Effectiveness of Blended Versus Traditional Refresher Training for Cardiopulmonary Resuscitation: Prospective Observational Study.

BACKGROUND: Generally, cardiopulmonary resuscitation (CPR) skills decline substantially over time. By combining web-based self-regulated learning with hands-on practice, blended training can be a time- and resource-efficient approach enabling individuals to acquire or refresh CPR skills at their convenience. However, few studies have evaluated the effectiveness of blended CPR refresher training compared with that of the traditional method. OBJECTIVE: This study investigated and compared the effectiveness of traditional and blended CPR training through 6-month and 12-month refresher sessions with CPR ability indicators. METHODS: This study recruited participants aged ≥18 years from the Automated External Defibrillator Donation Project. The participants were divided into 4 groups based on the format of the CPR training and refresher training received: (1) initial traditional training (a 30-minute instructor-led, hands-on session) and 6-month traditional refresher training (Traditional6 group), (2) initial traditional training and 6-month blended refresher training (an 18-minute e-learning module; Mixed6 group), (3) initial traditional training and 12-month blended refresher training (Mixed12 group), and (4) initial blended training and 6-month blended refresher training (Blended6 group). CPR knowledge and performance were evaluated immediately after initial training. For each group, following initial training but before refresher training, a learning effectiveness assessment was conducted at 12 and 24 months. CPR knowledge was assessed using a written test with 15 multiple-choice questions, and CPR performance was assessed through an examiner-rated skill test and objectively through manikin feedback. A generalized estimating equation model was used to analyze changes in CPR ability indicators. RESULTS: This study recruited 1163 participants (mean age 41.82, SD 11.6 years; n=725, 62.3% female), with 332 (28.5%), 270 (23.2%), 258 (22.2%), and 303 (26.1%) participants in the Mixed6, Traditional6, Mixed12, and Blended6 groups, respectively. No significant between-group difference was observed in knowledge acquisition after initial training (P=.23). All groups met the criteria for high-quality CPR skills (ie, average compression depth: 5-6 cm; average compression rate: 100-120 beats/min; chest recoil rate: >80%); however, a higher proportion (98/303, 32.3%) of participants receiving blended training initially demonstrated high-quality CPR skills. At 12 and 24 months, CPR skills had declined in all the groups, but the decline was significantly higher in the Mixed12 group, whereas the differences were not significant between the other groups. This finding indicates that frequent retraining can maintain high-quality CPR skills and that blended refresher training is as effective as traditional refresher training. CONCLUSIONS: Our findings indicate that 6-month refresher training sessions for CPR are more effective for maintaining high-quality CPR skills, and that as refreshers, self-learning e-modules are as effective as instructor-led sessions. Although the blended learning approach is cost and resource effective, factors such as participant demographics, training environment, and level of engagement must be considered to maximize the potential of this approach. TRIAL REGISTRATION: IGOGO NCT05659108; https://www.cgmh-igogo.tw.

Effects of Dispatcher-Assisted Public-Access Defibrillation Programs on the Outcomes of Out-of-Hospital Cardiac Arrest: A Before-and-After Study.

BACKGROUND: Public access defibrillation (PAD) programs have been implemented globally over the past decade. Although PAD can substantially increase the survival of cardiac arrest, PAD use remains low. This study aimed to evaluate whether drawing upon the successful experiences of dispatcher-assisted cardiopulmonary resuscitation programs would increase the use of PAD in dispatcher-assisted PAD programs. METHODS AND RESULTS: This study using a before-and-after design was conducted in Taoyuan City using a local out-of-hospital cardiac arrest registry system and data of dispatcher performance derived from audio recordings. The primary outcomes were the rate of bystander PAD use, sustained return of spontaneous circulation, survival to discharge, and favorable neurological outcomes. The secondary outcomes were the performance of dispatchers in terms of PAD instruction and dispatcher-assisted cardiopulmonary resuscitation administration, the time interval indicators of dispatcher-assisted cardiopulmonary resuscitation. A total of 1159 patients were included and divided into 2 groups: the before-run-in group (502 patients) and the after-run-in group (657 patients). No significant difference was observed between the 2 groups in terms of baseline characteristics. The rate of PAD use in the after-run-in group significantly increased from 5.0% to 8.7% (P=0.015). The rate of favorable neurological outcomes increased from 4.4% to 5.9%, which was not a statistically significant difference. Compared with the before-run-in group, the rate of successful automated external defibrillator acquisition was 13.5% in the after-run-in group (P<0.001). CONCLUSIONS: Implementing a dispatcher-assisted PAD protocol in a municipality setting significantly increased bystander PAD use without affecting dispatcher performance in out-of-hospital cardiac arrest recognition, cardiopulmonary resuscitation instruction, or dispatcher-assisted cardiopulmonary resuscitation time indicators.

Integrating the clinical frailty scale with emergency department triage systems for elder patients: A prospective study.

BACKGROUND: This prospective study investigated whether integrating the Clinical Frailty Scale (CFS) with a triage system would improve triage for older adult emergency department (ED) patients. METHODS: We enrolled ED patients aged 65 years or older at 5 study sites in Taiwan between December 2020 and April 2021. All eligible patients were assigned a triage level by using the Taiwan Triage and Acuity Scale (TTAS) in accordance with usual practice. A CFS score was collected from them. The primary outcome was critical events, defined as ICU admission or in-hospital mortality. The secondary outcomes were ED medical expenditures, number of orders in the ED, and length of hospital stay (LOS). We applied a reclassification concept and integrated the CFS and TTAS to create the Triage Frailty Acuity Scale (TFAS). We compared the outcomes achieved between the TTAS and TFAS. RESULTS: Of 1023 screened ED patients, 890 were enrolled. The majority were assigned to TTAS level 3 (73.26%) and had CFS scores of 4 to 9 (55.96%). The primary outcomes were better predicted by the TFAS than the TTAS (area under the curve [AUC] 0.82 vs. 064). Using multivariable approach, TTAS level 1 (odds ratio [OR], 4.8; 95% confidence interval [CI], 1.7-13.4) and CFS score (OR, 5.8; 95% CI, 1.9-17.2) were significantly associated with the primary outcomes. For older adults at the highest triage level, the TFAS was not associated with an increase in the primary outcomes compared with the TTAS; however, the TFAS was associated with a significant decrease in the number of older ED patients assigned to triage levels 3 to 5. In addition, TFAS had a longer average LOS but did not have a higher average number of orders or ED medical expenditures compared to TTAS. CONCLUSIONS: The TFAS identified more older ED patients who had been triaged as less emergent but proceeded to need ICU admission or in-hospital death. Incorporating the CFS into triage may reduce the under-triage of older adults in the ED.

Tree-Based Algorithms and Association Rule Mining for Predicting Patients' Neurological Outcomes After First-Aid Treatment for an Out-of-Hospital Cardiac Arrest During COVID-19 Pandemic: Application of Data Mining.

Objective: The authors performed several tree-based algorithms and an association rules mining as data mining tools to find useful determinants for neurological outcomes in out-of-hospital cardiac arrest (OHCA) patients as well as to assess the effect of the first-aid and basic characteristics in the EMS system. Patients and Methods: This was a retrospective cohort study. The outcome was Cerebral Performance Categories grading on OHCA patients at hospital discharge. Decision tree-based models inclusive of C4.5 algorithm, classification and regression tree and random forest were built to determine an OHCA patient's prognosis. Association rules mining was another data mining method which we used to find the combination of prognostic factors linked to the outcome. Results: The total of 3520 patients were included in the final analysis. The mean age was 67.53 (±18.4) year-old and 63.4% were men. To overcome the imbalance outcome issue in machine learning, the random forest has a better predictive ability for OHCA patients in overall accuracy (91.19%), weighted precision (88.76%), weighted recall (91.20%) and F1 score (0.9) by oversampling adjustment. Under association rules mining, patients who had any witness on the spot when encountering OHCA or who had ever ROSC during first-aid would be highly correlated with good CPC prognosis. Conclusion: The random forest has a better predictive ability for OHCA patients. This paper provides a role model applying several machine learning algorithms to the first-aid clinical assessment that will be promising combining with Artificial Intelligence for applying to emergency medical services.

Learning Effectiveness Assessment between Primary School Students and Adults in Basic Life Support Education.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) remains a big issue of critical care. It is well known that bystander cardiopulmonary resuscitation (CPR) with an automated external defibrillator (AED) used did improve the survival rate. Therefore, CPR education including basic life support (BLS) and AED has been advocated for years. It showed significant improvement of knowledge and willingness to perform CPR through adolescents after the course. However, little is known regarding the ability and learning effectiveness of school students who attend such courses. Therefore, this study aimed to evaluate the CPR effectiveness of both adolescents (12 years old) and adults who undergo the same course of BLS and AED. METHODS: This is a retrospective study. Sixth-grade elementary school students in Northern Taiwan were selected to compare with the adult group. Both took 90 minutes of the BLS and AED course by the doctor with BLS instructor qualification. The primary outcomes were CPR quality and passing or failing the skill examination parameters. The secondary outcome was the posttraining written test and questionnaire of CPR willingness. RESULTS: In the written test, there was a statistical difference in the pretest score except AED knowledge, but no difference was revealed in the posttest score. No statistical difference in CPR quality was noted. In the skill examination, only checking breathing status had statistical difference (elementary group (71%) vs. adult group (86%) (p=0.003)). CONCLUSION: We revealed that sixth-grade elementary students' performance in CPR and AED was similar to that of adults after completing the current 90-minute course. Therefore, we strongly advocate offering CPR and AED courses to 12-year-old children, and these courses should emphasize checking the victim's breathing status.

A Machine Learning Model for Predicting Unscheduled 72 h Return Visits to the Emergency Department by Patients with Abdominal Pain.

Seventy-two-hour unscheduled return visits (URVs) by emergency department patients are a key clinical index for evaluating the quality of care in emergency departments (EDs). This study aimed to develop a machine learning model to predict 72 h URVs for ED patients with abdominal pain. Electronic health records data were collected from the Chang Gung Research Database (CGRD) for 25,151 ED visits by patients with abdominal pain and a total of 617 features were used for analysis. We used supervised machine learning models, namely logistic regression (LR), support vector machine (SVM), random forest (RF), extreme gradient boosting (XGB), and voting classifier (VC), to predict URVs. The VC model achieved more favorable overall performance than other models (AUROC: 0.74; 95% confidence interval (CI), 0.69-0.76; sensitivity, 0.39; specificity, 0.89; F1 score, 0.25). The reduced VC model achieved comparable performance (AUROC: 0.72; 95% CI, 0.69-0.74) to the full models using all clinical features. The VC model exhibited the most favorable performance in predicting 72 h URVs for patients with abdominal pain, both for all-features and reduced-features models. Application of the VC model in the clinical setting after validation may help physicians to make accurate decisions and decrease URVs.

Traditional versus blended CPR training program: A randomized controlled non-inferiority study.

Cardiopulmonary resuscitation (CPR) training and its quality are critical in improving the survival rate of cardiac arrest. This randomized controlled study investigated the efficacy of a newly developed CPR training program for the public in a Taiwanese setting. A total of 832 adults were randomized to either a traditional or blended (18-minute e-learning plus 30-minute hands-on) compression-only CPR training program. The primary outcome was compression depth. Secondary outcomes included CPR knowledge test, practical test, quality of CPR performance, and skill retention. The mean compression depth was 5.21 cm and 5.24 cm in the blended and traditional groups, respectively. The mean difference in compression depth between groups was -0.04 (95% confidence interval -0.13 to infinity), demonstrating that the blended CPR training program was non-inferior to the traditional CPR training program in compression depth after initial training. Secondary outcome results were comparable between groups. Although the mean compression depth and rate were guideline-compliant, only half of the compressions were delivered with adequate depth and rate in both groups. CPR knowledge and skill retained similarly in both groups at 6 and 12 months after training. The blended CPR training program was non-inferior to the traditional CPR training program. However, there is still room for improvement in optimizing initial skill performance as well as skill retention. Clinical Trial Registration: NCT03586752; www.clinicaltrial.gov.

Impact of Transport Time and Cardiac Arrest Centers on the Neurological Outcome After Out-of-Hospital Cardiac Arrest: A Retrospective Cohort Study.

Background Should all out-of-hospital cardiac arrest (OHCA) patients be directly transported to cardiac arrest centers (CACs) remains under debate. Our study evaluated the impacts of different transport time and destination hospital on the outcomes of OHCA patients. Methods and Results Data were collected from 6655 OHCA patients recorded in the regional prospective OHCA registry database of Taoyuan City, Taiwan, between January 2012 and December 2016. Patients were matched on propensity score, which left 5156 patients, 2578 each in the CAC and non-CAC groups. Transport time was dichotomized into <8 and ≥8 minutes. The relations between the transport time to CACs and good neurological outcome at discharge and survival to discharge were investigated. Of the 5156 patients, 4215 (81.7%) presented with nonshockable rhythms and 941 (18.3%) presented with shockable rhythms. Regardless of transport time, transportation to a CAC increased the likelihoods of survival to discharge (<8 minutes: adjusted odds ratio [aOR], 1.95; 95% CI, 1.11-3.41; ≥8 minutes: aOR, 1.92; 95% CI, 1.25-2.94) and good neurological outcome at discharge (<8 minutes: aOR, 2.70; 95% CI, 1.40-5.22; ≥8 minutes: aOR, 2.20; 95% CI, 1.29-3.75) in OHCA patients with shockable rhythms but not in patients with nonshockable rhythms. Conclusions OHCA patients with shockable rhythms transported to CACs demonstrated higher probabilities of survival to discharge and a good neurological outcome at discharge. Direct ambulance delivery to CACs should thus be considered, particularly when OHCA patients present with shockable rhythms.

Impact of the caller's emotional state and cooperation on out-of-hospital cardiac arrest recognition and dispatcher-assisted cardiopulmonary resuscitation.

OBJECTIVE: This study determined the impact of the caller's emotional state and cooperation on out-of-hospital cardiac arrest (OHCA) recognition and dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) performance metrics. METHODS: This was a retrospective study using data from November 2015 to October 2016 from the emergency medical service dispatching centre in northern Taiwan. Audio recordings of callers contacting the centre regarding adult patients with non-traumatic OHCA were reviewed. The reviewers assigned an emotional content and cooperation score (ECCS) to the callers. ECCS 1-3 callers were graded as cooperative and ECCS 4-5 callers as uncooperative and highly emotional. The relation between ECCS and OHCA recognition, time to key events and DA-CPR delivery were investigated. RESULTS: Of the 367 cases, 336 (91.6%) callers were assigned ECCS 1-3 with a good inter-rater reliability (k=0.63). Dispatchers recognised OHCA in 251 (68.4%) cases. Compared with callers with ECCS 1, callers with ECCS 2 and 3 were more likely to give unambiguous responses about the patient's breathing status (adjusted OR (AOR)=2.6, 95% CI 1.1 to 6.4), leading to a significantly higher rate of OHCA recognition (AOR=2.3, 95% CI 1.1 to 5.0). Thirty-one callers were rated uncooperative (ECCS 4-5) but had shorter median times to OHCA recognition and chest compression (29 and 122 s, respectively) compared with the cooperative caller group (38 and 170 s, respectively). Nevertheless, those with ECCS 4-5 had a significantly lower DA-CPR delivery rate (54.2% vs 85.9%) due to 'caller refused' or 'overly distraught' factors. CONCLUSIONS: The caller's high emotional state is not a barrier to OHCA recognition by dispatchers but may prevent delivery of DA-CPR instruction. However, DA-CPR instruction followed by first chest compression is possible despite the caller's emotional state if dispatchers are able to skilfully reassure the emotional callers.

Validation of a Dispatch Protocol with Continuous Quality Control for Cardiac Arrest: A Before-and-After Study at a City Fire Department-Based Dispatch Center.

BACKGROUND: An optimized protocol to help dispatchers identify potential cases of cardiac arrest and provide phone instructions for cardiopulmonary resuscitation (CPR) may increase the provision of bystander CPR, further improving the survival rate and neurological outcomes. OBJECTIVE: We assessed a revised dispatcher-assisted (DA)-CPR protocol with a continuous quality-improvement feature in a county fire department-based emergency medical services system. METHODS: This was a before-and-after intervention prospective study conducted in Taoyuan City, Taiwan. The participants were out-of-hospital cardiac arrest (OHCA) patients from November 2014 to February 2016. Interventional quality control started in August 2015. Approximately 10% of the telephone calls from these OHCA patients were reviewed. RESULTS: In total, 66 and 64 cases were included in the before- and after-intervention groups, respectively. No significant differences were observed in sex, age, day, and time of events, or languages spoken by the callers. After the intervention, we found significant improvements in the rates at which cardiac arrests were recognized (54.5% vs. 68.8%; p = 0.007) and normal breathing was checked (51.5% vs. 76.6%, p = 0.003). Moreover, the frequency with which DA-CPR was provided by the dispatchers improved significantly (50.0% vs. 72.7%; p = 0.046). Significant improvement in patient outcomes was observed with regard to 24-h survival (7.6% vs. 20.3%, p = 0.036) but not with regard to survival to discharge (3.0% vs. 10.9%, p = 0.076). CONCLUSIONS: The study found this DA-CPR protocol, which includes continuous quality control, is promising as it improved the successful recognition of cardiac arrests.

Comparison of prehospital triage and five-level triage system at the emergency department.

OBJECTIVE: There is lack of scientific evidence regarding the effectiveness of prehospital triage systems. This study compared the two-level Taiwan Prehospital Triage System (TPTS) with the five-level Taiwan Triage and Acuity Scale (TTAS) at ED arrival regarding the prediction of patient outcomes and the utilisation of medical resources. DESIGN: This was a retrospective cohort study. Adult patients transported via the emergency medical service (EMS), who arrived at the ED of a medical centre in northern Taiwan during the study period were enrolled. TTAS acuity levels 1-2 were considered comparable to the designation of 'emergent' by the prehospital TPTS system. The outcomes were analysed by comparing TPTS and TTAS by acuity levels. RESULTS: Among 4430 enrolled patients, 25.2% and 74.8% were classified as emergent and non-emergent by TPTS; 44.1% and 55.9% were classified as levels 1-2 and levels 3-5 by TTAS. Of the TPTS emergent patients, 15.2% were classified as TTAS levels 3-5, whereas 30.4% of TPTS non-emergent transports were classified as TTAS levels 1-2 at the ED. TTAS levels 1-2 showed better predictability than TPTS emergent level for hospitalisation rate with a sensitivity of 70.3% (95% CI 68.3% to 72.2%) versus 41.1% (95% CI 39.0% to 43.2%), and a negative predictive value of 74.8% (95% CI 73.4% to 76.0%) versus 62.6% (95% CI 61.7% to 63.5%). CONCLUSION: The current prehospital triage system is insufficient and inappropriate in classifying patients transported to the ED. The present study offers supporting evidence for the introduction of a five-level triage system to prehospital EMS systems.

Features of hospital and emergency medical service in out-of-hospital cardiac arrest patients with shockable rhythm.

OBJECTIVE: Predicting the outcome of out-of-hospital cardiac arrest (OHCA) patients is crucial. We examined hospital characteristics and parameters of emergency medical service (including scene time interval and direct ambulance delivery to intensive heart hospitals) as survival or outcome predictors. STUDY DESIGN: Data from 546 consecutive OHCA shockable patients treated between January 2012 and December 2015 in Taoyuan City (Taiwan, ROC) were collected. In addition to demographic data, location of arrest, initial rhythm, availability of a hospital with or without 24/7 percutaneous coronary intervention (PCI), emergency medical service (EMS) time, provision of cardiopulmonary resuscitation by a bystander, presence of a witness at collapse, and level of life support were analysed. RESULTS: Multivariate analysis showed that hospitalisation with immediate PCI availability was an independent predictor (OR: 4.32; 95% CI: 1.27-14.70) solely for the outcome of survival until discharge. The presence of a witness while collapsing (OR: 3.52; 95% CI: 1.03-11.98), EMS response time (OR: 0.83; 95% CI: 0.70-0.98), and scene time interval (STI; OR: 0.89; 95% CI: 0.81-0.99) were valuable for predicting the neurological outcome. CONCLUSIONS: Direct ambulance delivery to intensive heart hospitals that had 24/7 PCI availability was associated with a higher probability of surviving until discharge in OHCA patients with shockable rhythms. Similarly, a witnessed collapse was correlated with being discharged alive from hospital and recovering with good cerebral performance. In addition, longer response time and scene time interval indicated poorer survival and neurological outcome.

Predicting emergency departments visit rates from septicemia in Taiwan using an age-period-cohort model, 1998 to 2012.

The aim of this study was to determine the age-period-cohort (APC) effects on the rate of infection-related emergency department (ED) visits from septicemia for predicting the same in recent periods.In our study, we investigated the longitudinal trends in septicemia-related visit rates. Using an APC model to decompose the septicemia visit rates into the effects of age, time period, and cohort, and examine whether their effects varied by sex.The septicemia ED visit rate was classified as the International Classification of Disease Code 038 by primary and secondary diagnosis between 1998 and 2012.In both males and females, the visit rate of septicemia showed an increase from 2003 through 2012. An increase in septicemia visit rate after 2003 was observed in all age groups. An APC model indicated a reversal increasing period effect, which increased prominently from 2003 to 2012 in both males and females. The age effect showed an increasing trend. The cohort effect tended to show a slight oscillation from 1913 to 1988. With reference to the prediction of the logarithms of the age-specific 5-year visit rates, we observed that the younger cohorts exhibited a slightly increasing trend, as compared to the older cohorts.The period effect can explain the increase in septicemia visit rates, suggesting the role of screening for septicemia. Furthermore, it is well known that aging is a relevant risk variable for infectious diseases. The present study concludes that the aged population exhibited a strong increasing future trend for septicemia-related ED visit rates.