Outcome assessment for out-of-hospital cardiac arrest patients in Singapore and Japan with initial shockable rhythm.

BACKGROUND: Singapore and Osaka in Japan have comparable population sizes and prehospital management; however, the frequency of ECPR differs greatly for out-of-hospital cardiac arrest (OHCA) patients with initial shockable rhythm. Given this disparity, we hypothesized that the outcomes among the OHCA patients with initial shockable rhythm in Singapore were different from those in Osaka. The aim of this study was to evaluate the outcomes of OHCA patients with initial shockable rhythm in Singapore compared to the expected outcomes derived from Osaka data using machine learning-based prediction models. METHODS: This was a secondary analysis of two OHCA databases: the Singapore PAROS database (SG-PAROS) and the Osaka-CRITICAL database from Osaka, Japan. This study included adult (18-74 years) OHCA patients with initial shockable rhythm. A machine learning-based prediction model was derived and validated using data from the Osaka-CRITICAL database (derivation data 2012-2017, validation data 2018-2019), and applied to the SG-PAROS database (2010-2016 data), to predict the risk-adjusted probability of favorable neurological outcomes. The observed and expected outcomes were compared using the observed-expected ratio (OE ratio) with 95% confidence intervals (CI). RESULTS: From the SG-PAROS database, 1,789 patients were included in the analysis. For OHCA patients who achieved return of spontaneous circulation (ROSC) on hospital arrival, the observed favorable neurological outcome was at the same level as expected (OE ratio: 0.905 [95%CI: 0.784-1.036]). On the other hand, for those who had continued cardiac arrest on hospital arrival, the outcomes were lower than expected (shockable rhythm on hospital arrival, OE ratio: 0.369 [95%CI: 0.258-0.499], and nonshockable rhythm, OE ratio: 0.137 [95%CI: 0.065-0.235]). CONCLUSION: This observational study found that the outcomes for patients with initial shockable rhythm but who did not obtain ROSC on hospital arrival in Singapore were lower than expected from Osaka. We hypothesize this is mainly due to differences in the use of ECPR.

Comparing outcomes of out-of-hospital cardiac arrest patients with initial shockable rhythm in Singapore and Osaka using population-based databases.

BACKGROUND: Previous research indicated outcomes among refractory out-of-hospital cardiac arrest (OHCA) patients with initial shockable rhythm were different in Singapore and Osaka, Japan, possibly due to the differences in access to extracorporeal cardiopulmonary resuscitation. However, this previous study had a risk of selection bias. To address this concern, this study aimed to evaluate the outcomes between Singapore and Osaka for OHCA patients with initial shockable rhythm using only population-based databases. METHODS: This was a secondary analysis of two OHCA population-based databases in Osaka and Singapore, including adult OHCA patients with initial shockable rhythm. A machine-learning-based prediction model was derived from the Osaka data (n = 3088) and applied to the PAROS-SG data (n = 2905). We calculated the observed-expected ratio (OE ratio) for good neurological outcomes observed in Singapore and the expected derived from the data in Osaka by dividing subgroups with or without prehospital ROSC. RESULTS: The one-month good neurological outcomes in Osaka and Singapore among patients with prehospital ROSC were 70% (791/1,125) and 57% (440/773), and among patients without prehospital ROSC were 10% (196/1963) and 2.8% (60/2,132). After adjusting patient characteristics, the outcome in Singapore was slightly better than expected from Osaka in patients with ROSC (OE ratio, 1.067 [95%CI 1.012 to 1.125]), conversely, it was worse than expected in patients without prehospital ROSC (OE ratio, 0.238 [95%CI 0.173 to 0.294]). CONCLUSION: This study showed the outcomes of OHCA patients without prehospital ROSC in Singapore were worse than expected derived from Osaka data even using population-based databases. (249/250 words).

Improved Out-of-Hospital Cardiac Arrest Survival with a Comprehensive Dispatcher-Assisted CPR Program in a Developing Emergency Care System.

OBJECTIVE: Out-of-hospital cardiac arrest (OHCA) is associated with poor survival. Studies have demonstrated improved survival with early bystander cardiopulmonary resuscitation (BCPR). This study evaluated the impact of a dispatcher-assisted CPR (DA-CPR) program on BCPR rate and outcomes of OHCA in a developing emergency medical services (EMS) system setting. METHODS: Data were extracted from the national cardiac arrest registry. A before-after analysis was performed between OHCA cases with cardiac etiology conveyed by EMS from April 2010-June 2012 (pre-intervention) and July 2012-December 2015 (post-intervention). Primary outcomes were survival-to-discharge/30 days post-arrest and favorable cerebral performance (Glasgow-Pittsburgh cerebral performance categories 1 and 2). RESULTS: 6365 OHCA cases were analyzed with 2129 in the pre-intervention and 4236 in the post-intervention group. In the post-intervention group, there was an increase in BCPR rates from 24.8% to 53.8% (p < 0.001), adjusted OR 3.67 (aOR; 95%CI: 3.26-4.13). OHCA outcomes also improved with survival-to-discharge rates increasing from 3.0%-4.5% (p < 0.01), aOR 2.10 (95%CI: 1.40-3.17) and favorable cerebral performance increasing from 1.6% to 2.7% (p < 0.05), aOR 2.82 (95%CI: 1.65-4.82). In patients with initial shockable rhythm, BCPR without dispatcher assistance was associated with significantly higher odds of survival-to-discharge (aOR 1.67, 95%CI: 1.06-2.64) and favorable cerebral performance (aOR 2.32, 95%CI: 1.26-4.27) compared to no BCPR. CONCLUSION: Our study showed that a simplified DA-CPR program can be successfully implemented in a developing EMS system and can contribute to higher BCPR rate and in turn, improve OHCA survival. Future studies can examine bystanders' characteristics and quality of the CPR performed to understand their impact on survival.

Comparison of Outcomes and Characteristics of Emergency Medical Services (EMS)-Witnessed, Bystander-Witnessed, and Unwitnessed Out-of-Hospital Cardiac Arrests in Singapore.

Objectives: The objective was to compare the survival outcomes of emergency medical services (EMS)-witnessed to bystander-witnessed, and unwitnessed out-of-hospital cardiac arrests (OHCA) in Singapore. Secondary aims are to describe the 5-year trend in survival rates of EMS-witnessed arrests. Methods: This was a retrospective analysis of the Singapore's OHCA registry data from 2011 to 2015. Excluded from the analysis were patients younger than 18 years old, arrests of traumatic etiology, resuscitation not attempted, and cases not conveyed by EMS. The primary outcome was survival to hospital discharge or 30 days post-arrest. Secondary outcomes were return of spontaneous circulation (ROSC) and survival to hospital admission. Results: 8,394 cases were analyzed, with 650 (7.7%) EMS-witnessed arrests, 4480 (53.4%) bystander-witnessed arrests, and 3264 (38.9%) unwitnessed arrests. Among EMS-witnessed arrests, the majority were presumed to be of cardiac etiology (62.8%) and the most common presenting rhythm was pulseless electrical activity (PEA; 57.2%). Survival to discharge or 30th day post-arrest was higher in EMS-witnessed arrests compared to bystander-witnessed and unwitnessed arrests (11.2% vs. 5.3% and 1.3%, p < 0.001). Survival to discharge for EMS-witnessed cases increased from 2011 (13.2%) to 2015 (18.9%). Conclusions: EMS-witnessed OHCAs were more likely to have favorable outcomes compared to bystander-witnessed and unwitnessed OHCAs. High PEA rates in EMS-witnessed arrests were associated with older patients with underlying preexisting medical conditions. Increasing public awareness on recognition of prodromal symptoms and early activation of EMS could improve post-arrest survival and neurological outcomes of OHCA.

Ethnic and Neighborhood Socioeconomic Differences In Incidence and Survival From Out-Of-Hospital Cardiac Arrest In Singapore.

Objective: We aimed to examine the association of ethnicity and socioeconomic status (SES) with Out-of-Hospital Cardiac Arrest (OHCA) incidence and 30-day survival in Singapore. Methods: We analyzed the Singapore cohort of Pan-Asia Resuscitation Outcome Study (PAROS), a multi-center, prospective OHCA registry between 2010 and 2015. The Singapore Socioeconomic Disadvantage Index (SEDI) score, obtained according to zip code, was used as surrogate for neighborhood SES. Age-adjusted OHCA incidence and Utstein survival were calculated by ethnicity and SES. Utstein survival was defined as the number of cardiac OHCA cases with initial rhythm of ventricular fibrillation witnessed by a bystander who survived 30-days or until hospital discharge. Logistic regression was used to investigate association of ethnicity with 30-day and Utstein survivals. Results: Our study population comprised 8,900 patients: 6,453 Chinese, 1,472 Malays, and 975 Indians. The overall age-adjusted incidence ratios (95% CI) for Malay/Chinese and Indian/Chinese were 1.93 (1.83-2.04) and 1.95 (1.83-2.08), respectively. The overall age-adjusted incidence ratios (95% CI) for average/low and high/low SEDI group were 1.12 (0.95-1.33) and 1.29 (1.08-1.53), respectively. Malay showed lesser Utstein survival of 8.1% compared to Chinese (14.6%) and Indian (20.4%) [p = 0.018]. Ethnicity did not reach statistical significance (p = 0.072) in forward selection model of Utstein survival, while SEDI score and category were not significant (p > 0.2 and p = 0.349). Conclusions: We found Malay and Indian communities to be at higher risks of OHCA compared to Chinese, and additionally, the Malay community is at higher risk of subsequent mortality than the Chinese and Indian communities. These disparities were not explained by neighborhood SES.

Modifiable Factors Associated With Survival After Out-of-Hospital Cardiac Arrest in the Pan-Asian Resuscitation Outcomes Study.

STUDY OBJECTIVE: The study aims to identify modifiable factors associated with improved out-of-hospital cardiac arrest survival among communities in the Pan-Asian Resuscitation Outcomes Study (PAROS) Clinical Research Network: Japan, Singapore, South Korea, Malaysia, Taiwan, Thailand, and the United Arab Emirates (Dubai). METHODS: This was a prospective, international, multicenter cohort study of out-of-hospital cardiac arrest in the Asia-Pacific. Arrests caused by trauma, patients who were not transported by emergency medical services (EMS), and pediatric out-of-hospital cardiac arrest cases (<18 years) were excluded from the analysis. Modifiable out-of-hospital factors (bystander cardiopulmonary resuscitation [CPR] and defibrillation, out-of-hospital defibrillation, advanced airway, and drug administration) were compared for all out-of-hospital cardiac arrest patients presenting to EMS and participating hospitals. The primary outcome measure was survival to hospital discharge or 30 days of hospitalization (if not discharged). We used multilevel mixed-effects logistic regression models to identify factors independently associated with out-of-hospital cardiac arrest survival, accounting for clustering within each community. RESULTS: Of 66,780 out-of-hospital cardiac arrest cases reported between January 2009 and December 2012, we included 56,765 in the analysis. In the adjusted model, modifiable factors associated with improved out-of-hospital cardiac arrest outcomes included bystander CPR (odds ratio [OR] 1.43; 95% confidence interval [CI] 1.31 to 1.55), response time less than or equal to 8 minutes (OR 1.52; 95% CI 1.35 to 1.71), and out-of-hospital defibrillation (OR 2.31; 95% CI 1.96 to 2.72). Out-of-hospital advanced airway (OR 0.73; 95% CI 0.67 to 0.80) was negatively associated with out-of-hospital cardiac arrest survival. CONCLUSION: In the PAROS cohort, bystander CPR, out-of-hospital defibrillation, and response time less than or equal to 8 minutes were positively associated with increased out-of-hospital cardiac arrest survival, whereas out-of-hospital advanced airway was associated with decreased out-of-hospital cardiac arrest survival. Developing EMS systems should focus on basic life support interventions in out-of-hospital cardiac arrest resuscitation.

Termination of Resuscitation Rules to Predict Neurological Outcomes in Out-of-Hospital Cardiac Arrest for an Intermediate Life Support Prehospital System.

AIM: Futile resuscitation can lead to unnecessary transports for out-of-hospital cardiac arrest (OHCA). The Basic Life Support (BLS) and Advanced Life Support (ALS) termination of resuscitation (TOR) guidelines have been validated with good results in North America. This study aims to evaluate the performance of these two rules in predicting neurological outcomes of OHCA patients in Singapore, which has an intermediate life support Emergency Medical Services (EMS) system. METHODS: A retrospective cohort study was carried out on Singapore OHCA data collected from April 2010 to May 2012 for the Pan-Asian Resuscitation Outcomes Study (PAROS). The outcomes of each rule were compared to the actual neurological outcomes of the patients. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and predicted transport rates of each test were evaluated. RESULTS: A total of 2,193 patients had cardiac arrest of presumed cardiac etiology. TOR was recommended for 1,411 patients with the BLS-TOR rule, with a specificity of 100% (91.9, 100.0) for predicting poor neurological outcomes, PPV 100% (99.7, 100.0), sensitivity 65.7% (63.6, 67.7), NPV 5.6% (4.1, 7.5), and transportation rate 35.6%. Using the ALS-TOR rule, TOR was recommended for 587 patients, specificity 100% (91.9, 100.0) for predicting poor neurological outcomes, PPV 100% (99.4, 100.0), sensitivity 27.3% (25.4, 29.3), NPV 2.7% (2.0, 3.7), and transportation rate 73.2%. BLS-TOR predicted survival (any neurological outcome) with specificity 93.4% (95% CI 85.3, 97.8) versus ALS-TOR 98.7% (95% CI 92.9, 99.8). CONCLUSION: Both the BLS and ALS-TOR rules had high specificities and PPV values in predicting neurological outcomes, the BLS-TOR rule had a lower predicted transport rate while the ALS-TOR rule was more accurate in predicting futility of resuscitation. Further research into unique local cultural issues would be useful to evaluate the feasibility of any system-wide implementation of TOR.

Variable importance analysis with interpretable machine learning for fair risk prediction.

Machine learning (ML) methods are increasingly used to assess variable importance, but such black box models lack stability when limited in sample sizes, and do not formally indicate non-important factors. The Shapley variable importance cloud (ShapleyVIC) addresses these limitations by assessing variable importance from an ensemble of regression models, which enhances robustness while maintaining interpretability, and estimates uncertainty of overall importance to formally test its significance. In a clinical study, ShapleyVIC reasonably identified important variables when the random forest and XGBoost failed to, and generally reproduced the findings from smaller subsamples (n = 2500 and 500) when statistical power of the logistic regression became attenuated. Moreover, ShapleyVIC reasonably estimated non-significant importance of race to justify its exclusion from the final prediction model, as opposed to the race-dependent model from the conventional stepwise model building. Hence, ShapleyVIC is robust and interpretable for variable importance assessment, with potential contribution to fairer clinical risk prediction.

Machine learning prediction of refractory ventricular fibrillation in out-of-hospital cardiac arrest using features available to EMS.

Background: Shock-refractory ventricular fibrillation (VF) or ventricular tachycardia (VT) is a treatment challenge in out-of-hospital cardiac arrest (OHCA). This study aimed to develop and validate machine learning models that could be implemented by emergency medical services (EMS) to predict refractory VF/VT in OHCA patients. Methods: This was a retrospective study examining adult non-traumatic OHCA patients brought into the emergency department by Singapore EMS from the Pan-Asian Resuscitation Outcomes Study (PAROS) registry. Data from April 2010 to March 2020 were extracted for this study. Refractory VF/VT was defined as VF/VT persisting or recurring after at least one shock. Features were selected based on expert clinical opinion and availability to dispatch prior to arrival at scene. Multivariable logistic regression (MVR), LASSO and random forest (RF) models were investigated. Model performance was evaluated using receiver operator characteristic (ROC) area under curve (AUC) analysis and calibration plots. Results: 20,713 patients were included in this study, of which 860 (4.1%) fulfilled the criteria for refractory VF/VT. All models performed comparably and were moderately well-calibrated. ROC-AUC were 0.732 (95% CI, 0.695 - 0.769) for MVR, 0.738 (95% CI, 0.701 - 0.774) for LASSO, and 0.731 (95% CI, 0.690 - 0.773) for RF. The shared important predictors across all models included male gender and public location. Conclusion: The machine learning models developed have potential clinical utility to improve outcomes in cases of refractory VF/VT OHCA. Prediction of refractory VF/VT prior to arrival at patient's side may allow for increased options for intervention both by EMS and tertiary care centres.

Clinicopathological correlates of out-of-hospital cardiac arrests.

Background: Sudden cardiac arrest with or without sudden cardiac death (SCD) represents a heterogeneous spectrum of underlying etiology but is often a catastrophic event. Despite improvements in pre-hospital response and post-resuscitation care, outcomes remain grim. Thus, we aim to evaluate the predictors of survival in out-of-hospital cardiac arrests (OHCAs) and describe autopsy findings of those with the uncertain cause of death (COD). Methods: This is a subgroup analysis of the Singapore cohort from the Pan Asian Resuscitation Outcome Study which studied 933 OHCAs admitted to two Singapore tertiary hospitals from April 2010 to May 2012. Results: Of the patients analysed, 30.2% (n = 282) had an initial return of spontaneous circulation (ROSC) at the emergency department, 18.0% (n = 168) had sustained ROSC with subsequent admission and 3.4% (n = 32) had survival to discharge. On multivariate analysis, an initial shockable rhythm, a witnessed event, prehospital defibrillation, and shorter time to hospital predicted ROSC as well as survival to discharge. A total of 163 (17.5%) autopsies were performed of which a cardiac etiology of SCD was noted in 92.1% (n = 151). Ischemic heart disease accounted for 54.3% (n = 89) of the autopsy cohort, with acute myocardial infarction (26.9%, n = 44) and myocarditis (3.7%, n = 6) rounding out the top three causes of demise. Conclusion: OHCA remains a clinical presentation that portends a poor prognosis. Of those with uncertain COD, cardiac etiology appears to predominate from autopsy study. Identification of prognostic factors will play an important role in improving individual-level and systemic-level variables to further optimize outcomes.

Inter-hospital trends of post-resuscitation interventions and outcomes of out-of-hospital cardiac arrest in Singapore.

INTRODUCTION: Hospital-based resuscitation interventions, such as therapeutic temperature management (TTM), emergency percutaneous coronary intervention (PCI) and extracorporeal membrane oxygenation (ECMO) can improve outcomes in out-of-hospital cardiac arrest (OHCA). We investigated post-resuscitation interventions and hospital characteristics on OHCA outcomes across public hospitals in Singapore over a 9-year period. METHODS: This was a prospective cohort study of all OHCA cases that presented to 6 hospitals in Singapore from 2010 to 2018. Data were extracted from the Pan-Asian Resuscitation Outcomes Study Clinical Research Network (PAROS CRN) registry. We excluded patients younger than 18 years or were dead on arrival at the emergency department. The outcomes were 30-day survival post-arrest, survival to admission, and neurological outcome. RESULTS: The study analysed 17,735 cases. There was an increasing rate of provision of TTM, emergency PCI and ECMO (P<0.001) in hospitals, and a positive trend of survival outcomes (P<0.001). Relative to hospital F, hospitals B and C had lower provision rates of TTM (≤5.2%). ECMO rate was consistently <1% in all hospitals except hospital F. Hospitals A, B, C, E had <6.5% rates of provision of emergency PCI. Relative to hospital F, OHCA cases from hospitals A, B and C had lower odds of 30-day survival (adjusted odds ratio [aOR]<1; P<0.05 for hospitals A-C) and lower odds of good neurological outcomes (aOR<1; P<0.05 for hospitals A-C). OHCA cases from academic hospitals had higher odds ratio (OR) of 30-day survival (OR 1.3, 95% CI 1.1-1.5) than cases from hospitals without an academic status. CONCLUSION: Post-resuscitation interventions for OHCA increased across all hospitals in Singapore from 2010 to 2018, correlating with survival rates. The academic status of hospitals was associated with improved survival.

The association between mode of transport and out-of-hospital cardiac arrest outcomes in Singapore.

OBJECTIVE: We aimed to examine the survival outcomes of out-of-hospital cardiac arrest (OHCA) patients, stratified by the transportation modes to the Emergency Department (ED). METHODS: This was a retrospective analysis of Singapore's Pan-Asian Resuscitation Outcomes Study registry from Apr 2010-Dec 2017. The primary outcome was survival to discharge or 30 days post-arrest. Secondary outcomes were the return of spontaneous circulation (ROSC) rate and neurological outcomes. A subgroup analysis was performed for OHCA cases who collapsed enroute. RESULTS: A total of 15,376 cases were analysed. 15,129 (98.4%) were conveyed by Emergency Medical Services (EMS), 111 (0.72%) by private ambulance, 106 (0.69%) by own transport and 30 (0.2%) by public transport. 80% of patients brought by public transport arrested enroute, compared to 48.1% by own transport, 25.2% by private ambulance and 2.5% in the EMS group. 33/120 (27.5%) of paediatric OHCA cases were brought in by non-EMS transport to paediatric hospitals. The EMS group had the lowest survival rate at 4.5%, compared to 13.3% for public transport, 11.3% for own transport and 14.4% for private ambulance. ROSC rate was statistically significant but not for neurological outcomes. For the subgroup analysis, there was no statistical difference for primary and secondary outcomes across the groups. CONCLUSION: In Singapore, most OHCA patients are conveyed by EMS to the hospital, but some OHCA patients still arrive via alternative transport without prehospital interventions like bystander CPR. More can be done to educate the public to recognise an impending cardiac arrest and to activate EMS early for such cases.

Validation of the CaRdiac Arrest Survival Score (CRASS) for predicting good neurological outcome after out-of-hospital cardiac arrest in an Asian emergency medical service system.

BACKGROUND: Survival with favorable neurological outcomes is an important indicator of successful resuscitation in out-of-hospital cardiac arrest (OHCA). We sought to validate the CaRdiac Arrest Survival Score (CRASS), derived using data from the German Resuscitation Registry, in predicting the likelihood of good neurological outcomes after OHCA in Singapore. METHODS: We conducted a retrospective population-based validation study among EMS-attended OHCA patients (≥18 years) in Singapore, using data from the prospective Pan-Asian Resuscitation Outcomes Study registry. Good neurological outcome was defined as a cerebral performance category of 1 or 2. To evaluate the CRASS score in light of the difference in patient characteristics, we used the default constant coefficient (0.8) and the adjusted coefficient (0.2) to calculate the probability of good neurological outcomes. RESULTS: Out of 11,404 analyzed patients recruited between April 2010 and December 2018, 260 had good and 11,144 had poor neurological function. The CRASS score demonstrated good discrimination, with an area under the curve of 0.963 (95% confidence interval: 0.952-0.974). Using the default constant coefficient of 0.8, the CRASS score consistently overestimated the predicted probability of a good outcome. Following adjustment of the coefficient to 0.2, the CRASS score showed improved calibration. CONCLUSION: CRASS demonstrated good discrimination and moderate calibration in predicting favorable neurological outcomes in the validation Singapore cohort. Our study established a good foundation for future large-scale, cross-country validations of the CRASS score in diverse sociocultural, geographical, and clinical settings.

Assessing unrealised potential for organ donation after out-of-hospital cardiac arrest.

BACKGROUND: Organ donation after brain death is the standard practice in many countries. Rates are low globally. This study explores the potential national number of candidates for uncontrolled donations after cardiac death (uDCD) amongst out-of-hospital cardiac arrest (OHCA) patients and the influence of extracorporeal cardiopulmonary resuscitation (ECPR) on the candidacy of these potential organ donors using Singapore as a case study. METHODS: Using Singapore data from the Pan-Asian Resuscitation Outcomes Study, we identified all non-traumatic OHCA cases from 2010 to 2016. Four established criteria for identifying uDCD candidates (Madrid, San Carlos Madrid, Maastricht and Paris) were retrospectively applied onto the population. Within these four groups, a condensed ECPR eligibility criteria was employed and thereafter, an estimated ECPR survival rate was applied, extrapolating for possible neurologically intact survivors had ECPR been administered. RESULTS: 12,546 OHCA cases (64.8% male, mean age 65.2 years old) qualified for analysis. The estimated number of OHCA patients who were eligible for uDCD ranged from 4.3 to 19.6%. The final projected percentage of potential uDCD donors readjusted for ECPR survivors was 4.2% (Paris criteria worst-case scenario, n = 532) to 19.4% of all OHCA cases (Maastricht criteria best-case scenario, n = 2428), for an estimated 14.3 to 65.4 uDCD donors per million population per year (pmp/year). CONCLUSIONS: In Singapore case study, we demonstrated the potential numbers of candidates for uDCD among resuscitated OHCA cases. This sizeable pool of potential donors demonstrates the potential for an uDCD program to expand the organ donor pool. A small proportion of these patients might however survive had they been administered ECPR. Further research into the factors influencing local organ and patient outcomes following uDCD and ECPR is indicated.

Early Coronary Angiography Is Associated with Improved 30-Day Outcomes among Patients with Out-of-Hospital Cardiac Arrest.

We evaluated the association between early coronary angiography (CAG) and outcomes in resuscitated out-of-hospital cardiac arrest (OHCA) patients, by linking data from the Singapore Pan-Asian Resuscitation Outcomes Study, with a national registry of cardiac procedures. The 30-day survival and neurological outcome were compared between patients undergoing early CAG (within 1-calender day), versus patients not undergoing early CAG. Inverse probability weighted estimates (IPWE) adjusted for non-randomized CAG. Of 976 resuscitated OHCA patients of cardiac etiology between 2011-2015 (mean(SD) age 64(13) years, 73.7% males), 337 (34.5%) underwent early CAG, of whom, 230 (68.2%) underwent PCI. Those who underwent early CAG were significantly younger (60(12) vs. 66(14) years old), healthier (42% vs. 59% with heart disease; 29% vs. 44% with diabetes), more likely males (86% vs. 67%), and presented with shockable rhythms (69% vs. 36%), compared with those who did not. Early CAG with PCI was associated with better survival and neurological outcome (adjusted odds ratio 1.91 and 1.82 respectively), findings robust to IPWE adjustment. The rates of bleeding and stroke were similar. CAG with PCI within 24 h was associated with improved clinical outcomes after OHCA, without increasing complications. Further studies are required to identify the characteristics of patients who would benefit most from this invasive strategy.

Prediction of ROSC After Cardiac Arrest Using Machine Learning.

Out-of-hospital cardiac arrest (OHCA) is an important public health problem, with very low survival rate. In treating OHCA patients, the return of spontaneous circulation (ROSC) represents the success of early resuscitation efforts. In this study, we developed a machine learning model to predict ROSC and compared it with the ROSC after cardiac arrest (RACA) score. Results demonstrated the usefulness of machine learning in deriving predictive models.

Nationwide trends in residential and non-residential out-of-hospital cardiac arrest and differences in bystander cardiopulmonary resuscitation.

AIMS: Singapore is highly-urbanized, with >90% of the population living in high-rise apartments. She has implemented several city-wide interventions such as dispatcher-assisted CPR, community CPR training and smartphone activation of volunteers to increase bystander CPR (BCPR) rates for out-of-hospital cardiac arrest (OHCA). These may have different impact on residential and non-residential OHCA. We aimed to evaluate the characteristics, processes-of-care and outcome differences between residential and non-residential OHCA and study the differences in temporal trends of BCPR rates. METHODS: This was a national, observational study in Singapore from 2010 to 2016, using data from the prospective Pan-Asian Resuscitation Outcomes Study. The primary outcome was survival (to-discharge or to-30-days). Multivariate logistic regression was performed to determine the effect of location-type on survival and a test of statistical interaction was performed to assess the difference in the temporal relationship of BCPR rates between location-type. RESULTS: 8397 cases qualified for analysis, of which 5990 (71.3%) were residential. BCPR and bystander automated external defibrillator (AED) rates were significantly lower in residential as compared to non-residential arrests (41.0% vs 53.6%, p < 0.01; 0.4% vs 10.8%, p < 0.01 respectively). Residential BCPR increased from 15.8% (2010) to 57.1% (2016). Residential cardiac arrests had lower survival-to-discharge (2.9% vs 10.1%, p < 0.01). Multivariate logistic regression analysis showed that location-type had an independent effect on survival, with residential arrests having poorer survival compared to non-residential cardiac arrests (adjusted OR 0.547 [0.435-0.688]). A test of statistical interaction showed a significant interaction effect between year and location-type for bystander CPR, with a narrowing of differences in bystander CPR between residential and non-residential cardiac arrests over the years. CONCLUSION: Residential cardiac arrests had poorer bystander intervention and survival from 2010 to 2016 in Singapore. BCPR had improved more in residential arrests compared to non-residential arrests over a period of city-wide interventions to improve BCPR.

Effectiveness of a community based out-of-hospital cardiac arrest (OHCA) interventional bundle: Results of a pilot study.

BACKGROUND: 70% of Out-of-hospital cardiac arrests (OHCA) in Singapore occur in residential areas, and are associated with poorer outcomes. We hypothesized that an interventional bundle consisting of Save-A-life (SAL) initiative (cardiopulmonary resuscitation (CPR)/automated external defibrillator (AED) training and public-housing AED installation), dispatcher-assisted CPR (DA-CPR) program and myResponder (mobile application) will improve OHCA survival. METHODS: This is pilot data from initial implementation of a stepped-wedge, before-after, real-world interventional bundle in six selected regions. Under the SAL initiative, 30,000 individuals were CPR/AED trained, with 360 AEDs installed. Data was obtained from Singapore's national OHCA Registry. We included all adult patients who experienced OHCA in Singapore from 2011 to 2016 within study regions, excluding EMS-witnessed cases and cases due to trauma/drowning/ electrocution. Cases occurring before and after intervention were allocated as control and intervention groups respectively. Survival was assessed via multivariable logistic regression. RESULTS: 1241 patients were included for analysis (Intervention: 361; Control: 880). The intervention group had higher mean age (70 vs 67 years), survival (3.3% [12/361] vs. 2.2% [19/880]), pre-hospital return of spontaneous circulation (ROSC) (9.1% [33/361] vs 5.1% [45/880]), bystander CPR (63.7% [230/361] vs 44.8% [394/880]) and bystander AED application (2.8% [10/361] vs 1.1% [10/880]). After adjusting for age, gender, race and significant covariates, the intervention was associated with increased odds ratio (OR) for survival (OR 2.39 [1.02-5.62]), pre-hospital ROSC (OR 1.94 [1.15-3.25]) and bystander CPR (OR 2.29 [1.77-2.96]). CONCLUSION: The OHCA interventional bundle (SAL initiative, DA-CPR, myResponder) significantly improved survival and is being scaled up as a national program.

Validation of the ROSC after cardiac arrest (RACA) score in Pan-Asian out-of-hospital cardiac arrest patients.

AIM: Survival is the most consistently captured outcome across countries for out-of-hospital cardiac arrests (OHCA), with return of spontaneous circulation (ROSC) representing the earliest endpoint for 'unbiased' initial resuscitation success. The ROSC after cardiac arrest (RACA) score was developed to predict ROSC and has been validated in several European countries. In this study, we aimed to evaluate the performance of RACA in a Pan-Asian population. METHODS: We conducted a retrospective analysis of data collected in the Pan-Asian Resuscitation Outcomes Study (PAROS) registry. We included OHCA cases from seven communities (Japan, South Korea, Malaysia, Singapore, Taiwan, Thailand, and United Arab Emirates) between January 2009 and December 2012. Paediatric cases, cases that were conveyed by non-emergency medical services (EMS), and cases with incomplete records were excluded from the study. RESULTS: The RACA score showed similar discrimination performance as the original German study and various European validation studies. However, it had poor calibration with the original constant regression coefficient, which was primarily due to the low ROSC rate (8.2%) in the PAROS cohort. The calibration performance of RACA significantly improved after the constant coefficient was modified to adjust for the disparity in ROSC rates between Asia and Europe. CONCLUSION: This is the largest validation study of the RACA score. RACA consistently performs well in both Pan-Asian and European communities and can thus be a valuable tool for evaluating EMS systems. However, to implement it, the constant coefficient has to be modified in the RACA formula with local historical data.

Implementation of a National 5-Year Plan for Prehospital Emergency Care in Singapore and Impact on Out-of-Hospital Cardiac Arrest Outcomes From 2011 to 2016.

Background Outcomes of patients from out-of-hospital cardiac arrest (OHCA) vary widely globally because of differences in prehospital systems of emergency care. National efforts had gone into improving OHCA outcomes in Singapore in recent years including community and prehospital initiatives. We aimed to document the impact of implementation of a national 5-year Plan for prehospital emergency care in Singapore on OHCA outcomes from 2011 to 2016. Methods and Results Prospective, population-based data of OHCA brought to Emergency Departments were obtained from the Pan-Asian Resuscitation Outcomes Study cohort. The primary outcome was Utstein (bystander witnessed, shockable rhythm) survival-to-discharge or 30-day postarrest. Mid-year population estimates were used to calculate age-standardized incidence. Multivariable logistic regression was performed to identify prehospital characteristics associated with survival-to-discharge across time. A total of 11 465 cases qualified for analysis. Age-standardized incidence increased from 26.1 per 100 000 in 2011 to 39.2 per 100 000 in 2016. From 2011 to 2016, Utstein survival rates nearly doubled from 11.6% to 23.1% (P=0.006). Overall survival rates improved from 3.6% to 6.5% (P<0.001). Bystander cardiopulmonary resuscitation rates more than doubled from 21.9% to 56.3% and bystander automated external defibrillation rates also increased from 1.8% to 4.6%. Age ≤65 years, nonresidential location, witnessed arrest, shockable rhythm, bystander automated external defibrillation, and year 2016 were independently associated with improved survival. Conclusions Implementation of a national prehospital strategy doubled OHCA survival in Singapore from 2011 to 2016, along with corresponding increases in bystander cardiopulmonary resuscitation and bystander automated external defibrillation. This can be an implementation model for other systems trying to improve OHCA outcomes.