Introduction
Injuries and sudden death due to cardiac arrest contribute to 9% and 15% of global mortality, respectively, with the low and middle-income countries (LMICs) experiencing majority of this burden.1 2 While out-of-hospital cardiac arrest (OHCA) remains a major challenge with a global incidence of 55 per 100 000 person-years,3 injuries are expected to become the third leading cause of death by 2030.4 Survival from both highly depends on immediate resuscitation and initiation of the chain of survival.5 However, application of the survival chain varies in different parts of the world, hence posing a challenge to reducing the mortality burden.
Every minute that passes by without initiating cardiopulmonary resuscitation (CPR) after OHCA decreases the likelihood of survival by 10–12%.6 Since more than 50% of cardiac arrest occurs outside the hospital, immediate intervention is required for a positive outcome.7 Development of robust prehospital set-up in high-income countries (HICs) has increased the overall survival for OHCA from 0% to 40%.8 However, scarcity of emergency medical services (EMS) and regional variation in LMICs continue to have adverse results.9 A multicenter study conducted in Pakistan shows a 1.6% survival rate post-OHCA at discharge from emergency department (ED), which then dropped to 0% at 2-month follow-up.10 Multifaceted causes for these poor results include delayed intervention, non-responsive bystander, and malfunctioning EMS.10
Penetrating wounds, blunt trauma, and injuries from shearing forces can also lead to life-threatening bleeding.11 Absence of timely treatment in these cases can result in a mortality rate of up to 50%,11 more than half of which could be prevented with adequate hemorrhage control by bystanders.12 In LMICs, trauma alone leads to an estimated mortality of 90%, with 80% of them occurring in a prehospital setting,13 having twice the odds of mortality as compared with HICs.
Where prehospital system fails to provide timely intervention, an impact can be created through bystanders at the scene. Literature shows that bystander CPR and bleeding control can improve the prehospital survival in patients.14 15 However, LMICs have a weak chain of survival due to underdeveloped EMS system and lack of bystander response in critical situations.16 Bystander’s role in performing CPR and first aid highly depends on their prior training experiences.17 18 To increase the knowledge and self-efficacy of bystanders in performing CPR and bleeding control, there is a need of public training which can cause positive ripples within prehospital care and improve survival.
With this notion, a sustainable and resource-friendly nationwide program was introduced in Pakistan, a developing country, to empower its citizens in the basic life-saving skills of CPR and bleeding control. Success of such large-scale interventions depends on a combination of multitiered factors, especially in a low-resource setting. Thereby, this article aims to use the Exploration, Preparation, Implementation and Sustainment (EPIS) framework to describe the feasible and sustainable application of Pakistan Life Savers Programme (PLSP) in a resource-limited setting (RLS).