© Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
EDITORIAL
Out-of-hospital cardiac arrest: the importance of a
registry
WY Wu, FHKCEM, FHKAM (Emergency
Medicine)
Hong Kong College of Emergency Medicine, Aberdeen,
Hong Kong
Corresponding author: Dr WY Wu (wuwy@union.org)
Out-of-hospital cardiac arrest (OHCA) is the most
time-critical and challenging medical emergency. Patient survival depends
on a “strong chain of survival” requiring the community, call centres,
ambulances, and hospitals working together. Early cardiopulmonary
resuscitation (CPR) and defibrillation are crucial for successful
outcomes. Despite improvements in early intervention, improved
surveillance, and increased public awareness in recent decades, the
overall survival rate of OHCA remains low. According to the United States
data in 2017, 10.4% of OHCA patients survived to hospital discharge.1 In Europe, 10.3% of OHCA patients survived for at least
30 days or to hospital discharge.2
A study published in 2017 found that the figure for Hong Kong was even
lower: only 2.3% of OHCA patients survived for at least 30 days or to
hospital discharge.3 Furthermore,
knowledge of automatic external defibrillator use and first aid training
among the general public in Hong Kong are also low.4
Researchers and medical practitioners have long
searched for better interventions that may prevent cardiac arrest or
reduce the number of deaths. Preventive measures such as screening for
high-risk groups and using implantable cardioverter-defibrillators are
effective in the prevention of cardiac arrest. However, these measures are
costly and there are procedural and long-term risks, such as infection and
device or lead malfunction, which limit their use and coverage.5 Therefore, OHCA remains a challenge and initiatives
aimed at optimising the quality and outcome of resuscitation are
important. The Resuscitation Academy of the United States6 has published numerous initiatives to improve OHCA
survival, among which setting up a Cardiac Arrest Registry was considered
as the first step for continuous quality improvement.
In 2015, the Institute of Medicine published a
report titled Strategies to Improve Cardiac Arrest Survival: A Time to
Act7 that emphasised the
significance of establishing a National Cardiac Arrest Registry as the
first recommendation out of eight. In this issue of the Hong Kong
Medical Journal, Lui et al8
review OHCA registries worldwide and discuss the urgent need for a
territory-wide registry for OHCA. They argue that setting up such a
registry is a critical step to improve the outcomes of OHCA in Hong Kong
as it enables data-driven assessment of the process and outcomes of OHCA
management. Through ongoing and systematic collection of high-quality
data, improvement efforts can be tracked, benchmarked, and refined.9 Data collected through an OHCA registry could enable
high-quality research to identify areas for improvement that would
strengthen the chain of survival.10
11 However, effective
implementation can be challenging. The government plays a crucial role in
assembling resources, infrastructure, and personnel that will be required
to successfully establish, implement and sustain an OHCA registry. It may
be practical to set up a government-led committee to govern and manage the
registry. Emergency medical services personnel and healthcare workers
would be ideally placed to oversee the overall operation of the registry
and ensure consistent data contributions.
Data collected through an OHCA registry can be used
for analysis and for planning improvements. In addition, these data can
reveal controversial aspects of cardiac arrest. Also in this issue of the
Hong Kong Medical Journal, So et al12
discuss the difficulties of making a declaration of medical futility and a
decision on termination of resuscitation (TOR). The decision of TOR is
difficult to make but it can help reduce futile medical care of OHCA
patients.13
Despite researchers working hard to refine the
guidelines for TOR best practice, the discussion over when to stop
resuscitation remains controversial. Clinical judgement will always be
critical in deciding TOR timing; however, surveillance data from an OHCA
registry can provide more objective figures for medical researchers to
analyse and establish better guidelines for TOR. It is extremely important
that TOR guidelines are regularly updated with the latest surveillance
data analysis and advances in medical technology.
An OHCA registry is a fundamental source of data
for cardiac arrest and a cornerstone for understanding the current OHCA
burden as well as for designing effective improvement plans. Potential
roles for an OHCA registry extend far beyond epidemiological research,
from deployment of resources to health economics, from the evaluation of
bystander CPR to monitoring the OHCA outcomes, and from outcome
improvement to the development of guidelines. Despite efforts by
researchers and medical professionals to uphold the current standards, the
survival rate of OHCA in Hong Kong remains very low. Hong Kong has already
implemented successful policies on protection of rescuers and public
access to defibrillators.14 15 Given the successful experiences from nearby
countries such as Japan and Singapore that have introduced OHCA
registries,16 17 18 it is of
pressing need to establish such a territory-wide OHCA registry in Hong
Kong.
Author contributions
The author contributed to the study, approved the
final version for publication, and takes responsibility for its accuracy
and integrity.
Conflicts of interest
The author has disclosed no conflicts of interest.
Funding/support
This editorial received no specific grant from any
funding agency in the public, commercial, or not-for-profit sectors.
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