Prevalence of emergency medical service utilisation in patients with out-of-hospital cardiac arrest in Thailand

Association between Mode of Transport and Patient Outcomes in the Emergency Department following Out-of-Hospital Cardiac Arrest: A Single-Center Retrospective Study

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) remains a health problem worldwide, carrying a high mortality rate. Comparison of emergency department (ED) return of spontaneous circulation (ROSC) after OHCA in relation to emergency medical services (EMS) and non-EMS modes of transportation to the hospital was conducted to assess the impact points of the EMS system in Thailand.

METHODS

This retrospective observational study enrolled all OHCA patients who visited the ED of Ramathibodi Hospital, a tertiary university hospital in Bangkok, between January 1, 2008, and May 31, 2020. Patients were differentiated into EMS and non-EMS groups according to mode of transportation to the ED. Patients' characteristics and comorbidities, witnessed arrests, bystander chest compression, initial rhythm, and resuscitation treatment were documented. ED-sustained ROSC, ED survival, 30-day survival, and 30-day survival with good cerebral performance category (CPC) scores were monitored and recorded. Multivariate logistic analyses were performed to assess factors influencing clinical outcomes.

RESULTS

A total of 339 patients were enrolled, 117 (34.51%) of whom were in the EMS transport group. There were no differences between the EMS and non-EMS groups in ED-sustained ROSC (adjusted odds ratio [aOR], 0.99; 95% confidence interval [CI], 0.58-1.70; P = 0.98), or ED survival (aOR, 0.99; 95% CI, 0.57-1.71; P = 0.97). There were also no differences in 30-day survival or 30-day survival with good CPC score between the two groups.

CONCLUSIONS

In our cohort data of OHCA, ED-sustained ROSC and ED survival outcomes were not superior in the EMS transportation group. Evidence to show that EMS transportation affected 30-day survival and 30-day good CPC score was also lacking. Thus, public promotion of Thailand's EMS system is advocated with a simultaneous improvement of EMS response to enhance OHCA outcomes.

Characteristics and outcomes of out-of-hospital cardiac arrest patients before and during the COVID-19 pandemic in Thailand

Background

Out-of-hospital cardiac arrest (OHCA) remains one of the leading causes of death worldwide, and bystander CPR with public-access defibrillation improves OHCA survival outcomes. The COVID-19 pandemic has posed many challenges for emergency medical services (EMS), including the suggestion of compression-only resuscitation and recommendations for complete personal protective equipment, which have created operational difficulties and prolonged response time. However, the risk factors affecting OHCA outcomes during the pandemic are poorly defined. This study aimed to assess the characteristics and outcomes of OHCA patients before and during the COVID-19 pandemic in Thailand.

Methods

This single-center, retrospective cohort study used data from electronic medical records and EMS paper records. All OHCA patients who visited Ramathibodi Hospital’s emergency department before COVID-19 (March 2018 to December 2019) and during COVID-19 (March 2020-December 2021) were identified, and the number of emergency department returns of spontaneous circulation (ED-ROSC) and characteristics in OHCA patients before and during the COVID-19 pandemic in Thailand were collected.

Results

A total of 136 patients were included (78 men [59.1%]; mean [SD] age, 67.9 [18] years); 60 of these were during the COVID-19 period (beginning March 2020), and 76 were before the COVID-19 period. The overall baseline characteristics that differed significantly between the two groups were bystander witness and mode of chest compression (p-values < 0.001 and < 0.001, respectively). The ED ROSC during the COVID-19 period was significantly lower than before the COVID-19 period (26.67% vs. 46.05%, adjusted OR 0.21, p-value < 0.001). There were significant differences in survival to admission between the COVID-19 period and before (25.00% and 40.79%, adjusted OR 0.26, p-value 0.005). However, 30-day survivals were not significantly different (3.3% during the COVID-19 period and 10.53% before the COVID-19 period).

Conclusions

During the COVID-19 pandemic in Thailand, ED ROSC and survival to admission in out-of-hospital cardiac arrest patients were significantly reduced. Additionally, the witness responses and mode of chest compression were very different between the two groups.

Trial registration

This trial was retrospectively registered on 7 December 2021 in the Thai Clinical Trial Registry, identification number TCTR20211207006.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12245-022-00444-2.

Fifteen Years of Sustainable Development in Emergency Medical Services under the Emergency Medicine Act of Thailand

BACKGROUND: Thailand’s emergency medical services (EMSs) are constantly evolving both in terms of personnel and technology in pre-hospital care. While sustainable development goals (SDGs) are used in part as a catalyst for development in all countries, there are currently no studies regarding the relationship between EMS research and SDGs in Thailand. AIM: This study aims to analyze how Thailand’s EMS research was affected after the National Institute for Emergency Medicine (NIEM) was established and how SDGs are related. METHODS: This was an analytical cross-sectional database study. Data were collected in the Scopus database with Thailand’s EMS records between 2008 and 2022. Three experienced emergency physicians were enrolled independently in this study for the purpose of giving opinions and feedback on the research. RESULTS: The three experts of this study are qualified emergency physicians in Thailand. The greatest number of the expert’s publications from the Scopus database was 117 articles. The greatest number of citations was 3994. The 175 documents were analyzed with three experts reviewing all documents and then narrowing it down to 25 documents. The most common SDG found in documents was Goal 3: GOOD HEALTH AND WELL-BEING. CONCLUSIONS: The development of Thailand’s EMS after the establishment of NIEM varied in aspects ranging from triage systems and care in ambulances to vehicle selection and technology. Goal 3: GOOD HEALTH AND WELL-BEING occurred most frequently in publications regarding SDGs in EMS studies.

Mode of transportation of out-of-hospital cardiac arrest patients, the role of community actions and interventions

The Emergency Medical Services constitutes a critical component in treating patients with out-of-hospital cardiac arrest (OHCA). Activating the EMS system is the first important step in deploying resources, but community involvement in the care of emergent patients is multifaceted and complex. How does the public access EMS services versus other modes of transport remains under investigated; and if the public opts for a different mode of transport to the hospital, how does this affect outcomes?

Unrecognized Out of Hospital Cardiac Arrest Symptoms during Thailand’s Emergency Medical Services

BACKGROUND: To improve survival rate, the main focus of adult cardiac arrest management includes rapid recognition, prompt administration of cardiopulmonary resuscitation (CPR), defibrillation for shockable rhythms, post-return of spontaneous circulation (ROSC) care, and identification and treatment of underlying causes. This study aimed to identify the determinants of unrecognized cardiac arrest, and to study the recognition rate of out-of-hospital cardiac arrest (OHCA) by emergency medical services call handlers. METHODS: We included OHCA patients who were transferred to hospital via Emergency Medical Services (EMS) of Srinagarind hospital, Khon Kaen, Thailand, from 1st January 2020 to 31st December 2020. The primary outcome was to identify symptoms that lead to an unrecognized cardiac arrest by the EMS call handlers. Secondary outcomes were to identify the recognition rate of OHCA by emergency medical services call handlers, and assess the outcome of CPR performed on OHCA patients. RESULTS: There were a total of 58 patients in the present study, 26 patients (44.8%) and 32 patients (55.2%) belonged to the unrecognized and recognized cardiac arrest groups, respectively. The most common symptoms that led to unrecognized cardiac arrest were a state of unconsciousness (46.2%), major trauma (15.4%), and seizure-like activity (11.5%). The rate of ROSC was higher in the unrecognized cardiac arrest group (34.6% vs. 15.6%) but the rate of survival to hospital discharge was higher in the recognized cardiac arrest group (6.3% vs 0%). CONCLUSIONS: Falling unconscious is the most common symptom of unrecognized OHCA cases seen by EMS in Thailand. Basic life support, especially an immediate assessment of a patient’s respiratory status should be taught in health programs in school or through public service channels.

Clinical outcomes from out-of-hospital cardiac arrest in low-resource settings - A scoping review

AIM OF THE SCOPING REVIEW

Scientific recommendations on resuscitation are typically formulated from the perspective of an ideal resource environment, with little consideration of applicability in lower-income countries. We aimed to determine clinical outcomes from out-of-hospital cardiac arrest (OHCA) in low-resource countries, to identify shortcomings related to resuscitation in these areas and possible solutions, and to suggest future research priorities.

DATA SOURCES

This scoping review was part of the continuous evidence evaluation process of the International Liaison Committee on Resuscitation (ILCOR), and was performed following the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. We identified low-resource countries as countries with a low- or middle gross national income per capita (World Bank data). We performed a literature search on outcomes after OHCA in these countries, and we extracted data on the outcome. We applied descriptive statistics and conducted a post-hoc correlation analysis of cohort size and ROSC rates.

RESULTS

We defined 24 eligible studies originating from middle-income countries, but none from low-income regions, suggesting a reporting bias. The number of reported patients in these studies ranged from 54 to 3214. Utstein-style reporting was rarely used. Return of spontaneous circulation varied from 0% to 62%. Fifteen studies reported on survival to hospital discharge (between 1.0 and 16.7%) or favourable neurological outcome (between 1.0 and 9.3%). An inverse correlation was found for study cohort size and the rate of return of spontaneous circulation (ρ = -0.48, p = 0.034).

CONCLUSION

Studies of OHCA outcomes in low-resource countries are heterogeneous and may be compromised by reporting bias. Minimum cardiopulmonary resuscitation standards for low-resource settings should be developed collaboratively involving local experts, respecting culture and context while balancing competing health priorities.

Education, Implementation, and Teams: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

For this 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, the Education, Implementation, and Teams Task Force applied the population, intervention, comparator, outcome, study design, time frame format and performed 15 systematic reviews, applying the Grading of Recommendations, Assessment, Development, and Evaluation guidance. Furthermore, 4 scoping reviews and 7 evidence updates assessed any new evidence to determine if a change in any existing treatment recommendation was required. The topics covered included training for the treatment of opioid overdose; basic life support, including automated external defibrillator training; measuring implementation and performance in communities, and cardiac arrest centers; advanced life support training, including team and leadership training and rapid response teams; measuring cardiopulmonary resuscitation performance, feedback devices, and debriefing; and the use of social media to improve cardiopulmonary resuscitation application.

Education, Implementation, and Teams: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

For this 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, the Education, Implementation, and Teams Task Force applied the population, intervention, comparator, outcome, study design, time frame format and performed 15 systematic reviews, applying the Grading of Recommendations, Assessment, Development, and Evaluation guidance. Furthermore, 4 scoping reviews and 7 evidence updates assessed any new evidence to determine if a change in any existing treatment recommendation was required. The topics covered included training for the treatment of opioid overdose; basic life support, including automated external defibrillator training; measuring implementation and performance in communities, and cardiac arrest centers; advanced life support training, including team and leadership training and rapid response teams; measuring cardiopulmonary resuscitation performance, feedback devices, and debriefing; and the use of social media to improve cardiopulmonary resuscitation application.

Efficacy of Thiamine in the Treatment of Postcardiac Arrest Patients: A Randomized Controlled Study

Background

Thiamine administration has been shown to improve survival in a postcardiac arrest animal study. We aimed to evaluate the efficacy of thiamine in comatose out-of-hospital cardiac arrest (OHCA) patients following return of spontaneous circulation.

Methods

A randomized, double-blinded, placebo-controlled study was conducted. Thirty-seven OHCA patients were randomly assigned to receive either thiamine 100 mg every 8 hours or a placebo. The primary outcome was 28-day all-cause mortality.

Results

Over the course of 2 years, 37 patients were randomized to either receive thiamine (n = 20) or a placebo (n = 17). The primary outcome was not different between the groups: 10/20 (50%) in the thiamine group vs. 8/17 (47.1%) in the placebo group (P=0.93 by the log-rank test). There were no significant differences in secondary outcomes between the groups (good neurological outcome, lactate level, and S100B level).

Conclusions

In this study, there were no significant differences in survival outcome. Further studies with a larger population are necessary to confirm these results.

Post out-of-hospital cardiac arrest care in a tertiary care center in southern Thailand: From emergency department to intensive care unit

Background:

Out-of-hospital cardiac arrest results in a high mortality rate. The 2015 American Heart Association guideline for post-cardiac arrest was launched and adopted into our institutional policy.

Objectives:

We aimed to evaluate post-cardiac arrest care and compare the results with the 2015 American Heart Association guideline and clinical outcomes of out-of-hospital cardiac arrest patients.

Methods

Included in this study were all adult patients who survived out-of-hospital cardiac arrest and were admitted to the Medical Intensive Care Unit of Songklanagarind Hospital, Thailand. The retrospective review was from 1 January 2016 to 31 December 2017.

Results:

From a total of 161 post-cardiac arrest patients admitted to the medical intensive care unit, 69 out-of-hospital cardiac arrest patients were identified. The most common cause of arrest was presumed cardiac in origin (45.0%) in which the majority was acute myocardial infarction (67.8%). Coronary intervention and targeted temperature management were performed in 27.5% and 13% of all out-of-hospital cardiac arrest patients, respectively. Survival to hospital discharge was 42%. Independent factors associated with survival to discharge were shockable rhythms, lower adrenaline doses, and the absence of hypotension at medical intensive care unit admission.

Conclusion:

Compliance with the 2015 American Heart Association post-cardiac arrest care guideline was low in our institution, especially in coronary intervention and targeted temperature management.

Outcomes of Emergency Medical Service Usage in Severe Road Traffic Injury during Thai Holidays

Introduction

Thailand has the highest mortality from road traffic injury (RTI) in the world. There are usually higher incident rates of RTI in Thailand over long holidays such as New Year and Songkran. To our knowledge, there have been no studies that describe the impact of emergency medical service (EMS) utilization by RTI patients in Thailand. We sought to determine the outcomes of EMS utilization in severe RTIs during the holidays.

Methods

We conducted a retrospective review study by using a nationwide registry that collected RTI data from all hospitals in Thailand during the New Year holidays in 2008–2015 and Songkran holidays in 2008–2014. A severe RTI patient was defined as one who was admitted, transferred to another hospital, or who died at the emergency department (ED) or during referral. We excluded patients who died at the scene, those who were not transported to the ED, and those who were discharged from the ED. Outcomes associated with EMS utilization were identified by using multiple logistic regression and adjusted by using factors related to injury severity.

Results

Overall we included 100,905 patients in the final analysis; 39,761 severe RTI patients (39.40%; 95% confidence interval [CI] 95% CI [39.10%–39.71%]) used EMS transportation to hospitals. Severe RTI patients transported by EMS had a significantly higher mortality rate in the ED and during referral than that those who were not (2.00% vs. 0.78%, p < 0.001). Moreover, EMS use was significantly associated with increased mortality rate in the first 24 hours of admission to hospitals (1.38% for EMS use vs. 0.57% for no EMS use, p < 0.001). EMS utilization was a significant predictor of mortality in EDs and during referral (adjusted odds ratio [OR] 2.19; 95% CI [1.88–2.55]), and mortality in the first 24 hours of admission (adjusted OR 2.31; 95% CI [1.95–2.73]).

Conclusion

In this cohort, severe RTI patients transported by EMS had a significantly higher mortality rate than those who went to hospitals using private vehicles during these holidays.

Intravenous Fluid Administration and the Survival of Pre hospital Resuscitated out of Hospital Cardiac Arrest Patients in Thailand

Introduction

Out of Hospital Cardiac Arrest (OHCA) is a leading cause of death worldwide. The Emergency Medical Service (EMS) provides early care to critical OHCA patients. Pre hospital intervention has been improving OHCA survival rate, however it is still unclear for the recommendation of routine infusion of Intravenous (IV) fluids during cardiac arrest resuscitation.

Aim

This study aimed to determine whether IV fluid administration was associated with increasing survival of resuscitated OHCA patients and to assess the survival rate of resuscitated OHCA patients.

Materials and Methods

This cross-sectional analytical study was conducted among 33,006 resuscitated OHCA patients who received emergency medical service in Thailand. Data set from the EMS Registry of the OHCA patients who received Advanced Life Support (ALS) and Cardiopulmonary Resuscitation (CPR) during January 2011 to December 2015 was enrolled as per inclusion criteria. Data were analysed by using both descriptive statistic and multiple logistic regression.

Results

The result indicated that 27,270 OHCA patients (82.62%:95%CI=82.121-83.030%) survived until they reached hospital. In addition, after adjusting for effect modifiers and covariates, it was found that adult (≥18 years) with IV fluid administration were more likely to survive (adjusted OR=4.389; 95% CI: 3.911-4.744) when compared to children (<18 years) with IV fluid administration (adjusted OR =2.952; 95% CI: 2.040-4.273). Other factors associated with OHCA patients' survival were female gender (adjusted OR =1.151; 95% CI: 1.067-1.241), response time per minutes (adjusted OR =0.993; 95% CI: 0.989-0.997), scene time per minutes (adjusted OR=0.948; 95% CI: 0.944-0.952) and transport time per minutes (adjusted OR=0.973, 95%CI: 0.968-0.978).

Conclusion

This study revealed that IV fluid administration was significantly associated with survival of OHCA patients while controlled other covariates including female gender, response time, scene time and transport time. Therefore, it is recommended that the IV fluid administration should be medicated for resuscitated OHCA patients.