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

Doctor NE, Ahmad NS, Pek PP, Yap S, Ong ME

Singapore Med J, 2017 07;58(7):456-458.
PMID: 28741005 DOI: 10.11622/smedj.2017057

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. Recognising the need for a collaborative prehospital emergency care research group in Asia, researchers from seven countries in the Asia-Pacific region (including Japan, South Korea, Taiwan, Thailand, United Arab Emirates-Dubai, Singapore and Malaysia) established the Pan-Asian Resuscitation Outcomes Study (PAROS) clinical research network in 2010. This paper gives the overview, methodology and research accomplishments of the PAROS network.
Fulltext Emergency medical services key performance measurement in Asian cities

Rahman NH, Tanaka H, Shin SD, Ng YY, Piyasuwankul T, Lin CH, et al.

Int J Emerg Med, 2015;8:12.
PMID: 25932052 DOI: 10.1186/s12245-015-0062-7

One of the key principles in the recommended standards is that emergency medical service (EMS) providers should continuously monitor the quality and safety of their services. This requires service providers to implement performance monitoring using appropriate and relevant measures including key performance indicators. In Asia, EMS systems are at different developmental phases and maturity. This will create difficultly in benchmarking or assessing the quality of EMS performance across the region. An attempt was made to compare the EMS performance index based on the structure, process, and outcome analysis.
Fulltext Buckling up in Singapore: residency and other risk factors for seatbelt non-compliance - a cross-sectional study based on trauma registry data

Wong TH, Lim GH, Chow KY, Trauma Coordinators and Trauma Service Representatives, Zaw NN, Nguyen HV, et al.

BMC Public Health, 2016 05 14;16:402.
PMID: 27180046 DOI: 10.1186/s12889-016-3080-3

BACKGROUND: Seatbelt non-compliance is a problem in middle income countries, and little is known about seatbelt compliance in populations with a high proportion of non-residents. This study analyses the profile of seatbelt non-compliance in Singapore based on trauma registry data from five of the six public hospitals.
METHODS: This is a cross-sectional study of seatbelt compliance of patients aged over 18 years, attending the emergency departments of five public hospitals in Singapore after road collisions from 2011-2014. Seatbelt data was obtained from paramedic and patient history.
RESULTS: There were 4,576 patients studied. Most were Singapore citizens (83.4 %) or permanent residents (2.4 %), with the largest non-resident groups from Malaysia, India, and China. Overall seatbelt compliance was 82.1 %. On univariate analysis, seatbelt compliance was higher in older patients (OR 1.02, 95 % CI 1.001-1.021, p
Fulltext Variation of current protocols for managing out-of-hospital cardiac arrest in prehospital settings among Asian countries

Lin CH, Ng YY, Chiang WC, Karim SA, Shin SD, Tanaka H, et al.

J Formos Med Assoc, 2016 Aug;115(8):628-38.
PMID: 26596689 DOI: 10.1016/j.jfma.2015.10.003

Protocols for managing patients with out-of-hospital cardiac arrest (OHCA) may vary due to legal, cultural, or socioeconomic concerns. We sought to assess international variation in policies and protocols related to OHCA.
Comparison of emergency medical services systems in the pan-Asian resuscitation outcomes study countries: Report from a literature review and survey

Ong ME, Cho J, Ma MH, Tanaka H, Nishiuchi T, Al Sakaf O, et al.

Emerg Med Australas, 2013 Feb;25(1):55-63.
PMID: 23379453 DOI: 10.1111/1742-6723.12032

Asia-Pacific countries have unique prehospital emergency care or emergency medical services (EMS) systems, which are different from European or Anglo-American models. We aimed to compare the EMS systems of eight Asia-Pacific countries/regions as part of the Pan Asian Resuscitation Outcomes Study (PAROS), to provide a basis for future comparative studies across systems of care.
Effect of known history of heart disease on survival outcomes after out-of-hospital cardiac arrests

Lee MH, Fook-Chong S, Wah W, Shin SD, Nishiuchi T, Ko PC, et al.

Emerg Med Australas, 2018 Feb;30(1):67-76.
PMID: 28568968 DOI: 10.1111/1742-6723.12809

OBJECTIVE: We aimed to investigate the effect of known heart disease on post-out-of-hospital cardiac arrest (OHCA) survival outcomes, and its association with factors influencing survival.
METHODS: This was an observational, retrospective study involving an OHCA database from seven Asian countries in 2009-2012. Heart disease was defined as a documented diagnosis of coronary artery disease or congenital heart disease. Patients with non-traumatic arrests for whom resuscitation was attempted and with known medical histories were included. Differences in demographics, arrest characteristics and survival between patients with and without known heart disease were analysed. Multivariate logistic regression was performed to identify factors influencing survival to discharge.
RESULTS: Of 19 044 eligible patients, 5687 had known heart disease. They were older (77 vs 72 years) and had more comorbidities like diabetes (40.9 vs 21.8%), hypertension (60.6 vs 36.0%) and previous stroke (15.2 vs 10.1%). However, they were not more likely to receive bystander cardiopulmonary resuscitation (P = 0.205) or automated external defibrillation (P = 0.980). On univariate analysis, known heart disease was associated with increased survival (unadjusted odds ratio 1.16, 95% confidence interval 1.03-1.30). However, on multivariate analysis, heart disease predicted poorer survival (adjusted odds ratio 0.76, 95% confidence interval 0.58-1.00). Other factors influencing survival corresponded with previous reports.
CONCLUSIONS: Known heart disease independently predicted poorer post-OHCA survival. This study may provide information to guide future prospective studies specifically looking at family education for patients with heart disease and the effect on OHCA outcomes.
Characteristics and outcomes of young adults who suffered an out-of-hospital cardiac arrest (OHCA)

Chia MY, Lu QS, Rahman NH, Doctor NE, Nishiuchi T, Leong BS, et al.

Resuscitation, 2017 02;111:34-40.
PMID: 27923113 DOI: 10.1016/j.resuscitation.2016.11.019

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. The primary outcome was favourable neurologic outcome (Cerebral Performance Category 1 or 2) at hospital discharge or at 30th day post OHCA if not discharged. Regression analysis was performed to identify factors associated with favourable neurologic outcomes.
RESULTS: 66,780 OHCAs were collected between January 2009 and December 2013; 3244 young OHCAs had resuscitation attempted by emergency medical services (EMS). 56.8% of patients had unwitnessed arrest; 47.9% were of traumatic etiology. 17.2% of patients (95% CI: 15.9-18.5%) had return of spontaneous circulation; 7.8% (95% CI: 6.9-8.8%) survived to one month; 4.6% (95% CI: 4.0-5.4%) survived with favourable neurologic outcomes. Factors associated with favourable neurologic outcomes include witnessed arrest (adjusted RR=2.42, p-value<0.0001), bystander CPR (adjusted RR=1.57, p-value=0.004), first arrest shockable rhythm (adjusted RR=27.24, p-value<0.0001), and cardiac etiology (adjusted RR=3.99, p-value<0.0001).
CONCLUSIONS: OHCA among young adults are not uncommon. Traumatic OHCA, occurring most frequently in young adults had dismal prognosis. First arrest rhythms of VF/VT/unknown shockable rhythm, cardiac etiology, bystander-witnessed arrest, and bystander CPR were associated with favourable neurological outcomes. The results of the study would be useful for planning preventive and interventional strategies, improving EMS, and guiding future research.
Fulltext Development and Asian-wide validation of the Grade for Interpretable Field Triage (GIFT) for predicting mortality in pre-hospital patients using the Pan-Asian Trauma Outcomes Study (PATOS)

Yu JY, Heo S, Xie F, Liu N, Yoon SY, Chang HS, et al.

Lancet Reg Health West Pac, 2023 May;34:100733.
PMID: 37283981 DOI: 10.1016/j.lanwpc.2023.100733

BACKGROUND: Field triage is critical in injury patients as the appropriate transport of patients to trauma centers is directly associated with clinical outcomes. Several prehospital triage scores have been developed in Western and European cohorts; however, their validity and applicability in Asia remains unclear. Therefore, we aimed to develop and validate an interpretable field triage scoring systems based on a multinational trauma registry in Asia.
METHODS: This retrospective and multinational cohort study included all adult transferred injury patients from Korea, Malaysia, Vietnam, and Taiwan between 2016 and 2018. The outcome of interest was a death in the emergency department (ED) after the patients' ED visit. Using these results, we developed the interpretable field triage score with the Korea registry using an interpretable machine learning framework and validated the score externally. The performance of each country's score was assessed using the area under the receiver operating characteristic curve (AUROC). Furthermore, a website for real-world application was developed using R Shiny.
FINDINGS: The study population included 26,294, 9404, 673 and 826 transferred injury patients between 2016 and 2018 from Korea, Malaysia, Vietnam, and Taiwan, respectively. The corresponding rates of a death in the ED were 0.30%, 0.60%, 4.0%, and 4.6% respectively. Age and vital sign were found to be the significant variables for predicting mortality. External validation showed the accuracy of the model with an AUROC of 0.756-0.850.
INTERPRETATION: The Grade for Interpretable Field Triage (GIFT) score is an interpretable and practical tool to predict mortality in field triage for trauma.
FUNDING: This research was supported by a grant of the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea (Grant Number: HI19C1328).
Associations between gender and cardiac arrest outcomes in Pan-Asian out-of-hospital cardiac arrest patients

Ng YY, Wah W, Liu N, Zhou SA, Ho AF, Pek PP, et al.

Resuscitation, 2016 May;102:116-21.
PMID: 26970031 DOI: 10.1016/j.resuscitation.2016.03.002

BACKGROUND: The incidence of out-of-hospital cardiac arrest (OHCA) in women is thought to be lower than that of men, with better outcomes in some Western studies.
OBJECTIVES: This study aimed to investigate the effect of gender on OHCA outcomes in the Pan-Asian population.
METHODOLOGY: This was a retrospective, secondary analysis of the Pan Asian Resuscitation Outcomes Study (PAROS) data between 2009 and 2012. We included OHCA cases which were presumed cardiac etiology, aged 18 years and above and resuscitation attempted by emergency medical services (EMS) systems. We used multi-level mixed-effects logistic regression models to account for the clustering effect of individuals within the country. Primary outcome was survival to hospital discharge.
RESULTS: We included a total of 40,159 OHCA cases, 40% of which were women. We found that women were more likely to be older and have an initial non-shockable arrest rhythm; they were more likely to receive bystander cardio-pulmonary resuscitation (CPR). The univariate analysis showed that women were significantly less likely to have return of spontaneous circulation (ROSC) at scene or in the emergency department (ED), and had lower rates of survival-to-admission and discharge, and poorer overall and cerebral performance outcomes. There was however, no significant gender difference on outcomes after adjustment of other confounders. Women in the reproductive age group (age 18-44 years) were significantly more likely to have ROSC at scene or in the ED, higher rates of survival-to-admission and discharge, and have better overall and cerebral performance outcomes after adjustment for differences in baseline and pre-hospital factors. Menopausal women (age 55 years and above) were less likely to survive to admission after adjusting for other pre-hospital characteristics but not after age adjustment.
CONCLUSION: Differences in survival outcomes between reproductive and menopausal women highlight a need for further investigations into the plausible social, pathologic or hormonal basis.
KEYWORDS: Gender; Out-of-hospital cardiac arrest; Registry
Outcomes for out-of-hospital cardiac arrests across 7 countries in Asia: The Pan Asian Resuscitation Outcomes Study (PAROS)

Ong ME, Shin SD, De Souza NN, Tanaka H, Nishiuchi T, Song KJ, et al.

Resuscitation, 2015 Nov;96:100-8.
PMID: 26234891 DOI: 10.1016/j.resuscitation.2015.07.026

The Pan Asian Resuscitation Outcomes Study (PAROS) Clinical Research Network (CRN) was established in collaboration with emergency medical services (EMS) agencies and academic centers in Japan, Singapore, South Korea, Malaysia, Taiwan, Thailand, and UAE-Dubai and aims to report out-of-hospital cardiac arrests (OHCA) and provide a better understanding of OHCA trends in Asia.