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Background The rate of survival after out‐of‐hospital cardiac arrest varies depending on the timeliness and effectiveness of prehospital interventions. This study was conducted to compare out‐of‐hospital cardiac arrest outcomes between intravenous and intraosseous routes and between upper and lower extremity routes for drug administration. Methods and Results We retrospectively analyzed data (collected using the Utstein template) from 1220 patients who had experienced out‐of‐hospital cardiac arrest in Taiwan's Taoyuan City between January 2021 and August 2023. The patients were stratified into intravenous and intraosseous groups by treatment approach and upper and lower extremity access groups by access site. The study outcomes were survival to discharge, favorable neurologic outcomes (Cerebral Performance Category score 1 or 2), and survival for >2 hours. The study groups were statistically compared before and after propensity score matching. Significant pre–propensity score matching differences were observed between intravenous and intraosseous groups, and the aforementioned study outcomes were better in the intravenous group than in the intraosseous group. However, the between‐group differences became nonsignificant after propensity score matching. Furthermore, lower extremity access and delayed epinephrine administration were associated with worse outcomes. Survival rates fell below 12.6% when time to treatment exceeded 15 minutes, particularly in the cases of intraosseous access and lower extremity access. Conclusions This study highlights the benefits of early intervention and upper extremity access for drug administration in patients with out‐of‐hospital cardiac arrest. Intraosseous access may serve as a viable alternative to intravenous access. Timely administration of essential drugs during resuscitation can improve clinical outcomes and thus has implications for emergency medical service training.

Background Survival following an out‐of‐hospital cardiac arrest depends on prompt defibrillation. Despite the efforts made to install automated external defibrillators (AEDs) in crowded areas, their usage rate remains suboptimal. This study evaluated the efficiency of installing AEDs at key landmarks in Taoyuan City to enhance accessibility and usage. METHODS AND RESULTS This retrospective cohort study analyzed nontraumatic public out‐of‐hospital cardiac arrest cases in Taoyuan City from 2017 to 2021, using data from the Taoyuan Fire Department and a regional registry. AED data were collected for 1163 devices. A geographic information system mapped target locations within the city, and real‐world walking routes were examined to assess coverage. The primary outcome was actual coverage and the coverage efficiency ratio, calculated as the actual coverage divided by the number of facilities at a location. The coverage efficiency ratio compared the coverage efficiency of target locations with existing public access defibrillators (PADs). Top locations for superior coverage in both downtown and outside downtown areas were bus stops and convenience stores (7‐Eleven and FamilyMart), which outperformed existing PADs. Convenience stores had a higher coverage efficiency ratio than the public service sector. Bus stops showed high AED usage rates before ambulance arrival. Conclusions The current PAD locations in Taoyuan City offer limited coverage, which highlights the need for strategically installed AEDs, particularly in convenience stores. Policymakers should consider using the cultural relevance and accessibility of convenience stores, particularly 7‐Eleven branches, to enhance AED usage rates.

BackgroundGenerally, cardiopulmonary resuscitation (CPR) skills decline substantially over time. By combining web-based self-regulated learning with hands-on practice, blended training can be a time- and resource-efficient approach enabling individuals to acquire or refresh CPR skills at their convenience. However, few studies have evaluated the effectiveness of blended CPR refresher training compared with that of the traditional method. ObjectiveThis study investigated and compared the effectiveness of traditional and blended CPR training through 6-month and 12-month refresher sessions with CPR ability indicators. MethodsThis study recruited participants aged ≥18 years from the Automated External Defibrillator Donation Project. The participants were divided into 4 groups based on the format of the CPR training and refresher training received: (1) initial traditional training (a 30-minute instructor-led, hands-on session) and 6-month traditional refresher training (Traditional6 group), (2) initial traditional training and 6-month blended refresher training (an 18-minute e-learning module; Mixed6 group), (3) initial traditional training and 12-month blended refresher training (Mixed12 group), and (4) initial blended training and 6-month blended refresher training (Blended6 group). CPR knowledge and performance were evaluated immediately after initial training. For each group, following initial training but before refresher training, a learning effectiveness assessment was conducted at 12 and 24 months. CPR knowledge was assessed using a written test with 15 multiple-choice questions, and CPR performance was assessed through an examiner-rated skill test and objectively through manikin feedback. A generalized estimating equation model was used to analyze changes in CPR ability indicators. ResultsThis study recruited 1163 participants (mean age 41.82, SD 11.6 years; n=725, 62.3% female), with 332 (28.5%), 270 (23.2%), 258 (22.2%), and 303 (26.1%) participants in the Mixed6, Traditional6, Mixed12, and Blended6 groups, respectively. No significant between-group difference was observed in knowledge acquisition after initial training (P=.23). All groups met the criteria for high-quality CPR skills (ie, average compression depth: 5-6 cm; average compression rate: 100-120 beats/min; chest recoil rate: >80%); however, a higher proportion (98/303, 32.3%) of participants receiving blended training initially demonstrated high-quality CPR skills. At 12 and 24 months, CPR skills had declined in all the groups, but the decline was significantly higher in the Mixed12 group, whereas the differences were not significant between the other groups. This finding indicates that frequent retraining can maintain high-quality CPR skills and that blended refresher training is as effective as traditional refresher training. ConclusionsOur findings indicate that 6-month refresher training sessions for CPR are more effective for maintaining high-quality CPR skills, and that as refreshers, self-learning e-modules are as effective as instructor-led sessions. Although the blended learning approach is cost and resource effective, factors such as participant demographics, training environment, and level of engagement must be considered to maximize the potential of this approach. Trial RegistrationIGOGO NCT05659108; https://www.cgmh-igogo.tw

Background Public access defibrillation (PAD) programs have been implemented globally over the past decade. Although PAD can substantially increase the survival of cardiac arrest, PAD use remains low. This study aimed to evaluate whether drawing upon the successful experiences of dispatcher‐assisted cardiopulmonary resuscitation programs would increase the use of PAD in dispatcher‐assisted PAD programs. Methods and Results This study using a before‐and‐after design was conducted in Taoyuan City using a local out‐of‐hospital cardiac arrest registry system and data of dispatcher performance derived from audio recordings. The primary outcomes were the rate of bystander PAD use, sustained return of spontaneous circulation, survival to discharge, and favorable neurological outcomes. The secondary outcomes were the performance of dispatchers in terms of PAD instruction and dispatcher‐assisted cardiopulmonary resuscitation administration, the time interval indicators of dispatcher‐assisted cardiopulmonary resuscitation. A total of 1159 patients were included and divided into 2 groups: the before‐run‐in group (502 patients) and the after‐run‐in group (657 patients). No significant difference was observed between the 2 groups in terms of baseline characteristics. The rate of PAD use in the after‐run‐in group significantly increased from 5.0% to 8.7% (P=0.015). The rate of favorable neurological outcomes increased from 4.4% to 5.9%, which was not a statistically significant difference. Compared with the before‐run‐in group, the rate of successful automated external defibrillator acquisition was 13.5% in the after‐run‐in group (P

Background. Out-of-hospital cardiac arrest (OHCA) remains a big issue of critical care. It is well known that bystander cardiopulmonary resuscitation (CPR) with an automated external defibrillator (AED) used did improve the survival rate. Therefore, CPR education including basic life support (BLS) and AED has been advocated for years. It showed significant improvement of knowledge and willingness to perform CPR through adolescents after the course. However, little is known regarding the ability and learning effectiveness of school students who attend such courses. Therefore, this study aimed to evaluate the CPR effectiveness of both adolescents (12 years old) and adults who undergo the same course of BLS and AED. Methods. This is a retrospective study. Sixth-grade elementary school students in Northern Taiwan were selected to compare with the adult group. Both took 90 minutes of the BLS and AED course by the doctor with BLS instructor qualification. The primary outcomes were CPR quality and passing or failing the skill examination parameters. The secondary outcome was the posttraining written test and questionnaire of CPR willingness. Results. In the written test, there was a statistical difference in the pretest score except AED knowledge, but no difference was revealed in the posttest score. No statistical difference in CPR quality was noted. In the skill examination, only checking breathing status had statistical difference (elementary group (71%) vs. adult group (86%) (p=0.003)). Conclusion. We revealed that sixth-grade elementary students’ performance in CPR and AED was similar to that of adults after completing the current 90-minute course. Therefore, we strongly advocate offering CPR and AED courses to 12-year-old children, and these courses should emphasize checking the victim’s breathing status.

Background Should all out‐of‐hospital cardiac arrest (OHCA) patients be directly transported to cardiac arrest centers (CACs) remains under debate. Our study evaluated the impacts of different transport time and destination hospital on the outcomes of OHCA patients. Methods and Results Data were collected from 6655 OHCA patients recorded in the regional prospective OHCA registry database of Taoyuan City, Taiwan, between January 2012 and December 2016. Patients were matched on propensity score, which left 5156 patients, 2578 each in the CAC and non‐CAC groups. Transport time was dichotomized into

Background: Emergency department (ED) overcrowding and overuse are global healthcare problems. Despite that substantial pieces of literature have explored quality parameters to monitor the patients' safety and quality of care in the ED, to the best of our knowledge, no reasonable patient-to-ED staff ratios were established. Objectives: This study aimed to find the association between unexpected emergency department cardiac arrest (EDCA) and the patient-to-ED staff ratio. Methods: A retrospective cohort study was conducted in a medical center in Taiwan. Non-trauma patients (age > 18) who visited the ED from January 1, 2016 to November 30, 2018 were included. The total number of patients in ED, number of patients waiting for boarding, length of stay over 48 hours, and physician/nurse number in ED were collected and analyzed. The primary outcome was the association of each parameter with the incidence of EDCA. Results: A total of 508 patients were included. The total number of patients in ED (> 361, RR: 1.54; 95% CI {1.239-1.917}), ED occupancy rate (> 280, RR: 1.54; 95% CI {1.245-1.898}), ED bed occupancy rate (> 184, RR: 1.63; 95% CI {1.308-2.034}), number of patients waiting for boarding (> 134, RR: 1.45; 95% CI {1.164-1.805}), number of patients in ED with length of stay over 48 hours (> 36, RR: 1.27; 95% CI {1.029-1.558}) and patient-to-nurse ratio (> 8.5, adjusted RR: 1.33; 95% CI {1.054-1.672}) had significant associations with higher incidence of EDCA. However, the patient-to-physician ratio was not associated with EDCA incidence. Discussions: Regarding loading parameters, the patient-to-nurse ratio is more representative than the patient-to-physician ratio as regards association with higher EDCA incidence. Conclusions: A higher patient-to-nurse ratio (> 8.5) was associated with an increment in the incidence of EDCA. Our findings provide a basis for setting different thresholds for different ED settings to adjust ED staff and develop individually tailored approaches corresponding to the level of ED overcrowding. [ABSTRACT FROM AUTHOR]

Objective: This study determined the impact of the caller's emotional state and cooperation on out-of-hospital cardiac arrest (OHCA) recognition and dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) performance metrics.Methods: This was a retrospective study using data from November 2015 to October 2016 from the emergency medical service dispatching centre in northern Taiwan. Audio recordings of callers contacting the centre regarding adult patients with non-traumatic OHCA were reviewed. The reviewers assigned an emotional content and cooperation score (ECCS) to the callers. ECCS 1-3 callers were graded as cooperative and ECCS 4-5 callers as uncooperative and highly emotional. The relation between ECCS and OHCA recognition, time to key events and DA-CPR delivery were investigated.Results: Of the 367 cases, 336 (91.6%) callers were assigned ECCS 1-3 with a good inter-rater reliability (k=0.63). Dispatchers recognised OHCA in 251 (68.4%) cases. Compared with callers with ECCS 1, callers with ECCS 2 and 3 were more likely to give unambiguous responses about the patient's breathing status (adjusted OR (AOR)=2.6, 95% CI 1.1 to 6.4), leading to a significantly higher rate of OHCA recognition (AOR=2.3, 95% CI 1.1 to 5.0). Thirty-one callers were rated uncooperative (ECCS 4-5) but had shorter median times to OHCA recognition and chest compression (29 and 122 s, respectively) compared with the cooperative caller group (38 and 170 s, respectively). Nevertheless, those with ECCS 4-5 had a significantly lower DA-CPR delivery rate (54.2% vs 85.9%) due to 'caller refused' or 'overly distraught' factors.Conclusions: The caller's high emotional state is not a barrier to OHCA recognition by dispatchers but may prevent delivery of DA-CPR instruction. However, DA-CPR instruction followed by first chest compression is possible despite the caller's emotional state if dispatchers are able to skilfully reassure the emotional callers. [ABSTRACT FROM AUTHOR]

Objective: There is lack of scientific evidence regarding the effectiveness of prehospital triage systems. This study compared the two-level Taiwan Prehospital Triage System (TPTS) with the five-level Taiwan Triage and Acuity Scale (TTAS) at ED arrival regarding the prediction of patient outcomes and the utilisation of medical resources.Design: This was a retrospective cohort study. Adult patients transported via the emergency medical service (EMS), who arrived at the ED of a medical centre in northern Taiwan during the study period were enrolled. TTAS acuity levels 1-2 were considered comparable to the designation of 'emergent' by the prehospital TPTS system. The outcomes were analysed by comparing TPTS and TTAS by acuity levels.Results: Among 4430 enrolled patients, 25.2% and 74.8% were classified as emergent and non-emergent by TPTS; 44.1% and 55.9% were classified as levels 1-2 and levels 3-5 by TTAS. Of the TPTS emergent patients, 15.2% were classified as TTAS levels 3-5, whereas 30.4% of TPTS non-emergent transports were classified as TTAS levels 1-2 at the ED. TTAS levels 1-2 showed better predictability than TPTS emergent level for hospitalisation rate with a sensitivity of 70.3% (95% CI 68.3% to 72.2%) versus 41.1% (95% CI 39.0% to 43.2%), and a negative predictive value of 74.8% (95% CI 73.4% to 76.0%) versus 62.6% (95% CI 61.7% to 63.5%).Conclusion: The current prehospital triage system is insufficient and inappropriate in classifying patients transported to the ED. The present study offers supporting evidence for the introduction of a five-level triage system to prehospital EMS systems. [ABSTRACT FROM AUTHOR]

A 73-year-old woman presented to the emergency department with shortness of breath accompanied by a mild productive cough for 2 days. She had a history of end-stage renal disease, congestive heart failure, and hypertension. The initial diagnosis was early-onset health care-associated pneumonia and fluid overload. Therefore, a 750 mg levofloxacin was initiated intravenously (IV), and hemodialysis was arranged for the following day. Eight hours after admission to the emergency department, sudden-onset altered mental status and apnea occurred with an electrocardiogram showing polymorphic ventricular tachycardia, and torsade de pointes was obvious. The patient regained spontaneous circulation after cardioversion and was then admitted to the intensive care unit. This case reminds us of the potentially lethal adverse effects of IV levofloxacin. Patients who present with long QT should be evaluated for the risk of drug-induced torsade de pointes, including reviewing medical and drug history and a routine check of heart rate-corrected QT interval on electrocardiogram prior to prescribing IV levofloxacin. [ABSTRACT FROM AUTHOR]

Inter-facility transfer of patients with type A aortic dissection (AD) requires timely and efficient medical care. However, the quality of care provided during the transfer remains largely unknown. This study aimed to evaluate the quality of care of patients with type A AD who underwent inter-facility transfer at a single medical center in Taiwan. This retrospective cohort study enrolled all patients with type A AD who underwent interfacility transfer between January 2017 and December 2019. Patients with complete transfer records and electronic medical charts in the emergency department (ED) were included. Patients who experienced a cardiac arrest episode before transfer were excluded due to poor outcomes. Patients were divided into two groups based on their hemodynamic status: the ideal group with values within the desirable range heart rate (HR) <60 bpm and systolic blood pressure (SBP): 100-120 mmHg and the control group with values out of range (HR >60 bpm or SBP <100 or >120 mmHg) before the transfer. We conducted an analysis of variations of hemodynamic status after the transfer. Among the 378 patients transferred with type A AD, 36 (31.9%) in the ideal group and 255 (96.2%) in the control group experienced hemodynamic deterioration after the transfer. In the ideal group and control group, the presence of nurses and emergency physicians assisting in the transfer accounted for only 6.2% and 7.95%, respectively. The ideal group had a significantly better survival outcome (adjusted OR (aOR): 1.25, 95% confidence interval (CI): 1.12-2.45) compared to the control group. The quality of interfacility transfer in patients with type A AD is inadequate. Hemodynamic deterioration should be managed by ambulance crews during the transfer. [ABSTRACT FROM AUTHOR]

Cardiac arrest in the emergency department is associated with the following three scenarios: out-of-hospital cardiac arrest, primary emergency department cardiac arrest (EDCA), and patients transferred from other hospitals after the return of spontaneous circulation from cardiac arrest. Among them, the primary cardiac arrest episode in the emergency department has been less studied. This aim of this study was to explore patient characteristics and the relationship between causes of EDCA and survival outcomes according to different patient management strategies. The main finding of this study was that EDCA with Cardiogenic etiology was associated with higher survival to discharge (OR: 2.31; 95% CI: 1.59-3.91) and discharged neurological outcome (OR: 2.84; 95% CI: 1.57-5.97). More favorable discharged neurological outcome were also found in EDCA patients with initial shockable rhythm (OR: 4.83; 95% CI: 2.33-10.01) and shorter resuscitation time (≤11.5 min, OR: 3.62; 95% CI: 1.57-8.32). EDCA patients under sedative medication (OR: 0.24; 95% CI: 0.10-0.59) and ventilator support by intubation before EDCA episode (OR: 0.26; 95% CI: 0.09-0.75) had poor neurological outcome. We conclude that EDCA patients with cardiogenic etiology have more favorable survival to discharge and discharged neurological outcomes. Prolonged CPR time during EDCA, post-intubation status and sedative medication use were prognostic factors of negative survival and neurological outcomes. [ABSTRACT FROM AUTHOR]

Emergency department (ED) crowdedness is a global phenomenon that can lead to many adverse effects. The relationship of crowdedness and emergency department cardiac arrest (EDCA) occurrence is still debated. The COVID-19 pandemic precipitated a change in the patient volume of the ED and the crowdedness of the ED varied with the epidemic in a continuous period. Different degrees of crowdedness provided us with an opportunity to study the relationship between crowdedness and EDCA occurrence. Our aim of this study was to determine the relationship between EDCA occurrence and prognosis and ED crowdedness.This was a longitudinal study conducted in a tertiary teaching hospital. The study period was from October 1, 2019, to September 30, 2020, and was divided into three periods according to daily patient volume and crowdedness. All nontraumatic and adult EDCA patients during the study period were included, and out-of-hospital cardiac arrest (OHCA) patients and patients with do-not-resuscitate orders were excluded.During the study period, a total of 126 EDCA patients were included. The ratio of EDCA events to daily patient volume was compared among these 3 periods, and there was no significant difference (P2: p = 0.109, P3: p = 0.761, P1 as reference). No significant difference in the prognosis of EDCA patients was found among the 3 periods, regardless of the return of spontaneous circulation (ROSC) (p = 0.437) or survival rates (p = 0.838). In conclusion, there was no obvious correlation between ED crowdedness and EDCA occurrence. The prognosis of EDCA patients was not significantly associated with crowdedness. The metrics of ED overcrowding is unknown and may need further study to develop a generally accepted standard or index. [ABSTRACT FROM AUTHOR]

Background: This study aimed to evaluate whether out-of-hospital cardiac arrest (OHCA) patients with initial shockable rhythm without prehospital return of spontaneous circulation (ROSC) who are directly transported to Heart Centers in appropriate time will have better post-cardiac arrest four months survival and neurological outcomes at discharge. Methods: This retrospective study assessed the data of 1,588 OHCA patients with shockable rhythm and without prehospital ROSC collected from the registry database of Taoyuan City between January 2014 and June 2018. The relationships of transport time to Heart Centers with survival at discharge and with neurological outcomes were investigated for survival analysis. Results: Among the 1,588 OHCA patients with initial shockable rhythm and without prehospital ROSC, 1,222 (77.0%) and 366 (23.0%) were transported to Heart Centers and non-Heart Centers, respectively. However, the transport to Heart Centers was associated with an increased survival at discharge (adjusted odds ratio [aOR] 2.00, 95% confidence interval [CI], 1.42-2.81) and good neurological outcomes (cerebral performance category [CPC] 1 and 2) (aOR 3.14, 95% CI, 1.88-5.23), regardless of the transport time. The overall mortality reduction for Heart Centers was 39% (hazard ratio [HR] = 0.61; 95% CI 0.47-0.78), compared to that for non-Heart Centers. At 120 days of follow-up, the results showed a higher survival rate for patients who were transported to Heart Centers within a short time. The percentages of good CPC showed a better distribution for non-Heart Centers versus those for Heart Centers. Conclusions: Adult OHCA patients with initial shockable rhythm and without prehospital ROSC who were transported to Heart Centers directly had better post-cardiac arrest survival and good neurologic outcomes, regardless of the transport time. [ABSTRACT FROM AUTHOR]