Study: Malaysia’s out-of hospital cardiac arrest survival below 5%
The survival to admission rate for out-of-hospital cardiac arrest (OHCA) ranges between 1.3 per cent and 6.7 per cent across three Malaysian regions, a new study found.
According to the study by Dr Sarah Shaikh Abdul Karim et. al, published last March 2 in the Medical Journal of Malaysia (MJM), the previous 2015 Pan Asian Resuscitation Outcome Study (Paros) found that Malaysia recorded a survival rate of 8 per cent, based on data from 2010 to 2012.
This declined to an overall 4.76 per cent rate in Dr Sarah Shaikh’s research that analysed emergency medical services (EMS) data from Sarawak, Penang, and the Klang Valley from 2010 to 2019.
Penang had the highest rate of survival to admission at 6.7 per cent, followed by the Klang Valley (4.0 per cent) and Sarawak (1.3 per cent).
“This may be due to a faster median time from call to ambulance arrival, higher bystander CPR rate and higher prehospital defibrillation rate,” researchers wrote.
“Penang also has a higher rate of mechanical CPR devices being used. The benefit of a mechanical CPR device during transport is its ability to provide a constant high-quality compression in a moving ambulance.”
Thailand has a much higher survival to admission rate at 40.8 per cent than Malaysia’s 4.8 per cent. This means that about four of 10 OHCA cases in Thailand make it to hospital admission, compared to less than five of 100 in Malaysia.
The Malaysian study reported a 2.8 per cent rate of return of spontaneous circulation (ROSC) before emergency department arrival, the secondary outcome of OHCA cases after survival to hospital admission. Penang’s ROSC rate was higher at 3.7 per cent.
Researchers also found that the overall median time from arrest to an emergency 999 call was 20 minutes, while the overall median time for ambulance arrival thereafter was 17 minutes. This translates to a median time of a whopping 37 minutes between arrest and ambulance arrival.
The median time from arrest to a 999 call ranged between 11 and 28 minutes, not much improved from the 19 minutes previously reported by the PAROS study. The Klang Valley had the longest median time from arrest to a 999 call of 28 minutes.
“After 10 years’ initiation of Malaysian Emergency Response System 999 (MERS999), we have yet to target or achieve two to three minutes time from arrest to 999 calls as seen in Japan, Korea, and Singapore,” researchers wrote.
Median time from 999 call to EMS arrival ranged between 17 and 19 minutes in the Malaysian study.
“This may reflect our hospital-based EMS where the ambulance is stationed within hospitals, rather than closer to the community. One of the modifiable factors to improve survival in OHCA is to have an EMS arrival time of less than eight minutes,” said researchers.
“Having a faster EMS arrival time improves the chances of shockable rhythm or Ventricular Fibrillation (VF) on first rhythm analysis.”
Their study found that detection of shockable rhythm or VF on first rhythm analysis by EMS ranged only between 3.9 per cent and 7.7 per cent.
“This finding has not improved from the PAROS report. Therefore, it is important for Malaysia, especially in densely populated areas, to improve its ambulance arrival time.”
The study reported an average bystander cardiopulmonary resuscitation (CPR) rate in Malaysia at 38 per cent, ranging from 36 per cent to 42 per cent, better than the previous PAROS research at 16.5 per cent to 21 per cent.
“999 Dispatchers in Malaysia have been providing Dispatch Assisted CPR (DA-CPR) instructions since 2011,” said researchers.
However, they pointed out that Malaysia’s 38 per cent bystander CPR rate was lower than other Asian countries that also provide DA-CPR intervention, such as South Korea (47.3 per cent) and Singapore (50.4 per cent).
“Both Korea and Singapore have implemented the Utstein Ten-Step Implementation Strategy (UTIS), which advocates community bundle programmes of DA-CPR and school CPR,” said researchers.
Researchers found that Malaysia’s bystander rate of using automated external defibrillators (AED) was only 1.5 per cent to 2.6 per cent. During the study period from 2010 to 2019, Malaysia had yet to initiate a nationwide Public Access Defibrillator (PAD) programme.
It was only in the state of Penang where a PAD programme was initiated by the state government in 2016. Then-Health Minister Khairy Jamaluddin proposed in 2022 to make AED compulsory in all government buildings.
“Since the majority of OHCA occurs within the home residence, it is also imperative that the public AED programme include residential areas, such as condominiums and public housing. Placement of AEDs within public access on its own will not lead to improved utilisation,” said researchers.
They also stressed the importance of reducing public fear about using AEDs.
The Malaysian study found that 71 per cent of OHCA cases occurred at home, compared to 10 per cent that occurred in public or commercial buildings. About 60 per cent of arrest were witnessed: by either bystanders (53 per cent) or EMS responders (7 per cent). Only 2 per cent of arrest occurred during EMS care within the ambulance during transportation.
“We need to start educating and at least adopt a school CPR programme in secondary schools,” researchers wrote.
“This initiative potentially leads to one rescuer for each household. This, together with DA-CPR will improve our bystander CPR rate. This is a critical factor to consider in the planning of Public Access AED programmes.”
The study showed that the majority of OHCA in Malaysia occurred among working adults in their mid-50s, with a mean age of 56 to 58 years, younger than Singapore (66 years) and Thailand (67 years).
“Our study found that survival to admission rates among OHCA patients in three regions of Malaysia are between 1.3 to 6.7 per cent,” researchers concluded.
“These survival rates are low and could be improved if Malaysia adopts the UTIS bundle programme aimed at improving modifiable OHCA survival factors, such as bystander CPR and defibrillation. This also includes increasing resources towards further efforts at improving EMS arrival time.”
The Malaysian study analysed a total of 2,435 OHCA cases in the Klang Valley, Penang, and Sarawak from 2010 to 2019. All OHCA cases where EMS performed CPR were included, regardless of age or aetiology.
This sample size was much bigger than the PAROS study that only analysed 389 cases in Malaysia from 2010 to 2012.
The median patient age in the latest study was 58 years. Seventy per cent of them were male and 63 per cent had underlying medical conditions, with hypertension being the most common.
Lead researcher Dr Sarah Shaikh is from the emergency and trauma department at Kuala Lumpur Hospital (HKL), while the other researchers are emergency medicine doctors from Sultanah Bahiyah Hospital in Alor Setar, Kedah; Al-Sultan Abdullah Hospital, Universiti Teknologi MARA (UiTM) in Selangor; Pulau Pinang Hospital in Penang; Sarawak General Hospital in Kuching, Sarawak; Miri Hospital in Sarawak; and Ampang Hospital in Selangor.
Category: MJN enews
