Resuscitation 122 (2018) 48–53

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Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation

Clinical paper

The effect of the number and level of emergency medical technicians

on patient outcomes following out of hospital cardiac arrest in Taipei夽
Jen-Tang Sun a,b , Wen-Chu Chiang c,d,∗ , Ming-Ju Hsieh c , Edward Pei-Chuan Huang c ,
Wen-Shuo Yang e , Yu-Chun Chien e , Yao-Cheng Wang e , Bin-Chou Lee f , Shyh-Shyong Sim a
, Kuang-Chao Tsai a , Matthew Huei-Ming Ma c,d,∗ , Lee-Wei Chen b,g,h,∗∗
a
Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
b
Institute of Emergency and Critical Care Medicine, National Yang Ming University, Taipei City, Taiwan
c
Department of Emergency Medicine, National Taiwan University Hospital, Taipei City, Taiwan
d
Department of Emergency Medicine, National Taiwan University Hospital, Yun-Lin Branch C, Taiwan
e
The Emergency Medical Services(ambulance) Division, Taipei City Fire Department, Taiwan
f
Department of Emergency Medicine, Taipei City Hospital, Chung-Shaw Branch, Taipei, Taiwan
g
Department of Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
h
Department of Biological Sciences, National Sun Yat-Sen University, Kaohsiung, Taiwan

a r t i c l e i n f o a b s t r a c t

Article history: Aim: The effect of the number and level of on-scene emergency medical technicians (EMTs) on the out-
Received 14 August 2017 comes of patients with out-of-hospital cardiac arrest (OHCA) remains unclear. We aimed to test the
Received in revised form 24 October 2017 association between the number and level of EMTs and the outcomes of patients with OHCA.
Accepted 19 November 2017
Methods: We analysed Utstein-based registry data on OHCA in Taipei from 2011 to 2015. The eligible
patients were adults, aged ≥20 years, with non-traumatic OHCA who underwent resuscitation attempts.
Keywords:
The exposures were the total number of EMTs or the EMT-Paramedic (EMT-P) ratio >50%. The outcome
Out of hospital cardiac arrest
of interest was survival to discharge.
Emergency medical services
Paramedic
Results: During study period, total 8262 OHCA cases were included, of which 1085 (13.1%) were
Emergency medical technician approached by crews with an EMT-P ratio >50%. While an increase in the number of EMTs on-scene
Advance life support was not associated with better chances of survival (adjusted odds ratio [aOR] 0.98, 95% confidence inter-
Teamwork val [CI] 0.89–1.08), an EMT-P ratio >50% was significantly associated with improved outcome (aOR 1.36,
95% CI 1.06–1.76). Subgroup analyses showed that EMT-P >50% significantly benefited survival in wit-
nessed OHCA cases with non-shockable rhythm (aOR 1.69, 95% CI 1.01–2.58). Survival was the highest
among cases seen by four EMTs with an EMT-P ratio >50% (aOR 2.54, 95% CI 1.43–4.50).
Conclusion: An on-scene EMT-P ratio >50% was associated with improved survival to discharge of OHCA
cases, especially in those with witnessed, non-shockable rhythm. The presence of four EMTs with an
EMT-P ratio >50% at the scene of OHCA was associated with the best outcome.
© 2017 Elsevier B.V. All rights reserved.

Introduction

Out of hospital cardiac arrest (OHCA) is a problem of paramount

夽 A Spanish translated version of the abstract of this article appears as Appendix
in the final online version at https://doi.org/10.1016/j.resuscitation.2017.11.048.
∗ Corresponding authors at: National Taiwan University Hospital Yunlin Branch,
No 579, Sec. 2, Yunlin Rd., Douliu City, Yunlin County 640, Taiwan.
∗∗ Corresponding author at: No.155, Sec.2, Linong Street, Taipei, 11221 Taiwan
(R.O.C.).
E-mail addresses: drchiang.tw@gmail.com (W.-C. Chiang),
mattma.tw@gmail.com, matthew@ntu.edu.tw (M.H.-M. Ma),
lwchen@vghks.gov.tw (L.-W. Chen).
importance worldwide. Although resuscitation science has made
significant progress in the past decades, survival following OHCA
remains unresolved [1]. In the United States, over 176,100 OHCA
patients are treated annually by emergency medical service (EMS)
teams [2]. In Taiwan, the incidence of OHCA was reported as 51.1
per 100,000 people from 2000 to 2012, or an average of 9815 cases
per year; the survival rate among these cases was 9.8% at 180 days
[3]. On-scene emergency medical technicians (EMTs) are the first-
line health care providers for OHCA patients in many countries.

https://doi.org/10.1016/j.resuscitation.2017.11.048
0300-9572/© 2017 Elsevier B.V. All rights reserved.
 J.-T. Sun et al. / Resuscitation 122 (2018) 48–53
Therefore, the number and level of EMTs in the field are considered
to influence the outcomes of patients with OHCA [4–7].
The number and level of EMTs on the scene for OHCA resus-
citation is one of possible modifiable factors in OHCA treatment.
However, their effects on outcomes of OHCA patients remain con-
troversial [4–6,8]. In a single-tiered system, Kajino et al. found
that the presence of three paramedics (100% paramedic ratio) in
resuscitation team was associated with improved favourable neu-
rologic outcomes in the witnessed OHCA group, although there was
no difference in the 30-day survival [4]. However, Hagiwara et al.
showed the opposite, reporting no significant favourable neuro-
logical outcomes in the resuscitation group with more than two
paramedics (i.e. 66.7–100% paramedic ratio) [8] In a two-tiered
system, Eschmann et al. revealed no significant survival benefits
in the group treated by the advanced life support (ALS) team with
an increasing number of paramedics, but the study did not inves-
tigate the influence of the total number of EMTs [6]. Another study
conducted by Warren et al. showed a positive association between
the total number of EMTs and survival of OHCA patients, but they
did not consider the number of on-scene paramedics in the resus-
citation team [5].
Taking both number and level of on-scene EMTs into considera-
tion is important in evaluating the effect of EMTs on the survival of
OHCA patients because there might be interactions between them,
such as workload or leadership. A sufficient number of EMTs is
essential for the management of OHCA patients. For example, two
EMTs may not be able to perform many treatments and simulta-
neously maintain a high quality of cardiopulmonary resuscitation
(CPR). Paramedics are usually more skilful and confident in per-
forming OHCA as they have more experience and training, and
theoretically could be team leaders for on-scene resuscitation.
However, too many paramedics might lead to ambiguous leader-
ship, thus threatening the team performance [9]. Proper paramedic
ratios could be an important component of EMS configuration.
Many EMS teams comprise different levels of EMTs, such as EMT-
intermediate (EMT-I) and paramedics, but the best paramedic ratio
in prehospital resuscitation is still unknown in both single-tiered
and-two-tiered systems [4,8].
This study aimed to evaluate the effect of the number and level
of on-scene EMTs on the outcomes of OHCA patients. We hypoth-
esized that more than two EMTs and a paramedic ratio >50% for
the resuscitation team would be associated with improved survival
among OHCA patients in Taipei City, Taiwan.
Materials and methods
Study design and setting
We conducted a 5-year retrospective cohort study using
prospectively collected Utstein-based registry data from the Taipei
EMS to investigate the association between the number of EMTs
and the paramedic ratio with OHCA patient outcomes [10]. The
study protocol was approved by the Institutional Review Board of
the National Taiwan University Hospital.
Taipei City is a metropolitan area with 2.65 million registered
residents; this number fluctuates to 3.0 million during working
hours due to the inflow of workers within 272 km2 . Taiwanese peo-
ple comprise the majority of the population. Taipei city has a one
fire-based EMS system with a two-tiered response consisting of a
basic life support plus defibrillator (BLS-D) team and an ALS team.
The BLS-D team is capable of performing defibrillation and placing
laryngeal mask airway (LMA). Taipei city has 45 prehospital BLS-
D stations with 1020 EMT intermediate staff, who have finished at
least 264 h of training and constitute the fire base crews. One BLS-D
station has two BLS-D ambulances. One BLS ambulance is teamed
49
with two EMTs-I, although sometimes there is a third staff member
(usually a volunteer EMT) in the ambulance.
The ALS team providers are authorised to perform endotracheal
tube intubation and intravenous injections of resuscitation medi-
cations, like adrenaline, atropine, and amiodarone, as per protocol
[10]. The ALS providers conduct OHCA re-training for ALS treat-
ment every year. There are four ALS stations staffed by 120 EMT
paramedics who have completed 1280 h of training as per the
requirements of the Taiwanese Ministry of Health and Welfare. One
ALS station has three ALS ambulances. One ALS ambulance is usu-
ally teamed up with two paramedics, while one BLS ambulance is
teamed with two EMTs-I, although sometimes there is a third staff
member (usually a volunteer EMT) in the ambulance. Taipei has a
single central dispatch centre to process all incoming EMS calls; all
dispatchers are required to complete 40 h of training on priority dis-
patch. BLS-D is the universal response for all dispatch calls. For cases
that meet the ALS dispatch criteria, additional ALS teams would be
dispatched to the scene together with BLS-D teams. For an ALS case
that occurs in an area close to an ALS squad, the nearby ALS team
would be the first response team to dispatch, and an additional ALS
team, as opposed to the BLS-D, would be activated if available.
Study population
From 1st January 2011, to 31st December 2015, non-traumatic
adult (age ≥ 20) patients with OHCA that activated the EMS teams
were included in the study. We excluded patients if they were not
transported to the hospital due to obvious death signs, such as rigor
mortis, or if the family requested a do-not-resuscitate (DNR) or the
patient had given pre-existing consent for DNR.
Definition of exposures
The exposures in our study were defined as EMT configuration
including the total number of EMTs and a paramedic ratio >50%,
defined as paramedic proportion among all on-scene EMTs. For the
paramedic ratio, we divided the ratio into two categories (>50% vs
≤50%) because this was more practically applied by the dispatch
centre.
Outcome measurements
The primary outcome was defined as survival to hospital dis-
charge. The secondary outcome was favourable neurologic status
at discharge defined as cerebral performance category level 1 and
level 2 (CPC ≤2) [11].
Our data were extracted from the Utstein-based OHCA registry
system in the Taipei EMS. This registry system was initially devel-
oped for OHCA quality control [10]. The rates of missing data ranged
from 0% (most data) to 2.6% (mainly “prehospital times”). The reg-
istry system collected data on dispatch records, modes and timing
of prehospital care, patient demographics (age, sex), arrest charac-
teristics (witness status, bystander CPR, initial rhythm on cardiac
monitor), records on automated external defibrillator (AED) avail-
ability, prehospital ALS treatment including airway and medication
used, patient records from the EMS-receiving hospitals, and patient
outcomes (survival to hospital discharge, and neurologic status at
discharge) [12,13].
We conducted a subgroup analysis using the new Utstein
template, with methods suggested by the International Liaison
Committee on Resuscitation (ILCOR) in 2014 to explore the effect
of a paramedic ratio >50% among different subgroup patients with
OHCA [11]. For this analysis, we stratified the data by shockable
bystander CPR groups, shockable bystander witness groups, and
non-shockable witness groups.
50 J.-T. Sun et al. / Resuscitation 122 (2018) 48–53
Fig. 1. Overview of study subjects.
Statistical analysis
We used Excel (Microsoft, Redmond, WA, USA) to record data
and SAS version 9.3 (SAS Institute, Cary, NC, USA) for analysis.
The descriptive statistics for the population were presented as
counts, percentages, or medians (interquartile range [IQR] Q1–Q3).
We conducted non-parametric Mann-Whitney rank sum tests to
analyse differences between continuous variables. We used Chi-
squared or Fisher’s exact tests to assess the associations between
categorical variables and the outcomes. All variables revealing an
association with outcomes (P < 0.05) from the univariate analy-
sis were included in the multivariate logistic regression analysis.
Characteristics previously determined to be associated with the
outcomes were also included in the multivariable logistic regres-
sion analysis to prevent overfitting. Odds ratios (ORs) and 95%
confidence intervals (CIs) were calculated and two-tailed P-values
<0.05 were considered statistically significant.
Results
Study subject characteristics
From 1st January 2011, to 31st December 2015, there were
16,062 cases of cardiac arrests activated by Taipei EMS, and 8262
cases were enrolled in this study (Fig. 1). Of those enrolled, 1085
(13.1%) had a paramedic ratio >50%. Among these, patients with
return of spontaneous circulation (ROSC), sustained ROSC, sur-
Abbreations: OHCA: out-of-hospital cardiac arrest
vival to discharge, and CPC ≤2 at discharge were 2289 (27.7%),
1973 (23.9%), 616 (7.5%), and 307 (3.7%), respectively. The aver-
age (±standard deviation) number of on-scene EMTs was 3.0 ± 1.0;
1085 (13.1%) OHCAs were treated by crews with a EMT-P ratio >50%.
Table 1 shows the demographic data and outcomes of the enrolled
patients categorized by paramedic ratio. Age, sex, and percent-
age of initial shockable rhythm were similar between two groups
(P > 0.05). More bystander-initiated CPR and longer response time
were noted in the group with a paramedic ratio >50% (P < 0.05). ALS
treatments including endotracheal (ET) intubation, drug admin-
istration, and scene time were also significantly higher among
patients in the paramedic ratio >50% group (P < 0.05). Those in the
paramedic ratio >50% group had better ROSC (32.63%), sustained
ROSC (28.20%), and survival to discharge (9.31%) (P < 0.05), how-
ever there was no significant difference in those with favourable
neurological outcomes (3.96%, P > 0.05).
Main result
The adjusted ORs (aOR) for survival among OHCA cases based on
the number of on-scene EMTs and a paramedic ratio >50%, as well as
the subgroups suggested by the Utstein 2014 methods, are shown in
Table 2. The confounders of OHCA survival determined by statistical
significance and prior knowledge including age, sex, witnessed sta-
tus, bystander CPR, shockable rhythm, shorter response and scene
times, and location of arrest, ALS treatment including ET intubation
and drug (atropine, amiodarone and other) administration were
 J.-T. Sun et al. / Resuscitation 122 (2018) 48–53 51

Table 1
Demographic data and outcomes of enrolled out-of-hospital cardiac arrest patients stratified based on emergency medical technician paramedic ratio group.

OHCA All EMS treated arrest (n = 8262) EMTP ratio >50% (n = 1085) EMTP ratio ≤50% (n = 7177) P-value

Patient
Age, years(Median,[Q1-Q3]) 77 (62–86) 77 (63–85) 77 (62–86) 0.54
Male, number (percent) 5239 (63.4%) 707 (65.2%) 4532 (63.2%) 0.20
Witness, number (percent) 2762 (33.4%) 387 (35.7%) 2375 (33.1%) 0.09
Bystander CPR, number (percent) 2753 (33.3%) 402 (37.0%) 2351 (32.8%) 0.005
Shockable rhythm, number (percent) 1018 (12.3%) 129 (11.9%) 889 (12.4%) 0.64
Location of arrest, EMS time interval and treatment (median [Q1–Q3] or%)
Public number(percent) 1086 (13.1%) 130 (12.0%) 956 (13.3%) 0.22
Response time, minutes(Median,[Q1-Q3]) 4.98 (3.97–6.02) 5.13 (4.03–6.87) 4.9 (3.9–6) 0.0001
Scene time, minutes(Median,[Q1-Q3]) 13.99 (11.2–16.78) 15 (12.35–18.22) 13.68 (11–16.28) 0.0001
Medical center, number(percent) 4509 (54.6%) 564 (52.0%) 3945 (55.0%) 0.07
Adrenaline, number(percent) 1418 (17.2%) 420 (38.7%) 998 (13.9%) 0.0001
Atropine/amiodarane/others, number(percent) 63 (0.8%) 24 (2.2%) 39 (0.5%) 0.0001
Endotracheal tube, number(percent) 826 (10%) 302 (27.8%) 524 (7.3%) 0.0001
Survival status, number (percent)
Any ROSC 2289 (27.7%) 354 (32.6%) 1935 (27.0%) 0.00010
Sustained ROSC 1973 (23.9%) 306 (28.2%) 1667 (23.2%) 0.00034
Survival to discharge 616 (7.5%) 101 (9.3%) 515 (7.2%) 0.013
CPC ≤ 2 at discharge 307 (3.7%) 43 (4.0%) 264 (3.7%) 0.64

Abbreviations (in alphabetical order): CPC ≤ 2, cerebral performance category level 1 and level 2; EMS, emergency medical services; EMTP, emergency medical technician
paramedic; OHCA, out-of-hospital cardiac arrest; ROSC, return of spontaneous circulation.

Table 2
Subgroup analysis of adjusted odds ratios for the outcome of survival stratified by the number of emergency medical technicians and the different emergency medical
technician paramedic ratios.

EMT number aOR EMTP ratio >50% EMTP ratio ≤50%

(95% CI) aOR (95% CI) aOR (95% CI)

All EMT Treated; n = 8262

Primary outcome: Survival to discharge 0.98(0.89,1.08) 1.36 (1.06,1.76)a the referent group
Secondary outcome: CPC1&2 0.94 (0.82,1.08) 1.26(0.86,1.83) the referent group
Subgroup 1: OHCAs with shockable rhythm and bystander CPR; n = 355
Primary outcome: Survival to discharge 1.03(0.81–1.31) 1.15 (0.59–2.24) the referent group
Secondary outcome: CPC1&2 0.93 (0.71–1.21 1.83 (0.89–3.79) the referent group
Subgroup 2: OHCAs with shockable rhythm and bystander witnessed; n = 559
Primary outcome: Survival to discharge 1.11 (0.91–1.37) 1.13 (0.63–2.02) the referent group
Secondary outcome: CPC1&2 0.93 (0.74–1.17) 1.62 (0.86–3.07) the referent group
Subgroup3: OHCAs with non-shockable rhythm and bystander witnessed; n = 1734
Primary outcome: Survival to discharge 1.11 (0.91–1.34) 1.72 (1.08–2.73)a the referent group
Secondary outcome: CPC1&2 1.16 (0.85–1.59) 0.85 (0.32–2.28) the referent group

Adjusted by age, sex, witness, bystander CPR, shockable rhythm, response time, scene time, public, medical center, endotracheal tube, adrenaline and
atropine/amiodarone/other drug.
Abbreviations(in alphabetical order): CPC1&2, cerebral performance category level 1 and level 2; CPR, cardiopulmonary resuscitation; EMS, emergency medical services;
EMT, emergency medical technician; EMTP, emergency medical technician paramedic; aOR (95% CI): adjusted odds ratios (95% confidence interval).
a
Statistically significant difference.

adjusted [13]. Although “administration of adrenaline” and “des- Discussion

tination in tertiary hospital” was not significant in the univariate
analysis, recent studies have shown their potential influence on
patient outcomes; therefore, we included them in the multivariate
analysis [14,15].
We determined that the number of EMTs was not associated
with survival to discharge, both in the primary as well as subgroup
analyses. The high paramedic ratio (i.e. >50%) had a significant effect
on survival, with aORs of 1.17 (95% CI 1.00–1.37), 1.36 (95% CI
1.06–1.76), and 1.26 (95% CI 0.86–1.83) for sustained ROSC, survival
to discharge, and favourable neurologic outcomes at discharge,
respectively. The subgroup analysis showed that the effect of the
paramedic ratio >50% was associated with a survival benefit (aOR
1.72, 95% CI 1.08–2.73) in the witnessed non-shockable patients
with OHCA.
The effect of a paramedic ratio >50% on survival to discharge
based on the number of on-scene EMTs is illustrated in Fig. 2. Tak-
ing the number and level of EMTs into consideration (Fig. 2), the
greatest survival to discharge occurred among patients treated by
four EMTs with an EMT-P ratio >50% (aOR 2.54, 95% CI 1.43–4.50)
when compared to crews with two EMTs. In paramedic ratio ≤50%
group, there was no significant effect on the survival to discharge
(P > 0.05).
In this large-scale study, we demonstrated that adult non-
traumatic OHCA patients treated by a team of on-scene EMTs
with a paramedic ratio >50% had a significantly higher chance of
survival to discharge. Compared with two EMTs-I, at least three
paramedics in a four EMT resuscitation team could achieve the best
outcome for OHCA patients treated by teams with a high paramedic
ratio (>50%). Of note, the most beneficial outcomes were observed
among the witnessed non-shockable OHCA patients. Our study pro-
vides informative recommendations for the configuration of EMS
teams worldwide.
Kajino et al. showed that 100% of paramedics (all crews of three
EMTs are paramedics) could improve favourable neurological out-
comes among the bystander-witnessed group in the single tiered
system [4]. We observed similar findings in our study, except that
we did not observe a significant benefit in favourable neurologic
outcomes at discharge; however, we contributed new knowledge
regarding this topic. Our study analysed more precise subgroups
among witness OHCA patients. We found that witnessed non-
shockable patients with OHCA had greater survival than shockable
patients. Additionally, we included all EMS treated patients and
revealed that the high paramedic ratio group had a significant effect
52 J.-T. Sun et al. / Resuscitation 122 (2018) 48–53
Fig. 2. The effect of emergency medical technician paramedic ratio on survival to discharge.
*Adjusted by age, gender, witness, bystander CPR, shockable rhythm, response time, scene time, public arrest, medical center, ETT, epinephrine and atropine/amiodarone/other
Abbreviations; (in alphabetical order): EMT, emergency medical technician; EMTP, emergency medical technician paramedic; OR, odds ratio; C.I., confidence interval.
on survival. Furthermore, we also found that four EMTs with a
high paramedic ratio had the greatest survival to discharge when
compared with two EMTs alone.
There are two reasonable explanations for the improved out-
comes among OHCA patients who received resuscitation by the
crews with a higher ratio of paramedics in our study. We
believed that ALS treatment might enhance the outcome. In our
study, patients with non-shockable witnessed OHCA benefited
the most from teams with a paramedic ratio >50%. ALS treat-
ment including the placement of an ET tube and administration
of amiodarone/atropine were significantly associated with sur-
vival to discharge in the univariate analysis. In Taipei, there are
previous studies showing that ALS can enhance the outcomes in
OHCA patients. In 2007, Matt Ma et al. found that an ALS team
can improve ROSC and survival to admission, especially for non-
shockable rhythm [7]. Chiang et al. found that when American
Heart Association’s ALS-termination of resuscitation (TOR) rule was
applied to OHCA patients in Taipei, there were still 4.9% of OHCA
patients with survival to discharge [13]. In another study, Chi-
ang et al. found that adrenaline in traumatic OHCA can improve
short term survival in the traumatic OHCA cases [12]. Chiang et al.
also found that successful out-of-hospital intubation improved out-
comes in OHCA cases [16].
Another potential explanation for our findings is that
paramedics are usually more experienced and enthusiastic [7].
According to the study conducted by Matt Ma et al., one paramedic
treated almost all of the 10 OHCA patients in 1 year in Taipei [7].
There are many studies demonstrating that more experience can
improve the outcomes of OHCA patients [17,18].
The differences in ALS effects on OHCA patients could be partly
explained by the local variations in study populations in previous
literature reviews [7]. However, in many OHCA studies from west-
ern countries, the study populations had a higher percentage of
shockable rhythm (approximately 30%) compared with our study
[19,20]. Theoretically, shockable rhythm can easily be converted
to survival by early defibrillation and high quality of CPR which
may be achieved by enhanced training of prehospital BLS providers.
We believe this to be the reason why the study by Warren et al.
revealed the greatest benefit among the shockable rhythm group.
In a Japanese study, the relatively low ALS treatment rate (ET-tube
6.5%), might have influenced the ALS effect [21]. In Taipei, the group
with a paramedic ratio ≤50% typically comprises of one BLS team
and one ALS team. However, there is a time gap between the arrivals
of the two ambulances. Thus, the BLS team might have inserted the
supraglottic airway and prepared to leave scene before the arrival
of the ALS team; consequently, the ALS team could not perform the
ALS treatment including ET intubation. This was likely the cause for
low ALS treatment rate in the group with a paramedic ratio ≤50%,
thus influencing the survival to discharge.
Not only the number of EMTs but the configuration of team
is also important to influence team performance when resuscitat-
ing patients [9,22]. The increase in the number of on-scene EMTs
alone was not associated with an improvement in outcomes of
OHCA patients in our study. These findings were contradictory to
those reported by Warren et al. [5] In another study conducted
by Eschmann et al., the number of paramedics was focused on,
regardless of the EMT levels. These investigators concluded that
the total number of paramedics were not influenced by the out-
comes of OHCA patients [6]. In previous studies, most resuscitation
teams were mixed with paramedics and various different levels
of EMTs were present on the scene [4,6]. Different configurations
may affect team performance; paramedics are usually the leaders
of resuscitation teams in Taipei. Kajino et al. also considered that
paramedics could offer good team-dynamics and improve survival
of OHCA patients [4]. In our studies, the total number of EMTs failed
to improve survival to discharge for OHCA patients; however, we
demonstrated that a paramedic ratio >50% could increase the OHCA
patient’s outcome for groups treated by three or four EMTs. Com-
pared to the study conducted by Warren et al., we decreased the
total number of EMTs in a specific configuration. In our study, we
also observed the same phenomenon as in the study by Warren et
al, i.e. when more than four EMTs were present and there was a high
ratio of paramedics, the effect disappeared. These findings may be
caused by teamwork failure in an overstaffed situation, resulting in
no clear role assignment or communication problems [23,24].
Limitations
This study was subject to several limitations. As this was a ret-
rospective cohort study, it was associated with inherent problems.
Although we had information on the average number of OHCA
patients treated, we did not have information on the individual
experiences of OHCA patients. Additionally, although we had qual-
ity control of CPR in Taipei fire department, it was mainly focused
on the verification of unnecessary hands-off time recorded in the
AED records. The chest compression fractions were not accurately
calculated for every OHCA case. Finally, although we observed
better outcomes in the high paramedic ratio group, the different
dispatcher systems or EMS teams may have different outcomes.
 J.-T. Sun et al. / Resuscitation 122 (2018) 48–53
Conclusions
In conclusion, an on-scene EMT-P ratio >50% was associated
with improved survival to discharge for OHCA cases, especially
for those with witnessed, non-shockable rhythm. The presence of
four EMTs with a paramedic ratio >50% at the scene of OHCA was
associated with the greatest survival.
Conflicts of interest
None.
Authors’ contributions
JTS drafted the manuscript. WCC, LWC, and MHMM provided
conception and design of the study and final approval of the version
to be submitted. WSY, YCC and YCW supervised the data collec-
tion. BCL, MJH, SSS, and EPCH performed acquisition and analysis
of data. KCT conceptualized and designed the study. All authors
contributed substantially to its revision. WCC, MHMM, and LWC
take responsibility for the manuscript as a whole.
Grant support
This study was funded by the Taiwan Ministry of Science and
Technology (Grant numbers: MOST 105-2314-B-002-182, MOST
105-2314-B-002-200-MY3 and 104-2314-B-002-032-MY2).
Acknowledgements
We appreciate the excellent performance of EMTs and the
quality assurance of the Ambulance Division of Taipei City. Their
commitment and accomplishments significantly improved prehos-
pital care. We are also grateful for the statistical assistance provided
by the Taiwan Clinical Trial Bioinformatics and Statistical Centre,
Training Centre, and Pharmacogenomics Laboratory (which was
found by the National Research Program for Biopharmaceuticals
[NRPB] at the Ministry of Science and Technology of Taiwan; MOST
104-2325-B-002-032), and the Department of Medical Research of
National Taiwan University Hospital.
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