Bystander CPR (bCPR) is known to improve survival from out-of-hospital cardiac arrest (OHCA). Data on the impact of quality of bCPR is limited and dated. The NSW Ambulance OHCA registry captures data on the quality of CPR provided by bystanders prior to EMS arrival. We sought to determine the impact of bCPR quality on 30-day survival in our region. METHODS:A population-based registry study was performed on cases occurring between 2021 and 2024. Bystander CPR was included in multivariate models as a dichotomous variable or stratified by bCPR quality, and compared with no bCPR. RESULTS:In all, 17,715 patients were included in the study. Bystander CPR was performed in 59.4% of cases and bCPR quality was recorded in 62.1%. Performance of bCPR was associated with a 70% increase in the odds of achieving 30-day survival (aOR = 1.70, 95% CI: 1.24-2.34). Good-quality bCPR was associated with a greater increase in the odds of survival (aOR = 2.62, 95% CI: 1.86-3.68) while poor-quality bCPR was not associated with 30-day survival (aOR = 0.99, 95% CI: 0.68-1.45). Younger age, witnessed arrest and non-residential location were associated with increased odds of bCPR being performed and being of good quality. Male sex and EMS response time less than 10 min were associated with lower odds of bCPR being performed but were not associated with quality of bCPR. CONCLUSION:Quality of bCPR is of greater importance than the fact that bCPR was performed. EMS systems and policy-makers should consider measures that support providers of bCPR to deliver effective compressions.

OBJECTIVE:Although guidelines recommend angiography and coronary intervention occur within 24 h of thrombolysis when percutaneous coronary intervention (PCI) is not available within 120 min, this target is difficult to achieve in rural and remote areas of New South Wales (NSW), Australia. METHODS:In this is secondary analysis we examine the impact of extending the existing 90-min road transport limit for patients in rural and remote areas of western NSW who have received initial treatment for ST-elevation myocardial infarction. RESULTS:The patient cohort consisted of 86 patients who were transported by road ambulance with transport times more than 90 min. Adverse events occurred in 20% of patient transports and rates were similar in patients transported directly from the scene or from a community hospital. The most common adverse events were hypotension and bradycardia. There was one cardiac arrest, four minor bleeding events and no major bleeding events. The main treatments provided were morphine analgesia, nitrates and anti-emetic medications. CONCLUSIONS:The primary study showed a significant reduction in time from first clinical contact to arrival at the PCI hospital. In this secondary analysis, we demonstrate that the rate of adverse events during long-distance road transport is low, the adverse events are mostly minor in nature and are within the scope of paramedic practice to manage.

BACKGROUND:Regionalised systems of care can improve outcomes for patients suffering ST-elevation myocardial infarction (STEMI). Most reports evaluate primary percutaneous intervention programs in metropolitan centres. We report the outcomes of a prehospital thrombolysis program in rural New South Wales (NSW) with particular focus on the impact of paramedic-delivered thrombolysis on total ischaemic time (TIT). METHOD:Prospective registry study of patients from rural and regional NSW who were diagnosed with STEMI while in the care of NSW Ambulance paramedics. RESULTS:Between 2008 and 2020, paramedics treated 2,710 patients diagnosed with STEMI while in their care, and 1,674 (61.9%) received thrombolysis in the field. TIT for patients treated in the field was shorter (94; interquartile range [IQR] 69-141 minutes) compared to the estimated time for those treated after arrival at hospital (172; IQR 124-250 minutes; p<0.0001). Multivariate analysis identified prehospital thrombolysis as the strongest predictor of reduced TIT. CONCLUSIONS:This program has delivered substantial reductions in TIT for STEMI patients in regional and rural NSW. Similar programs should be considered wherever a significant proportion of the population does not have timely access to percutaneous coronary intervention.

BACKGROUND:Rural vs metropolitan ST-elevation myocardial infarction (STEMI) patients experience delayed access to percutaneous coronary intervention (PCI). Existing New South Wales (NSW) Statewide Cardiac Reperfusion Strategy protocols provide thrombolysis and ambulance diversion for patients within 90 minutes of a PCI centre in regional and rural NSW. Rural patients presenting to non-PCI hospitals and those more than 90 minutes from PCI are not routinely, urgently, diverted under existing protocols. METHOD:Western NSW Local Health District, covering 250,000 km2 and a population of 278,759, implemented a centralised management system (CMS) in 2019, in partnership with NSW Ambulance, utilising existing STEMI thrombolysis protocols and extending "drip and ship" protocols for "hot transfer" of all patients to the 24/7 PCI centre, by direct ambulance diversion up to 120 minutes by road, or via multi-stage transfer by road or air, or via interhospital transfer. Data for 2 years post-CMS was compared to historical controls. Time from first clinical contact (FCC) to reperfusion, FCC to PCI centre, major adverse clinical events and percentage of patients undergoing angiography within 24 hours were compared in "medium" (90-120 minutes) and "long" (>120 minutes) transfer zones, not covered by existing protocols. RESULTS:Outcomes were recorded for 274 patients before and 348 after CMS implementation (17% medium and 31% long transfer zones). Medium and long transfer zones had greater proportions of smokers and Indigenous patients than short transfer zones. There was significantly lower ambulance utilisation in the long (38%) compared with the short transfer zone (55%, p<0.001). In the long transfer zone, there were significant improvements in FCC to reperfusion (40 vs 48 minutes, p<0.05), FCC to PCI centre (296 vs 344 minutes, p<0.01), and angiography in 24 hours (77% vs 58%, p<0.01), with no significant differences in major adverse clinical events. CONCLUSIONS:A rural STEMI CMS, with "hot transfer", can deliver patients from a vast geographical area directly to a rural PCI centre. Patients furthest away, with the greatest risk profile, benefit the most. Extension of this program and development of 24/7 PCI in NSW rural cardiac hubs stands to improve timely, definitive treatment, including access to angiography within 24 hours.

Aim This study aims to assess the impact of the COVID-19 pandemic on out-of-hospital cardiac arrest (OHCA) incidence, bystander cardiopulmonary resuscitation (CPR), EMS resuscitation attempts and survival across Australia and New Zealand. Method Data were extracted for all OHCAs patients attended by emergency medical services (EMS) between 2017 and 2021 from the Aus-ROC OHCA Epistry (Epidemiological registry). Logistic regression was used to explore differences between the pre-COVID-19 (January 1, 2017 to March 15, 2020) and COVID-19 (March 16, 2020 to December 31, 2021) periods for bystander CPR, EMS-attempted resuscitation, survival to hospital arrival (event survival) and survival to hospital discharge/30 days. Results The incidence of OHCA increased during COVID-19 in Australia and New Zealand, although this varied regionally. When compared to the pre-COVID-19 period, COVID-19 was associated with a significant increase in the odds of an EMS-attempted resuscitation in Queensland (adjusted odds ratio (aOR)=1.19; 95%CI: 1.01-1.40, p=0.03) and Western Australia (aOR=1.26; 95%CI: 1.03-1.54, p=0.02). The COVID-19 period was associated with a decrease in survival to hospital arrival in Australia overall (aOR=0.91; 95% CI:0.83-0.99, p=0.04), and by region in Victoria (aOR=0.74; 95% CI:0.63-0.87, p<0.01) and Tasmania (aOR=0.48; 95% CI:0.25-0.91, p=0.02), and with a decrease in survival to hospital discharge/30 days in Australia (aOR=0.82; 95% CI:0.70-0.96, p=0.01), and by region in Victoria (aOR=0.70; 95% CI:0.54-0.91, p<0.01) and South Australia (aOR=0.61; 95% CI:0.37-0.99, p=0.04). There were no significant changes in survival during COVID-19 in New Zealand. Conclusion Regional variations were observed with respect to the associations of COVID-19 with resuscitation attempts and OHCA survival.

[This corrects the article DOI: 10.1371/journal.pone.0301176.].

BACKGROUND:At a global level, regional variation in the management of ST-elevation myocardial infarction (STEMI) is influenced by patient demographics and geography. Rural patients with STEMI are disadvantaged in reaching timely care owing to distance and limited ambulance and healthcare resources. Optimising models of STEMI care is key to overcoming the excess rural vs metropolitan cardiovascular morbidity and mortality. In this descriptive study, we compare patient characteristics and STEMI management in three Local Health Districts (LHDs) across NSW: a rural LHD (Western NSW [WNSWLHD]), a regional LHD (Hunter New England), and a metropolitan site (Sydney LHD). METHOD:Data were collected from file audits conducted from 2019 to 2020 in a rural LHD with a single rural 24/7 cardiac catheter laboratory (WNSWLHD), a regional LHD with a part-time rural cardiac catheter laboratory, and a large regional 24/7 cardiac centre (Hunter New England LHD), and a metropolitan site (Sydney LHD), with two 24/7 cardiac centres. Patients with STEMI presenting in the three geographic regions were compared on demographics, differences in presentation, time to reperfusion treatment, time to percutaneous coronary intervention (PCI) centre, distances travelled, proportion of angiograms within 24 hours, and in-hospital mortality. RESULTS:During 2020, there were 675 recorded STEMI across the three regions. The rural site in WNSWLHD had the highest rate of STEMI per capita, with patients more likely to identify as Indigenous, less likely to call an ambulance, and more likely to present to a non-PCI hospital and to receive thrombolysis. Only 14% of these rural patients received primary PCI (PPCI), with patients presenting a median of 153 km from the PCI centre, vs 69% PPCI in the regional and 89% in metropolitan LHD. Thrombolysis was the main reperfusion treatment in WNSWLHD (76%), and the proportion of patients receiving no treatment was the same in all LHDs at 10%. The percentage of patients receiving angiography within 24 hours in the rural site was 84%. There was no substantial difference in in-hospital mortality among the three LHDs. CONCLUSIONS:We document large differences in the demographic profiles, use of ambulance, and access to PPCI in patients with STEMI across the three NSW centres. Current NSW health and ambulance protocols in a large, sparsely populated rural NSW LHD were able to deliver thrombolysis at the point of contact and facilitate "hot" transfer of patients with STEMI to a PCI centre. Long distances and transfer times mean that PPCI is a limited option in rural NSW, with scope for further improvement in models of care.

Background: Prehospital identification of STEMI reduces time to reperfusion by timely primary PCI or fibrinolytic therapy. We previously reported that 40-50% of prehospital ECG transmissions meeting Glasgow algorithm (GA) criteria for STEMI did not meet STEMI criteria on adjudication using the 4th Universal Definition of MI (4UDMI). These cases, herewith called ‘masquerading STEMI’, had high rates of late clinical complications. Here, we determined clinical factors predictive of late clinical outcomes among patients with masquerading STEMI. Methods: From June 2010 to October 2021, 2,992 patients with prehospital ECG transmissions to Liverpool Hospital, Sydney, Australia, who met GA criteria for STEMI were identified. These were adjudicated according to the 4UDMI as confirmed STEMI or masquerading STEMI. Using multivariate logistic regression, we identified baseline patient characteristics that were associated with the outcome of cardiovascular death, MI and stroke at 2 years, among the masquerading STEMI cohort. Results: 1553 (51%) patients were true-positive STEMI, while 1439 (49%) were masquerading STEMI. In the masquerading STEMI cohort, age, current smoking, and CKD (eGFR<60) were significant predictors of the 2-year cardiovascular death, MI stroke with OR of 1.05, 2.07, and 3.58, respectively (p<0.05 for all). Diabetes predicted MI re-presentation within 2 years (OR 3.76, p<0.05), and CKD predicted heart failure hospitalisation (OR 2.55, p<0.05). Conclusions: Among patients with masquerading STEMI, current smoking and CKD were associated with the 2-year cardiovascular death, MI stroke. Diabetes predicted a higher risk of re-presenting with MI within 2 years, and CKD predicted a higher risk of hospitalisation with heart failure. Therefore, in this cohort of patients with masquerading STEMI, despite not having a true STEMI, smoking cessation and opportunistic management of diabetes and CKD may modify prognosis.

Introduction The aim of this study was to develop a risk adjustment strategy, including effect modifiers, for benchmarking emergency medical service (EMS) performance for out-of-hospital cardiac arrest (OHCA) in Australia and New Zealand. Method Using 2017-2019 data from the Australasian Resuscitation Outcomes Consortium (Aus-ROC) OHCA Epistry, we included adults who received an EMS attempted resuscitation for a presumed medical OHCA. Logistic regression was applied to develop risk adjustment models for event survival (return of spontaneous circulation at hospital handover) and survival to hospital discharge/30 days. We examined potential effect modifiers, and assessed model discrimination and validity. Results Both OHCA survival outcome models included EMS agency and the Utstein variables (age, sex, location of arrest, witnessed arrest, initial rhythm, bystander cardiopulmonary resuscitation, defibrillation prior to EMS arrival, and EMS response time). The model for event survival had good discrimination according to the concordance statistic (0.77) and explained 28% of the variation in survival. The corresponding figures for survival to hospital discharge/30 days were 0.87 and 49%. The addition of effect modifiers did little to improve the performance of either model. Conclusion The development of risk adjustment models with good discrimination is an important step in benchmarking EMS performance for OHCA. The Utstein variables are important in risk-adjustment, but only explain a small proportion of the variation in survival. Further research is required to understand what factors contribute to the variation in survival between EMS.

Abstract Background The COVID-19 pandemic has seen a significant reduction in reported ACS cases, raising concerns of avoidance behaviour contributing to increased OHCA incidence; exploring this phenomenon can help identify potential mediating factors for these changes and better understand its impact on cardiovascular health. Purpose Australia's successful COVID-19 lockdown provides a unique opportunity to study whether it affected the incidence of ACS and OHCAs, shedding light on the impact of pandemic-related behavioural modifications on cardiovascular health. Method Using data from the NSW Government database for ACS and NSW Ambulance dispatch data for OHCA, along with climate, traffic, and air quality data, we estimated the excess number of cases using an interrupted time-series analysis that adjusted for seasonal variations, day of the week and temperature. As a sensitivity analysis, we also conducted a two-stage time series analysis for the excess OHCA. Results During COVID-19’s first lockdown period (15th March to 1st July 2020), there were reductions in both ACS (-1259 [95% CI -1530, -989]) and OHCA (-69[-235, -92]) (Fig1). In this period there was a clear changes in anthropogenic activities with reductions in traffic (5670±1380 in 2020 versus 9150±1220 in 2018 and 8640±2370 in 2019) and flights (207±169 versus 884±152 and 902±103).These reductions were accompanied with improvement in PM2.5 (5.1±2.1μg/m3 versus 9.0±3.2 in 2018 and 8.2±3.2 in 2019), PM10 (13.3±5.4μg/m3 versus 20.9±8.6 and 17.7±6.0), and NO2 (7.4±2.7 ppb versus 8.4±3.3 and 9.0±2.8) (Fig2). Conclusion During the first COVID-19 lockdown in NSW, there was a significant reduction in the number of ACS cases without any associated excess in OHCA. This may be caused, at least partly, by the improved air quality from the behavioural changes.Excess ACS (STEMI & NSTEMI) and OHCAChanges in Traffic and Flights Activitie

Rural versus metropolitan ST elevation infarction (STEMI) patients experience delays to care [1]. Existing NSW protocols only divert patients within 90 minutes to percutaneous coronary intervention (PCI) sites. In 2019, Western NSW Local Health District (WNSWLHD) and NSW Ambulance (NSWA) extended this range by implementing a fully centralised management system (CMS), with immediate hot transfer, for all STEMI patients to a PCI centre, covering a vast area of 250,000 km2.

Rural, versus metropolitan, Australians have higher cardiovascular mortality, driven by risk profile differences and reduced timely access to care for ST elevation myocardial infarction (STEMI) [1,2]. In 2019, a centralised management system (CMS), with routine, immediate hot transfer of STEMI patients to a PCI centre, was implemented in Western NSW Local Health District (WNSWLHD).

Access to timely care for ST elevation myocardial infarction (STEMI) is poorer in rural versus metropolitan NSW [1,2]. To mitigate this disadvantage, Western NSW Local Health District (WNSWLHD) and NSW Ambulance (NSWA) established a centralised management system (CMS) for routine "hot" transfer of all STEMI patients to a percutaneous coronary intervention (PCI) centre in Orange (OHS) in 2019.

Female STEMI patients are known to present later and have poorer outcomes compared to males. This study aimed to characterise male and female patients presenting early (≤60 minutes) and later after symptom onset.

Many studies report longer prehospital delay in female patients suffering from STEMI compared to male patients. We examined trends in prehospital delay over 12 years of a rural prehospital thrombolysis program.

Administration of prehospital thrombolysis (PHT) by paramedics has been shown to be safe. In NSW, Australia, paramedics have been delivering PHT in the field since 2008.

Background Patients with suspected ST-segment-elevation myocardial infarction (STEMI) and cardiac catheterization laboratory nonactivation (CCL-NA) or cancellation have reportedly similar crude and higher adjusted risks of death compared with those with CCL activation, though reasons for these poor outcomes are not clear. We determined late clinical outcomes among patients with prehospital ECG STEMI criteria who had CCL-NA compared with those who had CCL activation. Methods and Results We identified consecutive prehospital ECG transmissions between June 2, 2010 to October 6, 2016. Diagnoses according to the Fourth Universal Definition of myocardial infarction (MI), particularly rates of myocardial injury, were adjudicated. The primary outcome was all-cause death. Secondary outcomes included cardiovascular death/MI/stroke and noncardiovascular death. To explore competing risks, cause-specific hazard ratios (HRs) were obtained. Among 1033 included ECG transmissions, there were 569 (55%) CCL activations and 464 (45%) CCL-NAs (1.8% were inappropriate CCL-NAs). In the CCL activation group, adjudicated index diagnoses included MI (n=534, 94%, of which 99.6% were STEMI and 0.4% non-STEMI), acute myocardial injury (n=15, 2.6%), and chronic myocardial injury (n=6, 1.1%). In the CCL-NA group, diagnoses included MI (n=173, 37%, of which 61% were non-STEMI and 39% STEMI), chronic myocardial injury (n=107, 23%), and acute myocardial injury (n=47, 10%). At 2 years, the risk of all-cause death was higher in patients who had CCL-NA compared with CCL activation (23% versus 7.9%, adjusted risk ratio, 1.58, 95% CI, 1.24-2.00), primarily because of an excess in noncardiovascular deaths (adjusted HR, 3.56, 95% CI, 2.07-6.13). There was no significant difference in the adjusted risk for cardiovascular death/MI/stroke between the 2 groups (HR, 1.23, 95% CI, 0.87-1.73). Conclusions CCL-NA was not primarily attributable to missed STEMI, but attributable to "masquerading" with high rates of non-STEMI and myocardial injury. These patients had worse late outcomes than patients who had CCL activation, mainly because of higher rates of noncardiovascular deaths.

OBJECTIVES:We examined the appropriateness of prehospital cardiac catheter laboratory activation (CCL-A) in ST-segment elevation myocardial infarction (STEMI) utilizing the University of Glasgow algorithm (UGA) and remote interventional cardiologist consultation.BACKGROUND:The incremental benefit of prehospital electrocardiogram (PH-ECG) transmission on the diagnostic accuracy and appropriateness of CCL-A has been examined in a small number of studies with conflicting results.METHODS:We identified consecutive PH-ECG transmissions between June 2, 2010 and October 6, 2016. Blinded adjudication of ECGs, appropriateness of CCL-A, and index diagnoses were performed using the fourth universal definition of MI. The primary outcome was the appropriate CCL-A rate. Secondary outcomes included rates of false-positive CCL-A, inappropriate CCL-A, and inappropriate CCL nonactivation.RESULTS:Among 1088 PH-ECG transmissions, there were 565 (52%) CCL-As and 523 (48%) CCL nonactivations. The appropriate CCL-A rate was 97% (550 of 565 CCL-As), of which 4.9% (n = 27) were false-positive. The inappropriate CCL-A rate was 2.7% (15 of 565 CCL-As) and the inappropriate CCL nonactivation rate was 3.6% (19 of 523 CCL nonactivations). Reasons for appropriate CCL nonactivation (n = 504) included nondiagnostic ST-segment elevation (n = 128, 25%), bundle branch block (n = 132, 26%), repolarization abnormality (n = 61, 12%), artefact (n = 72, 14%), no ischemic symptoms (n = 32, 6.3%), severe comorbidities (n = 26, 5.2%), transient ST-segment elevation (n = 20, 4.0%), and others.CONCLUSIONS:PH-ECG interpretation utilizing UGA with interventional cardiologist consultation accurately identified STEMI with low rates of inappropriate and false-positive CCL-As, whereas using UGA alone would have almost doubled CCL-As. The benefits of cardiologist consultation were identifying "masquerading" STEMI and avoiding unnecessary CCL-As.