Clinical paperOut-of-hospital cardiac arrests occurring in primary health care facilities in Singapore☆
Introduction
Out-of-hospital cardiac arrest (OHCA) is an international health issue and published survival rates vary greatly.1 The “chain of survival” concept2 states that survival can be improved with early access, early cardio-pulmonary resuscitation (CPR), early defibrillation and early advanced care. There is currently good research that indicates this is true with shorter response times,3 early CPR,4, 5 and early defibrillation (<8 min).6, 7
Primary health care practitioners, general practitioners (GPs) and primary health care nurses can have an important role in the management of OHCA.8, 9 Cardiac arrests do occur in primary health care facilities or during home visits and health care practitioners may often be called to initiate resuscitation before emergency crews arrive.8 Primary health care practitioners can provide early CPR, activate the emergency medical services (EMS) and early defibrillation by GPs has been shown to improve outcome.10 However the local incidence of cardiac arrest occurring in primary health care clinics has not been studied previously. An earlier study did show that local primary care physicians do see themselves as having an important role in resuscitation.11
Singapore's EMS system is run by the Singapore Civil Defence Force (SCDF), which currently operates 31 ambulances based in 14 fire stations. It is primarily a single tier system, able to provide basic life support and defibrillation with automated external defibrillators (AEDs). The Cardiac Arrest and Resuscitation Epidemiology (CARE) study group includes representatives from the six major public hospitals in Singapore, the Singapore Civil Defence Force, Health Sciences Authority and the Clinical Trials and Epidemiology Research Unit, Singapore Health Services. The current report is part of the CARE study,12 which described out-of-hospital cardiac arrest (OHCA) epidemiology in Singapore and found overall survival to discharge from OHCA to be 2.0%. Mean EMS response time was 10.2 min.
In this study, we aim to describe the incidence of OHCA occurring in primary health care facilities in Singapore. We will also compare the patient, event and response characteristics with those arrests occurring in the community and look for possible areas of improvement in our national response to OHCA.
Section snippets
Materials and methods
This study is a prospective observational study of OHCA occurring in primary health care facilities and conveyed by the SCDF ambulance service. The SCDF operates the national 995 emergency telephone service; private ambulance operators do not convey emergency cases. The study period was 1 October 2001 to 14 October 2004.
Patients of all ages were included. Exclusion criteria were those ‘obviously dead’ as defined by the presence of decomposition, rigor mortis or dependant lividity. Patient
Results
From 1 October 2001 to 14 October 2004, the data from 2428 subjects were received, of which 138 patients were OHCA occurring in health care facilities (HCF) (Table 1). Based on a population of 4.1 million14 in Singapore during 2004, this is an incidence of 1.12/100,000 population per year. This constituted 6.0% of all OHCA occurring in Singapore over a year.
Table 1 shows there were a lower proportion of Chinese having arrests in HCF and a higher proportion of Malays and Indians compared to the
Discussion
In this study, we found the incidence of OHCA in primary health care facilities to be 1.12/100 000 population per year. This constituted 6.0% of all OHCA occurring in Singapore over a year. We consider this to be a significant number and it suggests that primary health care providers do have an important role locally in managing out-of-hospital cardiac arrest.
We note the differing racial distribution of cardiac arrests presenting to HCF compared to community arrests (Table 1). This may
Conclusion
In conclusion, we found 6.0% of all OHCA occurring in Singapore over a year were in primary health care facilities. This suggests that primary health care providers do have an important role locally in managing out-of-hospital cardiac arrest. We propose an initiative to encourage early defibrillation by primary health care providers.
Conflict of interest statement
All the authors have neither commercial nor personal associations or any sources of support that might pose a conflict of interest in the subject matter or materials discussed in this manuscript.
Acknowledgements
CARE study group. We thank the following CARE study group investigators: Rabind Antony Charles, MBBS (S’pore), FRCS Ed (A&E), Consultant, Department of Emergency Medicine, Singapore General Hospital; Fatimah Abdul Lateef, MBBS (S’pore), FRCS Ed (A&E), Consultant, Department of Emergency Medicine, Singapore General Hospital; Peter George Manning, MBBS (London), FACEP, Senior Consultant & Chief, Emergency Medicine Department, National University Hospital; Charles Chan Johnson, MBBS (S’pore), FRCS
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A Spanish translated version of the summary of this article appears as Appendix in the final online version at 10.1016/j.resuscitation.2006.11.004.