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A/Prof Marcus Ong Consultant, Senior Medical Scientist & Director of Research Department of Emergency Medicine Singapore General Hospital
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National Strategy for Improving Outcomes for Sudden Cardiac
Arrest in Singapore
A/Prof Marcus OngConsultant, Senior Medical Scientist
& Director of ResearchDepartment of Emergency Medicine
Singapore General HospitalAdjunct Associate Professor
Duke-NUS Graduate Medical SchoolOffice of Research
Prepared for the Advisory Committee on National Coronary Heart Disease Strategy.
What is the Epidemiology of Out-of-Hospital Cardiac Arrest in
Thailand?The importance of good research:
•Guide public health planning
•Mobilise public opinion and aid political decision making
•Measure cost effective interventions
Cardiac Arrest and Resuscitation Epidemiology
Characteristics of
Cardiac Arrest Patients
Data from the Cardiac Arrest and Resuscitation Epidemiology
in Singapore, 2001-2002
Cardiac Arrest and Resuscitation Epidemiology
CARE Study
Sudden Out-of-Hospital Cardiac Arrest Incidence Rate (Cardiac origin)
798 per year
(2001/2002)
(2005/6 estimates >1000/year
Cardiac Arrest and Resuscitation Epidemiology
CARE Study
Overall End-points
17.9% Return of spontaneous circulation
8.5% Survived to admission
2.0% Survived to Discharge
Cardiac Arrest and Resuscitation Epidemiology
Multi-Level Efforts
Resuscitation Centers ofExcellence• Hypothermia• 24/7 Revascularization• ICD
• High Quality CPR• CPR QA• ITD• Automated CPR
devices
• Rapid Response• AEDs• High Quality CPR• ITD
• Widespread CPR• Training• AEDs• Public Education Lay
Public
FirstResponder
EMSHospital
Survival
Cardiac Arrest and Resuscitation Epidemiology
The Take Heart Approach
Treatment Impact on Outcomes
Resuscitation Strategies and Their Impacts
InterventionExpected Survival
Improvement
Bystander CPR 2 – 5%
Rapid AED use 4 – 6%
Improved quality CPR by EMS 4 – 6%
Circulation enhancement by EMS and hospital personnel 4 – 6%
Rapid cooling, coronary vessel clearing and implanted
defibrillators in the hospital5 – 10%
Cardiac Arrest and Resuscitation Epidemiology
Chain of Survival
Courtesy of Life Support Training Centre, Singapore General Hospital
Cardiac Arrest and Resuscitation Epidemiology
Early AccessCARE Study: Relationship between Time call EMS vs Time of patient’s collapse
27.3% called EMS before patient collapsed
8.1% called EMS at time of patient collapsed
64.6% called EMS after patient collapsed
mean (sd) time from collapse to call is 10.6 (13.1) mins (median 6.9 mins)
Cardiac Arrest and Resuscitation Epidemiology
Early Access
CARE Study: EMS Response Time
Patient collaps
ed
Ambulance called
10.6
Ambulance
dispatched
0.7
Ambulance
arrived at location
9.5
Ambulance arrived at patient’s
side
2.4
CPR Started
1.8
1st shock given
2.3
ROSC
15.6
Arrival at ED
3.2
46.1
Time (Mins)
Cardiac Arrest and Resuscitation Epidemiology
DISCUSSIONDISCUSSIONNational EMS access number: 995
Mean delay of 10.6 mins after collapsed
Reflect possible:
Difficulty in recognizing a cardiac arrest
Unfamiliarity with the emergency access number
More work needed in educating public on:
recognizing a cardiac arrest
‘phone first’ and ‘phone fast’
Cardiac Arrest and Resuscitation Epidemiology
DISCUSSIONDISCUSSION
EMS response time greatly affects survival rates
Cardiac Arrest and Resuscitation Epidemiology
Singapore
Seow E, SMJ 1993, 11.40 mins +/- 4.88 mins
CARE 1 study 2002 - 10.5 mins with almost twice the number of ambulances
Continued effort required to reduce response time
DISCUSSIONDISCUSSION
Cardiac Arrest and Resuscitation Epidemiology
City Population No.Ambulances
No. EMSpersonnel
Ambulance/100,000population
New York 7.3 million 138 Overnight220 Daytime225 Evening
650 paramedics1700 EMT
2.78
Chicago 3 million 55 550 paramedics 1.83Singapore 4.1 million 32 Daytime
30 Overnight180 paramedics,35 PMT
0.78
DISCUSSIONDISCUSSION
Number of Ambulances/population
Cardiac Arrest and Resuscitation Epidemiology
Public/Community
Targeted Education to increase awareness of 995 universal number, and what to do in a cardiac arrest
Prevention efforts on major risk factors
RECOMMENDATIONSRECOMMENDATIONS
EMS
Aim to decrease response times for cardiac arrest to 90%< 8mins or lower
Use of Medical Priority Dispatching and Systems Status Management to maximise current SCDF resources (see CARE4 proposal)
Increase the ratio of ambulances: population to <1: 80,000 (current 1: 120,000)
Use of motorcycle and Fire Service first responders
RECOMMENDATIONSRECOMMENDATIONS
PADS I Study
Cardiac Arrest and Resuscitation Epidemiology
0
20
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0:00
-0:5
9
1:00
-1:5
9
2:00
-2:5
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3:00
-3:5
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4:00
-4:5
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5:00
-5:5
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-9:5
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:59
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:59
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0-23
:59
Time of collapse
No
. o
f ca
ses
PADS I Study
Number of cardiac arrest casesby hour
Cardiac Arrest and Resuscitation Epidemiology
Cardiac Arrest and Resuscitation Epidemiology
IMPROVED RESPONSE TIMES WITH MOTORCYCLE BASED IMPROVED RESPONSE TIMES WITH MOTORCYCLE BASED FAST RESPONSE PARAMEDICS IN AN URBAN SETTINGSFAST RESPONSE PARAMEDICS IN AN URBAN SETTINGS
Ong Marcus, MBBS, FRCS Ed (A&E)Registrar, Department of Emergency Medicine, Singapore General Hospital
Chan YH, PhdHead Biostatistics, Clinical Trials and Epidemiology Research Unit, Ministry of Health
A/P V Anatharaman, MBBS, MRCP, FRCS Ed (A&E), FAMSSenior Consultant and Head, Department of Emergency Medicine, SGH Clinical Associate Professor, Faculty of Medicine, NUS
introductionintroduction
aims/objectivesaims/objectives
methodsmethods
resultsresults
conclusionsconclusions
Pre-hospital response intervals are known to be an important factor in the level of care provided by any Emergency Medical System.In big cities, response intervals are known to be long due to traffic and accessibility problems.
To see if response intervals can be improved with motorcycle based Fast Response Paramedics (FRP) compared with standard ambulances in an urban setting.
A prospective, observational study.Simultaneous dispatch of motorcycles based FRP’s equipped with Automated External Defibrillators and standard ambulances for cardiac arrest, cardiac, respiratory conditions and road traffic accidents.
48 consecutive ambulance runs were recorded.Locations involved: home (41.7%), work (29.2%), road accident (20.8%) and others (8.3%)Ambulances took on average 4.96 minutes longer than motorcycles to respond (p<0.001, 95% CI 2.61 to 7.31). Adjusting (via multiple regression) for the day of the week, location, station, traffic and case, ambulances took on the average 4.71 (p<0.001, 95% CI 2.45 to 6.98) minutes longer to respond.Improvements in response times were greater when overall response times were longer (weekdays, residential/office location, moderate or heavy traffic).
Use of motorcycle based paramedics allow for faster response intervals and earlier interventions, especially early defibrillation in cardiac arrest. Larger follow-up studies are planned to assess the impact of implementation of more FRP’s on mortality and morbidity.
Cardiac Arrest and Resuscitation Epidemiology
Early Cardio-Pulmonary Resuscitation (CPR)
CARE Study: Bystander CPR
Early CPR
Bystander CPR rates Singapore 20% Auckland 55% King County 54% Minnesota 50% Chicago 28% Vancouver 16%
Lateef et al 2001 SGH ASM
Cardiac Arrest and Resuscitation Epidemiology
Quality of CPR:Pocket QCPR feedback device for use with manual CPR (CPREZY)
Cardiac Arrest and Resuscitation Epidemiology
Defibrillator pads incorporating an accelerometer for QCPR feedback (Zoll E series defibrillation pads)
Cardiac Arrest and Resuscitation Epidemiology
Defibrillator screen display incorporating QCPR feedback
indicators (Zoll E series)
Cardiac Arrest and Resuscitation Epidemiology
Public/Community
Increase bystander CPR rate to >50%
Increase proportion of population trained in CPR – mandatory CPR training for schools, military, driver’s license?
Improve the quality of CPR being performed – work with NRC to accredit CPR training centers, encourage use of QCPR feedback devices
RECOMMENDATIONSRECOMMENDATIONS
Cardiac Arrest and Resuscitation Epidemiology
EMS
Improve the quality of CPR performed by trained rescuers using Quality of CPR technology incorporated in the latest AEDs
Implement mechanical CPR devices during ambulance transport to provide more consistent, safe and reliable CPR
RECOMMENDATIONSRECOMMENDATIONS
Cardiac Arrest and Resuscitation Epidemiology
Public Access Defibrillation in Singapore: What is the Geographic-Time Distribution of Cardiac Arrests in Singapore? (PADS I Study)
PADS I Study
Early Defibrillation
PADS I Study
AreaPostal code
NMean Age of arrests(SD)
Esitmated Population base (2000
census)
Arrest Rate per year
over 3 years (per 100,000 population)
Alexandra (Bukit Merah/Redhill)
15 57 64.43 (22.41) 11,639163.24
Jalan Besar 21 26 61.37 (16.72) 8,017 108.10
Ghim Moh 27 32 70.35 (19.41) 12,436 85.77
South Bridge Road / Kreta Ayer
05 27 63.32 (14.55) 11,04781.47
Bedok (Bedok Reservoir)
47 38 52.71 (24.31) 19,99963.34
Sengkang 54 59 57.15 (20.11) 60,870 32.31
Towner 32 30 62.88 (21.88) 31,481 31.77
Clementi 12 84 64.52 (18.57) 90,864 30.82
Cardiac Arrest and Resuscitation Epidemiology
Early DefibrillationBreakdown of Location of Cardiac Arrest Cases
LocationNumber of
CasesPercentage of
Cases (%)Residential (HDB, private housing, condominum, condomium facilities) 1609 66.3Roadside / In Public Transport / In Private Vehicles 195 8Neighbourhood Shop / Town Center / TCM Clinic / Market / Food Center / Shopping Mall 117 4.8Industrial Estate / Shipyard 50 2.1Government / Commercial Building / Industrial Estate 32 1.3Changi Airport / Ferry Terminal / Immigration Checkpoint 26 1.1In Private Ambulances 26 1.1Bus Interchange / MRT Station 18 0.7Hotel 18 0.7School 13 0.5Stadiums / Sports & Swimming Complexes 12 0.5Mosque / Church / Temple 12 0.5Community Club 7 0.3
Cardiac Arrest and Resuscitation Epidemiology
Defibrillation by Health Care Providers
Breakdown of Location of Cardiac Arrest Cases :
Many are within reach of a GP/Clinic
(CARE Study Phase I & II - 1 Oct 2001 to 14 Oct 2004)
LocationNumber of
CasesPercentage of
Cases (%)GP Clinic / Hospital (non-inpatient) 78 3.2Nursing Home / Old Folks Home 38 1.6Dialysis Centre 19 0.8
1995: First Five Years of Pre-Hospital Automatic Defibrillation Project in Singapore
Cardiac Arrest and Resuscitation Epidemiology
Public/Community
Targeted Public Access Defibrillation programs for high arrest rate locations – Medical facilities, private ambulances, transport hubs (airport, MRT, bus terminals), public buildings (stadiums, casino, shopping malls, offices)
Community based PAD programs – Henderson estate pilot project
RECOMMENDATIONSRECOMMENDATIONS
Cardiac Arrest and Resuscitation Epidemiology
EMS
Aim to decrease time to 1st shock to 90%< 8mins or lower
Equipping training and utilising Fire or Police first responders with AEDs
RECOMMENDATIONSRECOMMENDATIONS
Cardiac Arrest and Resuscitation Epidemiology
Advanced Life Support (ALS)
Invest in EMS interventions for cardiac arrest
Multipronged effort at post-resuscitation care, coronary revascularisation and long term care, ICD use
Early Advanced Care
Cardiac Arrest and Resuscitation Epidemiology
Cardiac Arrest and Resuscitation Epidemiology
EMS
1. Invest in research/adoption of promising cardiac arrest interventions : Impedence Threshold Devices, Mechanical CPR, LMA, Intraosseous vascular access
2.Prehospital 12 lead ECG transmission for STEMI
RECOMMENDATIONSRECOMMENDATIONS
Dr Marcus Ong MBBS (Singapore), FRCS Ed (A&E), MPH, FAMSConsultant, Director of Research and Senior Medical ScientistDepartment of Emergency MedicineSingapore General Hospital
Improving Door-To-Balloon (D2B) Times In PatientsPresenting To The Department Of EmergencyMedicine For Acute ST Elevation Myocardial
Infarction Requiring Primary Percutaneous CoronaryIntervention- Usage of Pre-Hospital wireless 12 lead
electrocardiogram (ECG) transmission
Technical and Functional Features
Patient’s 12-lead ECG report, vital signs, and other information transmitted to DEM, as well as alert DEM staff of such incoming information.
Cardiac Arrest and Resuscitation Epidemiology
Emergency Department/ Hospital
1.Post-resuscitation hypothermia
2.24/7 provision of PCI for STEMI
3. ICD adoption
RECOMMENDATIONSRECOMMENDATIONS
““A Prospective Clinical Study Comparing Controlled
Therapeutic Hypothermia Post-Cardiac Arrest Using External
and Internal Cooling to Standard Intensive Care Unit Therapy”
Organised by:
Conference Secretariat:
Tel: (65) 6 379 5261/ 6 379 5259Fax: (65) 6 475 2077 Email: [email protected]
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See You in Singapore!