Association between Conversion to Shockable Rhythms and Survival with Favorable Neurological Outcomes for Out-of-Hospital Cardiac Arrests.

BACKGROUND: The initial cardiac rhythm in out-of-hospital cardiac arrest (OHCA) portends different prognoses and affects treatment decisions. Initial shockable rhythms are associated with good survival and neurological outcomes but there is conflicting evidence for those who initially present with non-shockable rhythms. The aim of this study is to evaluate if OHCA with conversion from non-shockable (i.e., asystole and pulseless electrical activity) rhythms to shockable rhythms compared to OHCA remaining in non-shockable rhythms is associated with better survival and neurological outcomes. METHOD: OHCA cases from the Pan-Asian Resuscitation Outcomes Study registry in 13 countries between January 2009 and February 2018 were retrospectively analyzed. Cases with missing initial rhythms, age <18 years, presumed non-medical cause of arrest, and not conveyed by emergency medical services were excluded. Multivariable logistic regression analysis was performed to evaluate the relationship between initial and subsequent shockable rhythm, survival to discharge, and survival with favorable neurological outcomes (cerebral performance category 1 or 2). RESULTS: Of the 116,387 cases included. 11,153 (9.6%) had initial shockable rhythms and 9,765 (8.4%) subsequently converted to shockable rhythms. Japan had the lowest proportion of OHCA patients with initial shockable rhythms (7.3%). For OHCA with initial shockable rhythm, the adjusted odds ratios (aOR) for survival and good neurological outcomes were 8.11 (95% confidence interval [CI] 7.62-8.63) and 15.4 (95%CI 14.1-16.8) respectively. For OHCA that converted from initial non-shockable to shockable rhythms, the aORs for survival and good neurological outcomes were 1.23 (95%CI 1.10-1.37) and 1.61 (95%CI 1.35-1.91) respectively. The aORs for survival and good neurological outcomes were 1.48 (95%CI 1.22-1.79) and 1.92 (95%CI 1.3 - 2.84) respectively for initial asystole, while the aOR for survival in initial pulseless electrical activity patients was 0.83 (95%CI 0.71-0.98). Prehospital adrenaline administration had the highest aOR (2.05, 95%CI 1.93-2.18) for conversion to shockable rhythm. CONCLUSION: In this ambidirectional cohort study, conversion from non-shockable to shockable rhythm was associated with improved survival and neurologic outcomes compared to rhythms that continued to be non-shockable. Continued advanced resuscitation may be beneficial for OHCA with subsequent conversion to shockable rhythms.

Impact of the life-sustaining treatment decision act on organ donation in out-of-hospital cardiac arrests in South Korea: a multi-centre retrospective study.

BACKGROUND: The demand for organ transplants, both globally and in South Korea, substantially exceeds the supply, a situation that might have been aggravated by the enactment of the Life-Sustaining Treatment Decision Act (LSTDA) in February 2018. This legislation may influence emergency medical procedures and the availability of organs from brain-dead donors. This study aimed to assess LSTDA's impact, introduced in February 2018, on organ donation status in out-of-hospital cardiac arrest (OHCA) patients in a metropolitan city and identified related factors. METHODS: We conducted a retrospective analysis of a regional cardiac arrest registry. This study included patients aged 16 or older with cardiac arrest and a cerebral performance category (CPC) score of 5 from January 2015 to December 2022. The exclusion criteria were CPC scores of 1-4, patients under 16 years, and patients declared dead or transferred from emergency departments. Logistic regression analysis was used to analyse factors affecting organ donation. RESULTS: Of the 751 patients included in this study, 47 were organ donors, with a median age of 47 years. Before the LSTDA, there were 30 organ donations, which declined to 17 after its implementation. In the organ donation group, the causes of cardiac arrest included medical (34%), hanging (46.8%), and trauma (19.2%). The adjusted odds ratio for organ donation before the LSTDA implementation was 6.12 (95% CI 3.09-12.12), with non-medical aetiology as associated factors. CONCLUSION: The enactment of the LSTDA in 2018 in South Korea may be linked to reduced organ donations among patients with OHCA, underscoring the need to re-evaluate the medical and legal aspects of organ donation, especially considering end-of-life care decisions.

Prevalence and Associated Factors of Depression and Anxiety Among Healthcare Workers During the Coronavirus Disease 2019 Pandemic: A Nationwide Study in Korea.

BACKGROUND: A healthcare system's collapse due to a pandemic, such as the coronavirus disease 2019 (COVID-19), can expose healthcare workers (HCWs) to various mental health problems. This study aimed to investigate the impact of the COVID-19 pandemic on the depression and anxiety of HCWs. METHODS: A nationwide questionnaire-based survey was conducted on HCWs who worked in healthcare facilities and public health centers in Korea in December 2020. Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) were used to measure depression and anxiety. To investigate factors associated with depression and anxiety, stepwise multiple logistic regression analysis was performed. RESULTS: A total of 1,425 participating HCWs were included. The mean depression score (PHQ-9) of HCWs before and after COVID-19 increased from 2.37 to 5.39, and the mean anxiety score (GAD-7) increased from 1.41 to 3.41. The proportion of HCWs with moderate to severe depression (PHQ-9 ≥ 10) increased from 3.8% before COVID-19 to 19.5% after COVID-19, whereas that of HCWs with moderate to severe anxiety (GAD-7 ≥ 10) increased from 2.0% to 10.1%. In our study, insomnia, chronic fatigue symptoms and physical symptoms after COVID-19, anxiety score (GAD-7) after COVID-19, living alone, and exhaustion were positively correlated with depression. Furthermore, post-traumatic stress symptoms, stress score (Global Assessment of Recent Stress), depression score (PHQ-9) after COVID-19, and exhaustion were positively correlated with anxiety. CONCLUSION: In Korea, during the COVID-19 pandemic, HCWs commonly suffered from mental health problems, including depression and anxiety. Regularly checking the physical and mental health problems of HCWs during the COVID-19 pandemic is crucial, and social support and strategy are needed to reduce the heavy workload and psychological distress of HCWs.

Impact of COVID-19 pandemic on interhospital transfer of patients with major trauma in Korea: a retrospective cohort study.

BACKGROUND: Interhospital transfer (IHT) is necessary for providing ultimate care in the current emergency care system, particularly for patients with severe trauma. However, studies on IHT during the pandemic were limited. Furthermore, evidence on the effects of the coronavirus disease 2019 (COVID-19) pandemic on IHT among patients with major trauma was lacking. METHOD: This retrospective cohort study was conducted in an urban trauma center (TC) of a tertiary academic affiliated hospital in Daegu, Korea. The COVID-19 period was defined as from February 1, 2020 to January 31, 2021, whereas the pre-COVID-19 period was defined as the same duration of preceding span. Clinical data collected in each period were compared. We hypothesized that the COVID-19 pandemic negatively impacted IHT. RESULTS: A total of 2,100 individual patients were included for analysis. During the pandemic, the total number of IHTs decreased from 1,317 to 783 (- 40.5%). Patients were younger (median age, 63 [45-77] vs. 61[44-74] years, p = 0.038), and occupational injury was significantly higher during the pandemic (11.6% vs. 15.7%, p = 0.025). The trauma team activation (TTA) ratio was higher during the pandemic both on major trauma (57.3% vs. 69.6%, p = 0.006) and the total patient cohort (22.2% vs. 30.5%, p < 0.001). In the COVID-19 period, duration from incidence to the TC was longer (218 [158-480] vs. 263[180-674] minutes, p = 0.021), and secondary transfer was lower (2.5% vs. 0.0%, p = 0.025). CONCLUSION: We observed that the total number of IHTs to the TC was reduced during the COVID-19 pandemic. Overall, TTA was more frequent, particularly among patients with major trauma. Patients with severe injury experienced longer duration from incident to the TC and lesser secondary transfer from the TC during the COVID-19 pandemic.

Prehospital factors associated with out-of-hospital cardiac arrest outcomes in a metropolitan city: a 4-year multicenter study.

BACKGROUND: Prehospital factors play a vital role in out-of-hospital cardiac arrest (OHCA) survivability, and they vary between countries and regions. We investigated the prehospital factors associated with OHCA outcomes in a single metropolitan city in the Republic of Korea. METHODS: This study included adult medical OHCA patients enrolled prospectively, using data from the citywide OHCA registry for patients registered between 2018 and 2021. The primary outcome was survival to hospital discharge. Multivariable logistic regression analysis was conducted to determine the factors associated with the study population's clinical outcomes, adjusting for covariates. We performed a sensitivity analysis for clinical outcomes only for patients without prehospital return of spontaneous circulation prior to emergency medical service departure from the scene. RESULTS: In multivariable logistic regression analysis, older age (odds ratio [OR] 0.96; 95% confidence interval [CI] 0.95-0.97), endotracheal intubation (adjusted odds ratio [aOR] 0.29; 95% [CIs] 0.17-0.51), supraglottic airway (aOR 0.29; 95% CI 0.17-0.51), prehospital mechanical chest compression device use (OR 0.13; 95% CI 0.08-0.18), and longer scene time interval (OR 0.96; 95% CI 0.93-1.00) were negatively associated with survival. Shockable rhythm (OR 24.54; 95% CI 12.99-42.00), pulseless electrical activity (OR 3.11; 95% CI 1.74-5.67), and witnessed cardiac arrest (OR 1.59; 95% CI 1.07-2.38) were positively associated with survival. In the sensitivity analysis, endotracheal intubation, supraglottic airway, prehospital mechanical chest compression device use, and longer scene time intervals were associated with significantly lower survival to hospital discharge. CONCLUSIONS: Regional resuscitation protocol should be revised based on the results of this study, and modifiable prehospital factors associated with lower survival of OHCA should be improved.

Impact of temporary closures of emergency departments during the COVID-19 outbreak on clinical outcomes for emergency patients in a metropolitan area.

BACKGROUND: During the early phase of the coronavirus disease 2019 (COVID-19) outbreak, many emergency departments (EDs) were exposed to COVID-19 and were temporarily closed according to national protocol of Korea. We aimed to evaluate the effect of concurrent and recurrent temporary closures of EDs on the clinical outcomes of patients who visited EDs during the COVID-19 outbreak. METHODS: This cross-sectional study used a nationwide emergency patient database. Patients who visited one of the 46 EDs in Daegu and Gyeongbuk between January 21 and April 14, 2020 were included. The main exposure variable was the first medical contact (ED visit or 119 call to emergency medical services (EMS)) during closure of at least one ED. There were 25 temporary closures of six Level-1 and Level-2 EDs between February 18 and March 17, 2020. We constructed a dataset by performing bidirectional crossover matching and conducted a conditional logistic regression analysis where the primary outcome was in-hospital mortality. RESULTS: Of the 94,360 eligible study participants, 36,327 were classified into the non-EMS-use group and 10,116 were classified into the EMS-use group. In-hospital mortality rates were 2.0% and 1.6% for the temporary-closure and no-closure groups in the non-EMS-use group (p-value, 0.03) and 8.7% and 7.4% in the EMS-use group (p-value, 0.02), respectively. In the conditional logistic analysis for in-hospital mortality, the odds ratios (95% confidence intervals) of the temporary-closure group compared the no-closure group were 1.22 (1.03-1.44) among the non-EMS-use group and 1.23 (1.04-1.46) among the EMS-use group. CONCLUSION: The temporary closures of EDs due to the unpredicted COVID-19 exposure resulted in an increase in emergency patients' in-hospital mortality rates irrespective of whether they used EMS. Preparing regional EMS systems to cope with new outbreaks is essential to protect the safety of all citizens.

Prehospital Notification Using a Mobile Application Can Improve Regional Stroke Care System in a Metropolitan Area.

BACKGROUND: Acute ischemic stroke is a time-sensitive disease. Emergency medical service (EMS) prehospital notification of potential patients with stroke could play an important role in improving the in-hospital medical response and timely treatment of patients with acute ischemic stroke. We analyzed the effects of FASTroke, a mobile app that EMS can use to notify hospitals of patients with suspected acute ischemic stroke at the prehospital stage. METHODS: We conducted a retrospective observational study of patients diagnosed with acute ischemic stroke at 5 major hospitals in metropolitan Daegu City, Korea, from February 2020 to January 2021. The clinical conditions and time required for managing patients were compared according to whether the EMS employed FASTroke app and further compared the factors by dividing the patients into subgroups according to the preregistration received by the hospitals when using FASTroke app. RESULTS: Of the 563 patients diagnosed with acute ischemic stroke, FASTroke was activated for 200; of these, 93 were preregistered. The FASTroke prenotification showed faster door-to-computed-tomography times (19 minutes vs. 25 minutes, P < 0.001), faster door-to-intravenous-thrombolysis times (37 minutes vs. 48 minutes, P < 0.001), and faster door-to-endovascular-thrombectomy times (82 minutes vs. 119 minutes, P < 0.001). The time was further shortened when the preregistration was conducted simultaneously by the receiving hospital. CONCLUSION: The FASTroke app is an easy and useful tool for prenotification as a regional stroke care system in the metropolitan area, leading to reduced transport and acute ischemic stroke management time and more reperfusion treatment. The effect was more significant when the preregistration was performed jointly.

QRS complex characteristics and patient outcomes in out-of-hospital pulseless electrical activity cardiac arrest.

BACKGROUND: Pulseless electrical activity (PEA) is increasingly observed in out-of-hospital cardiac arrest (OHCA), but outcomes are still poor. We aimed to assess the relationship between QRS characteristics and outcomes of patients with OHCA with initial PEA (OHCA-P). METHODS: This prospective observational study included patients aged at least 18 years who developed OHCA-P between 1 January 2016 and 31 December 2018, and were enrolled in the Daegu Emergency Medical Services registry, South Korea. We performed multivariable logistic regression analyses to identify the associations between QRS characteristics and OHCA-P outcomes, in which QRS complexes were considered separately (model 1) and simultaneously (model 2). The primary outcome was survival to hospital discharge and the secondary outcome was a favourable neurological outcome. RESULTS: Of the 3659 patients with OHCA, 576 were enrolled (median age 73 years; 334 men). A higher QRS amplitude was associated with survival to hospital discharge and a favourable neurological outcome in model 1 (adjusted OR (aOR) 1.077 and 1.106, respectively; 95% CI 1.021 to 0.136 and 1.029 to 1.190, respectively) and model 2 (aOR 1.084 and 1.123, respectively; 95% CI 1.026 to 1.145 and 1.036 to 1.216, respectively). A QRS width of <120 ms was associated with survival to hospital discharge and a favourable neurological outcome in model 1 (aOR 3.371 and 4.634, respectively; 95% CI 1.633 to 6.960 and 1.562 to 13.144, respectively) and model 2 (aOR 3.213 and 5.103, respectively; 95% CI 1.568 to 6.584 and 1.682 to 15.482, respectively). Survival to hospital discharge and neurological outcome were not associated with QRS frequency. CONCLUSION: OHCA-P outcomes were better when the initial QRS complex showed a higher amplitude or narrower width.

Comparison of COVID-19 Pandemic-Related Stress among Frontline Medical Personnel in Daegu City, Korea.

Background and Objectives: Frontline medical staff usually experience high levels of stress, which could greatly impact their work output. We conducted a survey to investigate the level of stress and its association with job types, work departments, and medical centers among COVID-19 pandemic frontline medical personnel. Materials and Methods: We conducted a cross-sectional survey using a self-administered questionnaire among 307 frontline medical staff who cared for COVID-19 patients in Daegu city. We used a 33-item questionnaire to assess respondents' general characteristics, job stress, personal effects associated with the COVID-19 pandemic, and their stress level. A general health questionnaire-12 (GHQ-12) was included in our questionnaire. Results: Majority (74.3%) of the respondents were in the stress group. The mean GHQ-12 score was 14.31 ± 4.96. More females (67.4%, p < 0.05) and nurses (73.3%, p = 0.001) were in the stress group compared to males and doctors. Medical staff in the general ward considered the severity of the COVID-19 pandemic situation higher. Nurses perceived work changes (p < 0.05), work burden (p < 0.05), and personal impact (p < 0.05) more serious than doctors. Medical staff in Level 3 emergency department (ED) perceived a lack of real-time information (p = 0.012), a lack of resources, and negative personal impacts associated with the pandemic as more serious than staff in Level 1 and Level 2 EDs. Medical staff in the intensive care unit perceived work changes (p < 0.05), work burden (p < 0.05), and lack of personal protective equipment (p = 0.002) as more serious than staff in the ED and general ward. Conclusion: Providing real-time information and resources for reducing work burden and negative personal impact is central to maximizing the work output of the COVID-19 pandemic frontline medical staff. Supporting their mental health through regular programs and intervention is also imperative.

Association of response time interval with neurological outcomes after out-of-hospital cardiac arrest according to bystander CPR.

BACKGROUND: This study intended to find out how association between response time interval (RTI) and good neurological outcome is affected by bystander CPR. We hypothesized that bystander CPR will ensure positive effect in relationship between RTI and clinical outcome. METHODS: A retrospective, observational study was made with Pan-Asian Resuscitation Outcome Study data from January 2009 to December 2016. Six cities from four Asian countries were selected. EMS-treated, non-traumatic witnessed out-of-hospital cardiac arrest (OHCA) cases were included. General demographic data, prehospital cardiac arrest details and clinical outcome were collected and analyzed according to whether bystander CPR was performed. Good neurological outcome and survival discharge were primary and secondary outcomes. RESULTS: A total of 13,245 OHCA cases were analyzed. Median EMS response time intervals were 6 min, regardless of bystander CPR. Dividing into RTI time range by 3 min, good neurological outcome and survival discharge were only significant in 3 to 6 minutes group (adjusted odds ratio [AOR] 1.42, 1.17-1.73 95% confidence interval [CI] and AOR 1.31, 1.15-1.51 95% CI) in non-bystander CPR group but in bystander CPR group significant RTI time range was 3 to 9 min (AOR 2.02, 1.82, 1.62-2.52, 1.48-2.25 95% CI for primary, AOR 1.66, 1.43, 1.41-1.96, 1.22-1.67 95% CI for secondary). CONCLUSIONS: As response time interval increased, slower deterioration of good neurological outcome and survival discharge was shown in cardiac arrest patients with bystander CPR performed. If bystander CPR is provided, RTI time range showing significant neurological outcome and survival improvement seems to be relatively lengthened.

Application of a Dual-Dispatch System for Out-of-Hospital Cardiac Arrest Patients: Will More Hands Save More Lives?

BACKGROUND: Recovery after out-of-hospital cardiac arrest (OHCA) is difficult, and emergency medical services (EMS) systems apply various strategies to improve outcomes. Multi-dispatch is one means of providing high-quality cardiopulmonary resuscitation (CPR), but no definitive best-operation guidelines are available. We assessed the effects of a basic life support (BLS)-based dual-dispatch system for OHCA. METHODS: This prospective observational study of 898 enrolled OHCA patients, conducted in Daegu, Korea from March 1, 2015 to June 30, 2016, involved patients > 18 years old with suspected cardiac etiology OHCA. In Daegu, EMS started a BLS-based dual-dispatch system in March 2015, for cases of cardiac arrest recognition by a dispatch center. We assessed the association between dual-dispatch and OHCA outcomes using multivariate logistic regressions. We also analyzed the effect of dual-dispatch according to the stratified on-scene time. RESULTS: Of 898 OHCA patients (median, 69.0 years; 65.5% men), dual-dispatch was applied in 480 (53.5%) patients. There was no difference between the single-dispatch group (SDG) and the dual-dispatch group (DDG) in survival at discharge and neurological outcomes (survival discharge, P = 0.176; neurological outcomes, P = 0.345). In the case of less than 10 minutes of on-scene time, the adjusted odds ratio was 1.749 (95% confidence interval [CI], 0.490-6.246) for survival discharge and 6.058 (95% CI, 1.346-27.277) for favorable neurological outcomes in the DDG compared with the SDG. CONCLUSION: Dual-dispatch was not associated with better OHCA outcomes for the entire study population, but showed favorable neurological outcomes when the on-scene time was less than 10 minutes.

New Termination-of-Resuscitation Models and Prognostication in Out-of-Hospital Cardiac Arrest Using Electrocardiogram Rhythms Documented in the Field and the Emergency Department.

BACKGROUND: Electrocardiogram (ECG) rhythms, particularly shockable rhythms, are crucial for planning cardiac arrest treatment. There are varying opinions regarding treatment guidelines depending on ECG rhythm types and documentation times within pre-hospital settings or after hospital arrivals. We aimed to determine survival and neurologic outcomes based on ECG rhythm types and documentation times. METHODS: This prospective observational study of 64 emergency medical centers was performed using non-traumatic out-of-hospital cardiac arrest registry data between October 2015 and June 2017. From among 4,608 adult participants, 4,219 patients with pre-hospital and hospital ECG rhythm data were enrolled. Patients were divided into 3 groups: those with initial-shockable, converted-shockable, and never-shockable rhythms. Patient characteristics and survival outcomes were compared between groups. Further, termination of resuscitation (TOR) validation was performed for 6 combinations of TOR criteria confirmed in previous studies, including 2 rules developed in the present study. RESULTS: Total survival to discharge after cardiac arrest was 11.7%, and discharge with good neurologic outcomes was 7.9%. Survival to discharge rates and favorable neurologic outcome rates for the initial-shockable group were the highest at 35.3% and 30.2%, respectively. There were no differences in survival to discharge rates and favorable neurologic outcome rates between the converted-shockable (4.2% and 2.0%, respectively) and never-shockable groups (5.7% and 1.9%, respectively). Irrespective of rhythm changes before and after hospital arrival, TOR criteria inclusive of unwitnessed events, no pre-hospital return of spontaneous circulation, and asystole in the emergency department best predicted poor neurologic outcomes (area under the receiver operating characteristic curve of 0.911) with no patients classified as Cerebral Performance Category 1 or 2 (specificity = 1.000). CONCLUSION: Survival outcomes and TOR predictions varied depending on ECG rhythm types and documentation times within pre-hospital filed or emergency department and should, in the future, be considered in treatment algorithms and prognostications of patients with out-of-hospital cardiac arrest. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03222999.

Effect of Dispatcher-Assisted Cardiopulmonary Resuscitation Program and Location of Out-of-Hospital Cardiac Arrest on Survival and Neurologic Outcome.

STUDY OBJECTIVE: We study the effect of a nationwide dispatcher-assisted cardiopulmonary resuscitation (CPR) program on out-of-hospital cardiac arrest outcomes by arrest location (public and private settings). METHODS: All emergency medical services (EMS)-treated adults in Korea with out-of-hospital cardiac arrests of cardiac cause were enrolled between 2012 and 2013, excluding cases witnessed by EMS providers and those with unknown outcomes. Exposure was bystander CPR categorized into 3 groups: bystander CPR with dispatcher assistance, bystander CPR without dispatcher assistance, and no bystander CPR. The endpoint was good neurologic recovery at discharge. Multivariable logistic regression analysis was performed. The final model with an interaction term was evaluated to compare the effects across settings. RESULTS: A total of 37,924 patients (31.1% bystander CPR with dispatcher assistance, 14.3% bystander CPR without dispatcher assistance, and 54.6% no bystander CPR) were included in the final analysis. The total bystander CPR rate increased from 30.9% in quarter 1 (2012) to 55.7% in quarter 4 (2014). Bystander CPR with and without dispatcher assistance was more likely to result in higher survival with good neurologic recovery (4.8% and 5.2%, respectively) compared with no bystander CPR (2.1%). The adjusted odds ratios for good neurologic recovery were 1.50 (95% confidence interval [CI] 1.30 to 1.74) in bystander CPR with dispatcher assistance and 1.34 (95% CI 1.12 to 1.60) in bystander CPR without it compared with no bystander CPR. For arrests in private settings, the adjusted odds ratios were 1.58 (95% CI 1.30 to 1.92) in bystander CPR with dispatcher assistance and 1.28 (95% CI 0.98 to 1.67) in bystander CPR without it; in public settings, the adjusted odds ratios were 1.41 (95% CI 1.14 to 1.75) and 1.37 (95% CI 1.08 to 1.72), respectively. CONCLUSION: Bystander CPR regardless of dispatcher assistance was associated with improved neurologic recovery after out-of-hospital cardiac arrest. However, for out-of-hospital cardiac arrest cases in private settings, bystander CPR was associated with improved neurologic recovery only when dispatcher assistance was provided.

The first-door-to-balloon time delay in STEMI patients undergoing interhospital transfer.

BACKGROUND: Interhospital transfer delays for ST-elevation myocardial infarction (STEMI) patients requiring primary percutaneous coronary intervention (PCI) may be shortened by improved regional care systems. We evaluated the transfer process and first door-to-balloon (D1toB) time in STEMI patients who underwent interhospital transfer for primary PCI. METHODS AND RESULTS: We evaluated the D1toB time in 1837 patients who underwent interhospital transfer for primary PCI from the Cardiovascular Disease Surveillance program in Korea. Only 29.3% of patients had a D1toB time less than 120 minutes, as recommended by the American College of Cardiology Foundation/American Heart Association guidelines for the management of STEMI. After adjusting for potential confounders, chest pain at presentation (adjusted odds ratio [AOR], 2.06; 95% confidence interval [CI], 1.18-3.83), transfer to a PCI center with an annual PCI volume greater than 200 (AOR, 1.35; 95% CI, 1.04-1.74), and higher urbanization level (AOR, 2.01 [95% CI, 1.40-2.91], for urban areas; AOR, 3.70 [95% CI, 2.59-3.83], for metropolitan areas) showed beneficial effects on reducing the D1toB time. The median length of stay in the referring hospital (D1LOS) and interhospital transport time were 50 (interquartile range [IQR], 30-100) minutes and 32 (IQR, 20-51) minutes, respectively. The median time interval from the door of the receiving hospital to balloon insertion was 55 (IQR, 40-79) minutes. CONCLUSIONS: Patients with STEMI undergoing interhospital transfer did not receive definite care within the recommended therapeutic time window. Delays in the transfer process (length of stay in the referring hospital and interhospital transport time) were major contributors to the delay in the D1toB time.

New Intervention Model of Regional Transfer Network System to Alleviate Crowding of Regional Emergency Medical Center.

Emergency department (ED) crowding is a serious problem in most tertiary hospitals in Korea. Although several intervention models have been established to alleviate ED crowding, they are limited to a single hospital-based approach. This study was conducted to determine whether the new regional intervention model could alleviate ED crowding in a regional emergency medical center. This study was designed as a "before and after study" and included patients who visited the tertiary hospital ED from November 2011 to October 2013. One tertiary hospital and 32 secondary hospitals were included in the study. A transfer coordinator conducted inter-hospital transfers from a tertiary hospital to a secondary hospital for suitable patients. A total of 1,607 and 2,591 patients transferred from a tertiary hospital before and after the study, respectively (P < 0.001). We found that the median ED length of stay (LOS) decreased significantly from 3.68 hours (interquartile range [IQR], 1.85 to 9.73) to 3.20 hours (IQR, 1.62 to 8.33) in the patient group after implementation of the Regional Transfer Network System (RTNS) (P < 0.001). The results of multivariate analysis showed a negative association between implementation of the RTNS and ED LOS (beta coefficient -0.743; 95% confidence interval -0.914 to -0.572; P < 0.001). In conclusion, the ED LOS in the tertiary hospital decreased after implementation of the RTNS.

Rationale, Methodology, and Implementation of a Dispatcher-assisted Cardiopulmonary Resuscitation Trial in the Asia-Pacific (Pan-Asian Resuscitation Outcomes Study Phase 2).

Abstract Background. Survival outcomes from out-of-hospital cardiac arrest (OHCA) in Asia are poor (2-11%). Bystander cardiopulmonary resuscitation (CPR) rates are relatively low in Asia. Dispatcher-assisted CPR (DA-CPR) has recently emerged as a potentially cost-effective intervention to increase bystander CPR and survival from OHCA. The Pan-Asian Resuscitation Outcomes Study (PAROS), an Asia-Pacific cardiac arrest registry, was set up in 2009, with the aim of understanding OHCA as a disease in Asia and improving OHCA survival. The network has adopted DA-CPR as part of its strategy to improve OHCA survival. Objective. This article aims to describe the conceptualization, study design, potential benefits, and difficulties for implementation of DA-CPR trial in the Asia-Pacific. Methods. Two levels of intervention, basic and comprehensive, will be offered to PAROS participating sites. The basic level consists of implementation of a DA-CPR protocol and training program, while the comprehensive level consists of implementation of the basic level, with the addition of a dispatch quality measurement tool, quality improvement program, and community education program. Sites that are not able to implement the package will contribute control data. The primary outcome of the study is survival to hospital discharge or survival to 30 days post cardiac arrest. DA-CPR and bystander CPR are secondary outcomes. Conclusion. Implementation of DA-CPR requires concerted efforts by EMS leaders and supervisors, dispatchers, hospital stakeholders, policy makers, and the general public. The DA-CPR trial implemented by the PAROS sites, if successful, can serve as a model for other countries considering such an intervention in their EMS systems.

Outcomes in patients with out-of-hospital cardiac arrest according to prehospital advanced airway management timing: a retrospective observational study.

BACKGROUND: In patients with out-of-hospital cardiac arrest (OHCA), guidelines recommend advanced airway (AA) management at the advanced cardiovascular life support stage; however, the ideal timing remains controversial. Therefore, we evaluated the prognosis according to the timing of AA in patients with OHCA. METHODS: We conducted a retrospective observational study of patients with OHCA at six major hospitals in Daegu Metropolitan City, South Korea, from August 2019 to June 2022. We compared groups with early and late AA and evaluated prognosis, including recovery of spontaneous circulation (ROSC), survival to discharge, and neurological evaluation, according to AA timing. RESULTS: Of 2,087 patients with OHCA, 945 underwent early AA management and 1,142 underwent late AA management. The timing of AA management did not influence ROSC in the emergency department (5-6 minutes: adjusted odds ratio [aOR], 0.97; p=0.914; 7-9 minutes: aOR, 1.37; p=0.223; ≥10 minutes: aOR, 1.32; p=0.345). The timing of AA management also did not influence survival to discharge (5-6 minutes: aOR, 0.79; p=0.680; 7-9 minutes: aOR, 1.04; p=0.944; ≥10 minutes: aOR, 1.86; p=0.320) or good neurological outcomes (5-6 minutes: aOR, 1.72; p=0.512; 7-9 minutes: aOR, 0.48; p=0.471; ≥10 minutes: aOR, 0.96; p=0.892). CONCLUSION: AA timing in patients with OHCA was not associated with ROSC, survival to hospital discharge, or neurological outcomes.

Inappropriate use of intravenous epinephrine leading to atrial fibrillation during prehospital anaphylaxis treatment: a case report.

In a prehospital setting, the narrow therapeutic window of epinephrine necessitates its cautious administration to avoid anaphylaxis. In this case, a 46-year-old man presented severe anaphylactic symptoms. Following the standard protocol, the emergency medical technician (EMT) administered intramuscular epinephrine; however, symptoms persisted. Under the oversight of the emergency medical services (EMS) medical director, an additional intravenous bolus of epinephrine was administered, unfortunately leading to atrial fibrillation. This case underscores the potential risks of intravenous epinephrine, which is not typically recommended for anaphylaxis without continuous monitoring. Since 2019, Korea has initiated a pilot program to expand the EMT scope of practice, which gives them the authority to administer epinephrine for anaphylaxis. The ultimate decision regarding epinephrine use for anaphylaxis, emphasizing patient safety, rests with the EMS medical director. Proper training for EMTs, coupled with the EMS medical director's comprehensive knowledge and meticulous protocol adherence, can ensure patient safety and optimal outcomes.

Causative Activities and Prognostic Factors of Open-Globe Injury: A Registry-Based City-Wide Multicentre Study.

PURPOSE: Traumatic globe injury is classified into closed-globe and open-globe injury (OGI); OGI leads to a worse prognosis. We aimed to identify causative activities and prognostic factors of OGI in a metropolitan city in South Korea. METHODS: This retrospective observational study used a prospective eye-injury registry conducted in Daegu, South Korea, between 1 August 2016 and 31 July 2021. We identified epidemiology and visual outcomes of OGI at four tertiary hospitals. Those with the best visual acuity lower than counting fingers at the 6-month follow-up were considered to have poor visual outcome. RESULTS: Of 9,208 patients with eye injuries, 282 had OGI. Most OGI patients were male (261, 92.6%), with the largest proportion in their 50s (76, 27.0%). The most frequent causative activity was mowing (59, 20.9%), and poor visual outcome was most seen in assault (7, 87.5%) and sports activity (9, 81.8%). Hammering, metal work, and sports activity were prevalent in those under 30, and mowing was most prevalent in those in their 50s (16, 21.1%) and 60s (29, 40.3%). In the multivariable logistic regression analysis, OGI related to traffic accident and sports activity were presented poor prognosis (adjusted odds ratio [aOR] 13.259, 95% confidence interval [CI] 1.202-146.205 for traffic accident; aOR 6.801, 95% CI 1.064-43.487 for sports activity). CONCLUSION: We need to develop advanced vehicle safety equipment, implement public education promoting seat belt usage and hazards of OGI, establish eye protection standards for key causal activities, and provide eye protection equipment for sports activities and mowing.

Recommendations on ambulance cardiopulmonary resuscitation in basic life support systems.

AIM: Cardiopulmonary resuscitation (CPR) during ambulance transport can be a safety risk for providers and can affect CPR quality. In many Asian countries with basic life support (BLS) systems, patients experiencing out-of-hospital cardiac arrest (OHCA) are routinely transported in ambulances in which CPR is performed. This paper aims to make recommendations on best practices for CPR during ambulance transport in BLS systems. METHODS: A panel consisting of 20 experts (including 4 North Americans) in emergency medical services (EMS) and resuscitation science was selected, and met over two days. We performed a literature review and selected 33 candidate issues in five core areas. Using Delphi methodology, the issues were classified into dichotomous (yes/no), multiple choice, and ranking questions. Primary consensus between experts was reached when there was more than 70% agreement. Questions with 60-69% agreement were made more specific and were submitted for a second round of voting. RESULTS: The panel agreed upon 24 consensus statements with more than 70% agreement (2 rounds of voting). The recommendations cover the following: length of time on the scene; advanced airway at the scene; CPR prior to transport; rhythm analysis and defibrillation during transport; prehospital interventions; field termination of resuscitation (TOR); consent for TOR; destination hospital; transport protocol; number of staff members; restraint systems; mechanical CPR; turning off of the engine for rhythm analysis; alternative CPR; and feedback for CPR quality. CONCLUSION: Recommendations for CPR during ambulance transport were developed using the Delphi method. These recommendations should be validated in clinical settings.