National Strategy for Improving Outcomes for Sudden Cardiac Arrest in Singapore
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National Strategy for Improving Outcomes for Sudden Cardiac Arrest in Singapore



A/Prof Marcus Ong

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 National Strategy for Improving Outcomes for Sudden Cardiac Arrest in Singapore Presentation Transcript

  • 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.
  • 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
  • Characteristics of Cardiac Arrest Patients Data from the Cardiac Arrest and Resuscitation Epidemiology in Singapore, 2001-2002
  • CARE Study
    • Sudden Out-of-Hospital Cardiac Arrest Incidence Rate (Cardiac origin)
    • 798 per year
    • (2001/2002)
    • (2005/6 estimates >1000/year
  • CARE Study
    • Overall End-points
    • 17.9% Return of spontaneous circulation
    • 8.5% Survived to admission
    • 2.0% Survived to Discharge
  • Multi-Level Efforts Resuscitation Centers of Excellence • 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 First Responder EMS Hospital Survival
  • The Take Heart Approach
  • Treatment Impact on Outcomes 5 – 10% Rapid cooling, coronary vessel clearing and implanted defibrillators in the hospital 4 – 6% Circulation enhancement by EMS and hospital personnel 4 – 6% Improved quality CPR by EMS 4 – 6% Rapid AED use 2 – 5% Bystander CPR Expected Survival Improvement Intervention Resuscitation Strategies and Their Impacts
  • Chain of Survival Courtesy of Life Support Training Centre, Singapore General Hospital
  • Early Access
    • CARE 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)
  • Early Access CARE Study: EMS Response Time Time (Mins) Patient collapsed 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
  • DISCUSSION National 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’
    • EMS response time greatly affects survival rates
    • 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
  • DISCUSSION Number of Ambulances/population
    • 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
    • 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
  • PADS I Study
  • PADS I Study Number of cardiac arrest cases by hour
  • IMPROVED RESPONSE TIMES WITH MOTORCYCLE BASED FAST RESPONSE PARAMEDICS IN AN URBAN SETTINGS Ong Marcus, MBBS, FRCS Ed (A&E) Registrar, Department of Emergency Medicine, Singapore General Hospital Chan YH, Phd Head Biostatistics, Clinical Trials and Epidemiology Research Unit, Ministry of Health A/P V Anatharaman, MBBS, MRCP, FRCS Ed (A&E), FAMS Senior Consultant and Head, Department of Emergency Medicine, SGH Clinical Associate Professor, Faculty of Medicine, NUS introduction aims/objectives methods results conclusions 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.
  • Early Cardio-Pulmonary Resuscitation (CPR) CARE Study: Bystander CPR
  • Early CPR Lateef et al 2001 SGH ASM
  • Quality of CPR: Pocket QCPR feedback device for use with manual CPR (CPREZY)
  • Defibrillator pads incorporating an accelerometer for QCPR feedback (Zoll E series defibrillation pads)
  • Defibrillator screen display incorporating QCPR feedback indicators (Zoll E series)
    • 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
    • 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
  • 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
  • 85.77 12,436 70.35 (19.41) 32 27 Ghim Moh 30.82 90,864 64.52 (18.57) 84 12 Clementi 32.31 60,870 57.15 (20.11) 59 54 Sengkang 31.77 31,481 62.88 (21.88) 30 32 Towner 63.34 19,999 52.71 (24.31) 38 47 Bedok (Bedok Reservoir) 81.47 11,047 63.32 (14.55) 27 05 South Bridge Road / Kreta Ayer 108.10 8,017 61.37 (16.72) 26 21 Jalan Besar 163.24 11,639 64.43 (22.41) 57 15 Alexandra (Bukit Merah/Redhill) Arrest Rate per year over 3 years (per 100,000 population) Esitmated Population base (2000 census) Mean Age of arrests(SD) N Postal code Area
  • Early Defibrillation Breakdown of Location of Cardiac Arrest Cases
  • 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)
  • 1995: First Five Years of Pre-Hospital Automatic Defibrillation Project in Singapore
    • 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
    • EMS
    • Aim to decrease time to 1 st shock to 90%< 8mins or lower
    • Equipping training and utilising Fire or Police first responders with AEDs
  • 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
    • EMS
    • Invest in research/adoption of promising cardiac arrest interventions : Impedence Threshold Devices, Mechanical CPR, LMA, Intraosseous vascular access
    • Prehospital 12 lead ECG transmission for STEMI
  • Dr Marcus Ong MBBS (Singapore), FRCS Ed (A&E), MPH, FAMS Consultant, Director of Research and Senior Medical Scientist Department of Emergency Medicine Singapore General Hospital
    • 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.
    • Emergency Department/ Hospital
    • Post-resuscitation hypothermia
    • 24/7 provision of PCI for STEMI
    • ICD adoption
  • “ “ 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 5259 Fax: (65) 6 475 2077 Email: admin@
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  • See You in Singapore!