Challenges and perceived impacts of ambulance diversions during emergency department overcrowding: a multi-stakeholder study.

Objectives: Ambulance diversion has emerged as a strategy to address Emergency Department (ED) overcrowding, but the question of when or whether diversion should be triggered is widely debated. Although the positive and adverse impacts of diversion have been primarily studied using quantitative data, little is known about the experience and perceptions of key stakeholders involved in diversions. Our study aims to explore the challenges and impacts of ambulance diversion as experienced by key stakeholders and their suggestions for improving the diversion process.

Variable importance analysis with interpretable machine learning for fair risk prediction.

Machine learning (ML) methods are increasingly used to assess variable importance, but such black box models lack stability when limited in sample sizes, and do not formally indicate non-important factors. The Shapley variable importance cloud (ShapleyVIC) addresses these limitations by assessing variable importance from an ensemble of regression models, which enhances robustness while maintaining interpretability, and estimates uncertainty of overall importance to formally test its significance. In a clinical study, ShapleyVIC reasonably identified important variables when the random forest and XGBoost failed to, and generally reproduced the findings from smaller subsamples (n = 2500 and 500) when statistical power of the logistic regression became attenuated.

Machine learning prediction of refractory ventricular fibrillation in out-of-hospital cardiac arrest using features available to EMS.

Background: Shock-refractory ventricular fibrillation (VF) or ventricular tachycardia (VT) is a treatment challenge in out-of-hospital cardiac arrest (OHCA). This study aimed to develop and validate machine learning models that could be implemented by emergency medical services (EMS) to predict refractory VF/VT in OHCA patients.

Methods: This was a retrospective study examining adult non-traumatic OHCA patients brought into the emergency department by Singapore EMS from the Pan-Asian Resuscitation Outcomes Study (PAROS) registry.

Increasing neurologically intact survival after out-of-hospital cardiac arrest among elderly: Singapore Experience.

Objectives: With more elderly presenting with Out-of-Hospital Cardiac Arrests (OHCAs) globally, neurologically intact survival (NIS) should be the aim of resuscitation. We aimed to study the trend of OHCA amongst elderly in a large Asian registry to identify if age is independently associated with NIS and factors associated with NIS.

Methods: All adult OHCAs aged ≥18 years attended by emergency medical services (EMS) from April 2010 to December 2019 in Singapore was extracted from the Pan-Asian Resuscitation Outcomes Study (PAROS) registry.

Does witness type affect the chance of receiving bystander CPR in out-of-hospital cardiac arrest?

Objectives: The relationship between the bystander witness type and receipt of bystander CPR (BCPR) is not well understood. Herein we compared BCPR administration between family and non-family witnessed out-of-hospital cardiac arrest (OHCA).

Background: In many communities, interventions in the past decade have contributed to an increased receipt of BCPR, for example in Singapore from 15% to 60%.

Validation of the CaRdiac Arrest Survival Score (CRASS) for predicting good neurological outcome after out-of-hospital cardiac arrest in an Asian emergency medical service system.

Background: Survival with favorable neurological outcomes is an important indicator of successful resuscitation in out-of-hospital cardiac arrest (OHCA). We sought to validate the CaRdiac Arrest Survival Score (CRASS), derived using data from the German Resuscitation Registry, in predicting the likelihood of good neurological outcomes after OHCA in Singapore.

Methods: We conducted a retrospective population-based validation study among EMS-attended OHCA patients (≥18 years) in Singapore, using data from the prospective Pan-Asian Resuscitation Outcomes Study registry.

The association between mode of transport and out-of-hospital cardiac arrest outcomes in Singapore.

Objective: We aimed to examine the survival outcomes of out-of-hospital cardiac arrest (OHCA) patients, stratified by the transportation modes to the Emergency Department (ED).

Methods: This was a retrospective analysis of Singapore's Pan-Asian Resuscitation Outcomes Study registry from Apr 2010-Dec 2017. The primary outcome was survival to discharge or 30 days post-arrest.

Implementation of a National 5-Year Plan for Prehospital Emergency Care in Singapore and Impact on Out-of-Hospital Cardiac Arrest Outcomes From 2011 to 2016.

Background Outcomes of patients from out-of-hospital cardiac arrest (OHCA) vary widely globally because of differences in prehospital systems of emergency care. National efforts had gone into improving OHCA outcomes in Singapore in recent years including community and prehospital initiatives. We aimed to document the impact of implementation of a national 5-year Plan for prehospital emergency care in Singapore on OHCA outcomes from 2011 to 2016.

Comparison of inhalational methoxyflurane (Penthrox®) and intramuscular tramadol for prehospital analgesia.

Introduction: Treatment of pain is an important component of prehospital care. Inhalational analgesia agents have attractive strengths, but there is a paucity of studies comparing these with more conventional agents. We aimed to compare inhalational methoxyflurane and intramuscular (IM) tramadol as first-contact analgesia in the Singapore national ambulance service.

Effectiveness of a community based out-of-hospital cardiac arrest (OHCA) interventional bundle: Results of a pilot study.

Background: 70% of Out-of-hospital cardiac arrests (OHCA) in Singapore occur in residential areas, and are associated with poorer outcomes. We hypothesized that an interventional bundle consisting of Save-A-life (SAL) initiative (cardiopulmonary resuscitation (CPR)/automated external defibrillator (AED) training and public-housing AED installation), dispatcher-assisted CPR (DA-CPR) program and myResponder (mobile application) will improve OHCA survival.

Methods: This is pilot data from initial implementation of a stepped-wedge, before-after, real-world interventional bundle in six selected regions.

Effect of vertical location on survival outcomes for out-of-hospital cardiac arrest in Singapore.

Background: A large proportion of out-of-hospital cardiac arrest (OHCA) cases occur in high-rise residential buildings. This study aims to investigate the effect of vertical location on survival outcomes and response times.

Methods: This is a retrospective study based on data obtained from the Singapore cohort of the Pan-Asian Resuscitation Outcomes Study (PAROS) from January 2011 to December 2014.

Comparison of Outcomes and Characteristics of Emergency Medical Services (EMS)-Witnessed, Bystander-Witnessed, and Unwitnessed Out-of-Hospital Cardiac Arrests in Singapore.

The objective was to compare the survival outcomes of emergency medical services (EMS)-witnessed to bystander-witnessed, and unwitnessed out-of-hospital cardiac arrests (OHCA) in Singapore. Secondary aims are to describe the 5-year trend in survival rates of EMS-witnessed arrests. This was a retrospective analysis of the Singapore's OHCA registry data from 2011 to 2015.

Modifiable Factors Associated With Survival After Out-of-Hospital Cardiac Arrest in the Pan-Asian Resuscitation Outcomes Study.

Study Objective: The study aims to identify modifiable factors associated with improved out-of-hospital cardiac arrest survival among communities in the Pan-Asian Resuscitation Outcomes Study (PAROS) Clinical Research Network: Japan, Singapore, South Korea, Malaysia, Taiwan, Thailand, and the United Arab Emirates (Dubai).

Methods: This was a prospective, international, multicenter cohort study of out-of-hospital cardiac arrest in the Asia-Pacific. Arrests caused by trauma, patients who were not transported by emergency medical services (EMS), and pediatric out-of-hospital cardiac arrest cases (<18 years) were excluded from the analysis.

The Pan-Asian Resuscitation Outcomes Study (PAROS) clinical research network: what, where, why and how.

Out-of-hospital cardiac arrest (OHCA) is a global health concern with an incidence rate of 50-60 per 100,000 person-years. To improve OHCA survival rates, several cardiac arrest registries have been set up in North America and Europe, such as the Resuscitation Outcomes Consortium, Cardiac Arrest Registry to Enhance Survival, Ontario Prehospital Advanced Life Support and European Registry of Cardiac Arrest. In Asia, however, there was previously no concerted effort in prehospital emergency care research owing to differences in prehospital emergency medical services systems, data collection methods and outcome reporting between countries.

Characteristics and outcomes of young adults who suffered an out-of-hospital cardiac arrest (OHCA).

Background: There is paucity of data examining the incidence and outcomes of young OHCA adults. The aim of this study is to determine the outcomes and characteristics of young adults who suffered an OHCA and identify factors that are associated with favourable neurologic outcomes.

Methods: All EMS-attended OHCA adults between the ages of 16 and 35 years in the Pan-Asian Resuscitation Outcomes Study (PAROS) registry were analysed.

Termination of Resuscitation Rules to Predict Neurological Outcomes in Out-of-Hospital Cardiac Arrest for an Intermediate Life Support Prehospital System.

Aim: Futile resuscitation can lead to unnecessary transports for out-of-hospital cardiac arrest (OHCA). The Basic Life Support (BLS) and Advanced Life Support (ALS) termination of resuscitation (TOR) guidelines have been validated with good results in North America. This study aims to evaluate the performance of these two rules in predicting neurological outcomes of OHCA patients in Singapore, which has an intermediate life support Emergency Medical Services (EMS) system.

A before-after interventional trial of dispatcher-assisted cardio-pulmonary resuscitation for out-of-hospital cardiac arrests in Singapore.

Aim: To evaluate the effects of a comprehensive dispatcher-assisted CPR (DACPR) training program on bystander CPR (BCPR) rate and the outcomes of out-of-hospital cardiac arrest (OHCA) in Singapore.

Methods: This is an initial program evaluation of a national DACPR intervention. A before-after analysis was conducted using OHCA cases retrieved from a local registry and DACPR information derived from audio recordings and ambulance notes.

Does pre-hospital endotracheal intubation improve survival in adults with non-traumatic out-of-hospital cardiac arrest? A systematic review.

Introduction: Endotracheal intubation (ETI) is currently considered superior to supraglottic airway devices (SGA) for survival and other outcomes among adults with non-traumatic out-of-hospital cardiac arrest (OHCA). We aimed to determine if the research supports this conclusion by conducting a systematic review.

Methods: We searched the MEDLINE, Scopus and CINAHL databases for studies published between January 1, 1980, and 30 April 30, 2013, which compared pre-hospital use of ETI with SGA for outcomes of return of spontaneous circulation (ROSC); survival to hospital admission; survival to hospital discharge; and favorable neurological or functional status.

Knowledge of signs and symptoms of heart attack and stroke among Singapore residents.

Aim: To determine the level of knowledge of signs and symptoms of heart attack and stroke in Singapore resident population, in comparison to the global community.

Methods: A population based, random sample of 7,840 household addresses was selected from a validated national sampling frame. Each participant was asked eight questions on signs and symptoms of heart attack and 10 questions on stroke.

Implications for public access defibrillation placement by non-traumatic out-of-hospital cardiac arrest occurrence in Singapore.

Introduction: The American Heart Association recommends automated external defibrillator placement in public areas with a high probability (>1) of out-of-hospital cardiac arrest (OHCA) occurring in 5 years. We aimed to determine the incidence rate of OHCA for different location categories in Singapore.

Methods: Cardiac arrest incidence was obtained from a national registry.

Recognition and treatment of out-of-hospital cardiac arrests by non-emergency ambulance services in Singapore.

Introduction: Prompt recognition of cardiac arrest and initiation of cardiopulmonary resuscitation (CPR) and defibrillation is necessary for good outcomes from out-of-hospital cardiac arrest (OHCA). This study aims to describe the recognition and treatment of OHCA in patients conveyed by non-emergency ambulance services (EAS) in Singapore.

Materials And Methods: This is a multi-centre, retrospective chart review, of cases presenting to public emergency departments (EDs), conveyed by non-EAS and found to be in cardiac arrest upon ED arrival.