Improving bystander automated external defibrillation application in Singapore: An 11-year population-based living-laboratory study
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Background
Bystander automated external defibrillator (BAED) use improves out-of-hospital cardiac arrest (OHCA) outcomes but remains uncommon globally. This study evaluated the outcomes of Singapore’s 11-year public-access AED expansion and volunteer-responder implementation in terms of trends in BAED application, associated factors, and clinical outcomes.
Methods
This population-based, retrospective cohort study used Singapore Pan-Asian Resuscitation Outcomes Study (SG-PAROS) data (2010–2020) for adult, non-traumatic OHCAs. The primary outcome was bystander AED application. Multivariable logistic regression identified factors associated with use. Secondary outcomes included favorable neurological status (CPC 1–2), survival to discharge, and prehospital return of spontaneous circulation (ROSC).
Results
Of 21,439 included OHCA cases (median age 70.0 years; 63.8% male), BAED application increased from 1.7% to 9.6% over 11 years, with a corresponding increase in overall survival from 2.4 to 4.0%. Malay ethnicity (aOR 1.25, 1.06–1.49), calendar year (aOR 1.26, 1.22–1.29), and delayed emergency medical services (aOR 1.24, 1.06–1.45) were positive predictors of BAED application. Conversely, BAED application was lower among females (aOR 0.80, 95% CI 0.69–0.94), at night (aOR 0.69, 0.56–0.86), and in residential settings (aOR 0.06, 0.05–0.07).
Volunteer arrival strongly increased application (aOR 4.16, 3.41–5.09), with a significant interaction (p<0.001); the effect was greater in residential (aOR 7.38, 5.81–9.38) than non-residential settings (aOR 1.71, 1.22–2.40). AED use predicted favorable neurological outcome (aOR 2.80, 2.24–3.50; NNT 8.7), survival (aOR 2.30, 1.89–2.80), and ROSC (aOR 2.11, 1.81–2.46).
Conclusion
Over 11 years, we saw a significant increase in BAED application and favorable neurological survival. This success was associated with the implementation of an integrated strategy combining widespread AED deployment, national training, and smartphone-activated volunteer responders. Singapore’s experience provides a scalable model for urban centers seeking to expand their AED strategy.
