Journal articles: 'Cardiac arrest Victoria'

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Mercier, Eric, Peter A. Cameron, Karen Smith, and Ben Beck. "Prehospital trauma death review in the State of Victoria, Australia: a study protocol." BMJ Open 8, no. 7 (July 2018): e022070. http://dx.doi.org/10.1136/bmjopen-2018-022070.

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IntroductionRegionalised trauma systems have been shown to improve outcomes for trauma patients. However, the evaluation of these trauma systems has been oriented towards in-hospital care. Therefore, the epidemiology and care delivered to the injured patients who died in the prehospital setting remain poorly studied. This study aims to provide an overview of a methodological approach to reviewing trauma deaths in order to assess the preventability, identify areas for improvements in the system of care provided to these patients and evaluate the potential for novel interventions to improve outcomes for seriously injured trauma patients.Methods and analysisThe planned study is a retrospective review of prehospital and early in-hospital (<24 hours) deaths following traumatic out-of-hospital cardiac arrest that were attended by Ambulance Victoria between 2008 and 2014. Eligible patients will be identified from the Victorian Ambulance Cardiac Arrest Registry and linked with the National Coronial Information System. For patients who were transported to hospital, data will be linked the Victoria State Trauma Registry. The project will be undertaken in four phases: (1) survivability assessment; (2) preventability assessment; (3) identification of potential areas for improvement; and (4) identification of potentially useful novel technologies. Survivability assessment will be based on predetermined anatomical injuries considered unsurvivable. For patients with potentially survivable injuries, multidisciplinary expert panel reviews will be conducted to assess the preventability as well as the identification of potential areas for improvement and the utility of novel technologies.Ethics and disseminationThe present study was approved by the Victorian Department of Justice and Regulation HREC (CF/16/272) and the Monash University HREC (CF16/532 – 2016000259). Results of the study will be published in peer-reviewed journals and reports provided to Ambulance Victoria, the Victorian State Trauma Committee and the Victorian State Government Department of Health and Human Services.

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Eastwood, David, Kylie Dyson, Emily Andrew, Stephen Bernard, and Karen Smith. "Exercise-related out of hospital cardiac arrest in Victoria, Australia." Resuscitation 130 (September 2018): e20. http://dx.doi.org/10.1016/j.resuscitation.2018.07.347.

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Eastwood, David, Emily Andrew, Karen Smith, Resmi Nair, Ziad Nehme, Stephen Bernard, and Kylie Dyson. "Exercise-related out-of-hospital cardiac arrest in Victoria, Australia." Resuscitation 139 (June 2019): 57–64. http://dx.doi.org/10.1016/j.resuscitation.2019.03.043.

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Jennings, Paul A., Peter Cameron, Tony Walker, Stephen Bernard, and Karen Smith. "Out‐of‐hospital cardiac arrest in Victoria: rural and urban outcomes." Medical Journal of Australia 185, no. 3 (August 2006): 135–39. http://dx.doi.org/10.5694/j.1326-5377.2006.tb00498.x.

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Nehme, Ziad, Emily Andrew, Peter A. Cameron, Janet E. Bray, Stephen A. Bernard, Ian T. Meredith, and Karen Smith. "Population density predicts outcome from out‐of‐hospital cardiac arrest in Victoria, Australia." Medical Journal of Australia 200, no. 8 (May 2014): 471–75. http://dx.doi.org/10.5694/mja13.10856.

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Nehme, Ziad, Steffi Burns, Jocasta Ball, Stephen Bernard, and Karen Smith. "The impact of ventricular fibrillation amplitude on successful cardioversion, resuscitation duration, and survival after out-of-hospital cardiac arrest." Critical Care and Resuscitation 23, no. 2 (June 7, 2021): 202–10. http://dx.doi.org/10.51893/2021.2.oa7.

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OBJECTIVE: We sought to examine the incidence of low amplitude ventricular fibrillation and its impact on successful cardioversion, duration of resuscitation, and survival to hospital discharge in patients with out-of-hospital cardiac arrest (OHCA). DESIGN: Retrospective analysis from a statewide registry. SETTING: Victoria, Australia. PARTICIPANTS: Consecutive initial ventricular fibrillation arrests with an emergency medical service (EMS)-attempted resuscitation between 1 February 2019 and 30 January 2020. MAIN OUTCOME MEASURES: Survival to hospital discharge, successful cardioversion, and duration of resuscitation. RESULTS: Of the 471 initial ventricular fibrillation arrests, 429 (91.1%) had sufficient electrocardiogram data for review. The median initial and final ventricular fibrillation amplitude did not differ (0.3 mV; interquartile range [IQR], 0.2–0.5 mV). The final pre-shock amplitude was ≤ 0.1 mV (very fine) and ≤ 0.2 mV (fine) in 22.8% and 37.5% of cases respectively. In a multivariable analysis, only the time between emergency call and first defibrillation was associated with a low initial ventricular fibrillation amplitude ≤ 0.2 mV (adjusted odds ratio [aOR], 1.07; 95% CI, 1.02–1.13; P = 0.004). After adjustment for arrest factors, every 0.1 mV increase in final amplitude was independently associated with survival to hospital discharge (aOR, 1.26; 95% CI, 1.14–1.39; P < 0.001) and initial cardioversion success (aOR, 1.19; 95% CI, 1.07–1.32; P = 0.001). The duration of resuscitation also increased by 1.7 minutes (95% CI, 1.03–2.36; P < 0.001) for every 0.1 mV increase in final amplitude. CONCLUSION: More than one-third of initial ventricular fibrillation OHCA cases were low in amplitude. Comparative international data are needed to better understand how low amplitude ventricular fibrillation rhythms confound the measurement of OHCA interventions and international benchmarks for survival outcomes.

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Dagan, Misha, Warwick Butt, Johnny Millar, Yves d’Udekem, Jenny Thompson, and Siva P. Namachivayam. "Changing Risk of In-Hospital Cardiac Arrest in Children Following Cardiac Surgery in Victoria, Australia, 2007–2016." Heart, Lung and Circulation 28, no. 12 (December 2019): 1904–12. http://dx.doi.org/10.1016/j.hlc.2018.11.003.

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Jennings, Paul, and John Pasco. "Survival from out-of-hospital cardiac arrest in the Geelong region of Victoria, Australia." Emergency Medicine 13, no. 3 (September 2001): 319–25. http://dx.doi.org/10.1046/j.1035-6851.2001.00235.x.

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Muller, Andrew, Kylie Dyson, Stephen Bernard, and Karen Smith. "Seasonal Variation in Out-of-Hospital Cardiac Arrest in Victoria 2008–2017: Winter Peak." Prehospital Emergency Care 24, no. 6 (January 23, 2020): 769–77. http://dx.doi.org/10.1080/10903127.2019.1708518.

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Dyson, Kylie, Janet Bray, Karen Smith, Stephen Bernard, Lahn Straney, and Judith Finn. "Paramedic exposure to out-of-hospital cardiac arrest is rare and declining in Victoria, Australia." Resuscitation 89 (April 2015): 93–98. http://dx.doi.org/10.1016/j.resuscitation.2015.01.023.

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Andrew, E., Z. Nehme, M. Lijovic, S. Bernard, and K. Smith. "Outcomes following out-of-hospital cardiac arrest with an initial cardiac rhythm of asystole or pulseless electrical activity in Victoria, Australia." Resuscitation 85, no. 11 (November 2014): 1633–39. http://dx.doi.org/10.1016/j.resuscitation.2014.07.015.

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Beck, Ben, Lahn Straney, Janet Bray, Judith Finn, Stephen Bernard, Kylie Dyson, Marijana Lijovic, and Karen Smith. "Regions of high out-of-hospital cardiac arrest incidence and low bystander CPR rates in Victoria, Australia." Resuscitation 96 (November 2015): 116. http://dx.doi.org/10.1016/j.resuscitation.2015.09.274.

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Straney, Lahn D., Janet E. Bray, Ben Beck, Judith Finn, Stephen Bernard, Kylie Dyson, Marijana Lijovic, and Karen Smith. "Regions of High Out-Of-Hospital Cardiac Arrest Incidence and Low Bystander CPR Rates in Victoria, Australia." PLOS ONE 10, no. 10 (October 8, 2015): e0139776. http://dx.doi.org/10.1371/journal.pone.0139776.

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Mercier, E., E. Andrew, Z. Nehme, M. Lijovic, S. Bernard, and K. Smith. "LO73: Long-term functional outcome and health-related quality of life of elderly out-of-hospital cardiac arrest survivors." CJEM 19, S1 (May 2017): S53. http://dx.doi.org/10.1017/cem.2017.135.

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Introduction: This study aims to describe the long-term functional outcome and health-related quality of life of elderly (≥65 years old) out-of-hospital cardiac arrest (OHCA) survivors in Victoria, Australia. Methods: Elderly OHCA patients who arrested between January 1st, 2010 and December 31st, 2014 were identified from the Victorian Ambulance Cardiac Arrest Registry (VACAR). Living status, Glasgow Outcome Scale-Extended (GOS-E), Euro-QoL (EQ-5D) and Twelve-item Short Form (SF-12) Health Survey were collected by telephone 12 months following the OHCA. Results: Emergency medical services attended on 14,678 elderly OHCA during the study period, 6,851 (46.7%) of which received a resuscitation attempt. Of these, 668 patients (9.8%) survived to hospital discharge. The mean age of the survivors was 75 (standard deviation (SD) 7.4) years and 504 (75.4%) were male. Eighty-five patients subsequently died within 12 months of their OHCA. A total of 483 patients were interviewed (response rate 82.9%). At 12 months, 313 responders (64.9%) were living at home without care. Most responders (n=324 (67.2%)) had a good long-term functional recovery with a GOS-E ≥7. The proportion of patients with a GOS-E≥7 progressively decreased with increasing age (65-74 years: 66.1%, 75-84 years: 53.0%,≥85 years: 27.3%). On the EQ-5D, the majority of survivors reported no problem with mobility (n=266 (55.1%)), self-care (n=403 (83.4%)), activity (n=293 (60.6%)), pain (n=335 (69.3%)) and anxiety (n=358 (74.1%)). On the SF-12, the mean mental component summary was 56.3 (SD 6.6) while the mean physical component summary was 44.7 (SD 11.4) (both measures range from 0-100). Among the 1,951 patients who arrested in a supported accommodation, 849 (43.5%) had a resuscitation attempt, and of these, 21 survived to hospital discharge (2.5%). Only eight (1.0%) of these patients were still alive 12 months after the OHCA and one survivor (0.12%) had a good functional outcome (GOS-E≥7). Conclusion: Most elderly OHCA survivors have an adequate long-term functional status and health-related quality of life. However, the likelihood of having a good functional recovery decreases with increasing age, and is rare for patients arresting in a supported accommodation.

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Eastwood, Kathryn, Stuart Howell, Ziad Nehme, Judith Finn, Karen Smith, Peter Cameron, Dion Stub, and Janet E. Bray. "Impact of a mass media campaign on presentations and ambulance use for acute coronary syndrome." Open Heart 8, no. 2 (October 2021): e001792. http://dx.doi.org/10.1136/openhrt-2021-001792.

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ObjectiveBetween 2009 and 2013, the National Heart Foundation of Australia ran mass media campaigns to improve Australian’s awareness of acute coronary syndrome (ACS) symptoms and the need to call emergency medical services (EMS). This study examined the impact of this campaign on emergency department (ED) presentations and EMS use in Victoria, Australia.MethodsThe Victorian Department of Health and Human Services provided data for adult Victorian patients presenting to public hospitals with an ED diagnosis of ACS or unspecified chest pain (U-CP). We modelled changes in the incidence of ED presentations, and the association between the campaign period and (1) EMS arrival and (2) referred to ED by a general practitioner (GP). Models were adjusted for increasing population size, ACS subtype and demographics.ResultsBetween 2003 and 2015, there were 124 632 eligible ED presentations with ACS and 536 148 with U-CP. In patients with ACS, the campaign period was associated with an increase in ED presentations (incidence rate ratio: 1.11; 95% CI 1.07 to 1.15), a decrease in presentations via a GP (adjusted OR (AOR): 0.77; 95% CI 0.70 to 0.86) and an increase in EMS use (AOR: 1.10; 95% CI 1.05 to 1.17). Similar, but smaller associations were seen in U-CP.ConclusionsThe Warning Signs Campaign was associated with improvements in treatment seeking in patients with ACS—including increased EMS use. The increase in ACS ED presentations corresponds with a decrease in out-of-hospital cardiac arrest over this time. Future education needs to focus on improving EMS use in ACS patient groups where use remains low.

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Nehme, Z., E. Andrew, S. Bernard, and K. Smith. "The impact of partial resuscitation attempts on the reported outcomes of out-of-hospital cardiac arrest in Victoria, Australia: Implications for Utstein-style outcome reports." Resuscitation 85, no. 9 (September 2014): 1185–91. http://dx.doi.org/10.1016/j.resuscitation.2014.05.032.

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Lijovic, Marijana, Marijana Lijovic, Karen Smith, Karen Smith, and Karen Smith. "The impact of increasing emergency medical services response time over a 10 year period on survival from out-of-hospital cardiac arrest in Victoria, Australia." Resuscitation 96 (November 2015): 29. http://dx.doi.org/10.1016/j.resuscitation.2015.09.067.

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Gao, Crystal, Zheng Jie Lim, Sabrina Yeh, Scott Santinon, Scott De Haas, and Kristy Austin. "Assessing the Efficacy of a One-day Structured Induction Program in Orienting Clinical Staff to a Novel Prehospital Medical Deployment Model." Prehospital and Disaster Medicine 34, s1 (May 2019): s102—s103. http://dx.doi.org/10.1017/s1049023x19002127.

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Introduction:St. John Ambulance Victoria provides first aid and medical services at a variety of mass gathering events (MGEs) throughout Victoria. Volunteer healthcare professionals and students (termed “volunteers”) form Medical Assistance Teams (MAT) at these MGEs. MAT deployments manage a variety of patient presentations which include critically ill patients. This reduces high acuity patient transfers to the hospital and, where possible, avoid ambulance and hospital utilization.Aim:To determine the effectiveness of interdisciplinary prehospital simulation workshops in preparing volunteers for MAT deployment at MGEs.Methods:A one-day, simulation-based training session within the MAT environment was implemented to introduce volunteers to the management of various scenarios faced at MGEs. All volunteers were provided an orientation to the equipment and setting up MAT deployments at MGEs. Volunteers then participated in interdisciplinary group-based scenarios such as cardiac arrest management, drug intoxication, spinal injuries, agitated patients, and airway management. To determine the effectiveness of this training session, volunteers were invited to participate in a post-training survey, comprising of Likert scores and open-ended responses.Results:Seventeen volunteers attended the training session with 10 (58.8%) completing the post-training survey. Volunteers were satisfied with environment familiarization in the MAT (Average 4.47/5.00) and found the simulation-based training helpful (Average 3.67/4.00). The induction overall was well-received (4.60/5.00) with volunteers feeling more confident in being deployed at MGEs (4.20/5.00).Discussion:The results of the simulation-based training session were positive with volunteers receptive to the need for a training day prior to MAT deployment at MGEs. The simulation session enables volunteers to be comfortable with working in MAT and managing a diverse range of patients at MGEs. This session is likely to improve interdisciplinary communication and teamwork in the MAT. Future research is aimed at following these volunteers after several MAT deployments to improve the training session for future participants.

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Flynn, Julie, Frank Archer, and Amee Morgans. "Sensitivity and Specificity of the Medical Priority Dispatch System in Detecting Cardiac Arrest Emergency Calls in Melbourne." Prehospital and Disaster Medicine 21, no. 2 (April 2006): 72–76. http://dx.doi.org/10.1017/s1049023x00003381.

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AbstractIntroduction:In Australia, cardiac arrest kills 142 out of every 100,000 people each year; with only 3–4% of out-of-hospital patients with cardiac arrest in Melbourne surviving to hospital discharge. Prompt initiation of cardiopulmonary resuscitation (CPR), defibrillation, and advanced cardiac care greatly improves the chances of survival from cardiac arrest. A critical step in survival is identifying by the emergency ambulance dispatcher potential of the probability that the person is in cardiac arrest. The Melbourne Metropolitan Ambulance Service (MAS) uses the computerized call-taking system, Medical Priority Dispatch System (MPDS), to triage incoming, emergency, requests for ambulance responses. The MPDS is used in many emergency medical systems around the world, however, there is little published evidence of the system's efficacy.Objective:This study attempts to undertake a sensitivity/specificity analysis to determine the ability of MPDS to detect cardiac arrest.Methods:Emergency ambulance dispatch records of all cases identified as suspected cardiac arrest by MPDS were matched with ambulance, patient-care records and records from the Victorian Ambulance Cardiac Arrest Registry to determine the number of correctly identified cardiac arrests. Additionally, cases that had cardiac arrests, but were not identified correctly at the point of call-taking, were examined. All data were collected retrospectively for a three-month period (01 January through 31 March 2003).Results:The sensitivity of MPDS in detecting cardiac arrest was 76.7% (95% confidence interval (CI): 73.6%–79.8%) and specificity was 99.2% (95% CI: 99.1–99.3%). These results indicate that cardiac arrests are correctly identified in 76.7% of cases.Conclusion:Although the system correctly identified 76.7% of cardiac arrest cases, the number of false negatives suggests that there is room for improvement in recognition by MPDS to maximize chances for survival in out-of-hospital cardiac arrest. This study provides an objective and comprehensive measurement of the accuracy of MPDS cardiac-arrest detection in Melbourne, as well as providing a baseline for comparison with subsequent changes to the MPDS.

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Smith, K. L., J. Bray, V. Barnes, M. Lodder, P. Cameron, S. Bernard, and A. Currell. "Victorian ambulance cardiac arrest registry." Resuscitation 81, no. 2 (December 2010): S4. http://dx.doi.org/10.1016/j.resuscitation.2010.09.030.

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Lord, Bill, Emily Andrew, Amanda Henderson, David J. Anderson, Karen Smith, and Stephen Bernard. "Palliative care in paramedic practice: A retrospective cohort study." Palliative Medicine 33, no. 4 (February 5, 2019): 445–51. http://dx.doi.org/10.1177/0269216319828278.

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Background: Paramedics may be involved in the care of patients experiencing a health crisis associated with palliative care. However, little is known about the paramedic’s role in the care of these patients. Aim: To describe the incidence and nature of cases attended by paramedics and the care provided where the reason for attendance was associated with a history of palliative care. Design: This is a retrospective cohort study. Setting/participants: Adult patients (aged >17 years) attended by paramedics in the Australian state of Victoria between 1 July 2015 and 30 June 2016 where terms associated with palliative care or end of life were recorded in the patient care record. Secondary transfers including inter-hospital transport cases were excluded. Results: A total of 4348 cases met inclusion criteria. Median age was 74 years (interquartile range 64–83). The most common paramedic assessments were ‘respiratory’ (20.1%), ‘pain’ (15.8%) and ‘deceased’ (7.9%); 74.4% ( n = 3237) were transported, with the most common destination being a hospital (99.5%, n = 3221). Of those with pain as the primary impression, 359 (53.9%) received an analgesic, morphine, fentanyl or methoxyflurane, and 356 (99.2%) were transported following analgesic administration. Resuscitation was attempted in 98 (29.1%) of the 337 cases coded as cardiac arrest. Among non-transported cases, there were 105 (9.6%) cases where paramedics re-attended the patient within 24 h of the previous attendance. Conclusion: Paramedics have a significant role in caring for patients receiving palliative care. These results should inform the design of integrated systems of care that involve ambulance services in the planning and delivery of community-based palliative care.

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Nehme, Z., E. Andrew, J. E. Bray, P. Cameron, S. Bernard, I. T. Meredith, and K. Smith. "The significance of pre-arrest factors in out-of-hospital cardiac arrests witnessed by emergency medical services: A report from the Victorian Ambulance Cardiac Arrest Registry." Resuscitation 88 (March 2015): 35–42. http://dx.doi.org/10.1016/j.resuscitation.2014.12.009.

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Lord, Bill, Emily Andrew, Karen Smith, Amanda Henderson, David J. Anderson, and Stephen Bernard. "OP7 Palliative care in paramedic practice: a retrospective cohort study." Emergency Medicine Journal 36, no. 10 (September 24, 2019): e4.3-e5. http://dx.doi.org/10.1136/emermed-2019-999abs.7.

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IntroductionParamedics may be involved in the care of patients experiencing a health crisis associated with palliative care. However, little is known about the paramedic’s role in the care of these patients. This study therefore aimed to describe the incidence and nature of cases attended by paramedics, the treatment provided, and the transport destination if transported, where the reason for attendance was associated with a history of palliative care.MethodsThis retrospective cohort study included all adult patients (aged > 17 years) attended by paramedics in the Australian state of Victoria between 1 July 2015 and 30 June 2016 where terms associated with palliative care, dying or end of life were recorded in the patient care record. Secondary transfers were excluded. Descriptive statistics were used to analyse the sample. Categorical data are presented as frequencies and proportions, with comparisons made using the χ2 test.Results4,348 cases met inclusion criteria. Most patients were aged between 61–80 years (47.9%). The most common assessments recorded by paramedics were ‘respiratory’ (20.1%), ‘pain’ (15.8%), and ‘deceased’ (7.9%). 54.0% (n=2,346) received treatment from the paramedics, and 74.4% (n=3,237) were transported, with the most common destination a hospital (99.5%, n=3,221). Of those with pain as the primary impression, 359 (53.9%) received an analgesic. Nausea and/or vomiting was documented in 15.6% (n=680) of cases attended. Antiemetics administered in these cases included metoclopramide (n=71, 10.4%), prochlorperazine (n=21, 3.1%), and ondansetron (n=9, 1.3%). Resuscitation was attempted in 98 (29.1%) of the 337 cases coded as cardiac arrest. Among non-transported cases, there were 105 (9.6%) cases where paramedics re-attended the patient within 24 hours of the previous attendance.Discussion and conclusionParamedics may become involved in the care of patients receiving palliative care due to exacerbation of symptoms or a new health emergency. As such, the paramedic has a key role in managing symptoms or liaising with other members of the patient’s palliative care team to provide appropriate care. The results should inform integrated systems of care that involve ambulance services in the planning and delivery of community-based palliative care.

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Fridman, Masha, Vanessa Barnes, Andrew Whyman, Alex Currell, Stephen Bernard, Tony Walker, and Karen L. Smith. "A model of survival following pre-hospital cardiac arrest based on the Victorian Ambulance Cardiac Arrest Register." Resuscitation 75, no. 2 (November 2007): 311–22. http://dx.doi.org/10.1016/j.resuscitation.2007.05.005.

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Lijovic, M., S. Bernard, Z. Nehme, T. Walker, and K. Smith. "Public access defibrillation—Results from the Victorian Ambulance Cardiac Arrest Registry." Resuscitation 85, no. 12 (December 2014): 1739–44. http://dx.doi.org/10.1016/j.resuscitation.2014.10.005.

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Magnuson, Nicole, Ziad Nehme, Steve Bernard, and Karen Smith. "Paramedic-witnessed paediatric out-of-hospital cardiac arrests in Victoria, Australia." Resuscitation 130 (September 2018): e144. http://dx.doi.org/10.1016/j.resuscitation.2018.07.310.

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Lijovic, Marijana, Stephen Bernard, Ziad Nehme, A/Prof Tony Walker, and A/Prof Karen Smith. "O153 Public access defibrillation- Results from the Victorian Ambulance Cardiac Arrest Registry (VACAR)." Global Heart 9, no. 1 (March 2014): e41-e42. http://dx.doi.org/10.1016/j.gheart.2014.03.1360.

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Andrew, Emily, Ziad Nehme, Marijana Lijovic, Stephen Bernard, and Karen Smith. "A comparison of three quality-of-life measurement tools in out-of-hospital cardiac arrest survivors: A report from the Victorian Ambulance Cardiac Arrest Registry." Resuscitation 96 (November 2015): 28. http://dx.doi.org/10.1016/j.resuscitation.2015.09.065.

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Cole, J., N. Cox, and D. Stub. "Optimising Outcomes of Patients With Out-of-Hospital Cardiac Arrest Presenting to a Single Major Victorian Tertiary Referral Hospital Network." Heart, Lung and Circulation 25 (August 2016): S184—S185. http://dx.doi.org/10.1016/j.hlc.2016.06.432.

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Haikerwal, Anjali, Michael J. Abramson, Malcolm R. Sim, Mick Meyer, Karen Smith, Muhammad Akram, and Martine Dennekamp. "O189 Out of Hospital Cardiac Arrests and Exposure to Fine Particulate Matter Air Pollution (PM2.5) during 2006-2007 Bushfires in Victoria, Australia." Global Heart 9, no. 1 (March 2014): e45-e46. http://dx.doi.org/10.1016/j.gheart.2014.03.1372.

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Paratz, E., L. Rowsell, J. Ball, D. Zentner, S. Parsons, N. Morgan, T. Thompson, et al. "Economic impact of sudden cardiac arrest." European Heart Journal 41, Supplement_2 (November 1, 2020). http://dx.doi.org/10.1093/ehjci/ehaa946.3542.

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Abstract Background Each year, there are approximately 5,000 out-of-hospital cardiac arrests (OHCAs) in the state of Victoria, Australia (population 6.4 million, state healthcare budget AUD$2.9 billion / €1.8billion). Mortality from OHCA approaches ninety percent. High mortality rates and survivors not returning to work is likely to have an adverse effect on the Victorian economy but this has not been previously investigated. Purpose To model the economic impact of OHCA mortality and survivors not returning to work. Methods Data on all OHCAs transported by Ambulance Victoria from July 2017- June 2018 in Victoria, Australia was collected, including age, gender, survival to hospital, survival to discharge, and survival to 12 months. Cases were excluded if arrest was precipitated by trauma, exsanguination, overdose, terminal illness, hanging, SIDS, electrocution, sepsis, respiratory causes, drowning, or neurological causes. Pre-arrest employment status of patients was modelled using the Australian Bureau of Statistics Economic Security dataset, which provides contemporary employment rates for gender-matched five-year cohorts for Australians aged 15–79 years. For survivors to 12 months, pre-arrest and post-arrest work status were confirmed. Economic impact was then calculated to a five year horizon utilizing a Markov model with probabilistic sensitivity analysis. Results 4,934 arrests meeting the inclusion criteria were transported by Ambulance Victoria in twelve months, of whom 4,639 were determined to be cardiac arrests without any exclusion criteria as a precipitant. 695 patients survived to hospital (15.0%), and 325 to discharge (7.0%). At 12 months, 303 patients were alive (6.5% of overall cases, 93.2% of those discharged from hospital). Economic modelling of age and gender-matched data indicated that 1516 patients (35%) would have been employed pre-cardiac arrest, but only 216 survivors (4.7%) would be employed at five years post-arrest. Using Markov modelling incorporating estimated earnings and the pre-determined value of a statistical life, the annual economic burden of cardiac arrest approximated AUD$4 billion (€2.5 billion) at a five-year horizon. Conclusion The annual economic impact of cardiac arrest in Victoria, Australia is approximately AUD$4 billion (€2.5 billion) in a five-year horizon. As the annual Victorian state budget for all healthcare is AUD$2.93 billion (€1.8 billion), our data suggests that the economic impact of cardiac arrest is under-appreciated. Therefore, research in this area and providing state-of-the-art care for all cardiac arrest patients should be a healthcare priority. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): NHMRC/NHF Postgraduate Scholarship, RACP JJ Billings Scholarship

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Lim, Shir Lynn, Karen Smith, Kylie Dyson, Siew Pang Chan, Arul Earnest, Resmi Nair, Stephen Bernard, et al. "Incidence and Outcomes of Out‐of‐Hospital Cardiac Arrest in Singapore and Victoria: A Collaborative Study." Journal of the American Heart Association 9, no. 21 (November 3, 2020). http://dx.doi.org/10.1161/jaha.119.015981.

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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 <0.001). Age‐adjusted OHCA incidence and survival rates increased in Singapore between 2011 and 2016 ( P <0.01 for trend), but remained stable, though higher, in Victoria. Likelihood of survival increased significantly ( P <0.001) with arrest in public locations (adjusted odds ratio [aOR] 1.81), witnessed arrest (aOR 2.14), bystander cardiopulmonary resuscitation (aOR 1.72), initial shockable rhythm (aOR 9.82), and bystander defibrillation (aOR 2.04) but decreased with increasing age (aOR 0.98) and emergency medical services response time (aOR 0.91). 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.

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Winship, Christian, Malcolm Boyle, and Brett Williams. "Out of Hospital Cardiac Arrest Management by First Responders: Retrospective Review of a Fire Fighter First Responder Program." Australasian Journal of Paramedicine 11, no. 5 (August 26, 2014). http://dx.doi.org/10.33151/ajp.11.5.59.

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IntroductionOver 9,500 people die annually in Australia from sudden cardiac arrest, with strong evidence suggesting early high quality CPR and early counter shock being paramount for improving survival from cardiac arrest. It has also been shown that first responder programs have been able to reduce response times and increase survival rates for out-of-hospital cardiac arrest. The objective of this study was to examine data from the first seven years of an Australian out-of-hospital cardiac arrest first responder program where fire fighters provided basic life support.MethodsThis study was a retrospective cohort study of all cardiac arrests attended by the Metropolitan Fire and Emergency Services Board (MFESB) as part of the Emergency Medical Response program over a seven-year period in Melbourne, Victoria, Australia.ResultsThe MFESB attended 4,450 cardiac arrests. The majority of patients presented in asystole 669 (63.7%) with just 243 (23.1%) presenting in a shockable rhythm. The majority of patients in cardiac arrest were males (64.2%) and the mean age of the patients was 67.5 years. The MFESB median response time during the study period was 5.7 minutes (IQR 2.25 minutes), range of 0.15 minutes to 31.7 minutes, which remained stable over the seven years. Patients spent a median time of 4.6 minutes (0.02 seconds to 36.5 minutes) in the care of fire fighters prior to the arrival of EMS. The rhythm on handover to paramedics was asystole in 787 (75.1%) cases with no shockable rhythms. One in three (31.3%) patients received bystander CPR, with a significant rise in the rate of bystander CPR occurring over the last two years.ConclusionThis study demonstrated acceptable response times to cardiac arrests and a low bystander CPR rate prior to arrival of the MFESB. The incidence of a shockable rhythm on arrival of the MFESB was low with the main rhythm being asystole. The main rhythm on handover to paramedics was asystole with non-shockable rhythms. Further research is required to determine the effect on patient outcomes.

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Villani, Melanie, Ziad Nehme, Emily Andrew, Jocasta Ball, and Karen Smith. "Abstract 9499: Prehospital Factors Associated With Cardiopulmonary Resuscitation Performance in Out-of-Hospital Cardiac Arrests." Circulation 144, Suppl_2 (November 16, 2021). http://dx.doi.org/10.1161/circ.144.suppl_2.9499.

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Introduction: Although high quality cardiopulmonary resuscitation (CPR) has been associated with improvements in survival from cardiac arrest, little is known about the arrest factors that influence CPR performance. This study examined the association between CPR performance and patient and arrest factors in out-of-hospital cardiac arrest (OHCA). Methods: A retrospective observational study using data from a statewide cardiac arrest registry in Victoria, Australia. The study included 2,408 adult, medical OHCA patients who arrested between 11 February 2019 and 10 February 2021. Fractional and logistic regression models were used to analyse factors associated with CPR performance outcomes, including the proportion of compressions at target depth and target rate and a compression fraction ≥90%. Results: The median proportion of compressions at target depth and target rate were 80% (interquartile range [IQR] 58, 92.5) and 62% (IQR 40, 79), respectively, and 70% achieved a compression fraction ≥90%. After multivariable adjustment, achieving a compression depth in the target range was associated with female sex (OR 1.14 [95% CI: 1.02, 1.28]), patient weight (per 10 kg increase, OR 1.08 [95% CI: 1.05, 1.12]), aged care facility location (OR 0.74 [95% CI: 0.58, 0.94]), fire-fighter presence (OR 1.29 [95% CI: 1.14, 1.46]), resuscitation duration (per 5 min increase, OR 1.08 [95% CI: 1.06, 1.10]) and number of rescuers (per 1 person increase, OR 1.06 [95% CI: 1.03, 1.09]). Achieving compressions within target rate were associated with public location (OR 0.81 [95% CI: 0.72, 0.91]) and fire-fighter presence (OR 1.12 [95% CI: 1.02, 1.24]). Achieving a compression fraction ≥90% was associated with female sex (OR 0.75 [95% CI: 0.62, 0.91]), arrests witnessed by emergency services (OR 0.44 [95% CI: 0.32, 0.61]), initial shockable rhythms (OR 0.66 [95% CI: 0.53, 0.81]), fire-fighter presence (OR 1.24 [95% CI: 1.01, 1.54]) and resuscitation duration (per 5 min increase, OR 1.05 [95% CI: 1.02, 1.08]). Conclusion: This study demonstrates that several prehospital factors that are associated with CPR performance which may help inform operational strategies to improve OHCA outcomes.

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Paratz, Elizabeth D., Alexander van Heusden, Dominica Zentner, Natalie Morgan, Karen Smith, Tina Thompson, Paul James, et al. "Causes, circumstances, and potential preventability of cardiac arrest in the young: insights from a state-wide clinical and forensic registry." EP Europace, August 29, 2022. http://dx.doi.org/10.1093/europace/euac141.

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Abstract Aims The causes, circumstances, and preventability of young sudden cardiac arrest remain uncertain. Methods and results A prospective state-wide multi-source registry identified all out-of-hospital cardiac arrests (OHCAs) in 1–50 year olds in Victoria, Australia, from 2019 to 2021. Cases were adjudicated using hospital and forensic records, clinic assessments and interviews of survivors and family members. For confirmed cardiac causes of OHCA, circumstances and cardiac history were collected. National time-use data was used to contextualize circumstances. 1319 OHCAs were included. 725 (55.0%) cases had a cardiac aetiology of OHCA, with coronary disease (n = 314, 23.8%) the most common pathology. Drug toxicity (n = 226, 17.1%) was the most common non-cardiac cause of OHCA and the second-most common cause overall. OHCAs were most likely to occur in sleep (n = 233, 41.2%). However, when compared to the typical Australian day, OHCAs occurred disproportionately more commonly during exercise (9% of patients vs. 1.3% of typical day, P = 0.018) and less commonly while sedentary (39.6 vs. 54.6%, P = 0.047). 38.2% of patients had known standard modifiable cardiovascular risk factors. 77% of patients with a cardiac cause of OHCA had not reported cardiac symptoms nor been evaluated by a cardiologist prior to their OHCA. Conclusion Approximately half of OHCAs in the young have a cardiac cause, with coronary disease and drug toxicity dominant aetiologies. OHCAs disproportionately occur during exercise. Of patients with cardiac cause of OHCA, almost two-thirds have no standard modifiable cardiovascular risk factors, and more than three-quarters had no prior warning symptoms or interaction with a cardiologist.

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Dyson, Kylie, Janet Bray, Karen Smith, Stephen Bernard, Lahn Straney, and Judith Finn. "Abstract 269: How Much Exposure to Resuscitation Do Emergency Medical Services Personnel Get?" Circulation 130, suppl_2 (November 25, 2014). http://dx.doi.org/10.1161/circ.130.suppl_2.269.

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Objectives: The exposure of emergency medical service personnel (paramedics) to out-of-hospital cardiac arrest (OHCA) and resuscitation procedures could be an important factor in skill maintenance and quality of care. This study aims to describe paramedic exposure to OHCA resuscitation in the state of Victoria, Australia (population 5.8 million). Methods: We extracted and linked data from the Victorian Ambulance Cardiac Arrest Registry (VACAR) and Ambulance Victoria’s employment dataset for the period 2003-2012. Paramedics were considered to have ‘exposure’ to OHCA if they attended a case where resuscitation was attempted. Individual rates were calculated for annual exposure (number of OHCA exposures for each paramedic/years employed in study period) and days between exposures (total paramedic days/total number of exposures). Results: Over the 10-year period, there were 49,107 OHCAs and 5,673 paramedics employed. Resuscitation was attempted in 44% of patients. An average of 3.2 (SD±1.1) paramedics attended each case. The median average exposure of paramedics was 2.2 (IQR=1.2-3.5) OHCAs/year. The proportion with no exposures in a year increased from 39% in 2003 to 43% in 2012 (p=0.036). OHCA exposure was significantly less in those employed part-time or casual (p<0.001), in a rural area (p<0.001) or with a lower qualification (p<0.001) (Table). Annual exposure to pediatric and traumatic OHCAs was particularly low (Table). Paramedics were exposed to an average of 0.006 OHCAs/day, meaning it would take an average of 163 days be exposed to OHCA and up to 12.5 years for rare cases, such as pediatric OHCAs. Conclusion: Our study identified paramedic exposure to resuscitation is low and has decreased over time. This highlights the importance of supplementing paramedic exposure with other methods, such as simulation, to maintain resuscitation skills. This may be particularly important to paramedics with low exposure and for rare case types, such as pediatric OHCA.

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Dyson, Kylie, Janet Bray, Karen Smith, Stephen Bernard, Lahn Straney, and Finn Judith. "Abstract 12334: How Much Exposure to Resuscitation Do Emergency Medical Service Personnel Get?" Circulation 130, suppl_2 (November 25, 2014). http://dx.doi.org/10.1161/circ.130.suppl_2.12334.

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Objectives: The exposure of emergency medical service personnel (paramedics) to out-of-hospital cardiac arrest (OHCA) and resuscitation procedures could be an important factor in skill maintenance and quality of care. This study aims to describe paramedic exposure to OHCA resuscitation in the state of Victoria, Australia (population 5.8 million). Methods: We extracted and linked data from the Victorian Ambulance Cardiac Arrest Registry (VACAR) and Ambulance Victoria’s employment dataset for the period 2003-2012. Paramedics were considered to have ‘exposure’ to OHCA if they attended a case where resuscitation was attempted. Individual rates were calculated for annual exposure (number of OHCA exposures for each paramedic/years employed in study period) and days between exposures (total paramedic days/total number of exposures). Results: Over the 10-year period, there were 49,107 OHCAs and 5,673 paramedics employed. Resuscitation was attempted in 44% of patients. An average of 3.2 (SD±1.1) paramedics attended each case. The median average exposure of paramedics was 2.2 (IQR=1.2-3.5) OHCAs/year. The proportion with no exposures in a year increased from 39% in 2003 to 43% in 2012 ( p =0.036). OHCA exposure was significantly less in those employed part-time or casual ( p <0.001), in a rural area ( p <0.001) or with a lower qualification ( p <0.001) (Table). Annual exposure to pediatric and traumatic OHCAs was particularly low (Table). Paramedics were exposed to an average of 0.006 OHCAs/day, meaning it would take an average of 163 days be exposed to OHCA and up to 12.5 years for rare cases, such as pediatric OHCAs. Conclusion: Our study identified paramedic exposure to resuscitation is low and has decreased over time. This highlights the importance of supplementing paramedic exposure with other methods, such as simulation, to maintain resuscitation skills. This may be particularly important to paramedics with low exposure and for rare case types, such as pediatric OHCA.

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Stehli, Julia, Diem Dinh, Misha Dagan, Stephen J. Duffy, Angela Brennan, Karen Smith, Emily Andrew, et al. "Sex Differences in Prehospital Delays in Patients With ST‐Segment–Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention." Journal of the American Heart Association 10, no. 13 (July 6, 2021). http://dx.doi.org/10.1161/jaha.120.019938.

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Background Women with ST‐segment–elevation myocardial infarction experience delays in reperfusion compared with men with little data on each time component from symptom onset to reperfusion. This study analyzed sex discrepancies in patient delays, prehospital system delays, and hospital delays. Methods and Results Consecutive patients with ST‐segment–elevation myocardial infarction treated with percutaneous coronary intervention across 30 hospitals in the Victorian Cardiac Outcomes Registry (2013–2018) were analyzed. Data from the Ambulance Victoria Data warehouse were used to perform linkage to the Victorian Cardiac Outcomes Registry for all patients transported via emergency medical services (EMS). The primary end point was EMS call‐to‐door time (prehospital system delay). Secondary end points included symptom‐to‐EMS call time (patient delay), door‐to‐device time (hospital delay), 30‐day mortality, major adverse cardiovascular events, and major bleeding. End points were analyzed according to sex and adjusted for age, comorbidities, cardiogenic shock, cardiac arrest, and symptom onset time. A total of 6330 (21% women) patients with ST‐segment–elevation myocardial infarction were transported by EMS. Compared with men, women had longer adjusted geometric mean symptom‐to‐EMS call times (47.0 versus 44.0 minutes; P <0.001), EMS call‐to‐door times (58.1 versus 55.7 minutes; P <0.001), and door‐to‐device times (58.5 versus 54.9 minutes; P =0.006). Compared with men, women had higher 30‐day mortality (odds ratio [OR], 1.38; 95% CI, 1.06–1.79; P =0.02) and major bleeding (OR, 1.54; 95% CI, 1.08–2.20; P =0.02). Conclusions Female patients with ST‐segment–elevation myocardial infarction experienced excess delays in patient delays, prehospital system delays, and hospital delays, even after adjustment for confounders. Prehospital system and hospital delays resulted in an adjusted excess delay of 10 minutes compared with men.

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Nehme, Ziad, Jocasta Ball, Melanie Villani, Michael Stephenson, Tony Walker, Dion Stub, and Karen L. Smith. "Abstract 12097: The Impact of a High-Performance Cardiopulmonary Resuscitation Protocol on Survival From Out-of-Hospital Cardiac Arrests Witnessed by Paramedics." Circulation 144, Suppl_2 (November 16, 2021). http://dx.doi.org/10.1161/circ.144.suppl_2.12097.

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Introduction: Some emergency medical services (EMS) have shown increases in survival from out-of-hospital cardiac arrest (OHCA) following the implementation of a high-performance cardiopulmonary resuscitation (CPR) protocol. Despite this, little is known about the effect of high-performance CPR on OHCA witnessed by EMS personnel. Methods: We performed a retrospective cohort study of adult, EMS-witnessed OHCA patients of medical etiology from a population-based registry in Victoria, Australia. Patients treated after the introduction of a high-performance CPR protocol and training program between February 2019 and January 2020 were compared to historical controls between January 2015 and January 2019. The effect of the intervention on survival to hospital discharge was examined using logistic regression models adjusted for temporal and arrest factors. Results: A total of 1,561 and 420 EMS-witnessed OHCA patients were treated in the control and intervention periods, respectively. Baseline characteristics were similar across control and intervention periods, including the median age of cases (69 vs. 69 years, p=0.97), male sex (65.2% vs. 60.5%, p=0.08) and initial shockable arrests (33.7% vs. 29.3%, p=0.09). Resuscitation interventions were similar across groups, except for the use of mechanical CPR which declined during the intervention period (17.0% vs. 10.7%, p<0.001). Unadjusted survival to hospital discharge was similar across control and intervention periods for the overall population (29.4% vs. 32.1%, p=0.27), but significantly higher during the intervention period for initial shockable arrests (66.6% vs. 76.9%, p=0.03). After adjustment for confounders, cases in the intervention period were associated with a 43% increase (adjusted odds ratio [AOR] 1.43; 95% CI: 1.05, 1.94; p=0.02) in the risk-adjusted odds of survival to hospital discharge or a 79% increase (AOR 1.79, 95% CI: 1.09, 2.95; p=0.02) for initial shockable arrests. Conclusions: The implementation of a high-performance CPR quality improvement intervention was associated with significant improvement in survival from EMS witnessed OHCA. Efforts to monitor and improve CPR performance could yield further improvements in patient outcomes.

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Fernando, Himawan, Ziad Nehme, Diem Dinh, Emily Andrew, Angela Brennan, William Shi, Jason Bloom, et al. "Impact of prehospital opioid dose on angiographic and clinical outcomes in acute coronary syndromes." Emergency Medicine Journal, April 26, 2022, emermed-2021-211519. http://dx.doi.org/10.1136/emermed-2021-211519.

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BackgroundAn adverse interaction whereby opioids impair and delay the gastrointestinal absorption of oral P2Y12 inhibitors has been established, however the clinical significance of this in acute coronary syndrome (ACS) is uncertain. We sought to characterise the relationship between prehospital opioid dose and clinical outcomes in patients with ACS.MethodsPatients given opioid treatment by emergency medical services (EMS) with ACS who underwent percutaneous coronary intervention (PCI) between 1 January 2014 and 31 December 2018 were included in this retrospective cohort analysis using data linkage between the Ambulance Victoria, Victorian Cardiac Outcomes Registry and Melbourne Interventional Group databases. Patients with cardiogenic shock, out-of-hospital cardiac arrest and fibrinolysis were excluded. The primary end point was the risk-adjusted odds of 30-day major adverse cardiac events (MACE) between patients who received opioids and those that did not.Results10 531 patients were included in the primary analysis. There was no significant difference in 30-day MACE between patients receiving opioids and those who did not after adjusting for key patient and clinical factors. Among patients with ST-elevation myocardial infarction (STEMI), there were significantly more patients with thrombolysis in myocardial infarction (TIMI) 0 or 1 flow pre-PCI in a subset of patients with high opioid dose versus no opioids (56% vs 25%, p<0.001). This remained significant after adjusting for known confounders with a higher predicted probability of TIMI 0/1 flow in the high versus no opioid groups (33% vs 11%, p<0.001).ConclusionsOpioid use was not associated with 30-day MACE. There were higher rates of TIMI 0/1 flow pre-PCI in patients with STEMI prescribed opioids. Future prospective research is required to verify these findings and investigate alternative analgesia for ischaemic chest pain.

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Eastwood, Kathryn J., Stuart Howell, Ziad Nehme, Judith Finn, Karen L. Smith, Peter Cameron, Dion Stub, and Janet Bray. "Abstract 11763: The impact of the Australian Warning Signs Campaign on Emergency Medical Service Use for Acute Coronary Syndrome and Unspecified Chest Pain." Circulation 144, Suppl_2 (November 16, 2021). http://dx.doi.org/10.1161/circ.144.suppl_2.11763.

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Background: Between 2009 and 2013, the National Heart Foundation of Australia ran mass media campaigns to improve Australian’s awareness of Acute Coronary Syndrome (ACS) symptoms and the need to call emergency medical services (EMS). This study examined the impact of this campaign on emergency department (ED) presentations and EMS use in Victoria, Australia. Methods: The Victorian Department of Health and Human Services provided data for adult Victorian patients presenting to public hospitals with an ED diagnosis of ACS or unspecified chest pain (U-CP). We modelled changes in the incidence of ED presentations, and the association between the campaign period and 1) EMS arrival and 2) referred to ED by a general practitioner (GP). Models were adjusted for increasing population size, ACS subtype and demographics. Results: Between 2003 and 2015, there were 124,632 eligible ED presentations with ACS and 536,148 with U-CP. In ACS patients, the campaign period was associated with an increase in ED presentations (Incidence Rate Ratio: 1.11; 95% CI: 1.07-1.15), a decrease in presentations via a GP (Adjusted Odds Ratio [AOR]: 0.77; 95% CI: 0.70-0.86), and an increase in EMS use (AOR: 1.10; 95%CI: 1.05-1.17). Similar, but smaller associations were seen in U-CP. Conclusions: The Warning Signs Campaign was associated with improvements in treatment seeking in ACS patients -including increased EMS use. The increase in ACS ED presentations corresponds with a decrease in out-of-hospital cardiac arrest over this time. Future education need to focus on improving EMS use in ACS patient groups where use remains low.

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Hook, Jack, Karen L. Smith, Emily Andrew, Jocasta Ball, and Ziad Nehme. "Abstract 12127: The Effect of Daylight Savings Time Transitions on the Incidence of Out-of-Hospital Cardiac Arrest: An Interrupted Time Series Analysis." Circulation 144, Suppl_2 (November 16, 2021). http://dx.doi.org/10.1161/circ.144.suppl_2.12127.

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Introduction: Many studies have reported increases in the risk of acute cardiovascular events following daylight savings time (DST) transitions. We sought to investigate the effect of DST transitions on the incidence of out-of-hospital cardiac arrest (OHCA) in Victoria, Australia. Methods: Between January 2000 and December 2020, we performed an interrupted time series analysis of the daily number of OHCA cases of medical etiology from the Victorian Ambulance Cardiac Arrest Registry. The effect of DST transition on OHCA incidence was estimated using negative binomial models and reported as either ‘immediate’ or ‘cumulative’ effects. Immediate effects were the average effects observed on the day of DST transition or each of the 6 days after DST transition. Cumulative effects were the sum of the average effects up to 6 days after the day of DST transition. Models were adjusted for population growth, temporal trends, and public holidays. Results: A total of 89,409 adult OHCA of medical etiology were included. Following the spring DST transition (i.e. shorter day), there was an immediate 13% (IRR 1.13, 95% CI: 1.02, 1.25; p=0.02) increased risk of OHCA on the day of transition (Sunday) and the cumulative risk of OHCA remained higher over the first 2 days (IRR 1.17, 95% CI: 1.02, 1.34; p=0.03) compared to non-transitional days. Following the autumn (fall) DST transition (i.e. longer day), there was a significant lagged effect on the Tuesday following transition, with a 12% (IRR 0.88, 95% CI: 0.77, 0.99; p=0.04) reduced risk of OHCA. The autumn (fall) DST transition also showed a cumulative effect on OHCA incidence, with a 30% (IRR 0.70, 95% CI: 0.51, 0.96; p=0.03) reduction in the incidence of OHCA by the end of the transitional week. Subgroups aged > 65 years and cases with initial non-shockable rhythms were most vulnerable to DST transitions. Conclusions: This study showed that there is a modest increased risk of OHCA in the 2 days following the spring DST transition and a decreased risk of OHCA in the week following the autumn DST transition. These findings should promote further research exploring strategies to reduce the risk of OHCA in vulnerable populations.

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Ashokkumar, S., E. Paratz, A. Van Heusden, K. Smith, D. Zentner, N. Morgan, S. Parsons, et al. "Obesity in young sudden cardiac death: rates, clinical features, and insights into people with body mass index >50kg/m2." European Heart Journal 43, Supplement_2 (October 1, 2022). http://dx.doi.org/10.1093/eurheartj/ehac544.2387.

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Abstract Background Obesity is common in young sudden cardiac death (SCD) victims but it is unclear whether it is more common than in the general population. This study aimed to contextualize young SCD obesity rates, identifying clinical and pathologic features in WHO class II and III obesity. Methods A prospective state-wide out-of-hospital cardiac arrest registry included all SCDs in Victoria, Australia from 2019–2021. Body mass indices (BMIs) of patients 18–50 years were compared to age-referenced general population. Characteristics of SCD patients with WHO Class II obesity (BMI ≥30kg/m2) and non-obesity (BMI <30kg/m2) were compared. Clinical characteristics of people with BMI >50kg/m2 were assessed. Results 504 patients were included. Obesity was strongly over-represented in young SCD compared to the age-matched general population (55.0% vs 28.7%, p<0.0001). Obese SCD patients more frequently had hypertension, diabetes and obstructive sleep apnoea (p<0.0001, p=0.009 and p=0.001 respectively), ventricular fibrillation as their arrest rhythm (p=0.008) and left ventricular hypertrophy (LVH) (p<0.0001). Obese patients were less likely to have toxicology positive for illicit substances (22.0% vs 32.6%, p=0.008) or significant alcohol history (18.8% vs 26.9%, p=0.030). Patients with BMI >50 kg/m2 represented 8.5% of young SCD. LVH (n=26, 60.5%) was their predominant cause of death and only 10 (9.3%) patients died from coronary disease. Conclusion Over half of young Australian SCD patients are obese, with all obesity classes over-represented compared to the general population. Obese patients had more cardiac risk factors. Almost two thirds of patients with BMI>50 kg/m2 died with LVH, with fewer than 10% dying from coronary disease. Funding Acknowledgement Type of funding sources: None.

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Nehme, Ziad, Emily Andrew, Jocasta Ball, and Karen L. Smith. "Abstract 12069: Long-Term Trends in the Incidence and Outcome of Refractory and Non-Refractory Ventricular Fibrillation Cardiac Arrest." Circulation 144, Suppl_2 (November 16, 2021). http://dx.doi.org/10.1161/circ.144.suppl_2.12069.

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Introduction: Although many developed countries are reporting temporal improvements in out-of-hospital cardiac arrest (OHCA) outcomes from initial shockable rhythms, trends in the incidence and outcome of refractory ventricular fibrillation are not well understood. Methods: Between 2010 and 2019, we performed a retrospective observational study of OHCA from a population-based registry in Victoria, Australia. We included all adult, non-traumatic OHCA with an initial shockable rhythm. Temporal trends in incidence and survival to hospital discharge were compared across non-refractory and refractory OHCA, defined as cases receiving 3 or more consecutive shocks for a persistent shockable rhythm. Risk-adjusted logistic regression models were used to describe the year-on-year change in the likelihood of refractory OHCA and survival to hospital discharge. Results: Of the 7,267 initial shockable OHCA with an attempted resuscitation, 4168 (57.4%) and 3,099 (42.6%) were non-refractory and refractory OHCA, respectively. The proportion of cases with refractory OHCA declined over the study period from 48.4% in 2010 to 40.2% in 2019 (p trend <0.001). Unadjusted survival to hospital discharge was higher in non-refractory OHCA (46.3% vs. 25.8%, p<0.001), although both populations experienced increases in survival over time (p trend <0.05 for both). After adjustment for arrest confounders, the likelihood of refractory VF decreased by 4.4% every year (adjusted odds ratio [AOR]: 0.96, 95% CI: 0.94, 0.97; p<0.001). Factors reducing the likelihood of refractory OHCA were female sex, bystander CPR, arrest witnessed by emergency medical services, and public location. In the survival model, refractory OHCA was independently associated with a reduction in survival to hospital discharge (AOR 0.50, 95% CI: 0.45, 0.56; p<0.001). Temporal improvements in survival were observed year-on-year (AOR 1.03, 95% CI: 1.02, 1.05; p<0.001) and this did not differ between non-refractory and refractory OHCA (group interaction, p = 0.51). Conclusions: The incidence of refractory OHCA is declining in our region and survival outcomes are improving. Further research identifying factors contributing to the decline in refractory OHCA may help to improve outcomes further.

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Bernard, Stephen A., Janet E. Bray, Karen Smith, Michael Stephenson, Judith Finn, Hugh Grantham, Cindy Hein, et al. "Effect of Lower vs Higher Oxygen Saturation Targets on Survival to Hospital Discharge Among Patients Resuscitated After Out-of-Hospital Cardiac Arrest." JAMA, October 26, 2022. http://dx.doi.org/10.1001/jama.2022.17701.

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ImportanceThe administration of a high fraction of oxygen following return of spontaneous circulation in out-of-hospital cardiac arrest may increase reperfusion brain injury.ObjectiveTo determine whether targeting a lower oxygen saturation in the early phase of postresuscitation care for out-of-hospital cardiac arrest improves survival at hospital discharge.Design, Setting, and ParticipantsThis multicenter, parallel-group, randomized clinical trial included unconscious adults with return of spontaneous circulation and a peripheral oxygen saturation (Spo2) of at least 95% while receiving 100% oxygen. The trial was conducted in 2 emergency medical services and 15 hospitals in Victoria and South Australia, Australia, between December 11, 2017, and August 11, 2020, with data collection from ambulance and hospital medical records (final follow-up date, August 25, 2021). The trial enrolled 428 of a planned 1416 patients.InterventionsPatients were randomized by paramedics to receive oxygen titration to achieve an oxygen saturation of either 90% to 94% (intervention; n = 216) or 98% to 100% (standard care; n = 212) until arrival in the intensive care unit.Main Outcomes and MeasuresThe primary outcome was survival to hospital discharge. There were 9 secondary outcomes collected, including hypoxic episodes (Spo2 &lt;90%) and prespecified serious adverse events, which included hypoxia with rearrest.ResultsThe trial was stopped early due to the COVID-19 pandemic. Of the 428 patients who were randomized, 425 were included in the primary analysis (median age, 65.5 years; 100 [23.5%] women) and all completed the trial. Overall, 82 of 214 patients (38.3%) in the intervention group survived to hospital discharge compared with 101 of 211 (47.9%) in the standard care group (difference, −9.6% [95% CI, −18.9% to −0.2%]; unadjusted odds ratio, 0.68 [95% CI, 0.46-1.00]; P = .05). Of the 9 prespecified secondary outcomes collected during hospital stay, 8 showed no significant difference. A hypoxic episode prior to intensive care was observed in 31.3% (n = 67) of participants in the intervention group and 16.1% (n = 34) in the standard care group (difference, 15.2% [95% CI, 7.2%-23.1%]; OR, 2.37 [95% CI, 1.49-3.79]; P &lt; .001).Conclusions and RelevanceAmong patients achieving return of spontaneous circulation after out-of-hospital cardiac arrest, targeting an oxygen saturation of 90% to 94%, compared with 98% to 100%, until admission to the intensive care unit did not significantly improve survival to hospital discharge. Although the trial is limited by early termination due to the COVID-19 pandemic, the findings do not support use of an oxygen saturation target of 90% to 94% in the out-of-hospital setting after resuscitation from cardiac arrest.Trial RegistrationClinicalTrials.gov Identifier: NCT03138005

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Ball, Jocasta, Ziad Nehme, Melanie Villani, and Karen L. Smith. "Abstract 11901: CPR Quality During the COVID-19 Pandemic - More Evidence of Collateral Damage During Out-of-Hospital Cardiac Arrest." Circulation 144, Suppl_2 (November 16, 2021). http://dx.doi.org/10.1161/circ.144.suppl_2.11901.

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Introduction: Many regions around the world have reported declining survival rates from out-of-hospital cardiac arrest (OHCA) during the COVID-19 pandemic. This has been attributed to COVID-19 infection and overwhelmed healthcare services in some regions and imposed social restrictions in others. However, the effect of the pandemic period on CPR quality, which has the potential to impact outcomes, has not yet been described. Methods: A retrospective observational study was performed using data collected in an established OHCA registry in Victoria, Australia. During a pre-pandemic period (11 February 2019-31 January 2020) and the COVID-19 pandemic period (1 February 2020-31 January 2021), 1,111 and 1,349 cases with attempted resuscitation had complete CPR quality data, respectively. The proportion of cases where CPR targets (chest compression fraction [CCF]≥90%, compression depth 5-10cm, compression rate 100-120 per minute, pre-shock pauses <6 seconds, post-shock pauses <5 seconds) were met was compared between the pre-pandemic and pandemic periods. Logistic regression was performed to identify the independent effect of the COVID-19 pandemic on achieving CPR targets. Results: The proportion of arrests where CCF≥90% significantly decreased during the pandemic (57% vs 74% in the pre-pandemic period, p<0.001) as did the proportion with pre-shock pauses <6 seconds (54% vs 62%, p=0.019) and post-shock pauses <5 seconds (68% vs 82%, p<0.001). However, the proportion within target compression rate significantly increased during the pandemic (64% vs 56%, p<0.001). Following multivariable adjustment, the COVID-19 pandemic period was independently associated with a decrease in the odds of achieving a CCF≥90% (adjusted odds ratio [AOR] 0.47 [95% CI 0.40, 0.56]), a decrease in the odds of achieving pre-shock pauses<6 seconds (AOR 0.71 [95% CI 0.52, 0.96]), and a decrease in the odds of achieving post-shock pauses<5 seconds (AOR 0.49 [95% CI 0.34, 0.71]). Conclusion: CPR quality was impacted during the COVID-19 pandemic period which may have contributed to a decrease in OHCA survival previously identified. These findings reinforce the importance of maintaining effective resuscitation practices despite changes to clinical context.

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Dawson, Luke P., Emily Andrew, Ziad Nehme, Jason Bloom, Sinjini Biswas, Shelley Cox, David Anderson, et al. "Association of Socioeconomic Status With Outcomes and Care Quality in Patients Presenting With Undifferentiated Chest Pain in the Setting of Universal Health Care Coverage." Journal of the American Heart Association 11, no. 7 (April 5, 2022). http://dx.doi.org/10.1161/jaha.121.024923.

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BACKGROUND This study aimed to assess whether there are disparities in incidence rates, care, and outcomes for patients with chest pain attended by emergency medical services according to socioeconomic status (SES) in a universal health coverage setting. METHODS AND RESULTS This was a population‐based cohort study of individually linked ambulance, emergency, hospital admission, and mortality data in the state of Victoria, Australia, from January 2015 to June 2019 that included 183 232 consecutive emergency medical services attendances for adults with nontraumatic chest pain (mean age 62 [SD 18] years; 51% women) and excluded out‐of‐hospital cardiac arrest and ST‐segment–elevation myocardial infarction. Age‐standardized incidence of chest pain was higher for patients residing in lower SES areas (lowest SES quintile 1595 versus highest SES quintile 760 per 100 000 person‐years; P <0.001). Patients of lower SES were less likely to attend metropolitan, private, or revascularization‐capable hospitals and had greater comorbidities. In multivariable models adjusted for clinical characteristics and final diagnosis, lower SES quintiles were associated with increased risks of 30‐day and long‐term mortality, readmission for chest pain and acute coronary syndrome, lower acuity emergency department triage categorization, emergency department length of stay >4 hours, and emergency department or emergency medical services discharge without hospital admission and were inversely associated with use of prehospital ECGs and transfer to a revascularization‐capable hospital for patients presenting to non‐percutaneous coronary intervention centers. CONCLUSIONS In this study, lower SES was associated with a higher incidence of chest pain presentations to emergency medical services and differences in care and outcomes. These findings suggest that substantial disparities for socioeconomically disadvantaged chest pain cohorts exist, even in the setting of universal health care access.

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Nehme, Emily, Ziad Nehme, Shelley Cox, and Karen Smith. "Outcomes of paediatric patients who are not transported to hospital by Emergency Medical Services: a data linkage study." Emergency Medicine Journal, October 6, 2022, emermed-2022-212350. http://dx.doi.org/10.1136/emermed-2022-212350.

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BackgroundData on the safety of non-transport decisions for paediatric patients attended by Emergency Medical Services (EMS) are lacking. We describe the characteristics and outcomes of paediatric non-transported patients in Victoria, Australia.MethodsA retrospective data linkage study of consecutive paediatric (aged <18 years) non-transported patients between January 2015 and June 2019. Patients were linked to ED, hospital admission and death records. Multivariable logistic regression analyses were used to determine factors associated with EMS recontact, ED presentation, hospital admission and an adverse event (death/cardiac arrest, intensive care unit admission or highest ED triage category) within 48 hours of the initial emergency call.ResultsIn total, 62 975 non-transported patients were included. The mean age was 7.1 (SD 6.0) years and 48.9% were male. Overall, 2.2% recontacted the EMS within 48 hours, 13.7% self-presented to a public ED, 2.4% were admitted to hospital and 0.1% had an adverse event, including two deaths. Among patients with paramedic-initiated non-transport (excluding transport refusals and transport via other means), 5.6% presented to a public ED, 1.1% were admitted to hospital and 0.05% had an adverse event. In the overall population, an abnormal vital sign on initial assessment increased the odds of hospital admission and an adverse event. Among paramedic-initiated non-transports, cases occurring in the early hours of the morning (04:00–08:00 hours) were associated with increased odds of subsequent hospital admission, while the odds of ED presentation and hospital admission also increased with increasing prior exposure to non-transported cases.ConclusionAdverse events were rare among paramedic-initiated non-transport cases. Vital sign derangements and attendance by paramedics with higher prior exposure to non-transports were associated with poorer outcomes and may be used to improve safety.

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Navani, R. V., L. Dawson, E. Andrew, Z. Nehme, J. Bloom, S. Cox, D. Anderson, et al. "Variation in health-care quality and outcomes according to time of chest pain presentation: a state-wide prospective cohort study." European Heart Journal 43, Supplement_2 (October 1, 2022). http://dx.doi.org/10.1093/eurheartj/ehac544.1474.

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Abstract Background Previous studies examining temporal variation in cardiovascular care have largely been limited to assessing weekend and after-hours effects whereby those presenting on the weekend or after-hours have a poorer outcome. However, emerging evidence suggests more complex patterns in patterns and outcomes may exist. Purpose We aimed to determine patterns of temporal variation in chest pain presentations and subsequent health-care quality and outcomes. Methods This was an observational, prospective-cohort study of adult patients aged 18 and over who were attended by emergency medical services for non-traumatic chest pain between 1 January 2015 and 30 June 2019 in Victoria, Australia. Major exclusion criteria included pre-hospital diagnosis of ST elevation myocardial infarction or an out of hospital cardiac arrest. The exposure variable was time of day and day of week stratified into 168 hourly time periods. The primary outcome measure was 30-day mortality. Results The study cohort comprised 196,365 ambulance attendances for acute non-traumatic chest pain; mean age 62.4 years (SD 18.3) and 99,497 (50.7%) females. Three temporal patterns were observed for chest pain presentations (Figure 1): (1) a diurnal pattern with a sharp increase in presentations from 8 am, peaking around midday, before decreasing into late evening with a nadir between 3–4 am, (2) a weekend effect where Saturday and Sunday had a relatively lower rate of presentations compared to during the week, and (3) a Monday – Sunday gradient where more presentations were likely earlier in the week, than later. Six patterns were identified across pre-hospital and hospital key performance indicators (KPI) (diurnal, in/after-hours, weekend effect, Monday – Sunday gradient, a peak period and morning vs afternoon/evening effect. Risk of 30-day mortality was associated with weekend presentation (OR 1.15, 95% CI 1.06–1.24, p=0.001) and morning presentation between midnight and midday (OR 1.17, 95% CI 1.09–1.25, p<0.001) (Figure 2). Conclusion Chest pain presentations, care quality and outcomes demonstrate complex temporal variation beyond the already established weekend and after-hours effect. Such relationships should be considered during resource allocation and quality improvement programs in order to improve treatment quality across all days and times of the week. Funding Acknowledgement Type of funding sources: None.

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Bray, Janet, Stuart Howell, Stephen Bernard, Karen L. Smith, Judith Finn, Dion Stub, and Peter Cameron. "Abstract 13205: Short and Long-Term Outcomes of OHCA Patients Admitted to Wards From the Emergency Department." Circulation 144, Suppl_2 (November 16, 2021). http://dx.doi.org/10.1161/circ.144.suppl_2.13205.

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Introduction: The majority of research has examined out-of-hospital cardiac arrest (OHCA) patients admitted to intensive care units (ICU). Little is known about patients who are admitted to non-ICU wards. Our study aims to describe short and long term outcomes in OHCA patients admitted directly to medical wards from the emergency department. Methods: Data were obtained from the Victorian Ambulance Cardiac Arrest Registry and 12 hospitals for adult, non-traumatic OHCA cases transported to ED between 2014 and 2016. Results: Of 1578 OHCAs, 213 (13.5%) were admitted to medical or cardiac wards -only four were admitted for palliation. The majority were witnessed (38% bystander, 58% paramedic), received bystander CPR (91%, n=81/89), median downtime was 4 minutes (IQR 2-12), 179 (84%) were in a shockable rhythm, and 15 received public access defibrillation. Most had ROSC on arrival at ED (99%) and were conscious in ED (91%). Re-arrest inhospital occurred in 16 cases, the majority had a cardiac aetiology (85%) and underwent angiography (75%, 112/160 proceeded to PCI). The majority were discharged alive (n=194, 91%) and most survivors were discharged home (n=176/194, 84%) with good neurological outcomes (CPC 0-2 =94%, CPC 3= 4%). Survivors from the wards made up 30% of the overall OHCA survivors. Of survivors, 175 were alive at 12 months and 159 completed follow-up. The majority of those working prior were working at 12-months (78/92, 85%), 87% in the same role. The mean EuroQol index score for respondents was 0.77 (SD, 0.15). The mean 12-item short form Mental Component Summary score for patients was 55.0 (SD, 8.1), whereas the mean Physical Component Summary score was 49.1 (SD, 9.1). Conclusion: In our region OHCA patients admitted to wards have favourable arrest characteristics, and have good short- and long-term outcomes which are similar to regular acute coronary syndrome patients.

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Journal articles on the topic 'Cardiac arrest Victoria'

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