Abstract / Summary
Background: Out-of-hospital-cardiac-arrest requires a robust emergency response system for survival. In low-resource settings like suburban and rural Sindh in Pakistan, little is known about the readiness of healthcare systems and communities. Aim: The aim of this study was to comprehensively assess the system-readiness for out-of-hospital-cardiac-arrest management in rural and suburban areas of Sindh, Pakistan by studying out-of-hospital and in-hospital elements of chain of survival in these areas. Methods: A triangulation mixed-methods design was used. The study was conducted in seven hospitals in the suburban and rural areas of upper, central and southern parts of the province of Sindh, Pakistan. Quantitative data from exit interviews ( n = 163) using the Patient Satisfaction Questionnaire-18 and a facility readiness checklist ( n = 7 hospitals) were analysed using descriptive statistics. Qualitative data were collected through focus group discussions with community members and ambulance crew, in-depth interviews with emergency room doctors and nurses, and key informant interviews with emergency room supervisors and cardiologists and were analysed using thematic analysis. Results: Exit interviews with 163 patients showed that the lowest proportions satisfied were for communication (26.4%), financial aspects (31.3%), accessibility and convenience (32.5%), technical quality of emergency room staff (40.5%), and time spent with doctors (47.2%). Among the seven facilities assessed, defibrillators were available in two, but neither was functional; epinephrine was available in four, pulse oximeters in three, and endotracheal tubes in three, while laryngeal mask airways were unavailable in all facilities. Qualitative data from 12 focus group discussions, 15 in-depth interviews, and three key informant interviews identified limited recognition of cardiac arrest, inadequate ambulance availability, poor road access, shortages of trained staff and resuscitation equipment, sociocultural and gender-related barriers, and weaknesses in emergency care governance and data systems. Conclusion: Triangulation of quantitative and qualitative findings showed that the Chain of Survival in rural and suburban Sindh is weak at several points, including the community, prehospital care, health facilities, and governance. The study shows that there is a need to strengthen the system at multiple levels. This includes training community members, ambulance crew and emergency room staff in cardiopulmonary resuscitation, setting minimum standards for resuscitation readiness, and creating out-of-hospital-cardiac-arrest registries.