院外心脏骤停复苏结果5年趋势观察研究

Trends in outcomes after out-of-hospital cardiac arrest:An observational study in Jiading District Shanghai

目的研究嘉定区院外心脏骤停(out-of-hospital cardiac arrest,OHCA)患者2015-2019年复苏后存活到院和存活出院的变化趋势及其相关影响因素。方法回顾性收集2015年1月1日到2019年12月31日发生在本区由疾病因素导致的、急救人员实施复苏的成人(≥18岁)OHCA患者的资料。资料来源本中心电子病历、派遣系统记录(录音)、急救医生的纸质记录和医院内就医记录。患者(旁观者)的基本资料、急救程序和复苏结果参照Utstein模式进行分组,并按年度描述。时间变化趋势采用χ^(2)检验,构建多因素Logistic回归模型,分析存活到院和存活出院的独立危险因素。结果1305例OHCA患者纳入标准,存活入院率为4.14%,从2015年的1.87%上升到2019年的7.31%(P=0.009)。出院存活率为1.23%,从2015年的0.37%增加到2019年的3.32%(P=0.003)。存活出院患者中神经功能分类(cerebral performance category,CPC)为良好(CPC1/CPC2)的构成比没有时间趋势的变化(P=0.339)。医生/调度员总体电话识别率12.87%,识别率从2015年的7.49%提高到2019年的19.27%(P<0.01)。旁观者心肺复苏(cardiopulmonary resuscitation,CPR)的比例为17.39%,从2015年的9.36%上升到2019年的25.19%(P=0.000)。可除颤心律(室颤/无脉性室速)的比例为4.06%,该构成比没有时间趋势的改变(P=0.323)。没有发现旁观者使用自动体外除颤器(automated external defibrillator,AED)病例,急救反应时间为(15.45±8.71)min,从2015年的(15.10±8.12)min缩短至2019年的(13.41±6.47)min(P<0.01)。多因素回归分析发现,男性患者(OR=0.315,95%CI:0.168~0.519,P=0.000)、不可除颤心律(OR=0.096,95%CI:0.043~0.012,P=0.000)和发生在公共场所(OR=2.411,95%CI:1.302~4.463,P=0.005)是院前存活到院的独立预测因素;男性患者(OR=0.247,95%CI:0.070~0.866,P=0.029)、不可除颤心律(OR=0.072,95%CI:0.016~0.318,P=0.001)、没有使用肾上腺素(OR=5.953,95%CI:1.222~29.012,P=0.005)和机械按压(OR=10.836,95%CI:1.361~86.309,P=0.024)是存活出院的独立预测因素。结论5年间OHCA患者的存活率有趋势性的改善,主要是由电话识别率的提高、旁观者CPR率增加和急救反应时间缩短等一系列OHCA生存链构建的累积结果,然而,总体存活率仍然较低,今后的重点应提高旁观者CPR质量,加快AED的布局,并鼓励旁观者使用,以进一步改善OHCA患者预后。

Objective This study aimed to investigate temporal trends in Event survival after OHCA from 2015 to 2019 in Jiading district Shanghai.And analysis the influencing factors.Methods This was a population based observational cohort study evaluating the temporal trends in survival after OHCA,we included consecutive patients who experienced an OHCA between January 1,2015 and December 31,2019,we included all adult patients aged≥18 years who presumed medical cause and were treated by emergency medical services(EMS)in Jiading District.The Data was obtained from Dispatch software system,The emergency case registration system,paper-based treatment records,dispatcher's telephone recording and in-hospital records,This Data organized according to the Utstein template using standard data element definitions.Temporal changes were measured by chi-square trend test.we constructed a multilevel logistic regression model to identify factors independently associated with event survival arrival at hospital and survival to hospital discharge.Results A total of 1305 patients with OHCA met study inclusion criteria during the study period.Survival to hospital admission was 4.14%increased from 1.87%in 2015 to 7.31%in 2019 for trend(P=0.009),survival to hospital discharge was 1.23%,increased from 0.37%in 2015 to 3.32%in 2019(P=0.003).But there was no evidence of a temporal change in survival to hospital discharge with good neurologic function(0.37 in 2015 to1.33%in 2019,P=0.339 for trend).In the subgroup,the rate of Recognition was increased from 7.49%in 2015 to 19.27%in 2019(P<0.01).The proportion of cases receiving bystander CPR was 17.39%,which increased from 9.36%in 2015 to 25.19%in 2019(P=0.000).The proportion of shockable rhythm was 4.06%,there was no evidence of a temporal change in the proportion of the overall rhythm(3.00%-4.65%,P=0.323 for trend),There were no cases of bystanders using automated external defibrillators(AEDs)in patients with cardiac arrest,The EMS response time(min)were15.45±8.71,which decreased from 15.10±8.12 in 2015 to 13.41±6.47 in 2019(P<0.0001).Multiple regression analysis showed that Male(OR=0.315,95%CI:0.168-0.519,P=0.000),Not Shockable rhythm(OR=0.096,95%CI:0.043-0.012,P=0.000),and public location(OR=2.411,95%CI:1.302-4.463,P=0.005)were independent predictor of Factors Associated with survival at hospital admission.Male(OR=0.247,95%CI:0.070-0.866,P=0.029),Not Shockable rhythm(OR=0.072,95%CI:0.016-0.318,P=0.001),and No Epinephrine administration(OR=5.953,95%CI:1.222-29.012,P=0.005)were independent predictor of Factors Associated with Survival to Hospital Discharge.Conclusions Survival after OHCA has improved over time.Several targeted initiatives established along the chain of survival of OHCA during the past 5-years may help explain the improvement in survival outcome observed in Jiading District,including improved the rate of Recognition,improved participation rates in bystander CPR and a reduction in EMS response time.In the future,more resources should be improving the quality of CPR training and expanding AEDs coverage and encouraging the public to have the courage to use them.