Preliminary data suggest that sudden cardiac death occur at a rate of 41.8/100,000 individuals in China, accounting for over 544,000 deaths annually. In 2015, American Heart Association (AHA) guidelines re-emphasized teamwork and high-quality cardiopulmonary resuscitation (CPR) as the key to saving patients with cardiac arrest.[2–5] Prehospital emergency medicine (PHEM), an integrated part of medical care and the social security system, plays a critical role in saving the lives of critically ill patients and responding to emergency events.[6,7]Administrative health departments worldwide have a major and urgent duty to establish efficient and effective prehospital emergency systems, as well as operate standardized and high-quality emergency centers fulfilling the lack of experienced emergency physicians.
As an international metropolis, Shanghai's resident population reached 2425.68 million people in 2014, with an average life expectancy of 82.29 years. With aging population and increasing demand for health care, the frequency of dispatched ambulances has increased annually, up to 310,200 times in 2014. Even with 43 first-aid sub-stations dispersed in the city center and the availability of one ambulance per 40,000 people, Shanghai's health care system does not meet the demand. Therefore, the development of Shanghai's PHEM system faces severe challenges in order to meet the needs of the residents.[9,10] However, the development of the entire system has been bottlenecked by the shortage of emergency physicians, high turnover rates, and an increased willingness of the staffs to quit. In line with the rapid economic development of Shanghai, on December 23, 2014, the Shanghai Municipal Commission of Health and Family Planning decided to transfer physicians from public hospitals to the Emergency Medical Center and increase the number of ambulances in rotation. Physician-based prehospital emergency services are established in some countries.[12,13] However, the benefit gained by utilizing professional physicians in the prehospital service is still controversial.[14–16] And a report on the success rate of CPR by physicians from public hospitals in the PHEM is absent. Meanwhile, population-based studies on the overall diseases category for patients after calling for an ambulance are scarce. Hence, high-quality epidemiological data are lacking; usually, what is known about these events is put together from anecdotal internet and news rep in Shanghai.
Therefore, the objectives of the present study were to determine whether the physicians from public hospitals were associated with greater success rate of CPR, and assess the difference of the effect in PHEM between the physicians from public hospitals and those from the Emergency Medical Center.
2.1 Study design
On December 23, 2014, the Shanghai Municipal Commission of Health and Family Planning and Shanghai Municipal Human Resources and Social Security Bureau jointly developed “Recommendations on the Continued Encouragement of Clinical Physicians from Public Medical Institutions to Regularly Work in Primary Medical Institutions.” Clinical physicians in the Emergency Department or anesthesiologists in the public hospitals, aged <50 years, were required to work at the Emergency Medical Center for 6 months before being promoted to a senior professional title. After a short training and 2 weeks of practice, all physicians were randomly assigned to ambulances to provide emergency medical services. Also, the first author in this study participated in providing emergency medical services.
2.1.1 Survey content
In this descriptive study, the data of prehospital emergencies between February 1, 2016, and May 31, 2016, were retrieved from the Shanghai Emergency Medical Center's electronic database. Data with complete records were selected for the analysis.
2.2 Statistical analysis
The data were analyzed using the Emergency Medical Center's database software and SPSS 19.0 statistical software (SPSS, Inc., Chicago, IL). The categorical variables were presented as proportions, and a Chi-square test (χ2) was used for comparisons. The success rate of CPR between the groups was tested using a Fisher exact test. P < .05 was considered statistically significant.
The study plan was reviewed and approved by the ethics committee of Rui Jin Hospital that is affiliated with Shanghai Jiao Tong University School of Medicine. Written informed consent was obtained from each patient or their family members.
3.1 Subject of study
Between February 1, 2016, and May 31, 2016, ambulances were dispatched in the urban area of Shanghai for a total of 107,341 times, with an average of 887 turnout per day. The average response time was 39 seconds, and the average time of arrival of the ambulance was 12 minutes and 16 seconds. The average on-site consultation time was 12 minutes and 16 seconds, and the mean transit time was 14 minutes and 26 seconds; data are summarized in Supplemental Table 1, http://links.lww.com/MD/C597. An overview of the turnout of ambulances in different districts of Shanghai is shown in Fig. 1.
In all of the 80,954 effective turnout, which excluded 26,387 invalid turnout including a cancellation or loss of calls, 25,901 cases were not required on-site emergency treatment and excluded from the study. Therefore, first-aid was administered 55,053 cases, which was 68.01% of the total effective turnout (Fig. 2).
3.2 Inclusion of patients
Among 55,053 cases that needed on-site emergency treatment, the number of noncritically ill patients encountered was 48,634 (88.34%), and the number of critically ill patients was 6419 (11.66%). The number of patients with cardiac arrest was 3012 (5.47%); the successful rate of CPR was 1.56% (n = 47), as shown in Fig. 2.
3.3 Diseases category and mortality in patients
Figure 3 illustrated the diseases category for 55,053 patients included in the study. The 6 principal causes for 55,053 patients included in the study were Trauma (n = 11,889, 21.60%), Cardiovascular diseases (n = 7509, 13.64%), Unknown diagnosis (symptoms and abnormal findings not classified elsewhere) (n = 6617, 12.02%), Respiratory disease (n = 6236, 11.33%), Cerebrovascular diseases (n = 5833, 10.60%), and Digestive diseases (n = 4806, 8.73%) as summarized in Table 1. The first disease with a high rate of cardiopulmonary arrest was unknown diagnosis. The second and third causes were Cardiovascular disease and Respiratory diseases respectively, as shown in Fig. 4. Table 2 described classification of diseases in CPR. The most successful cases of CPR was cardiovascular disease (n = 27).
Difference of the effect in PHEM between the physicians from public hospitals and those from the Emergency Medical Center: 445 of 4307 critically ill patients were treated by physicians from public hospitals, and 5974 of 50,746 critically ill patients treated by physician of emergency medical centers. The percentage of critically ill patients treated by physicians from public hospitals was 10.33% and that treated by physicians from the Emergency Medical Center was 11.77%. This difference was statistically significant (P = .005) (Fig. 5). One hundred sixty-three cardiac arrest patients were treated by physicians from public hospitals, and 2849 cardiac arrest patients were treated by physician of emergency medical centers. The percentage of patients with cardiopulmonary arrest treated by physicians from public hospitals was 3.78% (163 of 4307) and 36.63% (163 of 445), respectively, and the percentage of patients with cardiopulmonary arrest treated by the Emergency Medical Center was 5.61% (2849 of 50,746) and 47.69 (2849 of 5974), respectively (Tables 3 and 4), suggesting that the difference varied significantly between the 2 groups (P < .001). Two of 163 CPRs were conducted successfully by physicians from public hospitals, and 45 of 2849 were conducted by physicians of emergency medical centers. No obvious difference between the physicians from public hospitals and those from the Emergency Medical Center was observed with respect to the success rate of CPR (P > .05) (Fig. 6).
To the best of our knowledge, this is the first study investigating the difference of the success rate of rescue in PHEM between the physicians from public hospitals and those from the Emergency Medical Center. The important finding of this study showed no significant difference in the success rates of CPR between physicians from public hospitals and Emergency Medical Center personnel (P > .05).
Our study showed that in 2016 from February 1 to May 31, the total turnout number of ambulances in downtown Shanghai was 107,341 times, among which the effective turnout was 80,954 times, and first-aid was 55,053 times (68.01%). The 6 principal causes for calling ambulance service in Shanghai were Trauma, Cardiovascular diseases, Unknown diagnosis, Respiratory disease, Cerebrovascular diseases, and Digestive diseases. The overall mortality varied according to the diagnosis, with the highest mortality for patients with cardiovascular disease, respiratory diseases as well as Unknown diagnosis. This observation is almost consistent with previous studies.[17–20] The large proportion of unknown diagnosis found here is in agreement with the findings of a recent large cohort study in Denmark.
Another valuable finding of this study was that the percentage of critically ill patients (including cardiopulmonary arrest) treated by physicians from public hospitals was 10.33%, which was significantly less than 11.77% treated by the Emergency Center physicians (P < .001). This difference could be related to the distribution of bonuses for saving patients. For saving a patient, an Emergency Center physician receives a higher bonus than a public hospital physician. The physicians from public hospitals, because of the work arrangements, have no desire to complete the basic task of the job rather than the voluntary work of the physicians in the Emergency Center. With respect to the patients, those with milder conditions will be given priority by the public hospital physicians in order to avoid medical malpractice. Such tendency is particularly evident in treating patients who may require CPR; the percentage of patients with cardiopulmonary arrest treated by physicians from public hospitals was 3.78%, which was significantly lower than the percentage treated by the Emergency Center physicians (P < .001). The public hospital physicians will try to avoid critically ill patients, and hence, the number of patients with cardiopulmonary arrest encountered is significantly decreased.
Heavy workloads, difficult working conditions, limited reimbursements, and lack of recognition and respect from colleagues, contribute toward the difficulty in recruiting emergency physicians in Shanghai. With little potential for advancement and promotion within the system, this negative phenomenon would continue. Therefore, a regional plan should foresee these negative factors and afford excellent promotion opportunities and upper-level PHEM positions.
However, the current results show that transferring the attending physicians from public hospitals to the PHEM led to no improvement in the success rates of resuscitation. The success rate of CPR was 1.56% in 3012 patients, which was lower than that of the other countries.[22,23] In addition, the success rate of CPR by public hospital physicians (1.22%) was lower than that of physicians working in Emergency Center (1.58%), although it did not achieve statistical significance.
The reasons for the low success rates of resuscitation are as follows.
First, even in developed cities such as Shanghai, the prevalence of ACLS (advanced cardiovascular life support) and BLS (basic life support) training in the hospitals is not very high; many physicians did not undergo standardized training. In addition, the training time in the emergency center was extremely short for standardized training and did not reach the appropriate level to perform high-quality CPR.
Second, insufficient teamwork, which rendered prolonged the coping of the public hospital physicians with the other staff of the Emergency Center. If they could match each other well, the public hospital physicians might leave the Emergency Center. For many physicians who work in PHEM, emergency medicine was not their initial choice of specialty. Thus, it significantly affects the quality of prehospital care and patient outcome. The process to strengthen the national standards of personnel training and practice will continue to constitute the significant challenge.
As the author had only been at the Shanghai Emergency Medical Center for half a year, we investigated and analyzed only part of the data collected in Shanghai. However, the validity of the data is acceptable. One of the major strengths of the study is the population-based design, as it covered the whole city of Shanghai, which is one of the largest cities in the world. Another major strength is the availability of data, which were retrieved from the Shanghai Emergency Medical Center's electronic database. Apart from the diseases category and mortality, the data such as length of hospitalization, patient outcome are significant indicators for planning of prehospital.
Transferring the physicians from public hospitals to work in Emergency Medical Center showed no improvement in the success rates of resuscitation, and we analyzed the relevant reasons at the same time. Thus, a study focusing on these issues could provide insights into the disease burden and staffing of the health systems, thereby stimulating discussions about the future development of PHEM globally.
Conceptualization: Tongtian Ni, Weijun Zhou.
Data curation: Tongtian Ni, Weijun Zhou.
Formal analysis: Tongtian Ni, Min Chen.
Investigation: Tongtian Ni, Weijun Zhou.
Methodology: Tongtian Ni.
Resources: Jiong Zhao, Dan Jia.
Software: Min Chen.
Supervision: Min Chen, Weijun Zhou.
Writing – original draft: Tongtian Ni, Weijun Zhou.
Writing – review & editing: Tongtian Ni, Weijun Zhou.
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emergency medical center; physicians; prehospital emergency care
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