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While out-of-hospital cardiac arrest (OHCA) is associated with poor survival, early bystander CPR (B-CPR) and telephone CPR (T-CPR) improves survival from OHCA. American Heart Association (AHA) Scientific Statements outline recommendations for T-CPR. We assessed these recommendations and hypothesized that meeting performance standards is associated with increased likelihood of survival. Additional variables were analyzed to identify future performance measurements.We conducted a retrospective cohort study of non-traumatic, adult, OHCA using the Singapore Pan-Asian Resuscitation Outcomes Study. The primary outcome was likelihood of survival; secondary outcomes were pre-hospital Return of Spontaneous Circulation (ROSC) and B-CPR.From 2012 to 2016, 2,574 arrests met inclusion criteria. Mean age was 68 ± 15; of 2,574, 1,125 (44%) received T-CPR with 5% (135/2574) survival. T-CPR cases that met the Lerner et al. performance metrics analyzed, demonstrated no statistically significant association with survival. Cases which met the Kurz et al. criteria, "Time for Dispatch to Recognize Need for CPR" and "Time to First Compression," had adjusted odds ratios of survival of 1.01 (95% CI:1.00, 1.02; p = 0.01) and 0.99 (95% CI:0.99, 0.99; p = 0.01), respectively. Identified barriers to CPR decreased the odds of T-CPR and B-CPR being performed. Patients with prehospital ROSC had higher odds of B-CPR being performed. EMS response time 8 minutes was associated with increased survival among patients receiving T-CPR.AHA scientific statements on T-CPR programs serve as ideal starting points for increasing the quality of T-CPR systems and patient outcomes. More work is needed to identify other system performance measures.

Survival with favorable neurological outcomes is an important indicator of successful resuscitation in out-of-hospital cardiac arrest (OHCA). We sought to validate the CaRdiac Arrest Survival Score (CRASS), derived using data from the German Resuscitation Registry, in predicting the likelihood of good neurological outcomes after OHCA in Singapore.We conducted a retrospective population-based validation study among EMS-attended OHCA patients (≥18 years) in Singapore, using data from the prospective Pan-Asian Resuscitation Outcomes Study registry. Good neurological outcome was defined as a cerebral performance category of 1 or 2. To evaluate the CRASS score in light of the difference in patient characteristics, we used the default constant coefficient (0.8) and the adjusted coefficient (0.2) to calculate the probability of good neurological outcomes.Out of 11,404 analyzed patients recruited between April 2010 and December 2018, 260 had good and 11,144 had poor neurological function. The CRASS score demonstrated good discrimination, with an area under the curve of 0.963 (95% confidence interval: 0.952-0.974). Using the default constant coefficient of 0.8, the CRASS score consistently overestimated the predicted probability of a good outcome. Following adjustment of the coefficient to 0.2, the CRASS score showed improved calibration.CRASS demonstrated good discrimination and moderate calibration in predicting favorable neurological outcomes in the validation Singapore cohort. Our study established a good foundation for future large-scale, cross-country validations of the CRASS score in diverse sociocultural, geographical, and clinical settings.

Fewer out-of-hospital cardiac arrest (OHCA) patients received bystander cardiopulmonary resuscitation during the COVID-19 pandemic in Singapore. We investigated the impact of COVID-19 on barriers to dispatcher-assisted cardiopulmonary resuscitation (DA-CPR).We reviewed audio recordings of all calls to our national ambulance service call centre during the pandemic (January-June 2020) and pre-pandemic (January-June 2019) periods. Our primary outcome was the presence of barriers to DA-CPR. Multivariable logistic regression was used to assess the effect of COVID-19 on the likelihood of barriers to and performance of DA-CPR, adjusting for patient and event characteristics.There were 1241 and 1118 OHCA who were eligible for DA-CPR during the pandemic (median age 74 years, 61.6 % males) and pre-pandemic (median age 73 years, 61.1 % males) periods, respectively. Compared to pre-pandemic, there were more residential and witnessed OHCA during the pandemic (87 % vs 84.9 % and 54 % vs 38.1 %, respectively); rates of DA-CPR were unchanged (57.3 % vs 61.1 %). COVID-19 increased the likelihood of barriers to DA-CPR (aOR 1.47, 95 % CI: 1.25-1.74) but not performance of DA-CPR (aOR 0.86, 95 % CI: 0.73 - 1.02). Barriers such as 'patient status changed' and 'caller not with patient' increased during COVID-19 pandemic. 'Afraid to do CPR' markedly decreased during the pandemic; fear of COVID-19 transmission made up 0.5 % of the barriers.Barriers to DA-CPR were encountered more frequently during the COVID-19 pandemic but did not affect callers' willingness to perform DA-CPR. Distancing measures led to more residential arrests with increases in certain barriers, highlighting opportunities for public education and intervention.

Out-of-hospital cardiac arrest (OHCA) is associated with poor survival. Studies have demonstrated improved survival with early bystander cardiopulmonary resuscitation (BCPR). This study evaluated the impact of a dispatcher-assisted CPR (DA-CPR) program on BCPR rate and outcomes of OHCA in a developing emergency medical services (EMS) system setting.Data were extracted from the national cardiac arrest registry. A before-after analysis was performed between OHCA cases with cardiac etiology conveyed by EMS from April 2010-June 2012 (pre-intervention) and July 2012-December 2015 (post-intervention). Primary outcomes were survival-to-discharge/30 days post-arrest and favorable cerebral performance (Glasgow-Pittsburgh cerebral performance categories 1 and 2).6365 OHCA cases were analyzed with 2129 in the pre-intervention and 4236 in the post-intervention group. In the post-intervention group, there was an increase in BCPR rates from 24.8% to 53.8% (p 0.001), adjusted OR 3.67 (aOR; 95%CI: 3.26-4.13). OHCA outcomes also improved with survival-to-discharge rates increasing from 3.0%-4.5% (p 0.01), aOR 2.10 (95%CI: 1.40-3.17) and favorable cerebral performance increasing from 1.6% to 2.7% (p 0.05), aOR 2.82 (95%CI: 1.65-4.82). In patients with initial shockable rhythm, BCPR without dispatcher assistance was associated with significantly higher odds of survival-to-discharge (aOR 1.67, 95%CI: 1.06-2.64) and favorable cerebral performance (aOR 2.32, 95%CI: 1.26-4.27) compared to no BCPR.Our study showed that a simplified DA-CPR program can be successfully implemented in a developing EMS system and can contribute to higher BCPR rate and in turn, improve OHCA survival. Future studies can examine bystanders' characteristics and quality of the CPR performed to understand their impact on survival.

The Singapore myResponder is a novel smartphone application developed by the Singapore Civil Defence Force (SCDF) that notifies volunteer first responders of a suspected out-of-hospital cardiac arrest (OHCA) case and locations of Automated External Defibrillators (AED) in the vicinity so that they can assist with resuscitation. We aimed to examine the performance of this application, challenges encountered, and future directions.

Clinical performance audits are routinely performed in Emergency Medical Services (EMS) to ensure adherence to treatment protocols, to identify individual areas of weakness for remediation, and to discover systemic deficiencies to guide the development of the training syllabus. At present, these audits are performed by manual chart review, which is time-consuming and laborious. In this paper, we report a weakly-supervised machine learning approach to train a named entity recognition model that can be used for automatic EMS clinical audits. The dataset used in this study contained 58,898 unlabeled ambulance incidents encountered by the Singapore Civil Defence Force from 1st April 2019 to 30th June 2019. With only 5% labeled data, we successfully trained three different models to perform the NER task, achieving F1 scores of around 0.981 under entity type matching evaluation and around 0.976 under strict evaluation. The BiLSTM-CRF model was 1~2 orders of magnitude lighter and faster than our BERT-based models. Our proposed proof-of-concept approach may improve the efficiency of clinical audits and can also help with EMS database research. Further external validation of this approach is needed.

Aim Dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) can increase bystander CPR rates and improve outcomes in out-of-hospital cardiac arrest (OHCA). Despite the use of protocols, dispatchers may falsely recognise some cases to be in cardiac arrest. Hence, this study aimed to find the incidence of DA-CPR initiated for non-OHCA cases, its characteristics and clinical outcomes in the Singapore population. Methods This was a multi-centre, observational study of all dispatcher-recognised cardiac arrests cases between January to December 2017 involving three tertiary hospitals in Singapore. Data was obtained from the Pan-Asian Resuscitation Outcomes Study cohort. Audio review of dispatch calls from the national emergency ambulance service were conducted and information about patients’ clinical outcomes were prospectively collected from health records. Univariate analysis was performed to determine factors associated with in-hospital mortality among non-OHCA patients who received DA-CPR. Results Of the 821 patients recognised as having OHCA 328 (40.0%) were not in cardiac arrest and 173 (52.7%) of these received DA-CPR. No complications from chest compressions were found from hospital records. The top diagnoses of non-OHCA patients were cerebrovascular accidents (CVA), syncope and infection. Only final diagnoses of CVA (aOR 20.68), infection (aOR 17.34) and myocardial infarction (aOR 32.19) were significantly associated with in-hospital mortality. Conclusion In this study, chest compressions initiated on patients not in cardiac arrest by dispatchers did not result in any reported complications and was not associated with in-hospital mortality. This provides reassurance for the continued implementation of DA-CPR.

Despite numerous technological and medical advances, out-of-hospital cardiac arrests (OHCAs) still suffer from suboptimal survival rates and poor subsequent neurological and functional outcomes amongst survivors. Multiple studies have investigated the implementation of high-quality prehospital resuscitative efforts, and across these studies, different terms describing high-quality resuscitative efforts have been used, such as high-performance CPR (HP CPR), multi-tiered response (MTR) and minimally interrupted cardiac resuscitation (MICR). There is no universal definition for HP CPR, and dissimilar designs have been employed. This systematic review thus aimed to review current evidence on HP CPR implementation and examine the factors that may influence OHCA outcomes. Eight studies were systematically reviewed, and seven were included in the final meta-analysis. Random-effects meta-analysis found a significantly improved likelihood of prehospital return of spontaneous circulation (pooled odds ratio (OR) = 1.46, 95% CI: 1.16 to 1.82, p &lt, 0.001), survival-to-discharge (pooled OR = 1.32, 95% CI: 1.16 to 1.50, p &lt, 0.001) and favourable neurological outcomes (pooled OR = 1.24, 95% CI: 1.11 to 1.39, p &lt, 0.001) with HP CPR or similar interventions. However, the studies had generally high heterogeneity (I2 greater than 50%) and overall moderate-to-severe risk for bias. Moving forward, a randomised, controlled trial is necessary to shed light on the subject.

Introduction: Bystander cardiopulmonary resuscitation (B-CPR) is associated with improved out-ofhospital cardiac arrest survival. Community-level interventions including dispatcher-assisted CPR (DA-CPR) and myResponder were implemented to increase B-CPR. We sought to assess whether these interventions increased B-CPR. Methods: The Singapore out-of-hospital cardiac arrest registry captured cases that occurred between 2010 and 2017. Outcomes occurring in 3 time periods (Baseline, DA-CPR, and DA-CPR plus myResponder) were compared. Segmented regression of time-series data was conducted to investigate our intervention impact on the temporal changes in B-CPR. Results: A total of 13,829 out-of-hospital cardiac arrest cases were included from April 2010 to December 2017. Higher B-CPR rates (24.8% versus 50.8% vs 64.4%) were observed across the 3 time periods. B-CPR rates showed an increasing but plateauing trend. DA-CPR implementation was significantly associated with an increased B-CPR (level odds ratio [OR] 2.26, 95% confidence interval [CI] 1.79–2.88; trend OR 1.03, 95% CI 1.01–1.04), while no positive change was detected with myResponder (level OR 0.95, 95% CI 0.82–1.11; trend OR 0.99, 95% CI 0.98–1.00). Conclusion: B-CPR rates in Singapore have been increasing alongside the implementation of community-level interventions such as DA-CPR and myResponder. DA-CPR was associated with improved odds of receiving B-CPR over time while the impact of myResponder was less clear.

This study aimed to evaluate the impact of the Coronavirus Disease 2019 (COVID-19) pandemic on out-of-hospital cardiac arrest (OHCA) in Singapore. We used data from the Singapore Civil Defence Force to compare the incidence, characteristics and outcomes of all Emergency Medical Services (EMS)-attended adult OHCA during the pandemic (January–May 2020) and pre-pandemic (January–May 2018 and 2019) periods. Pre-hospital return of spontaneous circulation (ROSC) was the primary outcome. Binary logistic regression was used to calculate the adjusted odds ratios (aOR) for the characteristics of OHCA. Of the 3893 OHCA patients (median age 72 years, 63.7% males), 1400 occurred during the pandemic period and 2493 during the pre-pandemic period. Compared with the pre-pandemic period, OHCAs during the pandemic period more likely occurred at home (aOR: 1.48, 95% CI: 1.24–1.75) and were witnessed (aOR: 1.71, 95% CI: 1.49–1.97). They received less bystander CPR (aOR: 0.70, 95% CI: 0.61–0.81) despite 65% of witnessed arrests by a family member, and waited longer for EMS (OR ≥ 10 min: 1.71, 95% CI 1.46–2.00). Pre-hospital ROSC was less likely during the pandemic period (aOR: 0.67, 95% CI: 0.53–0.84). The pandemic saw increased OHCA incidence and worse outcomes in Singapore, likely indirect effects of COVID-19.

Background Western studies have highlighted alarmingly high rates of work-related violence experienced by emergency medical services (EMS) staff. As there is a paucity of Asian studies, we aimed to investigate the incidence of physical and verbal violence against the EMS crew in the Singapore Civil Defence Force (SCDF). Methods This was a cross-sectional study, utilising an online survey made available to all active paramedics in the SCDF. Paramedics with at least one year of work experience were eligible to participate. All responses were kept anonymous. Results The response rate was 50.9% (n = 246), out of 483 paramedics in service at the time of the study. The respondents consisted of 144 males (58.5%) and 102 females (41.5%). They were between 18 and 55 years old; 160 (65.0%) of them had worked in EMS for less than 6 years. The paramedics experienced high levels of verbal and physical violence, but there was reticence in reporting these incidents. The main risk factor for violence appeared to be alcohol intoxication. Conclusions Paramedics may benefit from security escort for clients with history of alcohol intoxication or violence and more teaching on self-defence and soft restraints. Current training and protocols should be revised to meet these needs.

OBJECTIVE: To understand the impact of COVID-19 restrictions on emergency medical services (EMSs) utilisation and out-of-hospital cardiac arrest outcomes in Singapore. METHODS: This was a retrospective observational study comparing data collected by the Singapore Civil Defence Force on EMS utilisation in Singapore from 1 April to 31 May 2020 to previous figures. RESULTS: Overall, EMS call volume and total out-of-hospital cardiac arrests remained comparable to past years. There was an appreciable decline in prehospital return of spontaneous circulation rates, albeit not statistically lower than pre-COVID periods (P = 0.078). CONCLUSION: The findings contribute to a growing body of literature internationally on the potential impact of the COVID-19 pandemic on EMS utilisation and outcomes.

Summary: Background: Bystander cardiopulmonary resuscitation (CPR) increases an individual's chance of survival from out-of-hospital cardiac arrest (OHCA), but the frequency of bystander CPR is low in many communities. We aimed to assess the cumulative effect of CPR-targeted public health interventions in Singapore, which were incrementally introduced between 2012 and 2016. Methods: We did a secondary analysis of a prospective cohort study of adult, non-traumatic OHCAs, through the Singapore registry. National interventions introduced during this time included emergency services interventions, as well as dispatch-assisted CPR (introduced on July 1, 2012), a training programme for CPR and automated external defibrillators (April 1, 2014), and a first responder mobile application (myResponder; April 17, 2015). Using multilevel mixed-effects logistic regression, we modelled the likelihood of receiving bystander CPR with the increasing number of interventions, accounting for year as a random effect. Findings: The Singapore registry contained 11 465 OHCA events between Jan 1, 2011, and Dec 31, 2016. Paediatric arrests, arrests witnessed by emergency medical services, and healthcare-facility arrests were excluded, and 6788 events were analysed. Bystander CPR was administered in 3248 (48%) of 6788 events. Compared with no intervention, likelihood of bystander CPR was not significantly altered by the addition of emergency medical services interventions (odds ratio [OR] 1·33 [95% CI 0·98–1·79]; p=0·065), but increased with implementation of dispatch-assisted CPR (3·72 [2·84–4·88]; p

Out-of-hospital cardiac arrests (OHCAs) occurring in high-rise buildings are a challenge to Emergency Medical Services (EMS). Contemporary EMS guidelines lack specific recommendations for systems and practitioners regarding the approach to these patients. This scoping review aimed to map the body of literature pertaining to OHCAs in high-rise settings in order to clarify concepts and understanding and to identify knowledge gaps. Databases were searched from inception through to 6 May 2021 including OVID Medline, PubMed, Embase, CINAHL, and Scopus. Twenty-three articles were reviewed, comprising 8 manikin trials, 14 observational studies, and 1 mathematical modelling study. High-rise settings commonly have lower availability of bystanders and automatic external defibrillators (AEDs), while height constraints often lead to delays in EMS interventions and suboptimal cardiopulmonary resuscitation (CPR), scene access, and extrication. Four studies found return of spontaneous circulation (ROSC) rates to be significantly poorer, while seven studies found rates of survival-to-hospital discharge (n = 3) and neurologically favourable survival (n = 4) to be significantly lower in multistorey settings. Mechanical chest compression devices, transfer sheets, and strategic defibrillator placement were suggested as approaches to high-rise OHCA management. A shift to maximising on-scene treatment time, along with bundling novel prehospital interventions, could ameliorate some of these difficulties and improve clinical outcomes for patients.

Background Worldwide, call-taker recognition of out-of-hospital cardiac arrests (CA) suffers from poor accuracy, leading to missed opportunities for dispatcher-assisted cardiopulmonary resuscitation (DACPR) in CA patients and inappropriate DACPR in non-CA patients. Diagnostic protocols typically ask 2 questions in sequence: ‘Is the patient conscious?’ and ‘Is the patient breathing normally?’ As part of quality improvement efforts, our national emergency medical call centre changed the breathing question to an instruction for callers to place their hand onto the patient's abdomen to evaluate for the presence of breathing. Methods We performed a prospective before-and-after study of all unconscious cases from the national call centre database over a 31-day period in 2018. Cases were placed in 2 groups: 1) ‘Before’ group (standard protocol) where call-takers asked ‘Is the patient breathing normally?’ and 2) ‘After’ group (modified protocol) where callers were instructed to place their hand on the patient’s abdomen. In an intention-to-treat analysis, the accuracy, sensitivity and specificity of both protocols for determining CA were compared. Results 1557 calls presented with unconsciousness, of which 513 cases were included. 231 cases were in the ‘Before’ group and 282 cases were in the ‘After’ group. The ‘After’ showed superior accuracy (84.4% vs 67.5%), sensitivity (75.0% vs 40.4%) and specificity (87.9% vs 75.4%) when compared to the standard protocol. Adherence in the ‘Before’ group to the standard protocol was 100%. However, adherence in the ‘After’ group to the modified protocol was 50.4%. Per protocol analysis comparing the modified protocol with the standard protocol showed vastly improved accuracy (96.5% vs 69.3%), sensitivity (94.1% vs 39.0%) and specificity (97.8% vs 77.2%) of the modified protocol. In patients with true cardiac arrest, the median time to 1st compression was 32.5 s longer in the modified protocol group when compared to the standard protocol group, approaching significance (199.5 s vs 167.0 s, p = 0.059). Median time to recognize CA was similar in both groups. Conclusion Dispatch assessment using the hand on abdomen method appeared feasible but uptake by dispatch staff was moderate. Diagnostic performance of this method should be verified in randomised trials.

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 P P 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.

Although clinical audit is generally accepted to be an essential part of quality review and continuous quality improvement, there are limited reports on and several barriers to the implementation of effective clinical audit in an emergency medicine services (EMS) organization. The barriers include the significant amount of time, resources, and effort often required to conduct the audit. In this paper, we present a technology-enabled clinical audit tool, termed Medical Service Transformation and Innovation Compass (MYSTIC), which has transformed the way the clinical audit is performed in our EMS department. MYSTIC is a Python program we developed in-house, that extracts data from data fields found in routine ambulance case records maintained by our paramedics, and automatically assigns “pass” or “fail” flags based on pre-defined audit criteria. Compared to previous manual auditing, implementation of the MYSTIC computerized audit system increased the coverage of cases undergoing audit from 10% to 100% of all EMS-attended cases, and we were able to promptly identify and address some deficits in training and knowledge amongst our paramedics.

This study examines the impact of a newly developed structured training on Singapore paramedics&rsquo, psychological comfort before the implementation of a prehospital termination of resuscitation (TOR) protocol. Following a before and after study design, the paramedics underwent a self-administered questionnaire to assess their psychological comfort level applying the TOR protocol, 22 months before and one month after a 3-h structured training session. The questionnaire addressed five domains: sociocultural attitudes on resuscitation and TOR, multi-tasking, feelings towards resuscitation and TOR, interactions with colleagues and bystanders and informing survivors. Overall psychological comfort total (PCT) scores and domain-specific scores were compared using the paired t-test with higher scores representing greater comfort. Ninety-six of the 345 eligible paramedics responded. There was no statistically significant change in the mean PCT scores at baseline and post-training, however, the &ldquo, feelings towards resuscitation and TOR&rdquo, domain improved by 4.77% (95% CI 1.42 to 8.13 and p = 0.006) and the multi-tasking domain worsened by 4.11% (95% CI &minus, 7.82 to &minus, 0.41 and p = 0.030). While the structured training did not impact on the overall psychological comfort levels, it led to improvements in the feelings of paramedics towards resuscitation and TOR. Challenges remain in improving paramedics&rsquo, psychological comfort levels towards TOR.