose of this study is to provide data for survival, quality of life and costs directly related to the cardiac arrest for a region of Switzerland served by one emergency medical service (EMS).MethodsEighty eight patients older than 18 years of age that were resuscitated by the EMS Winterthur in the year 2013 were included and retrospective analysis of EMS-protocols was performed. For patients alive at follow-up, 2 years after the event, a structured interview with quality of life questionnaires was conducted. This study was accepted by the local Ethics Committee.ResultsThirty five percent (n = 31) of resuscitated patients were admitted alive to the hospital following out-of-hospital cardiac arrest. This incidence was as high as 60%, if the patients had a shockable rhythm as first rhythm. Survival to follow-up was 16% (n = 14). These patients had an excellent quality of life overall, with little to no limitations in daily life. There was no significant difference in survival for patients in outlying regions with comparatively longer timespans until arrival of EMS. Median EMS-costs for deceased patients were CHF 1731 (inter-quartile range 346), for survivors CHF 2′169 (inter-quartile range CHF 444) and median hospital-costs were CHF 27′707 (inter-quartile range CHF 62′783). ConclusionQuality of care for patients with out-of-hospital cardiac arrest in the region of Winterthur is high, including patients in outlying regions. The associated costs are similar to other European countries.Trial registrationThis trial was registered with www.clinicaltrials.gov under NCT02625883.

Abstract 325: Characteristics and Outcomes of Hanging Induced Out-Of-Hospital Cardiac Arrest: Insights From the Paris Sudden Death Expertise Center Registry

Introduction: Hanging-induced Out-of-Hospital cardiac arrest (OHCA) is poorly studied and a better understanding of these specific OHCA could be helpful to improve patients’ outcome. The main objective of our study was to describe characteristics and outcomes in patients who had OHCA from hanging injuries. Methods: From May 2011 to December 2017 we analyzed a prospectively collected Utstein database for all OHCA adults. All cases due to hanging were included. Utstein style variables were compared for 2 groups of patients: those with a Return of Spontaneous Circulation (ROSC) and those without (non-ROSC). Continuous data are described as means (extremes). Results: Among 25 055 OHCA, 500 patients were included. They were 49 (18-100) years old. Seventy-three (14.6%) hanging were witnessed and 58 (11.6%) benefited from a bystander cardiopulmonary resuscitation before Emergency Medical Service (EMS) arrival. No-flow duration was 29.1 (4-180) minutes. Advance life support was initiated by EMS in 299 (59.8%) cases. Low-flow duration was 23.8 (2-79) minutes. Nine patients (1.8%) had a shockable initial rhythm. We observed 83 (16.6%) ROSC. Four (0.8%) patients were discharged alive from hospital. They were all CPC 1. Table 1 compares characteristics with significant differences between ROSC and non-ROSC groups. Conclusion: As expected, younger age, short no-flow and low-flow durations and shockable rhythm on EMS arrival were significantly associated with ROSC. Overall prognosis is dramatically poor when OHCA is due to hanging (&lt;1%), with a very low proportion of shockable rhythm, even if the rare survivors have an excellent CPC at discharge. Indeed, the best method to reduce the mortality rate of hanging is, with no contest, the prevention of suicidal act.

Abstract 291: Cardiopulmonary Resuscitation Prior to Arrival of Emergency Medical Services in Arizona Extended Care Facilities

Background: Extended care facilities (ECFs) house unique patient populations with increased risk of out of hospital cardiac arrest (OHCA) and with unique, generally medically trained first responders initiating care prior to arrival of emergency medical services (EMS). However, little is known about bystander cardiopulmonary resuscitation (CPR) and resuscitation outcomes in this population. Our aim is to assess rate of CPR delivery prior to EMS arrival in cases of OHCA among residents ECFs across the state of Arizona. Methods: Cases of OHCA between 2016-2018, cared for by participating Arizona EMS agencies, were included if OHCA occurred at an ECF, age 18+, and was of presumed cardiac etiology. Association between survival status at discharge and bystander CPR was examined first by Chi-squared test then by logistic regression, which adjusted for important risk factors and potential confounders including: age, gender, witnessed arrest, shockable initial rhythm, and return of spontaneous circulation (ROSC) in EMS care. Results: There were 1,046 cases included in this study after excluding 32 cases with DNR and 11 with unknown bystander CPR status. Median patient age was 74 (interquartile range 64, 83). The overall rate of CPR prior to EMS arrival was 78.4% (95% CI, 75.8%, 80.9%). Survival to hospital discharge and survival with favorable neurologic outcome were not different between nursing home patients who received CPR prior to EMS arrival and those who did not [6.2% vs. 4.4% (p = 0.34) and 3.1% vs. 1.8% (p = 0.29)]. There was no statistically significant difference in the adjusted analysis. Conclusions: In this study population CPR was commonly delivered prior to EMS arrival. However, delivery of CPR prior to EMS arrival was not associated with survival to hospital discharge or favorable neurologic outcome. The lack of positive association between CPR prior to arrival and survival to hospital discharge may be related to comorbid factors present in ECF patients or differences in the time between collapse and initiation of CPR. Further study is needed to identify factors that might improve survival in this unique population.

Abstract 474: Higher Mortality From Cardiac Arrest in North Carolina versus Washington State and Denmark: Implications for Improving Systems of Care

Introduction: Survival from out-of-hospital cardiac arrest (OHCA) remains low and with major regional variation. This study explored differences in patients, care, and survival in patients with OHCA in North Carolina (NC), Washington State (WA), and Denmark. Methods: We identified a total of 17,277 adult patients with OHCA from the Cardiac Arrest Registry to Enhance Survival (CARES) registry and the Danish Cardiac Arrest Register of presumed cardiac cause from 2013-2014. Patients were categorized into three regions: two states in the United States (NC, 9.1 million inhabitants, WA, 7.5 million inhabitants) and the country of Denmark (5.8 million inhabitants). Outcomes of cardiopulmonary resuscitation (CPR) and defibrillation performed by either professional first responder or lay bystanders prior to emergency medical service (EMS) arrival, as well as overall survival. Data were analyzed using multivariable logistic regression analyses adjusted for age, sex, calendar year, location of arrest and witnessed status. Results: Patients in NC and WA were younger and had more racial variation compared to Denmark. Survival was 9.3% in NC, 14.5% in WA and 13.3% in Denmark. Using the Danish cohort as reference, the odds for bystander CPR and defibrillation in NC (CPR: OR 0.41, 95%CI 0.38-0.44; defibrillation: OR 0.30, 95%CI 0.23-0.38) and WA (CPR: OR 0.71, 95%CI 0.65-0.77; defibrillation: OR 0.41, 95%CI 0.31-0.53) were lower, respectively. CPR and defibrillation performed by either a bystander or a professional first responder prior to EMS arrival were higher in NC (CPR: OR 2.67, 95%CI 2.43-2.93; defibrillation: OR 2.72 95%CI 2.30-3.21), but not in WA (CPR: OR 1.01, 95%CI 0.92-1.11; defibrillation OR 0.73, 95%CI 0.58-0.90), respectively. Compared with Denmark, survival was lower in NC (OR 0.39, 95%CI 0.34-0.45) and WA (OR 0.83, 95%CI 0.72-0.95). Conclusion: Survival following OHCA was higher in Denmark and WA than in NC, and was associated with higher rates of bystander CPR and defibrillation. However, CPR and defibrillation prior to EMS arrival, mainly from professional first responders, was significantly higher in NC. A combination of both bystander and first responder interventions may be the optimal approach to improve outcomes of cardiac arrest.

The use of screening tools in the early recognition of sepsis in the prehospital adult patient: a review of the literature

Background: Sepsis has been identified as a time critical and life-threatening condition resulting from the body's own systemic response to infection leading to multi-organ dysfunction and failure, and remains a major frontrunner in the morbidity and mortality of critically ill patients1–3. The 2016 Surviving Sepsis Campaign1 identified that similar to patients with polytrauma, stroke and acute myocardial infarction, the early identification and timeous delivery of appropriate treatment for patients with sepsis could improve patient outcomes and decrease mortality rates1,4. Prehospital sepsis screening tools could provide a systematic approach to critically ill patients in order to identify those patients with a high index of suspicion for sepsis and allow for early and aggressive management.Methods: A literature review was conducted for the period January 2011 to September 2017. A database search was conducted via the electronic databases Ovid MEDLINE (without revisions), CINAHL and The Cochrane Library. The websites ScienceDirect, Wiley Online Library, British Medical Journal (BMJ) and Google Scholar were also used in the search for literature. Full search strategies are detailed in Table 1. The selection and rejection of all articles can be reviewed in Figure 1.Results: All articles identified for full review (n = 13) were between the period January 2011 and September 2017. The three most common methodologies identified were systematic review (n = 3), prospective cohort study (n = 3) and prospective observational study (n = 3). Other methodologies included literature review (n = 1), retrospective cohort study (n = 1), retrospective analysis (n = 1), and retrospective cross-sectional study (n = 1). Through literature analysis, three main areas of interest were identified in which articles were reviewed: the early recognition of sepsis by Emergency Medical Services (EMS) staff (n = 2), the early recognition of sepsis using a prehospital sepsis screening tool by EMS (n = 6), and the impact of EMS sepsis recognition and management on patient outcomes (n = 4). A comparison summary of the various sepsis screening tools can be viewed in Table 2.Conclusion: Previous literature has described EMS transport rates of approximately 3.3 sepsis patients per 100 and approximately 40% of septic patients admitted having been transported by EMS5. Despite this relatively high prevalence, the review identified that recognition of sepsis by EMS personnel was poor. The use of various sepsis screening tools showed improved recognition by EMS but validation studies on the accuracy of these tools is required. In patients in whom a screening tool was used and early pre-notification given to receiving facilities, a decrease time to definitive management of these patients was identified. These varied findings in outcomes of septic patients transported by EMS identifies the need for further studies on EMS recognition of sepsis and the impact it has on the outcomes of these patients. A specific prehospital sepsis screening tool could possibly assist in the early recognition of sepsis. Pre-notification to receiving facilities could allow the facility to prepare for EMS arrival and continue aggressive early goal directed therapy (EGDT) as required.The author acknowledges the possibility of publication and selection bias within this review due to single author selection and only English studies being included.

P4169The crucial role of the bystander in out-of-hospital cardiac arrest resuscitation

Abstract Background Out-of-hospital cardiac arrest (OHCA) is a major public health concern in France, given that there are 61.5 cases per 100,000 inhabitants a year. The impact of bystander action, performed before the arrival of emergency medical services (EMS), on survival has never been studied in France. Purpose Determine whether bystander cardiopulmonary resuscitation (CPR), performed before the arrival of EMS, was correlated with an increased 30-day survival rate after an OHCA. Methods 24,885 out-of-hospital cardiac arrests witnessed in France from 1 January 2012 to 1 May 2018 were analysed to determine whether CPR, performed before the arrival of EMS, was correlated with survival. Data from the Electronic Registry of Cardiac Arrests was used. The association between the effect of CPR performed before the arrival of EMS and 30-day survival rate was studied, using propensity analysis (which included variables such as age and sex of the patient, location, cause, and year of cardiac arrest, initial cardiac rhythm, EMS response time and no-flow time). Results CPR was performed before the arrival of EMS in 14,904 cases (59.9%) and was not performed in 9,981 cases (40.1%). The 30-day survival rate was 10.2% when CRP was performed by bystanders versus 3.9% when CRP was not performed before the EMS arrival (p&lt;0.001). CPR performed by bystanders was associated with an increased 30-day survival rate (odds ratio 1.269; 1.207 to 1.334). The effect of bystander CPR on survival Conclusion Bystander CPR performed before the arrival of EMS was associated with an increased 30-day survival rate after an out-of-hospital cardiac arrest in France.

P4170Survival after dispatcher assisted CPR in out of hospital cardiac arrest compared to CPR without dispatcher assistance and no CPR before emergency medical services arrival – a nationwide study

Abstract Background Cardiopulmonary resuscitation (CPR) before arrival of emergency medical services (EMS) is associated with survival in out-of hospital cardiac arrest. Dispatcher assisted CPR (DA-CPR) has been shown to increase CPR rates. However there are several challenges to successful DA-CPR, such as identification of cardiac arrest, time delays to CPR instructions, time delays to start of chest compression and quality of CPR. Purpose The aim of this study is to assess survival in out of hospital cardiac arrest after no CPR, DA-CPR and CPR without dispatcher assistance before EMS arrival in a nationwide cardiac arrest register. Methods A register based observational study. All consecutive Out of Hospital Cardiac Arrests reported to the Swedish Register for Cardiopulmonary Resuscitation in 2010–2017 were collected. Patients with cardiac arrest witnessed by EMS, who received CPR by off-duty medical professionals, missing data on CPR, DA-CPR or survival were excluded. Exposure was categorized as either; no CPR before EMS arrival (NO-CPR), dispatcher assisted CPR before EMS arrival (DA-CPR) and CPR before EMS arrival without dispatcher assistance, spontaneous CPR (S-CPR). Propensity score matched cohorts were used for comparison between groups. Primary endpoint was 30-day survival. Results Out of 36309, a total of 15471 patients were included, 41.6% received NO-CPR 31.0% received DA-CPR and 27.4% received S-CPR. In propensity score matched cohorts survival to 30-days was 9.0% after NO-CPR, 13.6% after DA-CPR and 15.8% after S-CPR. Using DA-CPR as reference, NO-CPR was associated with lower survival (Conditional OR 0.61, 95% CI 0.52–0.72), absolute difference 4.6% (95% CI 3.0%-6.2%) and S-CPR was associated with higher survival (Conditional OR 1.21 (95% CI 1.05–1.39), absolute difference 2.3% (95% CI 0.5%-4.0%). 30-day survival Conclusion In this nationwide study spontaneous CPR was associated with the highest survival. When spontaneous CPR is not initiated DA-CPR is a reasonable option. Acknowledgement/Funding Swedish Heart and Lung Foundation

P1747Reducing the delay from first medical contact to reperfusion in patients with acute myocardial infarction in metropolitan and adjacent rural areas: data from a regional myocardial infarction registry

Abstract Background Time from symptom onset to reperfusion in STEMI patients has been described to depend on a fast and valid pre-hospital STEMI diagnosis which not only decreases pre-hospital, but also in-hospital treatment delays. A publicly funded, prospective joint intervention program (QS-Notfall) has been initiated within our regional myocardial infarction (MI) registry (B2HIR) between hospitals and emergency medical services (EMS). The objective of the program is to reduce care delays of MI patients by supporting emergency care personnel in diagnosing STEMI trough real-time telemedical ECG counselling and by introducing a respective e-learning platform: “STEMI recognition made easy!” Methods Comprehensive baseline data on pre-hospital and in-hospital care have been collected from EMS and hospital records of all 1927 STEMI diagnosed patients with symptom onset &lt;24 hours at 24 hospitals (with metropolitan and rural location) in 2016. The dataset reported here delineates the situation before the implementation of systematic ECG-related interventions. Results Pre-hospital phase: Mode of hospital admission of STEMI patients comprised physician-escorted EMS (60%), EMS w/o an escorting physician (10%) in the city, referral by a primary care physician (10%), and self-presentation to the emergency department (14%). Some patients were primarily admitted to a non-PCI-capable hospital and underwent secondary transfer to a PCI-capable hospital. The respective percentages were found to differ between the metropolitan (4%) and rural areas (17%), Treatment delays Time from symptom onset to arrival of the EMS took 33min (median) in the city and 38 min in rural areas. Time between EMS arrival and ECG recording was 16 min and did not differ between metropolitan and rural sites. The delay from ECG recording to arrival at the hospital was 32 min in the city and 44 min at rural sites. Door to balloon time was similar (63 min) at both regions. Time delay from symptom onset to reperfusion for STEMI patients without physician escorted EMS was up to 370 min and differed according to the admission mode. Shortest care Patients, who alarmed the EMS and were cared for by physician escorted EMS, were brought to a PCI-capable hospital, and were directly admitted to the cath-lab, bypassing the emergency room, attained a delay from symptom onset to ECG recording of 48 min in the city and 37 min at rural areas. The delay from ECG recording to reperfusion was 67 min at urban sites and 77 min at rural sites in these fastest-treated patients. At metropolitan and rural sites 18,5% and 11% of patients belonged to this group, respectively. Conclusion This pre-interventional baseline dataset shows that guideline-prescribed care delays are attainable for patients with acute MI. But the proportion of patients with optimal care delays is small and needs to be increased considerably, which is the objective of our ongoing joint intervention QS-Notfall program. Acknowledgement/Funding Innovation Fonds, Ministry of Health, Germany

Pre and in-hospital delay in the use of thrombolytic therapy for acute ischemic stroke patients in Egypt

Stroke patients in Egypt don’t receive enough i.v thrombolytic therapy because they presented outside the therapeutic time window. It's important to understand the factors behind pre- and in-hospital delays of those patients. This prospective observational study included 296 patient presented with acute ischemic stroke and did not receive thrombolytic therapy from January, 2018, to June, 2018. from 3 large tertiary university hospitals (Assiut, Cairo and Tanta). A detailed history including the demographic data, which alarm patients notified, time of emergency medical service arrival, onset-to-door time , door-to-examination time, door-to-imaging time , door-to-laboratory time, the time interval between obtaining the test result and the needle time. NIHSS and mRS were carried out for each patient at admission and discharge. 156 patients were male and 140 were female, 200 patients came from rural area, 96 from urban area. The mean age was 62.5. A prehospital delay was reported for all patients and it had multiple reasons like Stroke misdiagnosis, delay in alarming emergency services, time wasting in referral from hospital to another. Intra-hospital time wasting was calculated for patients who came only in therapeutic time window (117 patient). It has multiple factors in which time delay till obtaining laboratory results and making decision contributed the most. Pre and In-hospital delays reduced the number of patients eligible for IV thrombolysis in Egypt. Efforts should focus on increasing awareness about stroke and its symptoms between general population and Health care professionals, and improvement of the pathway organization inside the Hospitals.

Effectiveness of dispatcher instructions-dependent or independent bystander cardiopulmonary resuscitation on neurological survival among patients with out-of-hospital cardiac arrest

BackgroundWe evaluated the association between survival and bystandercardiopulmonary resuscitation (CPR) with or without dispatcher instructions (DI) considering the time from emergency call receipt by the dispatch center to emergency medical services (EMS) personnel’s contact with the patient (i.e. time to EMS arrival). MethodsThis prospective study conducted in Osaka City, Japan, from 2009 to 2015 included patients with medical cause-related out-of-hospital cardiac arrest who were ≥18 years old. The primary outcome was one-month favorable neurological survival. Using multiple logistic regression models, the adjusted odds ratios (AOR) of independent and DI-dependent CPR for the primary outcome were compared with no CPR. Adjustments were made for patients’ age, sex, activities of daily living before the cardiac arrest, year of cardiac arrest, location, presence or absence of witnesses, etiology of cardiac arrest, and the time from EMS contact with the patient to patient’s arrival at the hospital. The effective estimated “time to EMS arrival” was also calculated. ResultsFor analyses 10,925 individuals were eligible. Independent CPR had a significantly higher one-month favorable neurological survival than no CPR whereas there was no significant difference between DI-dependent CPR and no CPR (AOR, 1.90 [1.47–2.46] and 1.16 [0.91–1.47], respectively). The estimated “time to EMS arrival” for a one-month favorable neurological survival after independent CPR was ≤13min. ConclusionsBystander CPR that did not need DI was associated with significantly higher one-month favorable neurological survival than no CPR, with an effective estimated “time to EMS arrival” of ≤13min.

Effects of dispatcher-initiated telephone cardiopulmonary resuscitation after out-of-hospital cardiac arrest: A nationwide, population-based, cohort study

AimThis study aimed to investigate the effects of dispatcher-initiated telephone cardiopulmonary resuscitation (TCPR) in Japan using a nationwide population-based registry. MethodsAdult Japanese patients with out-of-hospital cardiac arrest (OHCA; n = 582,483, age ≥18 years) were selected from a nationwide Utstein-style database (2010–2016) and divided into 3 groups: no bystander CPR (NCPR) before emergency medical service arrival (n = 448,606), bystander-initiated CPR (BCPR) performed without assistance (n = 46,964), and TCPR (n = 86,913). The primary outcome was a favourable neurological outcome 1 month after OHCA. ResultsAfter adjusting for potential confounders, and relative to the NCPR group, significantly better 1-month neurological outcomes were observed in the BCPR group (odds ratio: 2.25, 95% confidence interval: 2.15–2.36; P < 0.001) and in the TCPR group (odds ratio: 1.30, 95% confidence interval: 1.24–1.36; P < 0.001). The collapse-to-CPR time was independently associated with the 1-month outcomes, with a rate of <1% for 1-month favourable neurological outcomes if CPR was initiated >5 min after the collapse. ConclusionPatients who received TCPR had significantly better outcomes than those who did not receive CPR. However, the TCPR outcomes were less favourable than those in the BCPR group. Better protocol development and enhanced education are needed to improve dispatcher instructions in Japan, which may help lessen the gap between the BCPR and TCPR outcomes and further improve the outcomes after OHCA.