Table 1. Policy Changes In the 1990s and 2000s.

From: Task-shift Model in Pre-hospital Care and Standardized Nationwide Data Collection in Japan: Improved Outcomes for Out-of-hospital Cardiac Arrest Patients

Policy process Policy content
Task shift in pre-hospital care Evaluation/research
EMT* ELSTs Laypeople
1990s
  • Media campaign started in 1989
  • MHW established the Commission for Emergency Care System in in 1989
  • The commission issued a report in 1990
  • FDMA established a working group for pre-hospital care in 1990
  • The group issued a report in 1990
  • Lawmakers decided to introduce a task-shift model, in which EMS personnel can provide some advanced procedures, and to enhance laypeople training
Guidelines for pre-hospital care procedures amended in 1991
EMTs-intermediate were allowed to:
  • Use an automatic CPR machine
  • Continue home-based treatments in the ambulance
  • Use pneumatic-anti-shock garments
  • Auscultate
  • Monitor blood pressure, SpO2, and ECG
  • Insert nasal airways
  • Remove foreign bodies using laryngoscope and Magill forceps
ELST Act enacted in 1991 and ELST system started in 1992
Under on-line physician instructions, ELSTs were allowed to:
  • Place intravenous lines
  • Insert supraglottic airways
  • Perform defibrillation using a semi-AED
FDMA Guidelines on training curriculum for laypeople and instructors issued in 1993 (training of BLS procedures) Standardized data collection activities started
  • Population-based studies using the Utstein style initiated (early 1990s)
  • The FDMA national registry started in July 1994
  • The Utstein Osaka Project started in 1998
2000s
  • Joint Commission for ELSTs’ services established in 2002 (by the health ministry and FDMA)
  • The Commission delivered a recommendation to expand ELSTs’ roles
  • Commission for Sophistication of Pre-hospital Care recommended introduction of the Utstein style to the national registry
Ordinance for Enforcement of the ELST Act amended
  • Defibrillation with an AED without on-line instructions started in 2003
  • Endotracheal intubation under on-line instructions started in 2004
  • Adrenaline administration under on-line instructions started in 2006
The health ministry issued a notice in 2004 stating
laypeople can use an AED in emergency situations, if a
physician is not availabl
  • Deployment of public-access AED started and increased
  • International Guidelines introduced in 2000
  • Establishment of Japan Resuscitation Council in 2002
  • SOS-KANTO study started in 2002
  • Establishment of Resuscitation Council of Asia in 2005
  • The Utstein style was introduced into the national registry in 2005
  • Resuscitation Council of Asia became a member of ILCOR in 2006
Table 2. Increasing Trends in Emergency Life-saving Technicians, Trained Laypeople, and Public-access AEDs

From: Task-shift Model in Pre-hospital Care and Standardized Nationwide Data Collection in Japan: Improved Outcomes for Out-of-hospital Cardiac Arrest Patients

EMS* Trained laypeople* Public-access
AEDs†
Year ELSTs in
EMS units, n
EMS units
(total), n
EMS units with
ELSTs, %
Trained in
3-hour
course, n
Trained in
8-hour
course, n
Short
course, n
Number of
units sold, n
1992 483 4237 4.0
1993 541 4229 5.2
1994 1,369 4331 11.5 246,356 10,680
1995 2,232 4387 16.6 395,045 19,212
1996 3,338 4416 23.9 491,300 25,758
1997 4,556 4483 29.7 589,798 33,670
1998 5,846 4515 37.2 655,700 34,807
1999 6,757 4553 44.8 797,979 41,135
2000 8,016 4582 51.2 861,699 48,393
2001 9,461 4,563 56.8 901,039 53,795
2002 10,823 4,596 62.8 970,898 58,410
2003 12,152 4,649 67.6 1,081,946 61,746
2004 13,505 4,711 73.0 1,053,715 65,895 1,307
2005 15,317 4,751 78.3 1,147,904 68,081 10,961
2006 16,468 4,779 82.4 1,388,212 78,922 45,417
2007 17,218 4,846 86.3 1,499,485 72,843 96,545
2008 18,336 4,871 88.5 1,541,459 77,660 164,343
2009 19,368 4,892 91.0 1,490,246 75,926 218,050
2010 20,383 4,910 93.1 1,408,864 76,999 264,165
2011 21,268 4,927 94.3 1,345,591 79,959 310,075
2012 22,118 4,965 95.9 1,410,981 84,898 224,230 364,959
2013 22,870 5,004 96.8 1,392,325 50,547 325,476 428,821
2014 23,560 5,028 97.4 1,376,149 84,864 392542 516,135
2015 24,223 5,069 97.8 1,355,791 84,307 409347 602,382
2016 24,973 5,090 98.4 1,315,946 82,385 443,943 688,329
2017 25,872 5,140 98.9 1,287,848 88,659 558,454 784,467
2018 26,581 5,179 99.1 1,245,971 91,014 656,226 881,467
Table 3. OHCA Occurrence Trends, Bystander Intervention (CPR and Defibrillation), and Prognoses.

From: Task-shift Model in Pre-hospital Care and Standardized Nationwide Data Collection in Japan: Improved Outcomes for Out-of-hospital Cardiac Arrest Patients

All transported OHCA patients* Bystander-witnessed cardiogenic OHCA*
Patient number Bystander CPR provided, % One-month survival, % Patient number Bystander CPR provided, % One-month survival, % Survival with
OPC/CPC 1-2, %
Those receiving bystander
defibrillation with public-access AED
Year Patient number Survival with
OPC/CPC 1-2, %
1994 31,206 13.4 2.6
1995 72,016 13.0 2.7
1996 72,542 15.1 2.7
1997 76,272 16.9 2.8
1998 80,970 19.7 3.2
1999 83,353 23.0 3.2
2000 84,899 24.9 3.4
2001 88,058 26.6 3.3
2002 91,691 27.8 3.5
2003 94,845 30.8 3.7
2004 94,920 33.5 3.9
2005 102,738 33.6 4.3 17,882 41.0 7.2 3.3 46 23.9
2006 105,942 35.3 4.7 18,897 42.9 8.4 4.1 144 29.2
2007 109,461 39.2 5.2 19,707 47.6 10.2 6.1 287 35.5
2008 113,827 40.7 5.3 20,769 48.0 10.4 6.2 429 38.2
2009 115,250 42.7 5.6 21,112 51.3 11.4 7.1 583 35.8
2010 123,095 42.7 5.9 22,463 49.8 11.4 6.9 667 38.2
2011 127,109 43.0 5.6 23,296 49.5 11.4 7.2 738 38.9
2012 127,866 44.3 5.8 23,797 51.5 11.5 7.2 881 36.0
2013 123,987 44.9 6.1 25,469 51.1 11.9 7.9 907 42.8
2014 125,951 47.2 6.1 25,255 54.2 12.2 7.8 1,030 43.3
2015 123,421 48.1 6.3 24,496 55.8 13.0 8.6 1,103 46.1
2016 123,554 48.9 6.7 25,569 56.1 13.3 8.7 1,204 45.4
2017 127,018 49.9 6.6 25,538 56.6 13.5 8.7 1,260 45.7
2018 127,718 50.7 6.8 25,756 58.1 13.9 9.1 1,254 48.2
Table 4. Future Challenges.

From: Task-shift Model in Pre-hospital Care and Standardized Nationwide Data Collection in Japan: Improved Outcomes for Out-of-hospital Cardiac Arrest Patients

  • Increase bystander CPR (still around 50% of patients receive bystander CPR). This would require:
 ・Training laypeople in first aid, including CPR
 ・Rescuer-protection mechanisms (legal, social, and psychological)
  • Increase the use of public-access AED by layperson bystanders (slow increase in use of public-access AED compared to rapid increase of public-access AED deployment)
  • Equalize pre-hospital and hospital care abilities (regional variations exist)
  • Facilitate and evaluate post-resuscitation intensive care (hypothermia and extracorporeal cardiopulmonary resuscitation)
  • Provide resuscitation according to patients’ wishes (poor management of end-of-life care)
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