Long term survival and disease burden from out-of-hospital cardiac arrest: a population-based cohort study

Background

Long-term outcomes of out-of-hospital cardiac arrest (OHCA) are important to evaluate the overall health burden of OHCA on society. The concept of disability-adjusted life years (DALY) have recently been utilised to measure disease burden in OHCA, but data in an Asian cohort remains limited. We aimed to quantify and identify predictors of long-term survival (up to 10 years follow up) in patients with OHCA, as well as to quantify the annual disease burden of OHCA estimated using DALY in a national multi-ethnic Asian cohort.

Methods

We conducted an open cohort study through the linkage of the Pan-Asian Resuscitation Outcomes Study and the Singapore Registry of Births and Deaths from 2010 to 2020 in Singapore [1]. We quantified long-term survival using the standardised mortality ratio (SMR) for each year of follow up and the annual disease burden using DALY. Predictors of long-term survival were identified using cox-proportional hazards models. Kaplan-Meier survival curves were constructed for the overall population, and by key characteristics. The proportion surviving (and 95% CI) was calculated for up to eight years post-OHCA.

Results

We included 802 cases in the analysis. The mean age was 56.0 (SD 17.8), 631 cases (78.7%) were male, and the majority (552 cases, 68.8%) were of Chinese ethnicity (Table 1). The proportion surviving at one year of follow up was 0.84 (95% CI: 0.81–0.87), at five years of follow up was 0.68 (95% CI 0.65–0.72), and at ten years of follow up was 0.62 (95% CI 0.57–0.67) (Figure 1). Age at arrest (HR 1.03, 95% CI: 1.02–1.04, p<0.001), shockable first arrest rhythm (HR 0.75, 95% CI: 0.52–0.93, p=0.015) and Cerebral Performance Category (CPC) (HR 4.62, 95% CI: 3.17–6.75, p<0.001) were independently associated with mortality (Figure 2, 3). At one year, the SMR was 14.9 (95% CI: 12.5–17.8), and this decreased to 1.2 (95% CI: 0.7–1.8) at three years, and 0.4 (95% CI: 0.2–0.8) at five years (Figure 4). The top three causes of death after OHCA based on ICD10 categories were pneumonia, chronic ischemic heart disease, and acute myocardial infarction. The total DALY increased from 304.1 in 2010 to 849.7 in 2015, followed by decreasing to 547.1 in 2018. The mean DALY decreased from 12.162 in 2010 to 3.599 in 2018.

Conclusions

Age at arrest and CPC category was independently associated with higher risk of mortality, while a shockable first arrest rhythm was independently associated with a lower risk of mortality in long-term OHCA survivors. Initial survivors of OHCA have an increased mortality rate compared to the general population for the first three years, but normalises to that of the general population subsequently, while the annual disease burden of OHCA quantified using DALY showed decreasing trends from 2010 to 2018. Further improvements in the surveillance and management of OHCA may be warranted to improve the long-term survivorship and decrease the burden of disease of OHCA globally.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Medical Research Council, Clinician Scientist Award, Singapore (NMRC/CSA/024/2010 and NMRC/CSA/0049/2013), Ministry of Health, Health Services Research Grant, Singapore (HSRG/0021/2012)

Resident as Teacher: General needs Assessment in Emergency Medicine

Introduction

Increasingly, residents are involved in the education of medical students, their peers and other health professionals. This study focused on the general needs assessment of the emergency medicine (EM) residents in developing a resident-as-teacher curriculum.

Methods

An anonymous and voluntary survey, which consisted of multiple choice and free text questions, was sent to all emergency physicians (EPs) working in the 7 restructured hospitals in Singapore.

Results

A total of 68 (60%) EPs completed the online survey. Overall, 19 (28%) EPs have undergone formal training in teaching. Majority of the EPs felt that it was important for the residents to acquire competent teaching skills at the end of their residency training. All of the EPs were in consensus that there should be formal instruction to the residents on how to teach. The four themes which emerged from the barriers to developing teaching skills in residents were time constraints, lack of faculty development, attitudes of both faculty and residents and a non-conducive work environment with high service requirements.

Conclusions

To develop the resident as an all rounded Emergency Physician, structured training and formal instruction for the developing of teaching and feedback skills must be included in the residency training. However in order for the new curriculum to be successful and achieve its primary objective of developing the residents' competencies in teaching, barriers hindering both the faculty and residents have to be addressed. Finally, faculty development needs to be done to equip the faculty with the appropriate teaching and feedback tools. (Hong Kong j.emerg.med. 2015;22:226-234)

Direct Observation as a Focused Teaching Tool for Doctors Newly Posted to the Emergency Department

Introduction

The emergency department (ED) is a high risk working environment with clinical and operational protocols in place to attenuate the risks for doctors new to the ED. We implemented a structured direct observation program for new ED doctors who were not Emergency Medicine trainees.

Method

An ED consultant observed each new ED doctor directly over two weeks without intervention in the clinical encounters. A structured form documented the doctor's performance in pre-defined areas relevant to patient care as well as mastery of operational procedures. Individual strengths and weaknesses were noted. Feedback was provided at the end of each session. After two weeks, the doctors completed a survey form with questions pertaining to their perceived level of competence in areas related to patient care and their experience with the direct observation program.

Results

There was an overall improvement in their perceived levels of competence in most areas pertaining to patient care. Most felt that this program was useful. Only a minority found it stressful. None felt that it was a waste of time.

Conclusion

Implementation of direct observation as a focused teaching tool is well received by both junior doctors and Emergency physicians. It provides early insight and feedback into the strengths and weaknesses of the junior doctors and helps new ED doctors to adapt quickly to the work process of the ED.

Circadian rhythm in cardiac arrest: the Singapore experience

INTRODUCTION

There appears to be a circadian rhythm in the timing of cardiovascular and neurovascular events. The majority of studies have been conducted in western populations. This is the first study to look at the peaks and distribution of out-of-hospital cardiac arrest (OHCA) patients in Singapore.

METHODS

The Cardiac Arrest and Resuscitation Epidemiology Studies I and II were prospective observation studies on OHCA in Singapore from October 1, 2001 to October 14, 2004. This study analysed data for patients older than 16 years. All data was collected and recorded as per the Utstein style template. Analysis was done for each of the quadrants of the 24-hour clock: 0001-0600, 0601-1200, 1201-1800 and 1801-2400 hours.

RESULTS

Of the 2,428 cases, 2,167 OHCA patients qualified for the final analysis. Their mean ages were in the 60s for all the four quadrants, with a male predominance. The two peaks noted were at 0800 and 1900 hours for cardiac causes of death (n = 1,591), and at 0900 and 2000 hours for non-cardiac causes of death (n = 576). At all times of the day, the majority of OHCA occurred in residences and the bystander cardiopulmonary resuscitation rate ranged from 14.6 to 24.3 percent in the different quadrants of the day.

CONCLUSION

OHCA has a bimodal distribution in our local cohort of patients. The information obtained will be utilised for fine-tuning emergency medical services strategies, as we strive to improve our current survival rates for OHCA.

When the stork arrives unannounced - seven years of emergency deliveries in a non-obstetric general hospital

INTRODUCTION

Emergency department deliveries are uncommon in the Singapore setting, but when they do occur, the emergency physician has to be able to deliver the child safely, perform neonatal resuscitation if needed, and try to prevent any birth trauma to the child or complications of delivery in the mother. We present our experience of emergency room deliveries spanning 7 years in a community hospital without obstetric or neonatal backup.

MATERIALS AND METHODS

This is a retrospective case series. A search was made through our electronic medical records system for patients presenting in labour or with deliveries from March 1997 to October 2004. They were studied for demographic and social factors, gravidity and parity, as well as any complications (during birth and in the immediate post-delivery period) in both parent and child.

RESULTS

Twenty-three patients presented to our emergency department with labour contractions, and 14 progressed to vaginal deliveries. Twelve were single mothers who had hidden their pregnancies, while another 2 married patients had unsuspected pregnancies. No neonate needed resuscitation or airway support, but there were 4 patients without episiotomy who sustained perineal tears, and another 2 patients in whom the placenta could not be delivered. A child (born to a single mother without antenatal care) had a low Apgar score, but improved with oxygen and suctioning.

CONCLUSIONS

An emergency department in a non-obstetric hospital should have in place adequate preparations to cater for the occasional unexpected emergency delivery and the associated need for neonatal resuscitation. In our series, there was a high proportion of concealed (hidden) and "unaware" pregnancies presenting in labour. Prompt referral to a maternity hospital with neonatal care should be made for any complications.