Chien-Hsiung Huang

Background and Objective: Triage is a cornerstone of modern emergency medicine. This study aimed to evaluate the predictive validity of the five-level Prehospital Taiwan Triage and Acuity Scale (TTAS-PH) for emergency department (ED) patient outcomes—specifically hospital admission, mortality, and ED length of stay (LOS)—compared to the former two-level system. Methods: This retrospective cohort study included 9,698 adult patients transported by Emergency Medical Services (EMS) to a tertiary academic medical center in Taoyuan City, Taiwan, during 2023. Logistic and linear regression models were utilized to analyze the impact of variables on clinical outcomes and ED LOS. Furthermore, Receiver Operating Characteristic (ROC) curve analysis evaluated the predictive performance of the triage systems. Results: Male gender, older age, and higher TTAS-PH acuity levels (Levels 1 and 2) were significantly associated with worse ED outcomes and longer ED LOS. TTAS-PH Level 1 patients faced drastically elevated risks of death (OR=83.9); while they represented only 10.72% of the cohort, they accounted for 79.59% of all ED deaths. Notably, a discrepancy was observed in high-acuity (Levels 1– 2) classification between the prehospital TTAS-PH (43%) and the in-hospital TTAS (8.7%). In predicting mortality, TTAS-PH demonstrated superior accuracy (AUROC=0.8829) compared to the traditional TPTS (AUROC=0.8296). Conclusion: The TTAS-PH system offers robust prehospital risk stratification, demonstrating superior predictive performance compared to the traditional TPTS. By functioning as a critical early warning mechanism, TTAS-PH facilitates proactive resource mobilization, effectively shifting emergency care from a reactive to a preemptive model.

Out-of-hospital cardiac arrest (OHCA) remains a critical emergency with low survival rates despite advanced prehospital interventions. Emerging evidence suggests that early administration of epinephrine is associated with improved outcomes compared to delayed epinephrine administration, particularly in non-shockable rhythms. While intravenous (IV) access is the standard route for drug delivery, it is often difficult to obtain in the prehospital setting. Intraosseous (IO) access offers a viable alternative, but its comparative survival benefit remains unclear. Few studies have examined the association of IO access on outcomes relative to patients who received no prehospital vascular access. This study aims to assess survival outcomes among OHCA patients receiving different prehospital vascular access strategies. This retrospective cohort study included adult patients with non-traumatic OHCA in Taoyuan, Taiwan (June 2021–June 2024). Patients were grouped based on the final attempted route: IV, IO, failed IV, or no-access attempt. The primary outcome was survival to discharge; secondary outcomes were prehospital ROSC, survival over 2 hours, and favorable neurological outcome. Multivariable logistic regression was performed, with sensitivity analyses including early treatment (≤15 min), EMT-P–level providers, and epinephrine stratification. Among 5093 adult OHCA patients, compared with the no-access attempt group, IO access was associated with higher survival to discharge (aOR 1.44; 95% CI 1.08–1.91). IV access also showed increased survival to discharge (aOR 1.25; 95% CI 1.01–1.58). However, in the subgroup analysis of patients treated by EMT-P providers, IV access demonstrated a stronger association with survival to discharge (aOR 3.65; 95% CI 1.16–11.49) compared to IO access (aOR 2.29; 95% CI 1.28–7.24). Failed IV attempts yielded the poorest outcomes. Sensitivity and stratified analyses demonstrated that early vascular access (≤15 min) significantly improved survival for both IO (aOR 2.03; 95% CI 1.45–2.85) and IV (aOR 1.25; 95% CI 1.11–1.49) routes, with treatment timing, provider level, and epinephrine use modifying these associations. Prehospital vascular access, either IV or IO, was associated with improved survival compared with no access attempt. Failed IV attempts were linked to the poorest outcomes, underscoring the potential harm of procedural delays. Early transition to IO may serve as an effective rescue strategy when IV access is difficult; however, successful IV or humeral IO should be preferred when feasible.

Background: Out-of-hospital cardiac arrest (OHCA) remains a critical emergency with low survival rates despite advanced prehospital interventions. Early epinephrine administration, particularly in non-shockable rhythms, improves outcomes. While intravenous (IV) access is the standard route for drug delivery, it is often difficult to obtain in the prehospital setting. Intraosseous (IO) access offers a viable alternative, but its comparative survival benefit remains unclear. Few studies have examined the impact of IO access on outcomes relative to patients who received no prehospital vascular access. This study aims to assess survival outcomes among OHCA patients receiving different prehospital vascular access strategies. Methods and Results: This retrospective cohort study included adult patients with non-traumatic OHCA in Taoyuan, Taiwan (June 2021–June 2024). Patients were categorized into four groups: IV, IO (humerus), failed IV, and no-access attempt. Primary outcomes were survival to discharge and favorable neurological status (CPC 1–2); secondary outcomes included prehospital ROSC and survival over 2 hours. Multivariable logistic regression adjusted for confounders. Among 4,424 patients, the IO group had the highest rates of ROSC (13.0%), 2-hour survival (28.0%), and discharge survival (16.6%), while the failed IV group had the lowest. IO access was associated with better outcomes than no-access attempt, with or without epinephrine. IO patients receiving epinephrine had the highest estimated survival and neurological outcomes. Each minute delay in epinephrine administration reduced survival odds by 4%. Conclusions: Prehospital vascular access—especially IO—was linked to improved OHCA survival and neurological outcomes. Prompt IO access should be considered when IV attempts fail. Clinical perspective: What Is New?: This is the first study to comparing vascular access including IV, IO, IV fails and no access attempt before arriving hospital on non-traumatic OHCA patients. In pre-hospital settings, IO access should be promptly established when IV fails, which significantly improving OHCA patient survival and neurological outcomes. What Are the Clinical Implications?: The study emphasizes the importance of establishing IO access while IV access failed on OHCA patients prior to hospital arrival in order to improve survival and neurological outcomes.

Background: The rate of survival after out‐of‐hospital cardiac arrest varies depending on the timeliness and effectiveness of prehospital interventions. This study was conducted to compare out‐of‐hospital cardiac arrest outcomes between intravenous and intraosseous routes and between upper and lower extremity routes for drug administration. Methods and Results: We retrospectively analyzed data (collected using the Utstein template) from 1220 patients who had experienced out‐of‐hospital cardiac arrest in Taiwan's Taoyuan City between January 2021 and August 2023. The patients were stratified into intravenous and intraosseous groups by treatment approach and upper and lower extremity access groups by access site. The study outcomes were survival to discharge, favorable neurologic outcomes (Cerebral Performance Category score 1 or 2), and survival for >2 hours. The study groups were statistically compared before and after propensity score matching. Significant pre–propensity score matching differences were observed between intravenous and intraosseous groups, and the aforementioned study outcomes were better in the intravenous group than in the intraosseous group. However, the between‐group differences became nonsignificant after propensity score matching. Furthermore, lower extremity access and delayed epinephrine administration were associated with worse outcomes. Survival rates fell below 12.6% when time to treatment exceeded 15 minutes, particularly in the cases of intraosseous access and lower extremity access. Conclusions: This study highlights the benefits of early intervention and upper extremity access for drug administration in patients with out‐of‐hospital cardiac arrest. Intraosseous access may serve as a viable alternative to intravenous access. Timely administration of essential drugs during resuscitation can improve clinical outcomes and thus has implications for emergency medical service training.

Background: Survival following an out‐of‐hospital cardiac arrest depends on prompt defibrillation. Despite the efforts made to install automated external defibrillators (AEDs) in crowded areas, their usage rate remains suboptimal. This study evaluated the efficiency of installing AEDs at key landmarks in Taoyuan City to enhance accessibility and usage. METHODS AND RESULTS: This retrospective cohort study analyzed nontraumatic public out‐of‐hospital cardiac arrest cases in Taoyuan City from 2017 to 2021, using data from the Taoyuan Fire Department and a regional registry. AED data were collected for 1163 devices. A geographic information system mapped target locations within the city, and real‐world walking routes were examined to assess coverage. The primary outcome was actual coverage and the coverage efficiency ratio, calculated as the actual coverage divided by the number of facilities at a location. The coverage efficiency ratio compared the coverage efficiency of target locations with existing public access defibrillators (PADs). Top locations for superior coverage in both downtown and outside downtown areas were bus stops and convenience stores (7‐Eleven and FamilyMart), which outperformed existing PADs. Convenience stores had a higher coverage efficiency ratio than the public service sector. Bus stops showed high AED usage rates before ambulance arrival. Conclusions: The current PAD locations in Taoyuan City offer limited coverage, which highlights the need for strategically installed AEDs, particularly in convenience stores. Policymakers should consider using the cultural relevance and accessibility of convenience stores, particularly 7‐Eleven branches, to enhance AED usage rates.

Background: Generally, cardiopulmonary resuscitation (CPR) skills decline substantially over time. By combining web-based self-regulated learning with hands-on practice, blended training can be a time- and resource-efficient approach enabling individuals to acquire or refresh CPR skills at their convenience. However, few studies have evaluated the effectiveness of blended CPR refresher training compared with that of the traditional method. Objective: This study investigated and compared the effectiveness of traditional and blended CPR training through 6-month and 12-month refresher sessions with CPR ability indicators. Methods: This study recruited participants aged ≥18 years from the Automated External Defibrillator Donation Project. The participants were divided into 4 groups based on the format of the CPR training and refresher training received: (1) initial traditional training (a 30-minute instructor-led, hands-on session) and 6-month traditional refresher training (Traditional6 group), (2) initial traditional training and 6-month blended refresher training (an 18-minute e-learning module; Mixed6 group), (3) initial traditional training and 12-month blended refresher training (Mixed12 group), and (4) initial blended training and 6-month blended refresher training (Blended6 group). CPR knowledge and performance were evaluated immediately after initial training. For each group, following initial training but before refresher training, a learning effectiveness assessment was conducted at 12 and 24 months. CPR knowledge was assessed using a written test with 15 multiple-choice questions, and CPR performance was assessed through an examiner-rated skill test and objectively through manikin feedback. A generalized estimating equation model was used to analyze changes in CPR ability indicators. Results: This study recruited 1163 participants (mean age 41.82, SD 11.6 years; n=725, 62.3% female), with 332 (28.5%), 270 (23.2%), 258 (22.2%), and 303 (26.1%) participants in the Mixed6, Traditional6, Mixed12, and Blended6 groups, respectively. No significant between-group difference was observed in knowledge acquisition after initial training (P=.23). All groups met the criteria for high-quality CPR skills (ie, average compression depth: 5-6 cm; average compression rate: 100-120 beats/min; chest recoil rate: >80%); however, a higher proportion (98/303, 32.3%) of participants receiving blended training initially demonstrated high-quality CPR skills. At 12 and 24 months, CPR skills had declined in all the groups, but the decline was significantly higher in the Mixed12 group, whereas the differences were not significant between the other groups. This finding indicates that frequent retraining can maintain high-quality CPR skills and that blended refresher training is as effective as traditional refresher training. Conclusions: Our findings indicate that 6-month refresher training sessions for CPR are more effective for maintaining high-quality CPR skills, and that as refreshers, self-learning e-modules are as effective as instructor-led sessions. Although the blended learning approach is cost and resource effective, factors such as participant demographics, training environment, and level of engagement must be considered to maximize the potential of this approach. Trial Registration: IGOGO NCT05659108; https://www.cgmh-igogo.tw

Background: Public access defibrillation (PAD) programs have been implemented globally over the past decade. Although PAD can substantially increase the survival of cardiac arrest, PAD use remains low. This study aimed to evaluate whether drawing upon the successful experiences of dispatcher‐assisted cardiopulmonary resuscitation programs would increase the use of PAD in dispatcher‐assisted PAD programs. Methods and Results: This study using a before‐and‐after design was conducted in Taoyuan City using a local out‐of‐hospital cardiac arrest registry system and data of dispatcher performance derived from audio recordings. The primary outcomes were the rate of bystander PAD use, sustained return of spontaneous circulation, survival to discharge, and favorable neurological outcomes. The secondary outcomes were the performance of dispatchers in terms of PAD instruction and dispatcher‐assisted cardiopulmonary resuscitation administration, the time interval indicators of dispatcher‐assisted cardiopulmonary resuscitation. A total of 1159 patients were included and divided into 2 groups: the before‐run‐in group (502 patients) and the after‐run‐in group (657 patients). No significant difference was observed between the 2 groups in terms of baseline characteristics. The rate of PAD use in the after‐run‐in group significantly increased from 5.0% to 8.7% ( P =0.015). The rate of favorable neurological outcomes increased from 4.4% to 5.9%, which was not a statistically significant difference. Compared with the before‐run‐in group, the rate of successful automated external defibrillator acquisition was 13.5% in the after‐run‐in group ( P <0.001). Conclusions: Implementing a dispatcher‐assisted PAD protocol in a municipality setting significantly increased bystander PAD use without affecting dispatcher performance in out‐of‐hospital cardiac arrest recognition, cardiopulmonary resuscitation instruction, or dispatcher‐assisted cardiopulmonary resuscitation time indicators.

BACKGROUND Generally, cardiopulmonary resuscitation (CPR) skills decline substantially over time. By combining web-based self-regulated learning with hands-on practice, blended training can be a time- and resource-efficient approach enabling individuals to acquire or refresh CPR skills at their convenience. However, few studies have evaluated the effectiveness of blended CPR refresher training compared with that of the traditional method. OBJECTIVE This study investigated and compared the effectiveness of traditional and blended CPR training through 6-month and 12-month refresher sessions with CPR ability indicators. METHODS This study recruited participants aged ≥18 years from the Automated External Defibrillator Donation Project. The participants were divided into 4 groups based on the format of the CPR training and refresher training received: (1) initial traditional training (a 30-minute instructor-led, hands-on session) and 6-month traditional refresher training (Traditional6 group), (2) initial traditional training and 6-month blended refresher training (an 18-minute e-learning module; Mixed6 group), (3) initial traditional training and 12-month blended refresher training (Mixed12 group), and (4) initial blended training and 6-month blended refresher training (Blended6 group). CPR knowledge and performance were evaluated immediately after initial training. For each group, following initial training but before refresher training, a learning effectiveness assessment was conducted at 12 and 24 months. CPR knowledge was assessed using a written test with 15 multiple-choice questions, and CPR performance was assessed through an examiner-rated skill test and objectively through manikin feedback. A generalized estimating equation model was used to analyze changes in CPR ability indicators. RESULTS This study recruited 1163 participants (mean age 41.82, SD 11.6 years; n=725, 62.3% female), with 332 (28.5%), 270 (23.2%), 258 (22.2%), and 303 (26.1%) participants in the Mixed6, Traditional6, Mixed12, and Blended6 groups, respectively. No significant between-group difference was observed in knowledge acquisition after initial training (P=.23). All groups met the criteria for high-quality CPR skills (ie, average compression depth: 5-6 cm; average compression rate: 100-120 beats/min; chest recoil rate: >80%); however, a higher proportion (98/303, 32.3%) of participants receiving blended training initially demonstrated high-quality CPR skills. At 12 and 24 months, CPR skills had declined in all the groups, but the decline was significantly higher in the Mixed12 group, whereas the differences were not significant between the other groups. This finding indicates that frequent retraining can maintain high-quality CPR skills and that blended refresher training is as effective as traditional refresher training. CONCLUSIONS Our findings indicate that 6-month refresher training sessions for CPR are more effective for maintaining high-quality CPR skills, and that as refreshers, self-learning e-modules are as effective as instructor-led sessions. Although the blended learning approach is cost and resource effective, factors such as participant demographics, training environment, and level of engagement must be considered to maximize the potential of this approach. CLINICALTRIAL IGOGO NCT05659108; https://www.cgmh-igogo.tw