*Klaudiusz Nadolny1, Joanna Gotlib2, Mariusz Panczyk2, Lukasz Szarpak1, 3, Jerzy Robert Ladny1, Daniel Slezak4, Michal Kucap5, Robert Galazkowski6
The role of the witness of the incident and the role of the emergency medical dispatcher in out-of-hospital sudden cardiac arrest
Rola świadka zdarzenia i dyspozytora medycznego podczas wystąpienia pozaszpitalnego nagłego zatrzymania krążenia
1Department of Emergency Medicine and Disasters, Medical University of Bialystok, Voivodeship Rescue Service in Katowice, Poland
2Faculty of Health Sciences, Division of Teaching and Outcomes of Education, Medical University of Warsaw, Poland
3Department of Emergency Medicine, Medical University of Warsaw, Poland
4Emergency Medicine Workshop, Department of Emergency Medicine, Faculty of Health Sciences, Medical University of Gdansk, Poland
5College of Strategic Planning in Dabrowa Gornicza, Voivodeship Rescue Service in Katowice, Poland
6Institute of Emergency Services, Medical University of Warsaw, Poland
Streszczenie
Wstęp. Nagłe zatrzymanie krążenia (NZK) jest poważnym i źle rokującym stanem medycznym. Jego występowanie jest bardzo zróżnicowane pod względem miejsca i czasu.
Cel pracy. Celem pracy była analiza roli świadka zdarzenia i dyspozytora medycznego w przypadkach pozaszpitalnego NZK w populacji objętej działalnością Wojewódzkiego Pogotowia Ratunkowego (WPR) w Katowicach.
Materiał i metody. Analizie poddano karty zlecenia wyjazdu oraz karty medycznych czynności ratunkowych WPR w Katowicach za rok 2016 (N = 249 872). Do badania retrospektywnego włączono przypadki pozaszpitalnego NZK u osób dorosłych (N = 1603). Parametry ilościowe przedstawiono jako wartości średnie wraz z odchyleniem standardowym. Zmienne niemetryczne opisano za pomocą wskaźników struktury. Analizę porównawczą przeprowadzono z wykorzystaniem testu t-studenta dla zmiennych ilościowych oraz testu χ2 Pearsona dla zmiennych niemetrycznych. Dla wszystkich analiz istotność statystyczną przyjęto na poziomie < 0,05.
Wyniki. Wśród badanych przypadków było 1005 mężczyzn (62,7%), 566 kobiet (35,3%) oraz 32 osoby (2,0%), dla których brak określenia płci. Kobiety zasadniczo były starsze (p = 0,000). Średnia wieku pacjentów wyniosła 65,7 roku. Współczynnik zapadalności wyniósł 59,37/100 000. Najczęściej do wystąpienia NZK dochodziło w warunkach domowych (p = 0,000), zazwyczaj w obecności świadka zdarzenia (p = 0,000). W 59,88% przypadków była prowadzona pierwsza pomoc przez świadków zdarzenia, najczęściej uciskanie klatki piersiowej (p = 0,000). Wyższy wskaźnik ROSC stwierdzono u pacjentów, u których były podejmowane czynności przez świadka zdarzenia przy instruktażu pierwszej pomocy przez telefon (p = 0,008) oraz w kodzie K-1 (p = 0,000). ROSC zanotowano w 33,4% przypadków.
Wnioski. Kluczową rolę w przypadkach NZK mają świadek zdarzenia oraz dyspozytor medyczny jako pierwszy element systemu ratownictwa medycznego. Prowadzenie działań zgodnie z aktualną wiedzą powoduje dużo wyższy wskaźnik ROSC.
Summary
Introduction. Sudden cardiac arrest (SCA) is a serious medical condition that does not bode well. The incidence of SCA varies depending on location and time.
Aim. The aim of the research was to analyze the role of the witness of the incident and the role of the emergency medical dispatcher in cases of out-of-hospital SCA in the area controlled by the Voivodeship Rescue Service (VRS) in Katowice.
Material and methods. The analysis covered dispatch orders forms and emergency medical procedure forms of the VRS in Katowice collected in 2016 (N = 249 872). The retrospective analysis involved cases of out-of-hospital SCA in adults (N = 1603). Quantitative parameters were presented as average values with a standard deviation. Non-metric variables were described by means of proportion. A comparative analysis was performed by means of the Student’s t-test for quantitative variables and the Pearson’s chi-squared test for non-metric variables. The statistical significance adopted for the purpose of all analyses was < 0.05.
Results. There were 1005 male patients (62.7%), 566 female patients (35.3%), and 32 cases (2.0%) with no gender reported. Women were generally older (p = 0.000). The average age of the group was 65.7 years. Attack rate amounted to 59.37/100 000. SCA most frequently occurred in domestic conditions (p = 0.000), usually in the presence of a witness (p = 0.000). In 59.88% of the cases, first aid was provided by the witness of the incident. The most frequent action was chest compression (p = 0.000). A higher ROSC (return of spontaneous circulation) rate was observed in cases where a witness of the incident provided first aid according to phone instructions given (p = 0.008) and in the highest priority code, C-1 (p = 0.000). ROSC was reported in 33.4% of the cases.
Conclusions. Both the witness of the incident and the emergency medical dispatcher play a crucial role in SCA cases. The emergency medical dispatcher is the first element of the system of emergency medical services. Performing actions in accordance with current knowledge leads to a significantly higher ROSC rate.
INTRODUCTION
There have been significant changes in the Emergency Medical Services (EMS) in Poland in the last two decades. The factors determining the changes were: political transformations, the accession to NATO (1997) and to the European Union (2004). Nowadays, there are numerous regulations determining the scope of the system of Emergency Medical Services. The most important document is the Law of 8 September 2006 on State Emergency Medical Services that defines the rules of functioning of the system, its financing and organization. The act also refers to the regulations on first aid education (1).
An emergency medical dispatcher:
– shall have full legal capacity,
– shall have the qualifications required from EMS doctors, EMS nurses or paramedics,
– shall have at least 5 years of experience in providing medical services in emergency services, a hospital emergency department, an anesthesiology and intensive care unit or a hospital admission department.
Sudden cardiac arrest (SCA) is a serious medical condition that does not bode well. It occurs in unexpected situations without any evident symptoms preceding SCA. Cardiac arrest is a common reason of patients’ death in Europe and the USA. SCA requires prompt reaction of both the witness of the incident and the emergency medical dispatcher. In Europe, SCA occurs in about 55-113/100 000 inhabitants per year (3, 4), whereas in the USA, the rate is even higher, amounting to 76/100 000 inhabitants per year. The differences may result from different diagnosis definitions and out-of-hospital SCA registers (5, 6). However, although there has been a visible increase in the survival rate in patients after out-of-hospital SCA, the overall mortality rate is still very high. Around 10.6% of patients survive hospital discharge (7). The witness of the incident plays a significant role: if they perform prompt chest compression and use an automated external defibrillator (AED), the return of circulation rate amounts to 59-76% (8, 9). The emergency medical dispatcher plays an important role in diagnosing SCA and instructing the witness of the incident on how to perform cardiopulmonary resuscitation. His responsibility is also to identify the place of incident and deliver AED. The faster the arrival of a medical emergency unit, the sooner the advanced resuscitation procedures.
AIM
The aim of the research was to analyze the role of a witness of the incident and the role of an emergency medical dispatcher in cases of out-of-hospital SCA in the area controlled by the Voivodeship Rescue Service (VRS) in Katowice.
MATERIAL AND METHODS
The analysis covered dispatch orders forms and emergency medical procedure forms of the VRS in Katowice collected in 2016 (N = 249 872). The retrospective analysis involved exclusively cases of out-of-hospital SCA in patients over the age of 18 years. The diagnosis (sudden cardiac arrest, I46 (ICD-10)) was based on the international classification of diseases, ICD-10. The above criteria were fulfilled in 1603 cases, i.e. 0.64% of all incidents in the period in question.
The VRS in Katowice is the greatest public operator in Poland, taking care of 2.7 mln inhabitants of the Silesian province. The VRS teams are managed by 3 integrated medical dispatch centers located in Katowice (41 teams), Gliwice (25 teams) and Jastrzebie Zdroj (19 teams). Emergency medical dispatchers work in the integrated dispatch centers where they answer 999 calls and 112 calls redirected by the provincial authority. The VRS in Katowice has answered almost 620 000 calls and provided almost 250 000 interventions.
Demographic data of out-of-hospital SCA cases (gender, age, location) was analyzed in detail. In addition to this, the SCA attack rate and the SCA mortality rate were determined. The conversations between witnesses of incidents and emergency medical dispatchers were analyzed as far as first aid instructions were concerned.
Quantitative variables with normal distribution were presented by means of descriptive statistics parameters: average and standard deviation. Non-metric variables were demonstrated by means of proportions: sample size and sampling rate. Depending on the form of distribution, a comparative analysis was performed by means of the Student’s t-test for quantitative variables. Pearson’s chi-squared test was applied in a comparative analysis for non-metric parameters. The statistical significance adopted for the purpose of all analyses was < 0.05. STATISTICA 6.1 (Statsoft Inc.) and IBM SPSS 24.0 software was used to analyze data.
RESULTS
There were 1603 cases of out-of-hospital SCA in adults in the area controlled by the VRS in Katowice in 2016. Return of spontaneous circulation rate amounts to 33.4% (N = 546). The group under research consisted of 1005 (62.7%) male patients, 566 (35.3%) female patients and 32 cases (2.0%) with no gender reported. Women were generally older than men (p = 0.000). The cross analysis of gender and the particular dispatch center did not indicate any statistical significance (p = 0.3888).
The average age of patients with out-of-hospital SCA was 65.7 years (fig. 1). The cross analysis of age and the particular dispatch centers did not indicate any statistically significant differences (p = 0.485).
Fig. 1. The age of patients with out-of-hospital sudden cardiac arrest according to medical dispatch centers
The attack rate in out-of-hospital SCA cases in the population under research resulted in 59.37/100 000 inhabitants, and was twice as high in men (37.22/100 000) as in women (20.96/100 000). The attack rate was increasing with patients’ age.
Most frequently, out-of-hospital SCA occurred in domestic conditions (N = 1136, 71.1%, p = 0.000). Further incidents occurred in public places (N = 234, 14.5%) and at schools (N = 1, 0.06%). SCA in male patients was more frequent away from home than at home (p < 0.015). The incident was usually witnessed by a third person (about 70% of cases, p = 0.000).
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