Singapore Basic Cardiac Life Support and Automated External Defibrillation Guidelines 2021

Enhancing survival outcomes in developing emergency medical service system: Continuous quality improvement for out-of-hospital cardiac arrest

Introduction

Emergency Medical Service (EMS) providers are essential for out-of-hospital cardiac arrest (OHCA) survival, however implementing high-performance CPR guidelines in developing EMS settings presents challenges. This study assessed the impact of Continuous Quality Improvement (CQI) initiatives on OHCA outcomes in a hospital-based EMS agency in Bangkok, Thailand.

Methods

A before-and-after study design was utilized, utilizing data from a prospective OHCA registry spanning 2019 to 2023. CQI interventions included low-dose high-frequency training in advanced airway management, high-performance CPR, and post-debriefing with video recording (VDO). Data collection encompassed patient characteristics, EMS management, and survival outcomes. Quality CPR metrics were assessed using the mobile defibrillator and CPR code review software. Statistical analyses compared outcomes between the pre-intervention period in 2019 and the post-full CQI implementation period in 2023.

Results

Among enrolled OHCA patients, with 88 cases occurring in 2019 and 91 cases in 2023. The bystander CPR rate was similar between both groups (47.73% in 2023 vs 53.85%, p = 0.413). In 2023, there was a significantly higher rate of prehospital intubation (93.40% vs 70.45%, p < 0.001) compared to 2019. Prehospital return of spontaneous circulation (ROSC) improved from 30.68% to 49.45% (p = 0.012), with an adjusted odds ratio (aOR) of 2.16 (95% CI: 1.14-4.07). Survival to discharge increased significantly from 2.27% in 2019 to 7.69% in 2023 (p = 0.27), with an aOR of 3.81 (95% CI: 0.46-31.79).

Conclusion

Tailored CQI initiatives in a developing EMS setting were significantly associated with improved prehospital ROSC but showed an insignificant increase in survival to discharge.

Singapore Advanced Cardiac Life Support Guidelines 2021

Advanced cardiac life support (ACLS) emphasises the use of advanced airway management and ventilation, circulatory support and the appropriate use of drugs in resuscitation, as well as the identification of reversible causes of cardiac arrest. Extracorporeal cardiopulmonary resuscitation and organ donation, as well as special circumstances including drowning, pulmonary embolism and pregnancy are addressed. Resuscitation does not end with ACLS but must continue in post-resuscitation care. ACLS also covers the recognition and management of unstable pre-arrest tachy- and bradydysrhythmias that may deteriorate further.