Evaluation of the PRESEP Score and the Miami Sepsis Score for Prehospital Sepsis Screening.

INTRODUCTION: Sepsis is a life-threatening organ dysfunction caused by a dysregulated response to an infection that requires early intervention. Prehospital sepsis screening tools have not yet been widely evaluated for their performance in clinical practice. OBJECTIVE: To evaluate the ability of the Prehospital Early Sepsis Detection (PRESEP) score and the Miami Sepsis Score to predict sepsis in prehospital settings. METHOD: This retrospective analysis included patients with diseases of internal cause who were transported by emergency medical services (EMS) to the hospital and hospitalized between January and June 2020. Data were extracted from the medical and EMS records. The primary outcome was sepsis diagnosis within 48 h of admission. The predictive abilities of the scores were assessed using the area under the receiver operating characteristic curve (AUC). Sensitivity, specificity, and positive and negative likelihood ratios (LRs) were calculated at cutoff values derived using Youden's index. RESULTS: Data from 354 patients were analyzed. The AUC for the PRESEP score was 0.83 (95% confidence interval [CI] 0.79-0.88) while that for the Miami Sepsis Score was 0.80 (0.75-0.85). The sensitivity, specificity, positive LR, and negative LR for the PRESEP score (cutoff was 5) were 0.83 (0.73-0.90), 0.68 (0.62-0.73), 2.59 (2.12-3.16), and 0.25 (0.15-0.40), respectively, and those for the Miami Sepsis Score (cu-off was 3) were 0.81 (0.71-0.89), 0.65 (0.59-0.71), 2.33 (1.93-2.83), and 0.30 (0.19-0.46), respectively. CONCLUSION: Due to their relatively good predictive abilities to detect septic patients and simplicities, the PRESEP and Miami Sepsis Scores could be used for screening patients for sepsis in prehospital settings. Further prospective validation and evaluation of effect on clinical outcomes are needed.

Revisiting older drivers' risks of at-fault motor vehicle collisions in Japan.

BACKGROUND: In Japan, older drivers have been encouraged to surrender their driving licenses for traffic safety despite the potential adverse social and health outcomes of driving cessation. We reconsidered such policies and social pressure by comparing the risk of at-fault motor vehicle collisions (MVCs) across the age groups of drivers. METHODS: Using the national data of police-reported MVCs that occurred between 2016 and 2020, we examined the number of at-fault MVCs per licensed driver (MVC rate) and the number of fatally and non-fatally injured persons per at-fault MVC by the sex and age groups of at-fault drivers. RESULTS: The MVC rate of older drivers was higher than that of middle-aged drivers but lower than that of young drivers. The number of injured persons among the collided counterparts (collided car occupants, motorcyclists, bicyclists, and pedestrians) per MVC caused by older drivers was not greater than that by drivers in other age groups. In fatal MVCs caused by older drivers, drivers themselves or their passengers tend to be killed rather than their collided counterparts. Overall, the results were mostly consistent between male and female drivers. CONCLUSIONS: The risk of at-fault MVCs increased with the advancing age of drivers after middle age; however, this risk among older drivers did not exceed that among young drivers, without posing a high risk of injuries to their collided counterparts.

Need for Improvements in Medical Device Management in Low- and Middle-Income Countries: Applying Learnings from Japan's Experience.

Medical devices provide important infrastructural support in modern healthcare systems. However, in low- and middle-income countries (LMICs), inadequate maintenance and management of devices due to a shortage of healthcare personnel (not only doctors and nurses but also other professionals including biomedical engineers [BMEs]) has resulted in inefficient and weak healthcare systems. High-income countries, including Japan, have resolved these problems by developing human resources and technologies to maintain and manage these systems. In this paper, we discuss the possibility of mitigating these problems in LMICs through human resource development and technology, based on lessons from Japan's experience. The problem of medical device management in LMICs stems from the fact that there are few professionals, such as BMEs, in charge of the management of medical devices and that clinical engineering departments in charge of device management have not been established. Since the 1980s, Japan has introduced a licensing system for BMEs, establishing operational guidelines to clarify their responsibilities within hospitals and using technology to utilize data and reduce workloads. Nevertheless, workload problems and high costs required to introduce computerized management systems persist. Moreover, it would be difficult to implement the same measures as those adopted in Japan in LMICs where there is an overwhelming shortage of medical personnel. It may be necessary to further reduce workloads for data entry and device management; use up-to-date, inexpensive, and user-friendly technology; and train non-BME personnel to operate and maintain equipment.

Managing Interhospital Referrals During a COVID-19 Patient Surge in Japan: Creating Available Beds by Exchanging Patients.

A COVID-19 patient surge in Japan from July to September 2021 caused a mismatch between patient severity and bed types because hospital beds were fully occupied and patient referrals between hospitals stagnated. Japan's predominantly private healthcare system lacks effective mechanisms to coordinate healthcare providers to address the mismatch. To address the surge, in August 2021, Tokyo Saiseikai Central Hospital started a scheme to exchange patients with other hospitals to mitigate the mismatch. In this article, we outline a retrospective observational study using medical records from a tertiary care medical center that treated severe COVID-19 cases. We describe daily patient admissions to our hospital's COVID-19 beds from July to September 2021, and compared the moving average of daily admissions before and after the exchange scheme was introduced. Bed occupancy reached nearly 100% in late July when the patient surge began and continued to exceed 100% in August when the surge peaked. However, the average daily admission did not decrease in August compared with July: the median daily admission (25th to 75th percentile) during each period was 2 (1 to 2.5) in late July and 3 (2 to 4) in August. The number of patients referred in from secondary care hospitals and the number of patients referred out was balanced in August. During the patient surge, the exchange scheme enabled the hospital to maintain and even increase the number of new admissions despite the bed shortage. Coordinating patient referrals in both directions simultaneously, rather than the usual 1-way transfer, can mitigate such mismatches.

Association between mandatory cognitive testing for license renewal and motor vehicle collisions and road injuries.

BACKGROUND: We examined whether the policy amendment from March 2017 for a cognitive screening test for older drivers at driver's license renewal was associated with the decreased risk of motor vehicle collisions for drivers and the increased risk of injuries for pedestrians and cyclists among older people. METHODS: This was a controlled interrupted time-series study. We used police-reported data on the number of collisions as drivers and injuries as pedestrians and cyclists among people aged 70 years or older in Japan from July 2012 to December 2019. As the outcome measures, we used the ratio of the monthly number of collisions per population among drivers of three groups aged 75 years or older (75-79, 80-84, and ≥85 years), who were targeted or exposed by the policy, to that among drivers aged 70 to 74 years, who were unaffected or unexposed by the policy and would serve as controls. The ratio of pedestrian and cyclist injuries was also calculated, as previous studies have shown a concomitant increase in these injuries after the introduction of cognitive screening for driver's licenses. RESULTS: During the study period, there were 602,885 collisions as drivers and 196,889 injuries as pedestrians and cyclists among people aged 70 years or older. After the policy amendment in March 2017, collisions decreased among male drivers, and injuries increased among some age subgroups in both sexes. Cumulative estimated changes in the numbers of collisions and injuries from March 2017 to December 2019 were -3670 (95% confidence interval: -5125, -2104) and 959 (95% confidence interval: 24, 1834), respectively. CONCLUSIONS: Following the policy amendment, there was a decrease in motor vehicle collisions as drivers and an increase in road injuries as pedestrians and cyclists among older people.

Trend in Alcohol-related Crashes Before and After the Introduction of Mandatory Breath Testing Among Commercial Truck Drivers.

BACKGROUND: Since 2011, commercial truck drivers have been required to take alcohol breath tests at the beginning and end of their working hours due to their employers' legal obligations. However, non-commercial truck drivers are not required to do so. We examined whether alcohol-related crashes had decreased after 2011 among commercial truck drivers. METHODS: Using police data, we conducted a joinpoint regression analysis to examine the trend in the proportion of alcohol-related crashes from 1995 through 2020 caused by commercial truck drivers (who were subjected to alcohol breath testing) and non-commercial truck drivers (who were not subjected to testing). The annual percentage change in this trend was also estimated. RESULTS: During the 26-year study period, truck drivers caused 1,846,321 at-fault crashes, and 0.4% of the crashes involved intoxicated driving. A significant decreasing trend in the proportion of alcohol-related crashes was identified among both commercial and non-commercial truck drivers in the 2000s, during which several legal amendments were made against drunk driving. The annual percentage change was -13.5% from 2001 to 2012 among commercial truck drivers, and -14.9% from 2001 to 2011 among non-commercial truck drivers. No decreasing trend was observed afterwards, despite the introduction of mandatory alcohol breath testing in 2011. CONCLUSION: The effect of mandatory alcohol breath testing on reducing alcohol-related crashes among commercial truck drivers was not evident.

A Successful Case of Cardiac Arrest due to Acute Myocarditis with COVID-19: 120 Minutes on Manual Cardiopulmonary Resuscitation then Veno-Arterial Extracorporeal Membrane Oxygenation.

Acute myocarditis is one of the common complications of coronavirus disease 2019 (COVID-19) with a relatively high case fatality. Here reported is a fulminant case of a 42-year-old previously healthy woman with cardiogenic shock and refractory cardiac arrest due to COVID-19-induced myocarditis who received veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) after 120 minutes of cardiopulmonary resuscitation (CPR). This is the first adult case of cardiac arrest due to COVID-19-induced myocarditis supported by ECMO that fully recovered with normal neurological functions. The success of the treatment course with full recovery emphasized the potential role of ECMO in treating these patients.

Initial medical protocol efforts using both CT and MRI/MRA for acute cerebral infarction.

BACKGROUND: Earlier administration of intravenous recombinant tissue-type plasminogen activator (rtPA) and mechanical thrombectomy (MT) improves the neurological prognosis of patients with acute ischemic stroke (AIS). We introduced a new protocol that includes head and chest computed tomography (CT) and magnetic resonance imaging (MRI)/ magnetic resonance angiography (MRA) for all patients, which is quite different from previously evaluated protocols. This study aimed to examine whether this protocol could contribute to the prompt therapeutic intervention of AIS. METHODS: This is a retrospective observational study analyzing patients with AIS who were transported to our hospital by ambulance between January 2015 and November 2021. An AIS initial treatment protocol was introduced in April 2020, under which, CT and MRI/MRA imaging were performed in all patients, and the indication for rtPA and MT were determined. The participants were divided into those who were treated before and after the protocol introduction (conventional treatment and protocol groups, respectively). The time from hospital arrival to the start of rtPA administration (door-to-needle time: DNT) and the time from hospital arrival to the start of endovascular treatment (door-to-puncture time: DPT) were compared between the groups. RESULT: A total of 121 patients were analyzed, wherein 63 patients received rtPA (18 in the conventional treatment group and 45 in the protocol group) and 98 patients received MT (32 in the conventional treatment group and 66 in the protocol group). The median DNT was 97.0 (IQR 49.0-138.0) min vs. 56.5 (IQR 41.0-72.0) min (p < 0.001) for the conventional treatment and the protocol groups, respectively. The median DPT was 129.0 (IQR 62.0-196.0) min vs. 55.0 (IQR 40.5-69.5) min (p < 0.001), respectively. Moreover, DNT was achieved within 60 min in 5.6% vs. 69.9% (p < 0.001) and DPT within 90 min in 25.0% vs. 85.7% (p < 0.001), respectively. CONCLUSION: The introduction of a protocol, including CT/MRI imaging, significantly shortened DNT and DPT.

Novel score for predicting early emergency endovascular therapy in trauma care using logistic LASSO regression.

Aim: To support decision-making for early interventional radiology, this study aimed to derive and validate a novel and simple scoring system for predicting the necessity of interventional radiology therapies in trauma patients. Methods: This retrospective study used data derived from the medical records of patients with severe traumatic injuries treated at a tertiary-level emergency institution. The score was derived from 168 patients treated between April 2015 and October 2016 and validated using data from 68 patients treated between November 2016 and July 2017. Logistic "least absolute shrinkage and selection operator (LASSO)" regression was used to select predictors. In order to compose the score, odds ratios derived from the logistic model were simplified to integer score coefficients. The score was evaluated using the area under the receiver operating characteristic curve. The best cut-off point for the score was determined using Youden's index, and sensitivity and specificity were calculated. Results: The derived score comprised three predictors (systolic blood pressure, positive findings in abdominal ultrasound assessment, and pelvic fracture) and ranged from 0 to 30. On validation, the area under the receiver operating characteristic curve for the score was 0.86 (95% confidence interval, 0.64-1.00). The sensitivity and specificity were 80% and 89%, respectively, with a cut-off point of 3. Conclusion: This simple score, requiring variables obtainable immediately after hospital arrival, could aid in facilitating early interventional radiology team activation.

Serum D-dimer level as a predictor of neurological functional prognosis in cases of head injuries caused by road traffic accidents.

BACKGROUND: The number of traffic fatalities is declining in Japan; however, a large proportion of head injuries are still attributable to traffic accidents. Severe head trauma may cause progressive and devastating coagulopathy owing to exacerbated coagulation and fibrinolysis, which results in massive bleeding and poor patient outcomes. D-dimer is a fibrinolytic marker, which remarkably increases in severe coagulopathy due to the exacerbated fibrinolytic system. Because the degree of coagulopathy is associated with patient outcomes, the D-dimer level is a useful prognostic predictor in patients with head trauma. However, the usefulness of D-dimer in cases of head trauma caused by road traffic accidents remains inadequately explored. In this study, we investigated the relationship between D-dimer levels and outcomes in head injuries caused by traffic accidents. METHODS: We extracted data on traffic injuries from Japan Neuro-Trauma Data Bank Project 2015, which is a prospective multicenter registry of head injuries. The analysis included 335 individuals with no missing data. The outcome variable was the score of the Glasgow Outcome Scale (GOS), a neurological outcome index. The participants were categorized into the favorable outcome (GOS score ≥ 4) and poor outcome (GOS score ≤ 3) groups. The serum D-dimer levels at the time of admission were divided into four categories at the quartiles, and the reference category was less than the first quartile (< 17.4 µg/mL). We performed a logistic regression analysis with GOS as the dependent variable and D-dimer as a predictor and performed a multivariate analysis that was adjusted for 10 physiological parameters. RESULTS: In the univariate analysis, all groups with serum D-dimer values ≥ 17.4 µg/dL showed significantly poorer outcomes than those of the reference group. In the multivariate analysis, after adjusting for other factors, D-dimer levels ≥ 89.3 µg/dL were an independent predictor of poor outcome. CONCLUSION: After adjusting for physiological parameters, high serum D-dimer levels can be an independent factor for predicting neurological prognosis in head trauma caused by road traffic accidents.

Why Bystanders Did Not Perform Cardiopulmonary Resuscitation on Out-of-Hospital Cardiac Arrest Patients: A Multi-Center Study in Hanoi (Vietnam).

AIM: The aim of this study was to determine why bystanders did not use formal Emergency Medical Services (EMS) or conduct cardiopulmonary resuscitation (CPR) on the scene for out-of-hospital cardiac arrest (OHCA) patients in Hanoi, Vietnam. METHODS: This was a prospective, observational study of OHCA patients admitted to five tertiary hospitals in the Hanoi area from June 2018 through January 2019. The data were collected through interviews (using a structured questionnaire) with bystanders. RESULTS: Of the 101 patients, 79% were aged <65 years, 71% were men, 79% were witnessed to collapse, 36% were transported to the hospital by formal EMS, and 16% received bystander CPR at the scene. The most frequently indicated reason for not using EMS by the attendants was "using a private vehicle or taxi is faster" (85%). The reasons bystanders did not conduct CPR at the scene included "not recognizing the ailment as cardiac arrest" (60%), "not knowing how to perform CPR" (33%), and "being afraid of doing harm to patients" (7%). Only seven percent of the bystanders had been trained in CPR. CONCLUSION: The information revealed in this study provides useful information to indicate what to do to increase EMS use and CPR provision. Spreading awareness and training among community members regarding EMS roles, recognition of cardiac arrest, CPR skills, and dispatcher training to assist bystanders are crucial to improve the outcomes of OHCA patients in Vietnam.

Effect of annual road safety publicity and enforcement campaign on road fatalities in Japan: a time series study from 1949 to 2019.

BACKGROUND: In 1948, Japan started a short-term publicity and enforcement campaign for traffic safety nationwide, and since 1952, the campaign has been conducted twice a year for 10 days. We aimed to quantify the short-term effect of the spring sessions of the campaign, which were conducted in different months in different years, on road fatalities in Japan using data from 1949 to 2019. METHODS: We obtained national police data on the monthly number of road deaths and conducted a time series regression analysis with three steps: smoothing the long-term patterns with the natural cubic spline function, calculating the ratio of the monthly number of deaths to the corresponding smoothed value, and regressing the ratio on the number of months from January 1949 and the binary variable for the conduct of spring sessions. We repeated the analysis for four subperiods (1949-1964, 1965-1989, 1990-2004 and 2005-2019). RESULTS: During the study period, there were 632577 road deaths. Our analysis revealed that the spring sessions changed the number of deaths per day by -2.5% (95% CI -4.1% to -0.9%) in the months when they were conducted. In the four subperiods, the estimated changes were -4.5% (95% CI -8.9% to -0.1%), -2.6% (95% CI -5.0% to -0.1%), -0.1% (95% CI -2.9 to 2.7) and -3.5% (95% CI -7.9 to 0.9). CONCLUSIONS: Road fatalities were reduced in the months when the spring sessions of the campaign were conducted, but the reduction was modest. The effect might have been somewhat larger until 1964, when Japan was a middle-income country.

Reduced Road Injuries While Commuting Due to Heavy Snowfall and Ensuing Modal Shifts Among Junior High School Students in Japan.

BACKGROUND: Modal shifts in transport may reduce overall road injuries. Cyclist junior high school students are at a high risk of road injuries while commuting in Japan, and injuries among junior high school students could be reduced if the cyclists switch to other transport modes. METHODS: We estimated the change in the incidence of road deaths and serious injuries while commuting in months with heavy snowfall, when cyclists are likely to switch to other transport modes. Using police data on the monthly number of road injuries while commuting among junior high school students in Japan between 2004 and 2013 and corresponding population statistics and snowfall data, we calculated the monthly injury rate (number of deaths and serious injuries divided by population) at the prefecture level. We conducted Poisson regression analysis to estimate the change in the rate in months with a snowfall of ≥100 cm, compared to months without snowfall. RESULTS: A total of 3,164 deaths and serious injuries occurred during 2004 to 2013. The injury rate among cyclists was almost zero in months with a snowfall of ≥100 cm. That among cyclists and pedestrians in these months was reduced by 68% (95% confidence interval, 43-82%). CONCLUSION: In months with heavy snowfall, road injuries while commuting were reduced due to the near-elimination of cycling injuries among junior high school students in Japan. Switching from cycling to other transport modes would reduce overall road injuries among this population, and inducing modal shifts can be an important tool for road safety.

Association between active cooling and lower mortality among patients with heat stroke and heat exhaustion.

Body cooling is recommended for patients with heat stroke and heat exhaustion. However, differences in the outcomes of patients who do or do not receive active cooling therapy have not been determined. The best available evidence supporting active cooling is based on a case series without comparison groups; thus, the effectiveness of this method in improving patient prognoses cannot be appropriately quantified. Therefore, we compared the outcomes of heat stroke patients receiving active cooling with those of patients receiving rehydration-only therapy. This prospective observational multicenter registry-based study of heat stroke and heat exhaustion patients was conducted in Japan from 2010 to 2019. The patients were stratified into the "severe" group or the "mild-to-moderate" group, per clinical findings on admission. After conducting multivariate logistic regression analyses, we compared the prognoses between patients who received "active cooling + rehydration" and patients who received "rehydration only," with in-hospital death as the endpoint. Sex, age, onset situation (i.e., exertional or non-exertional), core body temperature, liver damage, renal dysfunction, and disseminated intravascular coagulation were considered potential covariates. Among those who received active cooling and rehydration-only therapy, the in-hospital mortality rates were 21.5% and 35.5%, respectively, for severe patients (n = 231) and 3.9% and 5.7%, respectively, for mild-to-moderate patients (n = 578). Rehydration-only therapy was associated with a higher in-hospital mortality in patients with severe heat illness (adjusted odds ratio [aOR], 3.29; 95% confidence interval [CI], 1.21-8.90), whereas the cooling methods were not associated with lower in-hospital mortality in patients with mild-to-moderate heat illness (aOR, 2.22; 95% CI, 0.92-5.84). Active cooling was associated with lower in-hospital mortality only in the severe group. Our results indicated that active cooling should be recommended as an adjunct to rehydration-only therapy for patients with severe heat illness.

Unmet Need for Emergency Medical Services in Hanoi, Vietnam.

Low- and middle-income countries urgently need to improve emergency medical services (EMSs) as a component of their healthcare systems. Here, we detailed EMS resources and their provision in Hanoi, Vietnam, and discussed necessary policies to upgrade EMSs. Between 2013 and 2018, EMS resources, measured as provider-to-population and ambulance-to-population ratios, decreased, whereas service provision, measured as the number of patients transported by ambulance per population, increased. EMS resources and their provision in Hanoi are far below the standards of high-income countries or figures in neighboring Asian countries. Therefore, it is imperative to upgrade health policies for the appropriate allocation of healthcare resources to EMSs and hospital services.

Community surveillance of COVID-19 by village health volunteers, Thailand.

PROBLEM: To control the increasing spread of coronavirus disease 2019 (COVID-19), the government of Thailand enforced the closure of public and business areas in Bangkok on 22 March 2020. As a result, large numbers of unemployed workers returned to their hometowns during April 2020, increasing the risk of spreading the virus across the entire country. APPROACH: In anticipation of the large-scale movement of unemployed workers, the Thai government trained existing village health volunteers to recognize the symptoms of COVID-19 and educate members of their communities. Provincial health offices assembled COVID-19 surveillance teams of these volunteers to identify returnees from high-risk areas, encourage self-quarantine for 14 days, and monitor and report the development of any relevant symptoms. LOCAL SETTING: Despite a significant and recent expansion of the health-care workforce to meet sustainable development goal targets, there still exists a shortage of professional health personnel in rural areas of Thailand. To compensate for this, the primary health-care system includes trained village health volunteers who provide basic health care to their communities. RELEVANT CHANGES: Village health volunteers visited more than 14 million households during March and April 2020. Volunteers identified and monitored 809 911 returnees, and referred a total of 3346 symptomatic patients to hospitals by 13 July 2020. LESSONS LEARNT: The timely mobilization of Thailand's trusted village health volunteers, educated and experienced in infectious disease surveillance, enabled the robust response of the country to the COVID-19 pandemic. The virus was initially contained without the use of a costly country-wide lockdown or widespread testing.

Development of an emergency medical services system in Thailand: Roles of the universal health coverage and the national lead agency.

This paper describes how the Thai health sector developed nationwide emergency medical services (EMS), despite limited resources and we try to extract lessons applicable to other resource-constrained settings. The government of Thailand has strengthened EMS by integrating it into the general healthcare system and formulating a national development plan and lead agency for EMS. The government emphasized the deployment of low-cost basic-level EMS units stationed near the communities, named as 'first-responder units'. In Khon Kaen Province, which has led the nationwide EMS development of Thailand, the availability of EMS (number of EMS units) and utilisation of EMS (proportion of severe trauma patients transported to hospital by EMS) greatly increased from 2000 to 2017. This success is due to the emphasis on the first-responder units through consistent national policies.

Outcomes for out-of-hospital cardiac arrest transported to emergency departments in Hanoi, Vietnam: A multi-centre observational study.

OBJECTIVE: To describe the outcomes of patients with out-of-hospital cardiac arrest (OHCA) transported to hospital in Hanoi, Vietnam. METHODS: This was a multi-centre observational study of patients presenting with OHCA to one of five tertiary care hospital EDs in Hanoi from 2017 to 2019. RESULTS: We analysed data from 239 OHCA cases of which 70.7% were witnessed, and 8.4% received bystander cardiopulmonary resuscitation (CPR). The emergency medical services (EMS) transported 20.5% of cases to hospital with the remaining being transported by private vehicle. No patients received external defibrillation before arriving to hospital. Return of spontaneous circulation in hospital was 33.1%, with 3.8% of patients survived to hospital discharge and only one patient (0.4%) discharged from hospital with a favourable neurological outcome. CONCLUSIONS: In cases of OHCA in Hanoi, both the proportion of cases receiving bystander CPR and EMS transportation were small. Urgent investments in pre-hospital capacity, training and capabilities are required to improve outcomes for OHCA in Hanoi.

Community-Based First Responder Network in Rural Thailand: A Case Study of Out-of-Hospital Cardiac Arrest.

Recently, the Thai government introduced a novel program to train health volunteers as first responders to deal with increasing acute illness and injuries. This case study demonstrates the potential of this program to improve public access to emergency care through the integration of emergency care with a community-based health care system, specifically in a rural setting. A 39-year-old man collapsed with cardiac arrest in his village. Lay first responders from his neighborhood attended him immediately, administered chest compressions, and contacted Emergency Medical Services (EMS). They continued chest compressions until the EMS unit arrived. While the EMS transported him to the hospital, the patient attained return of spontaneous circulation and consciousness. He returned to his normal life without obvious neurological problems. The Thai strategy to develop a community-based first responder network through health volunteer training would address the issue of inequitable access to emergency care and improve patients' chances of survival and prognoses.

Task-shift Model in Pre-hospital Care and Standardized Nationwide Data Collection in Japan: Improved Outcomes for Out-of-hospital Cardiac Arrest Patients.

Out-of-hospital cardiac arrest (OHCA) is a growing worldwide public health concern. Previously, Japan experienced poorer outcomes among OHCA patients than in other high-income countries. In the early 1990s, through policy changes, the Japanese government introduced a task-shift model in pre-hospital care. Some medical practices previously provided by physicians exclusively were delegated to non-physicians, including laypeople. Additionally, we initiated a nationwide data collection system for evaluation. We started a nationwide registry of OHCA patients, a paramedic system to provide advanced life-support care, and basic life-support training for laypeople. In the 2000s, the procedures paramedics could provide were expanded, laypeople were allowed to use automated external defibrillators, and the Utstein style was introduced to the national registry. Consequently, pre-hospital advanced care and bystander first-aid increased, registry-based research contributed to evidence-based practices, and-most importantly-outcomes of OHCA patients considerably improved. These Japanese experiences demonstrate that streamlining pre-hospital care, including bystander interventions and standardized data collection, can improve OHCA patient outcomes. Despite this progress, however, there still exist many issues to be addressed in response to the changing and increasing care demands within Japan's aging population.