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Original research
Impact of pandemic-related movement restriction on public access defibrillation in Japan: a retrospective cohort study
  1. Kentaro Omatsu1,
  2. Akira Yamashita2,
  3. Hideo Inaba1,3
  1. 1 Department of Emergency Medical Sciences, Niigata University of Health and Welfare, Niigata, Japan
  2. 2 Department of Cardiology, Noto General Hospital, Nanao, Japan
  3. 3 Department of Emergency Medicine, Kanazawa Medical University, Kahoku-gun, Japan
  1. Correspondence to Dr Kentaro Omatsu; omatsu{at}nuhw.ac.jp

Abstract

Objectives To analyse monthly changes in public access defibrillation (PAD) incidence and outcomes of out-of-hospital cardiac arrest (OHCA) during the 2020–2021 COVID-19 pandemic compared with those during the 2016–2019 prepandemic period with consideration of pandemic-related movement restriction.

Design Retrospective cohort study.

Setting An extended database was created by combining and reconciling the nationwide Utstein-style OHCA and the emergency medical service (EMS) transportation databases in Japan.

Participants We analysed 226 182 EMS-witnessed, non-newborn and out-of-home OHCA cases in Japan.

Primary and secondary outcome measures The primary outcomes were the PAD incidence and neurologically favourable 1-month survival rate. The secondary outcomes were bystander cardiopulmonary resuscitation (CPR) provision and dispatcher-assisted CPR attempts.

Results The proportion of out-of-home OHCA cases slightly decreased during the pandemic (from 33.7% to 31.9%). Although the pandemic was associated with a decreased PAD incidence, 2-year trend analyses by an interaction test showed that the PAD incidence was lower during the first nationwide declaration of a state of emergency (p<0.001) and in the pandemic’s second year (p<0.01). Regardless of location, delays in basic life support (BLS) actions and EMS contact with patients were more common and the rate of PAD-induced return of spontaneous circulation was lower during the pandemic. PAD incidence reduction was significant only in locations with a recommendation of automated external defibrillator placement (p<0.001). In other locations, a pronounced delay in BLS was found during the pandemic. The neurologically favourable survival rate was reduced in parallel with the reduced PAD incidence during the pandemic (r=0.612, p=0.002).

Conclusions Prolonged and repeated movement restrictions during the COVID-19 pandemic worsened the OHCA outcomes concurrently with disturbed BLS actions, including the reduced PAD incidence in out-of-home settings. Maintaining BLS training, re-arranging automated external defibrillator placement and establishing a local alert system for recruiting well-trained citizens to the scene are essential.

  • COVID-19
  • cardiopulmonary resuscitation
  • defibrillators

Data availability statement

Data are available on reasonable request. The datasets generated and analysed during the current study are available from the corresponding author on reasonable request.

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STRENGTHS AND LIMITATIONS OF THIS STUDY

  • We used an extended database created by combining and reconciling the nationwide Utstein-style database of patients with out-of-hospital cardiac arrest and the emergency medical service transportation database in Japan.

  • There was a lack of detailed data on patients’ backgrounds.

  • Specific information regarding bystanders including age, sex and training experience was not included in the database and, therefore, could not be analysed in this study.

  • The fact that termination of resuscitation is not allowed in prehospital settings in Japan may limit the generalisation of our results to other countries.

Background

The implementation of a public access defibrillation (PAD) programme including placement recommendations and training for usage as a part of basic life support (BLS) has been shown to improve the neurologically favourable outcomes of out-of-hospital cardiac arrest (OHCA), particularly in patients with shockable initial rhythms.1–5 Since 2004, Japan has progressively implemented the PAD programme in various public settings such as in commercial institutes where many citizens gather,6 leading to the estimated placement of over 600 000 automated external defibrillators (AEDs) over two decades.7

The COVID-19 pandemic has greatly impacted citizens’ lifestyles and the healthcare system worldwide.8 In Japan, the Ministry of Health, Labour and Welfare requested Japanese citizens to avoid the ‘3 Cs’ (closed spaces with poor ventilation, crowded places and closed contact settings)9 and released the 2020 ‘Basic Policy for Countermeasures against New Coronavirus Infectious Diseases’.10 This policy included recommendations for non-essential workers to work from home, reduce working hours and refrain from travelling across prefectures, as well as the closure or reduction of operating hours for restaurants and entertainment facilities.

Early systematic reviews have shown that both outcomes of and citizens’ BLS actions in response to OHCA including PAD deteriorated during the first year of the pandemic in countries with a high infection rate.11 12 However, a later systematic review reported that bystander cardiopulmonary resuscitation (CPR) did not differ during the COVID-19 pandemic compared with that before, while the incidence of PAD was reduced during the pandemic.13 A previous study in Japan also reported a reduced incidence of PAD; however, they have reported contradictory findings on other citizens’ responses to and outcomes of OHCA.14

The PAD incidence may reflect a well-organised, integrated BLS action involving multiple rescuers within a community,15 as PAD is reportedly associated with superior neurologically favourable outcomes compared with bystander CPR alone, even when return of spontaneous circulation (ROSC) is not achieved by PAD before EMS arrival.16 We hypothesised that alterations of the out-of-home OHCA outcomes during the pandemic would be synchronised with those of the PAD incidence caused by the restriction of out-of-home activities. In this study, we analysed the trends in PAD and neurologically favourable outcomes of out-of-home OHCA in locations with the recommendation of AED placement, as well as in other locations.

Methods

Study design

This was a retrospective cohort study. Data from the All-Japan Utstein Registry, a prospective, nationwide, population-based registry of patients with OHCA, and nationwide data on EMS transportation in Japan from 1 January 2016 to 31 December 2021, were analysed after obtaining permission from the Fire and Disaster Management Agency (FDMA). This study has been reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology guidelines for observational studies.

Patient and public involvement

Patients were not involved in study design, data interpretation, or report writing.

Setting

As the healthcare system in Japan is generally under public insurance coverage, citizens are not charged for EMS use. Each ambulance team consists of three EMS personnel including at least one paramedic. EMS teams are not allowed to terminate resuscitation in the field unless a patient with OHCA is decapitated, incinerated or shows postmortem corruption.17 Paramedics are authorised to perform the following resuscitation procedures: use of airway adjuncts including supra-pharyngeal or laryngeal-mask airways, and peripheral venous infusion of Ringer’s lactate. Furthermore, authorised and specially trained paramedics are permitted to insert tracheal tubes and administer intravenous epinephrine. EMS teams manage patients with OHCA in accordance with their regional medical control council protocol based on the Japan Resuscitation Council Guidelines.18

After the first case of a patient with COVID-19 was reported in Japan, the FDMA notified all paramedics attending to patients with OHCA with confirmed or suspected COVID-19 to follow preventive measures.19 Dispatchers actively attempted dispatcher-assisted CPR (DA-CPR) instructions before the FDMA statement that instruction of compression-only CPR was recommended for all adult OHCA cases, regardless of bystanders’ training experience.

Participants

After the Utstein-style database of patients with OHCA between 1 January 2016 and 31 December 2021 was combined and reconciled with the EMS transportation database, we extracted non-EMS-witnessed non-newborn OHCA cases in out-of-home settings.

Databases

The All-Japan Utstein Registry includes information concerning patients’ background, clinical characteristics and critical time records based on the Utstein recommendations for reporting OHCA cases.20 The FDMA nationwide database for all EMS transportation cases includes location information, time records, classifications of accidents and underlying medical diseases.

Location subgroups

The Japanese Guidelines Optimal Placement and Accessibility of Public-access AEDs21 provide a list of institutions or facilities where AED placement is strongly recommended considering the OHCA incidence, OHCA risk of events, probability of witnesses and time duration from EMS service provision. We divided the arrest locations into two categories: locations with AED placement recommendations and others.

Outcome measures

The primary outcomes of this study were neurologically favourable 1-month survival rates defined by a Cerebral Performance Categories20 score of 1 or 2 points and PAD incidence was calculated by dividing the number of PAD-performed cases by the total number of out-of-home OHCA cases. The secondary outcomes were bystander CPR provision and DA-CPR attempts.

Statistical analyses

Differences in characteristics and outcomes between the 4 years before the pandemic (2016–2019) and the pandemic years (2020–2021) were analysed using the χ2 test for nominal variables and the Kruskal-Wallis test for continuous variables. The crude ORs and 95% CIs were calculated using the 4 years before the pandemic as the reference period for nominal variables. The effect of the pandemic on the 2-year trends of PAD incidence and neurologically favourable 1-month survival rate was assessed by a simple binominal interaction test (month and pandemic) to identify whether the monthly variations were affected by the pandemic. In location-subgroup analyses, the interaction between subgroups and the pandemic was reported, in addition to the differences in major characteristics and outcomes between the 4 years before the pandemic and 2 years during the pandemic.

Multivariable interaction tests were used to identify the association of various pandemic phases (the first/second/third state of emergency and first/second pandemic year) with the pandemic influence. Synchronous monthly changes in the PAD incidence and neurologically favourable 1-month survival rate during the pandemic were assessed by the correlation of monthly residual error values between the PAD incidence and survival rate. We considered two-sided p<0.05 to be statistically significant. All analyses were performed using the JMP Pro V.17 software (SAS Institute, Cary, North Carolina, USA).

Results

Case selection

After excluding 58 275 EMS-witnessed OHCA cases, 429 newborn OHCA cases, 19 cases without any location information and 457 160 at-home OHCA cases from a comprehensive database of 742 016 OHCA cases during the period of 2016–2021, 226 182 OHCA cases were ultimately selected for analysis (online supplemental figure 1).

Supplemental material

Two-year monthly trends in the proportion of out-of-home OHCA cases, PAD incidence and neurologically favourable 1-month survival rate

The proportion of out-of-home OHCA cases in all non-EMS-witnessed non-newborn OHCA cases during the 4 years before the pandemic showed an apparent seasonal variation; it was lower in the winter (1, 2, 12, 13, 14 and 24 months over the 2-year period) and higher in the summer (6–9 and 18–21 months). During the pandemic, the proportion decreased temporarily during the initial state of emergency, and the elevation during the summer months was attenuated (p for interaction between month and pandemic 2 years <0.001) (figure 1A).

Figure 1

Two-year monthly trends in OHCA case proportion, PAD incidence and neurologically favourable 1-month survival rate. OHCA, out-of-hospital cardiac arrest; PAD, public access defibrillation.

The 2-year monthly trends in the PAD incidence and neurologically favourable 1-month survival rate during the 2 years during the pandemic were notably different from those during the 4 years before the pandemic. During the pandemic, both the PAD incidence and survival rate were lower, mainly during the first state of emergency, and remained low throughout the second pandemic year (p<0.001) (figure 1B,C). This observation was statistically supported by a multivariate interaction test for neurologically favourable 1-month survival including three phasic classifications: the first state of emergency period/other periods, the first/second pandemic year and OHCA cases under any state of emergency/other cases. This analysis found significant interactions with the pandemic effect only in the first state of the emergency period and second pandemic year (online supplemental table 1). Furthermore, the neurologically favourable survival rate appeared to vary in parallel with the PAD incidence during the pandemic. A correlation analysis showed a significant correlation between the monthly residual errors of the PAD incidence and survival rate during the 2 years of the pandemic (r=0.612, p=0.002).

Effects of the pandemic on the epidemiology, characteristics and outcomes of OHCA

Analyses of 2-year trends (table 1) showed the following considerable pandemic effects in addition to decreases in the PAD incidence and survival rate: increases in the proportion of OHCA cases during daytime and at care/medical facilities, as well as that of OHCA cases of presumed cardiac aetiology; increases in the rates of all and compression-only bystander CPR; decreased proportions of all bystander-witnessed, friend/family-witnessed and accidental OHCA cases and a slightly altered age distribution of patients with OHCA (a decreased proportion of non-older adults and increased proportion of older adults).

Table 1

Biennial trends in epidemiology and characteristics of OHCA and prehospital resuscitation efforts

Comparisons of the pandemic effect between the two location groups with and without AED placement recommendation

The 2-year monthly trends of the PAD incidence and neurologically favourable 1-month survival rate in OHCA cases at sites with AED placement recommendations were impacted by the pandemic, mirroring trends observed across all out-of-home OHCA cases (figure 2). In areas without the recommendation, the trends in PAD incidence remains relatively unaffected (p=0.175), whereas the pandemic-induced changes in survival rates were consistent with those observed across all out-of-home OHCA and OHCA cases in locations with AED placement recommendations (figure 3).

Figure 2

Two-year monthly trends in PAD incidence and survival rate in locations with AED placement recommendations. AED, automated external defibrillator; OHCA, out-of-hospital cardiac arrest; PAD, public access defibrillation.

Figure 3

Two-year monthly trends in PAD incidence and survival rate in locations without AED placement recommendations. AED, automated external defibrillator; OHCA, out-of-hospital cardiac arrest; PAD, public access defibrillation.

These observations were supported by analyses of the interaction between the pandemic effect and location group for the main characteristics and outcomes of OHCA (online supplemental table 2). Significant interactions were detected only for the incidences of shockable initial rhythms and PAD and rate of compression-only bystander CPR.

More detailed analyses of bystanders’ responses to OHCA in bystander-witnessed OHCA cases showed that delayed BLS (the time interval between witnessing the event and bystander CPR or PAD ≥5 min) was more common during the pandemic (table 2). Moreover, the interaction test showed that this delay was significantly enhanced in locations without AED placement recommendations (p=0.047). Further analyses of bystander-witnessed OHCA cases with PAD showed that the rate of bystander CPR decreased during the pandemic only in locations without AED placement recommendation (p=0.04) and that the rate of PAD-induced ROSC before EMS contact with patients largely decreased by the pandemic in both areas (online supplemental table 3).

Table 2

Differential pandemic effects on time factors and outcomes of bystander-witnessed out-of-home OHCA between the location groups

Discussion

In Japan, the penetration rate of AEDs at home is extremely low. In this study, we found that the outcomes of out-of-home OHCA worsened during the COVID-19 pandemic due to prolonged and repeated movement restrictions. This was accompanied by a reduction in PAD incidence in out-of-home settings, which was attributed to the disturbed BLS actions.

The Basic Policy for Countermeasures against New Coronavirus Infectious Diseases10 released by the Japanese government included a recommendation of working at home for non-essential workers and a shortening of working hours, as well as an order to refrain from large public and commercial events. Furthermore, workers and students with COVID-19 and those having close contact with an infected person were forced to stay home for at least 10 days. These policies were likely to produce chaotic changes in the BLS actions of bystanders in response to out-of-home OHCA and, presumably, an imbalance between demand and supply of well-trained or high-quality BLS.

The pandemic significantly lowered the overall proportion of out-of-home OHCA cases across all non-newborn, non-EMS-witnessed cases, particularly during seasons other than winter (figure 1A). However, the degree of this decrease was small, presumably due to the COVID-19 movement restrictions in Japan during all states of emergency declarations, which were government requests rather than legally enforced lockdowns.1 Furthermore, the proportion of outdoor OHCA cases among out-of-home OHCA cases was unaltered and that of OHCA cases in locations with recommendations for AED placement, particularly in care/medical facilities with a high incidence of OHCA, was augmented by the pandemic. Thus, the demand for BLS in out-of-home settings was neither largely decreased nor increased by the pandemic.

In contrast, the supply of early high-quality BLS was likely to be reduced by the pandemic. This study’s detailed analyses of BLS actions in bystander-witnessed OHCA cases support this assumption. Delays in BLS actions by bystanders and EMS contact with patients were more common during the pandemic. The decline in PAD incidence resulted in a more significant reduction in the PAD-induced ROSC rate than anticipated.

An increased number of rescuers has been reported to improve the outcomes of OHCA in out-of-home settings.15 In PAD cases, more than two rescuers including at least one who is well-trained are needed to increase the chance of prehospital ROSC before EMS contact with patients. It is highly possible that the pandemic reduced the proportion of this ideal situation. Many facility staff members with recent training experience in BLS who had close contact with an infected person were forced to stay at home and were replaced with other staff or part-time workers without the training experience.22 Furthermore, the number of potential volunteers for BLS actions in the community decreased because BLS training courses conducted by fire departments and other organisations were reduced in frequency and scale as an infection control policy.23 The situation may have been poorer in care/medical facilities, where strict infection control was conducted and the number of staff, particularly nurses, was consistently lower than required.

This study showed that out-of-home OHCA cases of presumed cardiac aetiology increased during the pandemic, whereas those with shockable initial rhythms decreased. COVID-19 is a multisystem disease that can include cardiovascular manifestations.24 Deterioration of underlying diseases and/or increased incidence of ischaemic heart disease due to decreased hospital visits and lack of exercise during the pandemic might underline this observation. However, the main cause of cardiac arrest in patients with COVID-19 was respiratory and the most common initial ECG rhythm was asystole,25 although a large delay in the initiation of BLS action might convert shockable initial rhythms to asystole. We failed to clarify the exact reasons for the decreased incidence of shockable initial rhythms because detailed information on underlying diseases was lacking in our database.

Developing alternative methods for providing BLS training is necessary during a pandemic. New teams and staff recruited at locations with a high chance of witnessing OHCA should be targeted for BLS training. Exact information on the risks and benefits of performing BLS should be provided to citizens. This may improve subjective norms for performing BLS in the community.26 A local alert system to recruit well-trained bystanders to the scene of OHCA27 and the rearrangement of AEDs to easily accessible places may effectively increase the number of well-trained rescuers at the location.

Limitations

This study had some limitations that need to be considered. First, a lack of detailed data on patients’ backgrounds made it difficult to determine whether they had different risk factors related to OHCA. Second, specific information regarding bystanders including age, sex and training experience was not included in the database and, therefore, could not be analysed in this study. This information could have potentially affected the results and their interpretation. Third, the fact that termination of resuscitation is not allowed in prehospital settings in Japan may have contributed to differences in our results compared with those from other countries. Finally, similar to other observational studies, data validity represents a potential limitation.

Conclusions

Prolonged and repeated movement restrictions during the COVID-19 pandemic reduced the neurologically favourable survival rate of patients with OHCA concurrently with disturbed BLS actions, including the reduced incidence of PAD in out-of-home settings. To prevent deterioration of OHCA outcomes during the pandemic, it is crucial to continue providing BLS training, reposition AEDs and establish a local alert system to call on well-trained citizens to assist at the scene.

Data availability statement

Data are available on reasonable request. The datasets generated and analysed during the current study are available from the corresponding author on reasonable request.

Ethics statements

Patient consent for publication

Ethics approval

This study was approved by the Research Ethics Committee of Kanazawa Medical University as a study project (I-729) and conducted in accordance with the Guidelines for Medical and Health Research Involving Human Subjects issued by the Japanese Ministry of Health, Labour and Welfare as well as the tenets of the Declaration of Helsinki. The requirement for obtaining written informed consent was waived because the data analysed in this study were anonymised and secondary.

Acknowledgments

We thank the Japan Utstein Registry of the Fire and Disaster Management Agency for providing this database. We also thank Editage (www.editage.jp) for English language editing.

References

Footnotes

  • Contributors KO is responsible for the writing of this manuscript accuracy of the data and accepts full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish. Conception and study design: KO, HI; data analyses and/or interpretation: KO, HI; manuscript drafting: KO, AY and HI. All authors have read and approved the final manuscript.

  • Funding The Japan Society for the Promotion of Science Grants-in-Aid for Scientific Research (Grant Number JP23K02268) supported this study.

  • Disclaimer The funders had no role in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review or approval of the manuscript and decision to submit the manuscript for publication.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.