OBJECTIVES:The relationship between the bystander witness type and receipt of bystander CPR (BCPR) is not well understood. Herein we compared BCPR administration between family and non-family witnessed out-of-hospital cardiac arrest (OHCA). BACKGROUND:In many communities, interventions in the past decade have contributed to an increased receipt of BCPR, for example in Singapore from 15% to 60%. However, BCPR rates have plateaued despite sustained and ongoing community-based interventions, which may be related to gaps in education or training for various witness types. The purpose of this study was to investigate the association between witness type and BCPR administration. METHODS:Singapore data from 2010-2020 was extracted from the Pan-Asian Resuscitation Outcomes Study (PAROS) network registry (n = 25,024). All adult, layperson witnessed, non-traumatic OHCAs were included in this study. RESULTS:Of 10,016 eligible OHCA cases, 6,895 were family witnessed and 3,121 were non-family witnessed. After adjustment for potential confounders, BCPR administration was less likely for non-family witnessed OHCA (OR 0.83, 95% CI 0.75, 0.93). After location stratification, non-family witnessed OHCAs were less likely to receive BCPR in residential settings (OR 0.75, 95% CI 0.66, 0.85). In non-residential settings, there was no statistically significant association between witness type and BCPR administration (OR 1.11, 95% CI 0.88, 1.39). Details regarding witness type and bystander CPR were limited. CONCLUSION:This study found differences in BCPR administration between family and non-family witnessed OHCA cases. Elucidation of witness characteristics may be useful to determine populations that would benefit most from CPR education and training.

Introduction: Female sex is associated with lower receipt of bystander cardiopulmonary resuscitation (BCPR) in public. Telephone-assisted CPR (TCPR) may attenuate this known sex difference. It is unknown whether the introduction of community-wide, bystander-focused interventions may reduce this known sex difference and improve outcomes for females. Objectives: We sought to assess whether implementation of bystander-focused, out-of-hospital cardiac arrest (OHCA) interventions attenuated the sex difference seen in receipt of BCPR. We hypothesized that implementation of bystander-focused interventions would reduce the known difference observed in males compared to females in receipt of BCPR in public. Methods: We conducted a retrospective study of adult, non-traumatic OHCAs from the Singapore OHCA registry (1/2011-12/2020). Bystander-focused interventions included TCPR (7/2012 - present), CPR/AED training (04/2014 - present), and myResponder (4/2015 - present). We examined the differences between males vs females in receipt of BCPR in public using descriptive statistics, a sex-intervention interaction term, and hierarchical regression modeling. Results: The registry contained 19,321 events (2011-2020). Excluding pediatric, traumatic, EMS witnessed, and healthcare facility arrests, 18,925 events were analyzed. Of these, mean age was 68±16 and 64% were male. BCPR was administered in 56% of the events, with 61% of males and 54% of females receiving BCPR in public (p-value <0.01). Females had a 29% decreased odds of receiving BCPR compared to males in public (OR: 0.72 (95% CI: 0.58-0.90), p-value <0.01). With inclusion of implementation of bystander-focused interventions as an interaction term with sex, the difference in receipt of BCPR between males and females was no longer observed (p-value: ns). The sex-intervention interaction term was statistically significant (p-value<0.01). No sex differences were observed when modelling survival as an outcome. Conclusion: The introduction of community-wide, bystander-focused interventions may lessen differences seen in receipt of BCPR by males and females in public. Further research on OHCA interventions is needed to increase provision of BCPR and consider addressing this disparity.

Background Training and motivating more laypeople to respond to out-of-hospital cardiac arrest (OHCA) is associated with improved OHCA survival rates. This study involved measuring the change in knowledge, attitudes and practice after a 60-minute CPR-AED training. Method We administered pre-/post-training surveys to 337 participants who underwent CPR/AED training. McNemar’s and paired t-tests were used to analyse responses. Compression performance was measured during 2 compression performance rounds on the same day. Results Favourable shift in knowledge was observed in post-training survey (p<0.001) as follows: ‘First thing to do…’ (pre 48.2% vs post 90.9%, p<0.0001); ‘Correct number to dial…’ (pre 88.4% vs post 99.7%, p<0.0001); ‘…after getting dispatcher on the phone…’ (pre 65.5% vs post 96.0%, p<0.0001); ‘…how deep to compress’ (pre 47.0% vs post 96.4%, p<0.0001); ‘…how fast to compress’ (pre 14.7% vs post 56.1%, p<0.0001). Attitudes improved towards CPR and AED use where 71.5% and 72.5% said ‘I don’t know/unlikely/very unlikely’ to perform CPR and use AED at pre-training then improved to 79.5% and 82.2% would ‘likely/very likely’ afterwards. In CPR practice, average optimal CPR compression depth improved from 70% to 74.9% (t(336)=-3.74, p<0.001); however, compressions at >120 per minute increased from 22.5% to 31.1% (t(336)=-5.72, p<0.001). Conclusion We observed favourable shifts in knowledge, attitudes and practice for CPR-AED use amongst our participants that were likely due to undergoing the brief CPR/AED training. The increased average rate observed in the second round of compressions could be an effect of fatiguing. Conflict of interest None. Funding Ministry of Health, Singapore.

Objective: Reduced rates of bystander cardiopulmonary resuscitation (BCPR) in out-of-hospital cardiac arrest (OHCA) were observed during the Coronavirus Disease-2019 (COVID-19) pandemic in many regions. We investigated the impact of COVID-19 on barriers to Dispatcher-Assisted Cardiopulmonary Resuscitation (DA-CPR) in Singapore. Methods: This nationwide retrospective cohort study involved all calls to our national 995 call center for adult (≥ 18 years old) OHCA not witnessed by Emergency Medical Services. We reviewed audio recordings during the pandemic (January-June 2020) and pre-pandemic (January-June 2019) periods to compare the OHCA characteristics, and the types of “barriers” to DA-CPR — the reason why DA-CPR was not performed. Our primary outcome was the presence/absence of barriers to DA-CPR. Multivariable logistics regression was used to estimate the adjusted odds ratio (aOR) for the likelihood of barriers to DA-CPR accounting for patient and event characteristics. The effect of COVID-19 on DA-CPR rates was evaluated using interrupted time series analysis. Results: There were 1481 OHCA during the pandemic (median age 73 years, 62.7% male), and 1400 prior to the pandemic (median age 72 years, 63.6% male). Residential OHCA and witnessed OHCA increased during the pandemic (78.9% vs 75.5%, p=0.03 and 56.1% vs 39.9%, p<0.01 respectively), but not BCPR and DA-CPR (64.3% vs 65.6%, p=0.44, and 49.1% vs 48.1%, p=0.57 respectively). There were increased barriers to DA-CPR during the pandemic — ‘patient status changed’ (difficulty with recognition) and ‘caller not with patient’ (witnesses calling family rather than 995) doubled in proportion during COVID-19. ‘afraid to do CPR’ fell to 3.8% during the pandemic, while the fear of COVID-19 transmission made up 0.5% of the barriers. Logistic regression showed that females and OHCAs occurring in home residences were more likely to have barriers to DA-CPR (aOR 1.27 and 2.63 respectively). COVID-19 did not have an impact on the trend of DA-CPR rates (p=0.49). Conclusion: COVID-19 did not affect callers’ willingness to perform DA-CPR. Distancing measures led to more residential arrests with an increase in proportion with barriers to DA-CPR, highlighting opportunities for public education and intervention.

INTRODUCTION:Hospital-based resuscitation interventions, such as therapeutic temperature management (TTM), emergency percutaneous coronary intervention (PCI) and extracorporeal membrane oxygenation (ECMO) can improve outcomes in out-of-hospital cardiac arrest (OHCA). We investigated post-resuscitation interventions and hospital characteristics on OHCA outcomes across public hospitals in Singapore over a 9-year period. METHODS:This was a prospective cohort study of all OHCA cases that presented to 6 hospitals in Singapore from 2010 to 2018. Data were extracted from the Pan-Asian Resuscitation Outcomes Study Clinical Research Network (PAROS CRN) registry. We excluded patients younger than 18 years or were dead on arrival at the emergency department. The outcomes were 30-day survival post-arrest, survival to admission, and neurological outcome. RESULTS:The study analysed 17,735 cases. There was an increasing rate of provision of TTM, emergency PCI and ECMO (P<0.001) in hospitals, and a positive trend of survival outcomes (P<0.001). Relative to hospital F, hospitals B and C had lower provision rates of TTM (≤5.2%). ECMO rate was consistently <1% in all hospitals except hospital F. Hospitals A, B, C, E had <6.5% rates of provision of emergency PCI. Relative to hospital F, OHCA cases from hospitals A, B and C had lower odds of 30-day survival (adjusted odds ratio [aOR]<1; P<0.05 for hospitals A-C) and lower odds of good neurological outcomes (aOR<1; P<0.05 for hospitals A-C). OHCA cases from academic hospitals had higher odds ratio (OR) of 30-day survival (OR 1.3, 95% CI 1.1-1.5) than cases from hospitals without an academic status. CONCLUSION:Post-resuscitation interventions for OHCA increased across all hospitals in Singapore from 2010 to 2018, correlating with survival rates. The academic status of hospitals was associated with improved survival.

Background The automated external defibrillator (AED) can restore normal heart rhythm in cardiac arrest victims. Early defibrillation correlates with increased rate of out-of-hospital cardiac arrest (OHCA) survival. However, AED availability remains a challenge. We aimed to measure key time intervals and observe impact of mobilizing the taxi’s AEDs on pre-hospital return of spontaneous circulation (ROSC). Method One-hundred and twenty taxi drivers were CPR and AED trained. They were then assigned to taxis equipped with AEDs, and thereafter alerted to OHCA cases via phone app. A retrospective analysis of this intervention was conducted. Results From November 2015 to December 2017, 4088 phone alerts were sent out to taxis, 374 accepted the cases, and 127 arrived at scene. Of those who arrived on scene, 18 walked 198.6 metres on average, while 104 drove an average of 891.8 metres; 5 are missing data. Average time for drivers to accept a case when activated was 1 minute, 4 seconds (fastest=0, slowest=13 minutes); from activation to arrival at scene was 6 minutes, 22 seconds (fastest=1, slowest=31 minutes), and from acceptance to arrival at scene was 5 minutes, 19 seconds (fastest=0, slowest=30 minutes). Only two cases resulted in pre-hospital ROSC. Conclusion Our data shows that taxis with AEDs arrived on scene within 7 minutes on average, which is faster than the average for EMS ambulances. Taxis can get AEDs on scene before an ambulance arrives, however further exploration into reason(s) and solutions for low response is needed. Conflict of interest None. Funding Singapore Heart Foundation and Temasek Cares.

Background Quality cardiopulmonary resuscitation (CPR) correlates to out-of-hospital cardiac arrest (OHCA) survival. A real-time feedback device can guide rescuers towards delivering quality CPR. This study reports results of CPR quality during practice and during emergency use. Method Rescuers in 17 OHCA cases used the CPRcard, a real-time feedback device, that they received/used during their CPR training. Corresponding weighted average of CPR quality measures (rate and depth) during training sessions were computed for comparison. Optimal CPR rate and depth in Singapore are 100–120cpm and 40–60mm, respectively. Paired t-tests were used for analysis. Results There was no difference in average compression rate between practice (109.69) and emergency use (110.94; p=0.72). There was a significant difference in average compression depth (practice 48.20mm vs emergency 41.42mm; t(16)=2.24, p<0.05). During emergency use, the majority depth was in the <40mm range (practice 10.88% vs emergency 43.25%; t(15)=-3.47, p<0.01). Majority depth during practice was in the optimal range of 40–60mm (practice 83.69% vs emergency 49.13%; t(15)=4.21, p<0.01). Majority rate during practice was in the optimal range of 100–120 (practice 94.69% vs emergency 64.82%; t(16)=3.64, p<0.01). Majority rate during emergency use was above the optimal range (practice 4.0% vs emergency 23.76%; t(16)=-2.66, p<0.05). Conclusion The CPRcard helped guide CPR performance considering that on average rate and depth were kept within standard. Nonetheless, CPR quality during emergencies slightly worsened vs. training. Fatigue induced leaning was possible as emergency CPR duration was longer (average time for practice 136.18 seconds vs emergency 351.06 seconds; t(16)=-3.07, p<0.01). Conflict of interest None. Funding Ministry of Health, Singapore.

Care for patients who experience out-of-hospital cardiac arrest (OHCA) has rapidly evolved in the past decade. Increased sophistication of care in the community, emergency medical services (EMS) and hospital setting is associated with improved patient-centred outcomes. Notably, Utstein survival doubled from 11.6% to 23.1% between 2011 and 2016. These achievements involved collaboration between policymakers, clinicians and researchers, and were made possible by a strategic interplay of policy, research and implementation. We review the development and current state of OHCA in Singapore using primary population-based data from the Pan-Asian Resuscitation Outcomes Study and an unstructured search of research databases. We discuss the roles of important milestones in policy, community, dispatch, EMS and hospital interventions. Finally, we relate these interventions to relevant processes and outcomes, such as the relationship between the strategic implementation of bystander cardiopulmonary resuscitation and placement of automated external defibrillator with return of spontaneous circulation, survival to discharge and survival with favourable neurological outcomes.

Introduction: Bystander cardiopulmonary resuscitation (B-CPR) may increase a victim’s chance of survival from sudden cardiac arrest (SCA), but B-CPR rates are low in many communities. Few studies have examined the association of city-wide public health interventions on B-CPR. Objectives: We sought to assess whether there is variation in B-CPR by intervention and location of arrest. We hypothesized that implementation of dispatch-assisted CPR (DA-CPR), CPR/AED training, and a first responder mobile application (myResponder) would increase B-CPR by two-fold. Methods: We conducted a retrospective study of adult, non-traumatic SCAs from the Singapore registry (4/2010-12/2016). Interventions included DA-CPR (7/2012 - present), CPR/AED training (04/2014 - present), and myResponder (4/2015 - present). Using logistic regression, we modeled the likelihood of receiving B-CPR by increased number of interventions over time. We examined these effects together, in the home, and public accounting for patient-level confounding. Results: From 2010-2016, the Singapore registry contained 12,546 SCA events. Excluding pediatric, EMS witnessed, and healthcare facility arrests, 7,476 were analyzed. Of these, mean age was 66±15 and 68% were male. B-CPR was administered in 45% of the events and varied by location (home: 43% v public: 52%). With implementation of DA-CPR, likelihood of B-CPR increased (OR: 3.5 (2.9-4.2) p<0.01) compared to no intervention; with implementation of CPR/AED training, likelihood of B-CPR increased compared to no intervention (OR: 5.8 (4.8-7.0), p<0.01). Lastly, implementation of myResponder resulted in a 7.09 increased likelihood of B-CPR compared to no intervention (OR: 7.1 (5.9-8.4), p<0.01). Variation was seen when examining likelihood of B-CPR by all interventions compared to no intervention, in the home (OR: 8.7 (7.0-10.7)) and the public (OR: 4.0 (2.9-5.6)). Survival increased, corresponding to the increase in B-CPR. Conclusion: City-level public health interventions increased the likelihood of layperson B-CPR, while variation was seen in the home and public. Understanding the impact of public health interventions may shed light on strategies to increase B-CPR and inform targeted initiatives to improve survival from SCA.

Objectives: This study aims to describe frequent users of Emergency Medical Services (EMS) conveyed to a Singapore tertiary hospital, focusing on a comparison between younger users (age <65) and older users in diagnoses and admission rates. Methods: All patients conveyed by EMS to a tertiary hospital 4 times or more over a 1-year period in 2015 had their EMS ambulance charts and Emergency Department (ED) electronic records retrospectively analyzed (n = 243), with admission the primary outcome. Results: The 243 frequent users were analyzed with a combined total of 1,705 visits, out of a total of 10,183 patients with 12,839 visits conveyed by EMS to Singapore General Hospital (SGH) in 2015. Younger frequent users (<65 years age) were found to be predominantly male (79.6%, p = 0.001) and were on average responsible for more visits than elderly frequent users (8.6 vs. 5.7, p = 0.004). Medical co-morbidities were significantly more prevalent in older users. Younger frequent users were more likely to be smokers (60.2% vs. 22.3%), heavy drinkers (51.3% vs. 8.5%), substance abusers (12.4% vs. 0.8%), and bad debtors (49.6% vs. 20.0%, p < 0.001). A larger proportion presented with altered mental states (11.7% vs. 5.4%, p < 0.001) and alcohol related diagnoses (34.7% vs. 5.3%, p < 0.001). Many were picked up from public areas (45.5% vs. 19.6%, p < 0.001), and had lower acuity triage scores at both EMS (p < 0.001) and ED (p = 0.001). They had lower admission rates (40.5% vs. 78.7%, p < 0.001) and shorter length of stay (4.3 vs. 5.9 days, p < 0.001). Univariable and multivariable analysis showed alcohol related diagnoses, history of alcohol abuse and lower triage scores were less likely to require admissions. Conclusion: Frequent EMS users consume a disproportionate amount of healthcare resources. Two broad subgroups of patients were identified: younger patients with social issues and older patients with multiple medical conditions. EMS usage by older patients was significantly associated with higher rates of admission

INTRODUCTION Victims of out-of-hospital cardiac arrests require timely cardiopulmonary resuscitation (CPR) and early defibrillation. Callers to emergency medical services are asked to provide dispatcher-guided responses until an ambulance arrives. Knowing what to expect in such circumstances should reduce both delay and confusion. METHODS This study was conducted among schoolchildren aged 11-17 years using ten-item pre- and post-training surveys. We aimed to observe any knowledge and attitude shifts regarding CPR and automated external defibrillator (AED) use subsequent to the training. RESULTS A total of 1,196 students across five schools completed the pre- and post-training surveys. Survey questions tested basic CPR knowledge and attitudes towards CPR and AED use. The overall response rate was 80.8% and 81.5% in the pre- and post-training surveys, respectively. There was a statistically significant improvement in the students' CPR knowledge. The number of students who selected all the correct answers for the knowledge-based questions in the post-training survey increased by 64.7% (95% confidence interval 61.9%-67.5%; p < 0.001). There was also an improvement in their willingness to administer CPR (likely/very likely to administer CPR pre-training vs. post-training: 13.0% vs. 71.0%; p < 0.001) and use AED (likely/very likely to administer AED pre-training vs. post-training: 11.7% vs. 78.0%; p < 0.001) after training. CONCLUSION The training programme imparted new information and skills, and improved attitudes towards providing CPR and using AED. However, some concerns persisted about hurting the victim while performing CPR.

Aim Data on the quality of lay person CPR during emergencies are sparse. We present compression quality data derived from use of a novel CPR feedback device during actual cases prior to ambulance arrival. Method The credit-card sized CPRcardTM device provided visual indication of compression depth and rate in real-time, and stored the data. Median rate, depth; proportion within targets (100–120/minute; depth:4–6 cm); and flow-time were used to determined compression quality. Bystanders' emergency performances were compared to their training performances. Results Median depth during emergencies vs trainings was 39 mm (95% CI: 30 to 49 mm, p=0.028) vs 55 mm (95% CI: 50 to 57 mm, p=0.028); and median rates were 114 cpm (95% CI: 109 to 120 cpm, p=0.104) vs 109 cpm (95% CI: 105 to 112 cpm, p=0.104). Of total emergency vs training delivered compressions, 6% (95% CI: 0% to 49%, p=0.008) vs 63% (95% CI: 56 to 90%, p=0.008) were within target depth; 54% (95% CI: 32% to 79%, p=0.028) vs 94% (95% CI: 81 to 97%, p=0.028) were within target rate. Of the lay bystanders' during emergencies vs trainings, 4 (50%, p=0.398) vs 5 (71%, p=0.398) met both compression and depth targets. Emergency vs training compression flow-time was 95% (95% CI: 85% to 99%, p=0.099) vs 100% (95% CI: 96 to 100%, p=0.099), respectively. Lay bystanders overall reported positive experience using the card but some expressed reluctance to compress deeply for fear of harming the victims. Conclusion Training compressions were better quality. The results show the quality of chest compressions delivered by lay bystanders in actual cases, and highlights depth as an area of concern that could improve with training enhancement. Conflict of interest None Funding Ministry of Health grant

INTRODUCTION:There is a need for a simple-to-use and easy-to-carry CPR feedback device for laypersons. We aimed to determine if a novel CPRcard™ feedback device improved the quality of chest compressions. METHODS:We compared participants' chest compression rate and depth with and without feedback. Compression data was captured through the CPRcard™ or Resusci Anne's SimPad® SkillReporter™. Compression quality was defined based on 2010 international guidelines for rate, depth and flow fraction. RESULTS:Overall, the CPRcard group achieved a better median compression rate (CPRcard 117 vs. control 122, p = 0.001) and proportion of compressions within the adequate rate range (CPRcard 83% vs. control 47%, p < 0.001). Compared to the no-card and blinded-card groups, the CPRcard group had a higher proportion of adequate compression rate (CPRcard 88% vs. no-card 46.8%, p = 0.037; CPRcard 73% vs. blinded-card 43%, p = 0.003). Proportion of compressions with adequate depth was similar in all groups (CPRcard 52% vs. control 48%, p = 0.957). The CPRcard group more often met targets for compression rate of 100-120/min and depth of at least 5 cm (CPRcard 36% vs. control 4%, p = 0.022). Chest compression flow fraction rate was similar but not statistically significant in all groups (92%, p = 1.0). Respondents using the CPRcard expressed higher confidence (mean 2.7 ± 2.4; 1 = very confident, 10 = not confident). CONCLUSION:Use of the CPRcard by non-healthcare workers in simulated resuscitation improved the quality of chest compressions, thus boosting user confidence in performing compressions.

Mass Cardio-Pulmonary Resuscitation (CPR) training using less expensive and easily portable manikins is one way to increase the number of trained laypeople in a short time. The easy-to-carry, low-cost CPR training model called Push Heart (PH) is widely used in Japan. The aim of this study was to examine if PH can achieve chest compression quality that is similar to that using more conventional Little Anne (LA) manikins for training laypersons.

BackgroundWe aimed to see if a novel credit card size cardiopulmonary resuscitation (CPR) feedback device helped to improve the quality of chest compressions by lay participants compared to compressions done without feedback. Materials and methodsThis study had non-healthcare workers aged 25 -70 years old randomized into either a real-time feedback group that got the CPRcard, which provided real-time feedback for both chest compression rate and depth, or the no feedback group.Participants in the control group (no feedback) either used a blinded CPRcard or performed compressions without a CPRcard. ResultsParticipants in the CPRcard group achieved a better median compression rate (CPRcard: 117 vs control: 122, p-value = 0.001) and higher proportion of compressions within the adequate range of 100 to 120 per minute (CPR Card: 83% vs control: 47%, p-value < 0.001).CPRcard group had a higher percentage of adequate compressions (CPRcard: 88% vs. no card: 46.8%, p-value = 0.037; CPRcard: 73% vs blinded card: 43%, p-value = 0.003).The participants in the CPRcard group more often performed better quality CPR, defined as simultaneously meeting targets for both compression rate of 100 to 120 and depth of at least 5cm (CPRcard: 36% vs control: 4%, p-value = 0.022). ConclusionsUse of the CPRcard by non-healthcare workers improved the quality of CPR chest compressions.