Pan-Asian Resuscitation Outcomes Study Measures Care for Out-of-Hospital Cardiac Arrest

Out-of-hospital cardiac arrest (OHCA) is a global health concern. EMS systems around the world face challenges in terms of increasing workload and limited resources. Cardiac arrest registries can play an important role in helping to drive policy and improve outcomes for OHCA. In 2010, the Pan-Asian Resuscitation Outcomes Study (PAROS) Clinical Research Network (CRN) was established in collaboration with countries across Asia, including Japan, Singapore, South Korea, Malaysia, Taiwan, Thailand and UAE-Dubai. The CRN has since expanded to include China, India, Pakistan, UAE-Abu Dhabi, Vietnam, Philippines, Saudi Arabia, Qatar and Indonesia in the past two years.

Pan-Asian out-of-hospital cardiac arrest registry

International participants in the PAROS cardiac arrest registry.

You can’t improve what you can’t measure

The CRN aims to provide a better understanding of OHCA trends in Asia by collecting data on OHCA patients to will help quality improvement efforts and improve survival rates. This Asia-Pacific cardiac arrest registry will help to provide international benchmarking and study best practices in Asian EMS systems.

Our long-term aim is to increase community awareness, change attitudes toward prehospital emergency care and to improve survival rates, in addition to recording an objective evaluation of the EMS system and community-level interventions.

The registry will also provide a unique opportunity for analysis of preventable risk factors and systematic predictors for survival of OHCA.

With these objectives in mind, the PAROS CRN adopted a constitution, with an executive committee comprising a chair, three co-chairs and two nominated representatives per participating country.

The PAROS mission is to establish a clinical resuscitation research network in the Asia-Pacific region that will provide baseline information about OHCA prevalence, management and outcomes. This network will enable us to describe variations among emergency medical systems in the region, compare the systems and evaluate structural interventions to address OHCA.

With an Internet-based electronic data capture system in place, the network (ePAROS) will serve as a platform to support research into cost-effective strategies to improve survival from sudden cardiac arrest and other prehospital emergency conditions.

Data is collected using Utstein recommendations and includes information on bystander CPR, advanced life support (ALS) interventions such as intravenous drugs and advanced airway management, and specialized post-resuscitation care such as hypothermia and extracorporeal membrane oxygenation (ECMO).

What we have accomplished so far:

  1. A total of 15 countries across the Asia-Pacific region are participating in this study.
  2. More than 160,000 OHCA cases have been enrolled in the PAROS registry to date.
  3. 36 collaborative papers have been published from the group in international journals.
  4. PAROS has won several awards and recognition for its work, notably the Ian G. Jacobs Award for International Group Collaboration to Advance Resuscitation Science presented by the American Heart Association in 2014.

The PAROS CRN has published its landmark paper in November 2015 on variations in OHCA outcomes across the Asia-Pacific countries. Study sites represented a population base of 89 million, which is the aggregated population base of all EMS system participating in the study.

The paper reported a total of 66,780 OHCA cases observed in seven countries over a period of 2.5 years between 2009 and 2012. Overall survival to discharge rates ranged from 0.5% to 8.5%. Those who survived with good neurological function (CPC score of 1 and 2) ranged from 1.6% to 3%. Utstein survival to discharge is at 18.8% as shown in the figure below.

Pan-Asian out-of-hospital cardiac arrest registry

PAROS Phase 2

Bystander CPR rates are relatively low in Asia. Dispatcher-assisted CPR (DA-CPR) has recently emerged as a cost-effective intervention to increase bystander CPR and OHCA survival rates.

The PAROS Phase 2 adopted DA-CPR as part of the strategy to improve OHCA survival. The aim of the study was to assess the impact of system-based DA-CPR on bystander CPR rates and OHCA survival rates. The study compared outcomes before and after implementation of DA-CPR.

The DA-CPR package consists of five main compartments:

  1. A standardized dispatch protocol that will guide users to systematically question callers to determine whether the patient is in cardiac arrest.
  2. The dispatchers underwent a training package to give CPR instructions over the phone and to handle the call confidently.
  3. A standardized quality improvement (QI) tool is used to collect data on individual dispatchers and organizational-level performance through review of the dispatch audio recordings.
  4. An integrated QI program that provides feedback at the individual and organizational level. It involves review of DA-CPR audio recordings and use of the QI tool mentioned in step 3.
  5. A community education program was conducted to update the public on DA-CPR.

The PAROS Phase 2–conducted in Singapore, Japan and Korea–showed an overall improvement in outcomes for OHCA. In Singapore, the bystander CPR rate has doubled since the implementation in July 2012 from 22.4 % to 42.1%.

The PAROS network is focused on improving survival from cardiac arrest and implementing best practice in prehospital emergency care. The target is to increase survival rates by 50%.

We have now adopted the Resuscitation Academy Model on 10 steps to improve cardiac arrest survival in the community. This hopefully can increase our survival rates.

Pan-Asian out-of-hospital cardiac arrest registry

JEMS international article

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Marcus Eng Hock Ong is a member of the JEMS International Editorial Board representing Singapore. Marcus is a Senior Consultant, Clinician Scientist and Director of Research for the Deptartment of Emergency Medicine at Singapore General Hospital; Senior Consultant for the Ministry of Health in Prehospital Emergency Care; Director of the Unit for Pre-hospital Emergency Care at the Ministry of Health; and Associate Professor at Duke-National University.

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