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Global resuscitation alliance utstein recommendations for developing emergency care systems to improve cardiac arrest survival
Accepted Manuscript Title: Global Resuscitation Alliance Utstein Recommendations for Developing Emergency Care Systems to improve Cardiac Arrest Survival Authors: G.D. Nadarajan, L. Tiah, A.F.W. Ho Ho, A. Azazh, M.K. Castren, S.L. Chong, M.J. El Sayed, T. Hara, B.S. Leong, F.K. Lippert, M.H.M. Ma, Y.Y. Ng, H.M. Ohn, J. Overton, P.P. Pek, S. Perret, L.A Wallis, K.D. Wong, M.E.H. Ong PII: DOI: Reference:
S0300-9572(18)30799-8 https://doi.org/10.1016/j.resuscitation.2018.08.022 RESUS 7729
To appear in:
Resuscitation
Received date: Revised date: Accepted date:
9-4-2018 16-8-2018 22-8-2018
Please cite this article as: Nadarajan GD, Tiah L, Ho Ho AFW, Azazh A, Castren MK, Chong SL, El Sayed MJ, Hara T, Leong BS, Lippert FK, Ma MHM, Ng YY, Ohn HM, Overton J, Pek PP, Perret S, Wallis LA, Wong KD, Ong MEH, Global Resuscitation Alliance Utstein Recommendations for Developing Emergency Care Systems to improve Cardiac Arrest Survival, Resuscitation (2018), https://doi.org/10.1016/j.resuscitation.2018.08.022 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Global Resuscitation Alliance Utstein Recommendations for Developing Emergency Care Systems to improve Cardiac Arrest Survival Authors: Nadarajan GD, Tiah L, Ho AFW, Azazh A, Castren MK, Chong S L, El Sayed MJ, Hara T, Leong BS, Lippert FK, Ma MHM, Ng YY, Ohn HM, Overton J, Pek PP, Perret S, Wallis LA, Wong KD, Ong MEH.
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As for my affiliations: - May I edit my credential to MBBS (London) and add on MMed (Emergency Med, S'pore), MRCEM (UK), FAMS (Emergency Med) - My affiliations are with: - Department of Emergency Medicine, Singapore General Hospital and Duke-NUS Medical School
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Abstract Introduction
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The Global Resuscitation Alliance (GRA) was established in 2015 to improve survival for Outof-Hospital Cardiac Arrest (OHCA) using the best practices developed by the Seattle Resuscitation Academy. However, these 10 programs were recommended in the context of developed Emergency Care Systems (ECS). Implementing these programs can be challenging for ECS at earlier stages of development. We aimed to explore barriers faced by developing ECS and to establish pre-requisites needed. We also developed a framework by which developing ECS may use to build their emergency response capability. Method
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A consensus meeting was held in Singapore on 1st -2nd August 2017. The 74 participants were key stakeholders from 26 countries, including Emergency Medical Services (EMS) directors, physicians and academics, including two Physicians who sit on the World Health Organisation (WHO) panel for development of Emergency Care Systems. Five discussion groups examined the chain of survival: community, dispatch, ambulance and hospital; a separate group considered perinatal resuscitation. Discussion points were voted upon to reach a consensus.
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Results
Conclusion
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The answers and discussion points from each group were classified into a table adapted from WHO’s framework of development for Emergency Services. After which, it was used to construct the modified survival framework with the chain of survival as the backbone. Eleven key statements were then derived to describe the pre-requisites for achieving the GRA 10 programs. The participants eventually voted on the importance and feasibility of these 11 statements as well as the GRA 10 programs using a matrix that is used by organisations to prioritise their action steps.
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In this paper, we propose a modified framework of survival for developing ECS systems. There are barriers for developing ECS systems to improve OHCA survival rates. These barriers may be overcome by systematic prioritisation and cost-effective innovative solutions.
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Keywords: Emergency Medical Services Emergency Care Systems Cardiac arrest OHCA Global Resuscitation Alliance Global Health Perinatal mortality Systems of care
Introduction The importance of ECS in low resource settings
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The Emergency Care System (ECS) refers to a system of emergency care provision, from prehospital, including community and care during transport to facility-based care. It includes first responders, dispatch, ambulance and hospital-based care. 1,2 In this paper. we use the term ECS in preference to EMS (Emergency Medical Services), as it gives a broader framework rather than just ambulance services. Most of the world live in areas where the ECS is still developing and lacks maturity. There is often disparity between a country’s economic and its ECS development, where ECS lags behind the economic growth. 3–5
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Typically, in developing health systems, where resources are limited, health dollars are more likely to be spent on facility-based services. However, this model of care delivery is designed for stable or sub-acute medical conditions. For acute emergency conditions, timely and appropriate healthcare access becomes important for good outcomes.
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The United Nations (UN) Sustainable Development Goal 3- achieving good health for all includes reducing “untimely” or premature deaths. 6 The burden of premature death is represented by the disability adjusted life years (DALYs).7 Today, non-communicable diseases such as cardiac diseases, and stroke are superseding communicable diseases as the leading causes of premature DALYs as population demographics evolve with development.7–9 Untimely deaths and disability can be prevented if emergency presentations are attended to in a prompt manner 7,10. Usually, it is the acute emergency rather than the disease process itself that results in mortality and morbidity; to reduce this, there is an increasing need for emergency care5,11,12 especially in low resource settings. Advancements in healthcare treatment can be inaccessible if there is no good system to deliver it to the people who need it most.9,13,14 Hence development of the ECS needs to be a priority.
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Relevance of OHCA in developing ECS
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Out of hospital cardiac arrest (OHCA) survival was used as the case study as it is the reference disease around which modern ECS systems were developed and has helped to shape systems thinking. Good data is already available on factors that improve OHCA survival rates and these involve capacity building at a systems level. 13,16–18 Internationally, OHCA outcomes are often used as a surrogate marker of the effectiveness of ECS. Studies have shown large differences in cardiac arrest survival between communities with similar resources; this is largely attributed to the “system effect”.4,15 GRA 10 programs to improve OHCA
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Research and discussion into ways to improve OHCA have led to the adoption of the Seattle/King County 10 programs by the19 Global Resuscitation Alliance (GRA) at an Utstein Implementation meeting in Stavanger in June 2015 for better OHCA outcomes. It was proposed that implementation of the 10 programs are critical to improving OHCA rates.20 However these are more applicable in mature ECS.4,15 The gap between existing practices of lesser developed ECS and standards set for them is large. Little work has been done to develop recommendations for improving OHCA survival in these countries. We hypothesize that the needs and readiness (cultural and infrastructural) of developing/newly-developed ECS require customized shortterm goals to bridge the gap before its implementation.
For the purposes of this paper, we define “developing ECS” as those that are lacking in either an established dispatch system, equipped ambulances with trained personnel or trained hospital-based emergency department staff but are in the process of development. “Developing ECS” was preferred over “low-middle income countries” (LMIC) because it was recognized that the stage of development of the country’s ECS is often not congruent with the economic development of the country.
Aims
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We aimed to understand the perceived barriers for developing ECS to implement the GRA 10 program, and to develop a consensus-based list of pre-requisites prioritised by importance, feasibility and ‘implementability’. A secondary aim was to utilise these pre-requisites to develop toolkits to improve ECS.
Methods
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Setting and Definitions
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In this paper, we report the findings of a two-day GRA Utstein-style consensus meeting held in Singapore on 1st-2nd August 2017. The main objective was to develop recommendations for developing ECS. This meeting was hosted by the Asian Association for EMS and endorsed by the International Federation for Emergency Medicine, supported by the Laerdal Foundation.
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Participants
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The participants were key stakeholders from 26 countries including EMS directors, EMS physicians and academics. There were 74 participants with deliberate global representation, from the continents of Asia, Europe, Africa, North America and South America (Annex 1). Our Australian representative was unable to be present on the day itself but was involved in the conference advisory committee. Two of them in the meeting were the ‘voice’ of WHO, as they sit on the WHO panel for development of Emergency Care Services; their input was valuable in highlighting the WHO workplan as well as to present this consensus meeting at WHO. Meeting Design
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During the meeting breakout sessions, the participants were divided into five subgroups, namely 1) Community, 2) Ambulance, 3) Dispatcher, 4) Healthcare facility and 5) Perinatal resuscitation. The subgroups were tasked to brainstorm on the following questions:
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1. What are the pre-requisites/essential elements to building an ECS? How would you rank them in terms of importance? 2. What are the barriers to establishing these pre-requisites/essential elements? How can they be overcome? 3. Which of the GRA 10 programs are more applicable and which are less relevant for developing ECS?
4. For the steps that are deemed to be more applicable, what are the challenges to implementing them in developing ECS? 5. What other enablers and/or modifications are needed for developing ECS? 6. What are some innovative solutions that can be implemented to systematically improve OHCA survival rates? Highlight case studies.
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Based on the above, the discussion points were presented and consolidated into WHO derived table format with the aim of developing a framework and consensus statements to guide developing systems. This was followed by a voting process to help prioritise the statements.
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Consensus Procedure and Data Analysis Our consensus procedure was defined as a general agreement and single voting process. Throughout the 2 days, agreement and feedback was obtained from the participants for the discussion points. These points were translated into the Frame of Survival (Fig. 2) and the 11 Consensus Statements (Fig. 1). Eventually, a simple voting system was used to prioritise the statements. Each participant was allocated one vote per consensus statement, for a total of eleven votes per participant. Each consensus statement was given a 3x3 matrix (Fig. 3) with the axes of importance and feasibility, creating nine possible options with unique degree of importance and feasibility. The mode sector for each consensus statement allows the eleven statements to be prioritized on a range from highest priority (High in importance and feasibility), to lowest priority (low in importance and feasibility).
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Section 1: Current state of OHCA care in countries represented at the meeting
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A total of 26 countries with ECS in different phases of development were represented at the meeting. Annex 2 illustrates the feasibility of implementation of GRA 10-program for OHCA care in respective countries. Section 2: Consolidation of discussion themes
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The discussion themes that emerged from the breakout sessions was broadly categorised into (a) pre-requisites that are essential for building an ECS, (b) barriers to the establishment of these pre-requisites, and (c) possible solutions to overcome these barriers. (Annex 3, 4, 5)
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The five subgroups brainstormed for key components that were essential for the respective aspects of an EMS system – community, ambulance, dispatcher, healthcare facility and perinatal resuscitation.
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Barriers to the establishment of these pre-requisites were categorised under human resources and training, infrastructure and technology, information and research, or leadership and governance. Lack of funding was a recurring limiting factor in all categories. Possible solutions to some of these barriers is summarised in Annex 5. Section 3: End-product of the meeting Synthesis from the above discussion resulted in a modified frame of survival to improve OHCA outcomes in developing ECS (Fig. 2). It comprises the chain of survival at the core, encapsulated by the essential pre-requisites that are being differentiated by whether they are
likely to be within the control of the local ECS (the inner frame) or unlikely to be within their control and subjected to governmental bodies (the outer frame). This provides the missing link between the barriers faced in developing ECS and the GRA 10 programs. After several revisions based on the group feedback, the final modified framework of survival reflects the main line of action written by World Health Organisation (WHO) to promote health in the 2030 agenda for sustainable development and the agenda of the UN meeting on non-communicable diseases. 8,14,22
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In addition, 11 consensus statements on fundamental elements for improving OHCA survival in developing ECS were constructed (Fig. 1). In the voting exercise for prioritisation, having “standards of care for ECS” was deemed to be the top priority based on the degree of importance and feasibility among the 11 fundamental elements (Fig. 3).
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Discussion
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This consensus meeting provided the platform for developing ECS to discuss barriers as well as potential solutions. The case studies gave key stakeholders an opportunity to understand various systems, challenges and innovative solutions present in other developing systems.
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The GRA 10 programs as a reference point, gave a context to help the participants conceptualise the framework of survival. Though it is aimed at the GRA 10 programs to improve OHCA, it can also be used for other outcomes that require timely intervention.
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Funding
Leadership
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Systems need sustainable funding to build capacity; this should be cost effective. Rather than new purchases, an existing system can be developed. Innovative methods utilising social media or crowd sourcing may be a cost-effective solution. 21 There is also the option of partnership with philanthropic organisations and private funders to establish a basic infrastructure before using the results to advocate for domestic funding for sustainability.
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Research
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Good ECS leadership is crucial as a strong link between the inner and the outer frame. A good leader can implement, monitor systems and represent the ECS with policymakers and government. The relationship of the leader with policy makers can help accelerate modification within the outer frame.
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Research, in various forms, appears multiple times within the frame of survival as it is an important bridging pre-requisite. It allows definition of the problem, identification of the magnitude of contributing factors and eventually, cost-effective solutions. Collection and sharing of data is important. Without data to monitor progression, development may be stunted. This is especially important for developing ECS where resources and financing are limited, necessitating prioritisation and implementation of low-cost pragmatic solutions.23,24 Research in the inner frame, describes audits and quality improvement while research environment in the outer frame refers to the support given by the countries’ healthcare system. Support via international grants may help to create such an environment. 12
Community involvement
The chain starts with the community25. Increasing awareness and willingness to help involve a mindset change, which may be more challenging than the financial barriers. This not only involves health education and campaigns, it also comes from publicising good health outcomes. Sharing the success stories of how members of the community play an important role, reinforces the need for active citizenry. This could create a culture of social responsibility within the community.
Prioritisation matrix
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The prioritisation matrix was eventually used for voting. This matrix is used to prioritize tasks at hand and determine immediate, intermediate and long term goals. Such a matrix helps break down goals into compact tasks, which may be less daunting to work towards.
Future plans
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Following this consensus meeting, there are plans to use this framework, matrix and a checklist to conduct a workshop for developing ECS. This framework can be used to identify gaps within the ECS system and prioritise the consensus statements for them to work on. And lastly, getting the ECS system directors to develop and work on an action plan to achieve the bridging prerequisites within the constraints of their resources.
Limitations
Conclusion
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Since majority of the participants were from Asia, the findings may not be representative of other developing ECS. In addition, as the voting process was not anonymous, we cannot exclude the possibility of “herd mentality” or social desirability bias. Also, as there is limited published synthesis of evidence for much of what has been discussed, this was by necessity a consensus and expert-based rather than evidence-based process. Lastly, the perinatal group had limited stakeholders and there was no United Nations Representative present at this meeting.
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In this paper, we propose a modified framework of survival for developing ECS. There are barriers for these systems to improve OHCA survival rates. These barriers may be overcome by working on the pre-requisites, systematic prioritisation and cost effective innovative solutions. Funding
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The consensus meeting was support by the Laerdal Foundation grant, grant no: 50005
Conflict of Interest There was no conflict of interest, except for the following members of the meeting. Freddy Lippert from EMS Copenhagen; receives unrestricted research grants from Laerdal Foundation and from the Danish TrygFoundation. Faith Joan Mesa-Gaerlan from Philippines (through the Southern Philippines Medical Centre) is recipient of a grant to implement the GRA 10-steps in Davao City. Jose Maria E. Ferrer is a staff at the American Heart Association, a non-profit organization that’s involved in resuscitation. Maaret Castren who is secretary of ILCOR.
Acknowledgements The authors gratefully acknowledge the pioneering work of the Resuscitation Academy which led to the establishment of the GRA. We particularly appreciate the foundational work of Drs Mickey Eisenberg, Peter Kudenchuk, Tom Rea, Michael Sayre, and of Ann Doll.
We would like to express our appreciation for the help rendered by the following organising team members:
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Susan Yap, Nur Shahidah Binte Ahmad, Patricia Tay, Garion Koh Zhi Xiong, Janson Ng Cheng Ji, Yogeswary Pasupathi, Noor Azuin Jumaat, Annisa Rakun, Mas’Uud Ibnu Samsudin, Elizabeth Tan Sein Jieh, Muthuwadura Waruni Subashini De Silva, Ivan Chua Si Yong, Ho Shufang, Steffi Chan Kang Ting, Ng Han Xian,
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We are also grateful to the following faculty, facilitators and participants for their contributions to the discussion:
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Truls Østybe, Kyoung Jun Song, Ricardo Romero, Ramana Rao, Joao Vissoci, Bryan McNally, Fei Min, Ali Haedar, Panjasilpa Somboon, Saichol, Nakharin, Fumiko Nakamura, Kentaro Kajino, Patrick Ko, Raghib Manzoor, Pairoj Khruekarnchana, Axel Siu Yuet Chung, Hyun Wook Ryoo, Hideharu Tanaka, Sang Do Shin, Thammapad Piyasuwankul, Atchariya Pangma, Jirawadee Thepkasetkul, Pornthida Yampayonta, Aidan Tasker-Lynch, Joan Tasker-Lynch, Sabariah Faizah Jamaluddin, Goh E-Shaun, Chong Shu-Ling, Hany Zaky, Lu Yi-Ming, Ngoc Do Son, Ridvan Atilla, Faith Joan C. Mesa-Gaerlan, Chanodom Piankusol, Han Lynn Htun, Jose Ferrer, Ali Haedar, Munawar Khursheed, Jeremy Cordero, Cai Wenwei, Dr Jin, Myat Noe, Doctor Nausheen Edwin, Nguyen Tuan Dat, Ng Wei-Ming, Kuo Chan-Wei, Zhang Lin, Lin Chih-Hao, Fang Pin-Hui
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8. Beaglehole R, Bonita R, Alleyne G, et al. UN high-level meeting on non-communicable diseases: Addressing four questions. Lancet. 2011;378(9789):449-455. doi:10.1016/S01406736(11)60879-9. 9. WHO | 50 Facts: Global health situation and trends 1955-2025. WHO. 2013. http://www.who.int/whr/1998/media_centre/50facts/en/. Accessed December 15, 2017.
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10. de Ramirez SS, Doll J, Carle S, et al. Emergency Response in Resource-poor Settings: A Review of a Newly-implemented EMS System in Rural Uganda. Prehosp Disaster Med. 2014;29(3):311-316. doi:10.1017/S1049023X14000363.
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11. Anderson PD, Suter RE, Mulligan T, Bodiwala G, Razzak JA, Mock C. World Health Assembly Resolution 60.22 and its importance as a health care policy tool for improving emergency care access and availability globally. Ann Emerg Med. 2012;60(1):35-44. doi:10.1016/j.annemergmed.2011.10.018.
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12. Varmus H, Klausner R, Zerhouni E, Acharya T, Daar AS, Singer PA. Grand Challenges in Global Health. Science (80- ). 2003;302(5644):398-399. doi:10.1126/science.1091769. 13. Iwami T, Nichol G, Hiraide A, et al. Continuous improvements in “chain of survival” increased survival after out-of-hospital cardiac arrests: A large-scale population-based study. Circulation. 2009;119(5):728-734. doi:10.1161/CIRCULATIONAHA.108.802058. 14. Sacco RL, Smith SC, Holmes D, et al. Accelerating progress on non-communicable diseases. Lancet. 2013;382(9895):e4-e5. doi:10.1016/S0140-6736(11)61477-3.
15. Ong ME, Cho J, Ma MHM, et al. Comparison of emergency medical services systems in the pan-Asian resuscitation outcomes study countries: Report from a literature review and survey. EMA - Emerg Med Australas. 2013;25(1):55-63. doi:10.1111/1742-6723.12032.
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16. Cummins RO, Ornato JP, Thies WH, Pepe PE. Improving survival from sudden cardiac arrest: the “chain of survival” concept. A statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Association. Circulation. 1991;83(5):1832-1847. http://circ.ahajournals.org/content/circulationaha/83/5/1832.full.pdf. Accessed December 15, 2017. 17. Sasson C, Rogers MAM, Dahl J, Kellermann AL. Predictors of Survival From Out-ofHospital Cardiac Arrest: A Systematic Review and Meta-Analysis. Circ Cardiovasc Qual Outcomes. 2010;3(1):63-81. doi:10.1161/CIRCOUTCOMES.109.889576.
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18. McCarthy JJ, Carr B, Sasson C, et al. Out-of-Hospital Cardiac Arrest Resuscitation Systems of Care: A Scientific Statement From the American Heart Association. Circulation. 2018:CIR.0000000000000557. doi:10.1161/CIR.0000000000000557.
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20. Kim YT, Shin S Do, Hong SO, et al. Effect of national implementation of utstein recommendation from the global resuscitation alliance on ten steps to improve outcomes from Out-of-Hospital cardiac arrest: a ten-year observational study in Korea. BMJ Open. 2017;7(8):e016925. doi:10.1136/bmjopen-2017-016925.
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21. Mock CN, Tiska M, Adu-Ampofo M, Boakye G. Improvements in Prehospital Trauma Care in an African Country with no Formal Emergency Medical Services. J Trauma. 2002;53(July):90-97. doi:10.1097/00005373-200207000-00018. 22. Bonita R, Magnusson R, Bovet P, et al. Country actions to meet UN commitments on non-communicable diseases: A stepwise approach. Lancet. 2013;381(9866):575-584. doi:10.1016/S0140-6736(12)61993-X.
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23. Aufderheide TP, Nolan JP, Jacobs IG, et al. Global Health and Emergency Care: A Resuscitation Research Agenda-Part 1. Acad Emerg Med. 2013;20(12):1289-1296. doi:10.1111/acem.12270.
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24. Hock Ong ME, Aufderheide TP, Nichol G, et al. Global Health and Emergency Care: A Resuscitation Research Agenda-Part 2. Acad Emerg Med. 2013;20(12):1297-1303. doi:10.1111/acem.12272.
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25. Debenham S, Fuller M, Stewart M, Price RR. Where There is No EMS: Lay Providers in Emergency Medical Services Care - EMS as a Public Health Priority. Prehosp Disaster Med. 2017;32(6):593-595. doi:10.1017/S1049023X17006811.
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The above is Figure 1: The 11 consensus statements
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The above is Figure 2: The Frame of Survival
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The above is Figure 3: the Prioritisation Matrix
S0300-9572(18)30799-8 https://doi.org/10.1016/j.resuscitation.2018.08.022 RESUS 7729
To appear in:
Resuscitation
Received date: Revised date: Accepted date:
9-4-2018 16-8-2018 22-8-2018
Please cite this article as: Nadarajan GD, Tiah L, Ho Ho AFW, Azazh A, Castren MK, Chong SL, El Sayed MJ, Hara T, Leong BS, Lippert FK, Ma MHM, Ng YY, Ohn HM, Overton J, Pek PP, Perret S, Wallis LA, Wong KD, Ong MEH, Global Resuscitation Alliance Utstein Recommendations for Developing Emergency Care Systems to improve Cardiac Arrest Survival, Resuscitation (2018), https://doi.org/10.1016/j.resuscitation.2018.08.022 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Global Resuscitation Alliance Utstein Recommendations for Developing Emergency Care Systems to improve Cardiac Arrest Survival Authors: Nadarajan GD, Tiah L, Ho AFW, Azazh A, Castren MK, Chong S L, El Sayed MJ, Hara T, Leong BS, Lippert FK, Ma MHM, Ng YY, Ohn HM, Overton J, Pek PP, Perret S, Wallis LA, Wong KD, Ong MEH.
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As for my affiliations: - May I edit my credential to MBBS (London) and add on MMed (Emergency Med, S'pore), MRCEM (UK), FAMS (Emergency Med) - My affiliations are with: - Department of Emergency Medicine, Singapore General Hospital and Duke-NUS Medical School
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Word count: 2109
Abstract Introduction
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The Global Resuscitation Alliance (GRA) was established in 2015 to improve survival for Outof-Hospital Cardiac Arrest (OHCA) using the best practices developed by the Seattle Resuscitation Academy. However, these 10 programs were recommended in the context of developed Emergency Care Systems (ECS). Implementing these programs can be challenging for ECS at earlier stages of development. We aimed to explore barriers faced by developing ECS and to establish pre-requisites needed. We also developed a framework by which developing ECS may use to build their emergency response capability. Method
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A consensus meeting was held in Singapore on 1st -2nd August 2017. The 74 participants were key stakeholders from 26 countries, including Emergency Medical Services (EMS) directors, physicians and academics, including two Physicians who sit on the World Health Organisation (WHO) panel for development of Emergency Care Systems. Five discussion groups examined the chain of survival: community, dispatch, ambulance and hospital; a separate group considered perinatal resuscitation. Discussion points were voted upon to reach a consensus.
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Results
Conclusion
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The answers and discussion points from each group were classified into a table adapted from WHO’s framework of development for Emergency Services. After which, it was used to construct the modified survival framework with the chain of survival as the backbone. Eleven key statements were then derived to describe the pre-requisites for achieving the GRA 10 programs. The participants eventually voted on the importance and feasibility of these 11 statements as well as the GRA 10 programs using a matrix that is used by organisations to prioritise their action steps.
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In this paper, we propose a modified framework of survival for developing ECS systems. There are barriers for developing ECS systems to improve OHCA survival rates. These barriers may be overcome by systematic prioritisation and cost-effective innovative solutions.
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Keywords: Emergency Medical Services Emergency Care Systems Cardiac arrest OHCA Global Resuscitation Alliance Global Health Perinatal mortality Systems of care
Introduction The importance of ECS in low resource settings
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The Emergency Care System (ECS) refers to a system of emergency care provision, from prehospital, including community and care during transport to facility-based care. It includes first responders, dispatch, ambulance and hospital-based care. 1,2 In this paper. we use the term ECS in preference to EMS (Emergency Medical Services), as it gives a broader framework rather than just ambulance services. Most of the world live in areas where the ECS is still developing and lacks maturity. There is often disparity between a country’s economic and its ECS development, where ECS lags behind the economic growth. 3–5
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Typically, in developing health systems, where resources are limited, health dollars are more likely to be spent on facility-based services. However, this model of care delivery is designed for stable or sub-acute medical conditions. For acute emergency conditions, timely and appropriate healthcare access becomes important for good outcomes.
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The United Nations (UN) Sustainable Development Goal 3- achieving good health for all includes reducing “untimely” or premature deaths. 6 The burden of premature death is represented by the disability adjusted life years (DALYs).7 Today, non-communicable diseases such as cardiac diseases, and stroke are superseding communicable diseases as the leading causes of premature DALYs as population demographics evolve with development.7–9 Untimely deaths and disability can be prevented if emergency presentations are attended to in a prompt manner 7,10. Usually, it is the acute emergency rather than the disease process itself that results in mortality and morbidity; to reduce this, there is an increasing need for emergency care5,11,12 especially in low resource settings. Advancements in healthcare treatment can be inaccessible if there is no good system to deliver it to the people who need it most.9,13,14 Hence development of the ECS needs to be a priority.
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Relevance of OHCA in developing ECS
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Out of hospital cardiac arrest (OHCA) survival was used as the case study as it is the reference disease around which modern ECS systems were developed and has helped to shape systems thinking. Good data is already available on factors that improve OHCA survival rates and these involve capacity building at a systems level. 13,16–18 Internationally, OHCA outcomes are often used as a surrogate marker of the effectiveness of ECS. Studies have shown large differences in cardiac arrest survival between communities with similar resources; this is largely attributed to the “system effect”.4,15 GRA 10 programs to improve OHCA
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Research and discussion into ways to improve OHCA have led to the adoption of the Seattle/King County 10 programs by the19 Global Resuscitation Alliance (GRA) at an Utstein Implementation meeting in Stavanger in June 2015 for better OHCA outcomes. It was proposed that implementation of the 10 programs are critical to improving OHCA rates.20 However these are more applicable in mature ECS.4,15 The gap between existing practices of lesser developed ECS and standards set for them is large. Little work has been done to develop recommendations for improving OHCA survival in these countries. We hypothesize that the needs and readiness (cultural and infrastructural) of developing/newly-developed ECS require customized shortterm goals to bridge the gap before its implementation.
For the purposes of this paper, we define “developing ECS” as those that are lacking in either an established dispatch system, equipped ambulances with trained personnel or trained hospital-based emergency department staff but are in the process of development. “Developing ECS” was preferred over “low-middle income countries” (LMIC) because it was recognized that the stage of development of the country’s ECS is often not congruent with the economic development of the country.
Aims
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We aimed to understand the perceived barriers for developing ECS to implement the GRA 10 program, and to develop a consensus-based list of pre-requisites prioritised by importance, feasibility and ‘implementability’. A secondary aim was to utilise these pre-requisites to develop toolkits to improve ECS.
Methods
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Setting and Definitions
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In this paper, we report the findings of a two-day GRA Utstein-style consensus meeting held in Singapore on 1st-2nd August 2017. The main objective was to develop recommendations for developing ECS. This meeting was hosted by the Asian Association for EMS and endorsed by the International Federation for Emergency Medicine, supported by the Laerdal Foundation.
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Participants
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The participants were key stakeholders from 26 countries including EMS directors, EMS physicians and academics. There were 74 participants with deliberate global representation, from the continents of Asia, Europe, Africa, North America and South America (Annex 1). Our Australian representative was unable to be present on the day itself but was involved in the conference advisory committee. Two of them in the meeting were the ‘voice’ of WHO, as they sit on the WHO panel for development of Emergency Care Services; their input was valuable in highlighting the WHO workplan as well as to present this consensus meeting at WHO. Meeting Design
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During the meeting breakout sessions, the participants were divided into five subgroups, namely 1) Community, 2) Ambulance, 3) Dispatcher, 4) Healthcare facility and 5) Perinatal resuscitation. The subgroups were tasked to brainstorm on the following questions:
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1. What are the pre-requisites/essential elements to building an ECS? How would you rank them in terms of importance? 2. What are the barriers to establishing these pre-requisites/essential elements? How can they be overcome? 3. Which of the GRA 10 programs are more applicable and which are less relevant for developing ECS?
4. For the steps that are deemed to be more applicable, what are the challenges to implementing them in developing ECS? 5. What other enablers and/or modifications are needed for developing ECS? 6. What are some innovative solutions that can be implemented to systematically improve OHCA survival rates? Highlight case studies.
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Based on the above, the discussion points were presented and consolidated into WHO derived table format with the aim of developing a framework and consensus statements to guide developing systems. This was followed by a voting process to help prioritise the statements.
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Consensus Procedure and Data Analysis Our consensus procedure was defined as a general agreement and single voting process. Throughout the 2 days, agreement and feedback was obtained from the participants for the discussion points. These points were translated into the Frame of Survival (Fig. 2) and the 11 Consensus Statements (Fig. 1). Eventually, a simple voting system was used to prioritise the statements. Each participant was allocated one vote per consensus statement, for a total of eleven votes per participant. Each consensus statement was given a 3x3 matrix (Fig. 3) with the axes of importance and feasibility, creating nine possible options with unique degree of importance and feasibility. The mode sector for each consensus statement allows the eleven statements to be prioritized on a range from highest priority (High in importance and feasibility), to lowest priority (low in importance and feasibility).
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Results
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Section 1: Current state of OHCA care in countries represented at the meeting
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A total of 26 countries with ECS in different phases of development were represented at the meeting. Annex 2 illustrates the feasibility of implementation of GRA 10-program for OHCA care in respective countries. Section 2: Consolidation of discussion themes
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The discussion themes that emerged from the breakout sessions was broadly categorised into (a) pre-requisites that are essential for building an ECS, (b) barriers to the establishment of these pre-requisites, and (c) possible solutions to overcome these barriers. (Annex 3, 4, 5)
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The five subgroups brainstormed for key components that were essential for the respective aspects of an EMS system – community, ambulance, dispatcher, healthcare facility and perinatal resuscitation.
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Barriers to the establishment of these pre-requisites were categorised under human resources and training, infrastructure and technology, information and research, or leadership and governance. Lack of funding was a recurring limiting factor in all categories. Possible solutions to some of these barriers is summarised in Annex 5. Section 3: End-product of the meeting Synthesis from the above discussion resulted in a modified frame of survival to improve OHCA outcomes in developing ECS (Fig. 2). It comprises the chain of survival at the core, encapsulated by the essential pre-requisites that are being differentiated by whether they are
likely to be within the control of the local ECS (the inner frame) or unlikely to be within their control and subjected to governmental bodies (the outer frame). This provides the missing link between the barriers faced in developing ECS and the GRA 10 programs. After several revisions based on the group feedback, the final modified framework of survival reflects the main line of action written by World Health Organisation (WHO) to promote health in the 2030 agenda for sustainable development and the agenda of the UN meeting on non-communicable diseases. 8,14,22
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In addition, 11 consensus statements on fundamental elements for improving OHCA survival in developing ECS were constructed (Fig. 1). In the voting exercise for prioritisation, having “standards of care for ECS” was deemed to be the top priority based on the degree of importance and feasibility among the 11 fundamental elements (Fig. 3).
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Discussion
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This consensus meeting provided the platform for developing ECS to discuss barriers as well as potential solutions. The case studies gave key stakeholders an opportunity to understand various systems, challenges and innovative solutions present in other developing systems.
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The GRA 10 programs as a reference point, gave a context to help the participants conceptualise the framework of survival. Though it is aimed at the GRA 10 programs to improve OHCA, it can also be used for other outcomes that require timely intervention.
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Funding
Leadership
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Systems need sustainable funding to build capacity; this should be cost effective. Rather than new purchases, an existing system can be developed. Innovative methods utilising social media or crowd sourcing may be a cost-effective solution. 21 There is also the option of partnership with philanthropic organisations and private funders to establish a basic infrastructure before using the results to advocate for domestic funding for sustainability.
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Research
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Good ECS leadership is crucial as a strong link between the inner and the outer frame. A good leader can implement, monitor systems and represent the ECS with policymakers and government. The relationship of the leader with policy makers can help accelerate modification within the outer frame.
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Research, in various forms, appears multiple times within the frame of survival as it is an important bridging pre-requisite. It allows definition of the problem, identification of the magnitude of contributing factors and eventually, cost-effective solutions. Collection and sharing of data is important. Without data to monitor progression, development may be stunted. This is especially important for developing ECS where resources and financing are limited, necessitating prioritisation and implementation of low-cost pragmatic solutions.23,24 Research in the inner frame, describes audits and quality improvement while research environment in the outer frame refers to the support given by the countries’ healthcare system. Support via international grants may help to create such an environment. 12
Community involvement
The chain starts with the community25. Increasing awareness and willingness to help involve a mindset change, which may be more challenging than the financial barriers. This not only involves health education and campaigns, it also comes from publicising good health outcomes. Sharing the success stories of how members of the community play an important role, reinforces the need for active citizenry. This could create a culture of social responsibility within the community.
Prioritisation matrix
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The prioritisation matrix was eventually used for voting. This matrix is used to prioritize tasks at hand and determine immediate, intermediate and long term goals. Such a matrix helps break down goals into compact tasks, which may be less daunting to work towards.
Future plans
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Following this consensus meeting, there are plans to use this framework, matrix and a checklist to conduct a workshop for developing ECS. This framework can be used to identify gaps within the ECS system and prioritise the consensus statements for them to work on. And lastly, getting the ECS system directors to develop and work on an action plan to achieve the bridging prerequisites within the constraints of their resources.
Limitations
Conclusion
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Since majority of the participants were from Asia, the findings may not be representative of other developing ECS. In addition, as the voting process was not anonymous, we cannot exclude the possibility of “herd mentality” or social desirability bias. Also, as there is limited published synthesis of evidence for much of what has been discussed, this was by necessity a consensus and expert-based rather than evidence-based process. Lastly, the perinatal group had limited stakeholders and there was no United Nations Representative present at this meeting.
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In this paper, we propose a modified framework of survival for developing ECS. There are barriers for these systems to improve OHCA survival rates. These barriers may be overcome by working on the pre-requisites, systematic prioritisation and cost effective innovative solutions. Funding
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The consensus meeting was support by the Laerdal Foundation grant, grant no: 50005
Conflict of Interest There was no conflict of interest, except for the following members of the meeting. Freddy Lippert from EMS Copenhagen; receives unrestricted research grants from Laerdal Foundation and from the Danish TrygFoundation. Faith Joan Mesa-Gaerlan from Philippines (through the Southern Philippines Medical Centre) is recipient of a grant to implement the GRA 10-steps in Davao City. Jose Maria E. Ferrer is a staff at the American Heart Association, a non-profit organization that’s involved in resuscitation. Maaret Castren who is secretary of ILCOR.
Acknowledgements The authors gratefully acknowledge the pioneering work of the Resuscitation Academy which led to the establishment of the GRA. We particularly appreciate the foundational work of Drs Mickey Eisenberg, Peter Kudenchuk, Tom Rea, Michael Sayre, and of Ann Doll.
We would like to express our appreciation for the help rendered by the following organising team members:
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Susan Yap, Nur Shahidah Binte Ahmad, Patricia Tay, Garion Koh Zhi Xiong, Janson Ng Cheng Ji, Yogeswary Pasupathi, Noor Azuin Jumaat, Annisa Rakun, Mas’Uud Ibnu Samsudin, Elizabeth Tan Sein Jieh, Muthuwadura Waruni Subashini De Silva, Ivan Chua Si Yong, Ho Shufang, Steffi Chan Kang Ting, Ng Han Xian,
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We are also grateful to the following faculty, facilitators and participants for their contributions to the discussion:
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Truls Østybe, Kyoung Jun Song, Ricardo Romero, Ramana Rao, Joao Vissoci, Bryan McNally, Fei Min, Ali Haedar, Panjasilpa Somboon, Saichol, Nakharin, Fumiko Nakamura, Kentaro Kajino, Patrick Ko, Raghib Manzoor, Pairoj Khruekarnchana, Axel Siu Yuet Chung, Hyun Wook Ryoo, Hideharu Tanaka, Sang Do Shin, Thammapad Piyasuwankul, Atchariya Pangma, Jirawadee Thepkasetkul, Pornthida Yampayonta, Aidan Tasker-Lynch, Joan Tasker-Lynch, Sabariah Faizah Jamaluddin, Goh E-Shaun, Chong Shu-Ling, Hany Zaky, Lu Yi-Ming, Ngoc Do Son, Ridvan Atilla, Faith Joan C. Mesa-Gaerlan, Chanodom Piankusol, Han Lynn Htun, Jose Ferrer, Ali Haedar, Munawar Khursheed, Jeremy Cordero, Cai Wenwei, Dr Jin, Myat Noe, Doctor Nausheen Edwin, Nguyen Tuan Dat, Ng Wei-Ming, Kuo Chan-Wei, Zhang Lin, Lin Chih-Hao, Fang Pin-Hui
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The above is Figure 1: The 11 consensus statements
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The above is Figure 2: The Frame of Survival
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The above is Figure 3: the Prioritisation Matrix