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National Strategy for Improving Outcomes for Sudden Cardiac Arrest in Singapore A/Prof Marcus Ong Consultant, Senior Medical Scientist & Director of Research Department of Emergency Medicine Singapore General Hospital Adjunct Associate Professor Duke-NUS Graduate Medical School Office of Research Prepared for the Advisory Committee on National Coronary Heart Disease Strategy.

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A/Prof Marcus OngConsultant, Senior Medical Scientist& Director of ResearchDepartment of Emergency MedicineSingapore General Hospital

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Page 1: Cardiac Arrest Strategy

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.

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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

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Cardiac Arrest and Resuscitation Epidemiology

Characteristics of

Cardiac Arrest Patients

Data from the Cardiac Arrest and Resuscitation Epidemiology

in Singapore, 2001-2002

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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

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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

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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

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Cardiac Arrest and Resuscitation Epidemiology

The Take Heart Approach

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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%

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Cardiac Arrest and Resuscitation Epidemiology

Chain of Survival

Courtesy of Life Support Training Centre, Singapore General Hospital

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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)

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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)

Page 13: Cardiac Arrest Strategy

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’

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Cardiac Arrest and Resuscitation Epidemiology

DISCUSSIONDISCUSSION

EMS response time greatly affects survival rates

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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

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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

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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

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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

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PADS I Study

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Cardiac Arrest and Resuscitation Epidemiology

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Time of collapse

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PADS I Study

Number of cardiac arrest casesby hour

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Cardiac Arrest and Resuscitation Epidemiology

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Cardiac Arrest and Resuscitation Epidemiology

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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.

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Cardiac Arrest and Resuscitation Epidemiology

Early Cardio-Pulmonary Resuscitation (CPR)

CARE Study: Bystander CPR

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Early CPR

Bystander CPR rates Singapore 20% Auckland 55% King County 54% Minnesota 50% Chicago 28% Vancouver 16%

Lateef et al 2001 SGH ASM

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Cardiac Arrest and Resuscitation Epidemiology

Quality of CPR:Pocket QCPR feedback device for use with manual CPR (CPREZY)

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Cardiac Arrest and Resuscitation Epidemiology

Defibrillator pads incorporating an accelerometer for QCPR feedback (Zoll E series defibrillation pads)

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Cardiac Arrest and Resuscitation Epidemiology

Defibrillator screen display incorporating QCPR feedback

indicators (Zoll E series)

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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

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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

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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

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PADS I Study

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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

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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

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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

Page 38: Cardiac Arrest Strategy

1995: First Five Years of Pre-Hospital Automatic Defibrillation Project in Singapore

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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

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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

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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

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Cardiac Arrest and Resuscitation Epidemiology

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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

Page 44: Cardiac Arrest Strategy

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

Page 45: Cardiac Arrest Strategy

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.

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Cardiac Arrest and Resuscitation Epidemiology

Emergency Department/ Hospital

1.Post-resuscitation hypothermia

2.24/7 provision of PCI for STEMI

3. ICD adoption

RECOMMENDATIONSRECOMMENDATIONS

Page 47: Cardiac Arrest Strategy

““A Prospective Clinical Study Comparing Controlled

Therapeutic Hypothermia Post-Cardiac Arrest Using External

and Internal Cooling to Standard Intensive Care Unit Therapy”

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Organised by:

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Conference Secretariat:

Tel: (65) 6 379 5261/ 6 379 5259Fax: (65) 6 475 2077 Email: [email protected]

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Visit our website :

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See You in Singapore!