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      Incidence and Outcomes of Out‐of‐Hospital Cardiac Arrest in Singapore and Victoria: A Collaborative Study

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          Abstract

          Background

          Incidence and outcomes of out‐of‐hospital cardiac arrest (OHCA) vary between communities. We aimed to examine differences in patient characteristics, prehospital care, and outcomes in Singapore and Victoria.

          Methods and Results

          Using the prospective Singapore Pan‐Asian Resuscitation Outcomes Study and Victorian Ambulance Cardiac Arrest Registry, we identified 11 061 and 32 003 emergency medical services‐attended adult OHCAs between 2011 and 2016 respectively. Incidence and survival rates were directly age adjusted using the World Health Organization population. Survival was analyzed with logistic regression, with model selection via backward elimination. Of the 11 061 and 14 834 emergency medical services‐treated OHCAs (overall mean age±SD 65.5±17.2; 67.4% males) in Singapore and Victoria respectively, 11 054 (99.9%) and 5595 (37.7%) were transported, and 440 (4.0%) and 2009 (13.6%) survived. Compared with Victoria, people with OHCA in Singapore were older (66.7±16.5 versus 64.6±17.7), had less shockable rhythms (17.7% versus 30.3%), and received less bystander cardiopulmonary resuscitation (45.7% versus 58.5%) and defibrillation (1.3% versus 2.5%) (all P<0.001). Age‐adjusted OHCA incidence and survival rates increased in Singapore between 2011 and 2016 ( P<0.01 for trend), but remained stable, though higher, in Victoria. Likelihood of survival increased significantly ( P<0.001) with arrest in public locations (adjusted odds ratio [aOR] 1.81), witnessed arrest (aOR 2.14), bystander cardiopulmonary resuscitation (aOR 1.72), initial shockable rhythm (aOR 9.82), and bystander defibrillation (aOR 2.04) but decreased with increasing age (aOR 0.98) and emergency medical services response time (aOR 0.91).

          Conclusions

          Singapore reported increasing OHCA incidence and survival rates between 2011 and 2016, compared with stable, albeit higher, rates in Victoria. Survival differences might be related to different emergency medical services practices including patient selection for resuscitation and transport.

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          Most cited references31

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          Regional variation in out-of-hospital cardiac arrest incidence and outcome.

          Graham Nichol, Elizabeth Thomas, Clifton Callaway … (2008)
          The health and policy implications of regional variation in incidence and outcome of out-of-hospital cardiac arrest remain to be determined. To evaluate whether cardiac arrest incidence and outcome differ across geographic regions. Prospective observational study (the Resuscitation Outcomes Consortium) of all out-of-hospital cardiac arrests in 10 North American sites (8 US and 2 Canadian) from May 1, 2006, to April 30, 2007, followed up to hospital discharge, and including data available as of June 28, 2008. Cases (aged 0-108 years) were assessed by organized emergency medical services (EMS) personnel, did not have traumatic injury, and received attempts at external defibrillation or chest compressions or resuscitation was not attempted. Census data were used to determine rates adjusted for age and sex. Incidence rate, mortality rate, case-fatality rate, and survival to discharge for patients assessed or treated by EMS personnel or with an initial rhythm of ventricular fibrillation. Among the 10 sites, the total catchment population was 21.4 million, and there were 20,520 cardiac arrests. A total of 11,898 (58.0%) had resuscitation attempted; 2729 (22.9% of treated) had initial rhythm of ventricular fibrillation or ventricular tachycardia or rhythms that were shockable by an automated external defibrillator; and 954 (4.6% of total) were discharged alive. The median incidence of EMS-treated cardiac arrest across sites was 52.1 (interquartile range [IQR], 48.0-70.1) per 100,000 population; survival ranged from 3.0% to 16.3%, with a median of 8.4% (IQR, 5.4%-10.4%). Median ventricular fibrillation incidence was 12.6 (IQR, 10.6-5.2) per 100,000 population; survival ranged from 7.7% to 39.9%, with a median of 22.0% (IQR, 15.0%-24.4%), with significant differences across sites for incidence and survival (P<.001). In this study involving 10 geographic regions in North America, there were significant and important regional differences in out-of-hospital cardiac arrest incidence and outcome.
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            Global incidences of out-of-hospital cardiac arrest and survival rates: Systematic review of 67 prospective studies.

            Jocelyn Berdowski, Robert A Berg, Jan Tijssen … (2010)
            The aim of this investigation was to estimate and contrast the global incidence and outcome of out-of-hospital cardiac arrest (OHCA) to provide a better understanding of the variability in risk and survival of OHCA. We conducted a review of published English-language articles about incidence of OHCA, available through MEDLINE and EmBase. For studies including adult patients and both adult and paediatric patients, we used Utstein data reporting guidelines to calculate, summarize and compare incidences per 100,000 person-years of attended OHCAs, treated OHCAs, treated OHCAs with a cardiac cause, treated OHCA with ventricular fibrillation (VF), and survival-to-hospital discharge rates following OHCA. Sixty-seven studies from Europe, North America, Asia or Australia met inclusion criteria. The weighted incidence estimate was significantly higher in studies including adults than in those including adults and paediatrics for treated OHCAs (62.3 vs 34.7; P<0.001); and for treated OHCAs with a cardiac cause (54.6 vs 40.8; P=0.004). Neither survival to discharge rates nor VF survival to discharge rates differed statistically significant among studies. The incidence of treated OHCAs was higher in North America (54.6) than in Europe (35.0), Asia (28.3), and Australia (44.0) (P<0.001). In Asia, the percentage of VF and survival to discharge rates were lower (11% and 2%, respectively) than those in Europe (35% and 9%, respectively), North America (28% and 6%, respectively), or Australia (40% and 11%, respectively) (P<0.001, P<0.001). OHCA incidence and outcome varies greatly around the globe. A better understanding of the variability is fundamental to improving OHCA prevention and resuscitation. Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.
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              Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis.

              Comilla Sasson, Mary Rogers, Jason F. Dahl … (2010)
              Prior studies have identified key predictors of out-of-hospital cardiac arrest (OHCA), but differences exist in the magnitude of these findings. In this meta-analysis, we evaluated the strength of associations between OHCA and key factors (event witnessed by a bystander or emergency medical services [EMS], provision of bystander cardiopulmonary resuscitation [CPR], initial cardiac rhythm, or the return of spontaneous circulation). We also examined trends in OHCA survival over time. An electronic search of PubMed, EMBASE, Web of Science, CINAHL, Cochrane DSR, DARE, ACP Journal Club, and CCTR was conducted (January 1, 1950 to August 21, 2008) for studies reporting OHCA of presumed cardiac etiology in adults. Data were extracted from 79 studies involving 142 740 patients. The pooled survival rate to hospital admission was 23.8% (95% CI, 21.1 to 26.6) and to hospital discharge was 7.6% (95% CI, 6.7 to 8.4). Stratified by baseline rates, survival to hospital discharge was more likely among those: witnessed by a bystander (6.4% to 13.5%), witnessed by EMS (4.9% to 18.2%), who received bystander CPR (3.9% to 16.1%), were found in ventricular fibrillation/ventricular tachycardia (14.8% to 23.0%), or achieved return of spontaneous circulation (15.5% to 33.6%). Although 53% (95% CI, 45.0% to 59.9%) of events were witnessed by a bystander, only 32% (95% CI, 26.7% to 37.8%) received bystander CPR. The number needed to treat to save 1 life ranged from 16 to 23 for EMS-witnessed arrests, 17 to 71 for bystander-witnessed, and 24 to 36 for those receiving bystander CPR, depending on baseline survival rates. The aggregate survival rate of OHCA (7.6%) has not significantly changed in almost 3 decades. Overall survival from OHCA has been stable for almost 30 years, as have the strong associations between key predictors and survival. Because most OHCA events are witnessed, efforts to improve survival should focus on prompt delivery of interventions of known effectiveness by those who witness the event.
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                Author and article information

                Contributors
                Marcus Eng Hock Ong:
                ORCID: https://orcid.org/0000-0001-7874-7612
                marcus.ong.e.h@singhealth.com.sg
                Journal
                Journal ID (nlm-ta): J Am Heart Assoc
                Journal ID (iso-abbrev): J Am Heart Assoc
                Journal ID (doi): 10.1002/(ISSN)2047-9980
                Journal ID (publisher-id): JAH3
                Journal ID (hwp): ahaoa
                Title: Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease
                Publisher: John Wiley and Sons Inc. (Hoboken )
                ISSN (Electronic): 2047-9980
                Publication date (Electronic): 23 October 2020
                Publication date Collection: 03 November 2020
                Volume: 9
                Issue: 21 ( doiID: 10.1002/jah3.v9.21 )
                Electronic Location Identifier: e015981
                Affiliations
                [ 1 ] Department of Cardiology National University Heart Centre Singapore
                [ 2 ] Center for Research and Evaluation Ambulance Victoria Doncaster Victoria Australia
                [ 3 ] Department of Epidemiology and Preventive Medicine Monash University Victoria Australia
                [ 4 ] Department of Medicine Yong Loo Lin School of Medicine Singapore
                [ 5 ] Cardiovascular Research Institute National University Heart Centre Singapore
                [ 6 ] Intensive Care Department The Alfred Hospital Melbourne Victoria Australia
                [ 7 ] Emergency Department National University Hospital Singapore
                [ 8 ] Medical Department Singapore Civil Defence Force Singapore
                [ 9 ] Home Team Medical Service Division Ministry of Home Affairs Singapore
                [ 10 ] Lee Kong Chian School of Medicine Nanyang Technological University Singapore
                [ 11 ] Department of Emergency Medicine Singapore General Hospital Singapore
                [ 12 ] Health Services and Systems Research Duke‐NUS Medical School Singapore
                Author notes
                [*] [* ] Correspondence to: Marcus Eng Hock Ong, MBBS, MPH, Department of Emergency Medicine, Singapore General Hospital, Outram Road, Singapore 169608. E‐mail: marcus.ong.e.h@ 123456singhealth.com.sg

                Author information
                https://orcid.org/0000-0002-1151-2357
                https://orcid.org/0000-0002-0037-3195
                https://orcid.org/0000-0001-7874-7612
                Article
                Publisher ID: JAH35618
                DOI: 10.1161/JAHA.119.015981
                PMC ID: 7763419
                PubMed ID: 33094661
                SO-VID: 44848cd7-96f4-461b-a8fe-691c5d367700
                Copyright © © 2020 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.
                License:

                This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

                History
                Date received : 30 March 2020
                Date accepted : 17 September 2020
                Page count
                Figures: 4, Tables: 3, Pages: 12, Words: 7708
                Funding
                Funded by: National Medical Research Council, Singapore , open-funder-registry 10.13039/501100001349;
                Funded by: Ministry of Health, Singapore , open-funder-registry 10.13039/501100001350;
                Funded by: Victorian Government Department of Health
                Categories
                Subject: Original Research
                Subject: Original Research
                Subject: Resuscitation Science
                Custom metadata
                source-schema-version-number 2.0
                cover-date 03 November 2020
                details-of-publishers-convertor Converter:WILEY_ML3GV2_TO_JATSPMC version:5.9.3 mode:remove_FC converted:03.11.2020

                ScienceOpen disciplines: Cardiovascular Medicine
                Keywords: cardiac arrest,emergency medical services,survival,cardiopulmonary arrest,cardiopulmonary resuscitation and emergency cardiac care
                Data availability:
                ScienceOpen disciplines: Cardiovascular Medicine
                Keywords: cardiac arrest, emergency medical services, survival, cardiopulmonary arrest, cardiopulmonary resuscitation and emergency cardiac care

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